**Meet the editor**

Prof. (Dr.) Mandeep Singh Virdi, is a leading practising and academically active Paedodontist in N.C.R. of Delhi, India. He obtained his degree in dentistry B.D.S. and post graduate M.D.S. in Paedodontics and Preventive Dentistry, from AB Shetty Memorial Institute of Dental Sciences in Mangalore, Karnataka, India. He is Honorary Secretary of Indian Dental Association, West Delhi

Branch, Member of Indian Association of Paediatric Dentistry, Affiliate Member of American Dental association and Fellow of Pierre Fauchard Academy (U.S.A.). He has taught paediatric dentistry to undergraduate and post graduate dental students since 2000. His research interests include clinical paediatric dentistry and dental education, the subjects in which he has published several research papers in the national and international journals. He has been operating a paedodontics specialist practice in New Delhi, India, besides being consultant to various hospitals. He is presently Professor of Paediatric and Preventive Dentistry at a Dental College the NCR. His forte is in dental treatment under general anaesthesia of children and special need patients. He is active participant in various Continuing Dental Education, Continuing Medical Education and Community Extension Programmes of Indian Dental Association and Indian Medical Association.

## Contents

**Preface XIII**

#### **Section 1 Pediatric and Preventive Dentistry 1**


Agim Begzati, Merita Berisha, Shefqet Mrasori, Blerta Xhemajli-Latifi, Prokshi, Haliti, Valmira Maxhuni, Vala Hysenaj-Hoxha and Vlera Halimi

#### Chapter 3 **Improving Antimicrobial Activity of Dental Restorative Materials 65**

J.M.F.A. Fernandes, V.A. Menezes, A.J.R. Albuquerque, M.A.C. Oliveira, K.M.S. Meira, R.A. Menezes Júnior and F.C. Sampaio

Chapter 4 **Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of Recent Evidences in This Field 83**

Mariana Minatel Braga, Isabela Floriano, Fernanda Rosche Ferreira, Juliana Mattos Silveira, Alessandra Reyes, Tamara Kerber Tedesco, Daniela Prócida Raggio, José Carlos Pettorossi Imparato and Fausto Medeiros Mendes

Chapter 5 **Dental Caries and Quality of Life Among Preschool Children 117** Joana Ramos-Jorge, Maria Letícia Ramos-Jorge, Saul Martins de

Paiva, Leandro Silva Marques and Isabela Almeida Pordeus

#### Contents **X** Contents **VII**


### **Section 3 Orthodontics 315**

Chapter 6 **Herbal Dentifrices for Children 127**

Preetika Chandna and Vivek K. Adlakha

Contents **VI** Contents **VII**

**Section 2 Prosthetics, Geiatric and Implant Dentistry 191**

Chapter 9 **Denture and Overdenture Complications 193**

Murariu Magureanu and Marina Imre

and Cristina Teodora Preoteasa

Dongliang Zhang and Lei Zheng

Chapter 10 **Does the Demographic Transition Impact Health? The Oral**

**Epidemiological Profile of the Elder Population 227**

Chapter 11 **Narrow Diameter and Mini Dental Implant Overdentures 241**

Chapter 13 **Factors Associated with the Presence of Teeth in the Adult and**

Chapter 14 **Oral Health Care Needs in the Geriatric Population 305**

Chapter 8 **Comparative School Dental Sealant Program to Alleviate Dental Caries Problem — Thai versus International**

Gaspar Diaz

Chapter 7 **Infant Oral Health 151**

**Perspective 165** Sukanya Tianviwat

Villanueva Vilchis

Derek S J D'Souza

Chapter 12 **Dental Implants 265**

Marisa Alves Nogueira Diaz, Isabela de Oliveira Carvalho and

Elena Preoteasa, Cristina Teodora Preoteasa, Laura Iosif, Catalina

Javier de la Fuente Hernández, Sergio Sánchez García, Fátima del Carmen Aguilar Díaz, Erika Heredia Ponce and María del Carmen

Elena Preoteasa, Marina Imre, Henriette Lerner, Ana Maria Tancu

**Elderly Xukuru Indigenous Population in Ororubá, 2010 287** Cecilia Santiago Araujo de Lima and Rafael da Silveira Moreira


Chapter 24 **Assorted Errands in Prevention of Children's Oral Diseases and Conditions 545**

H.S. Mbawala, F.M. Machibya and F.K. Kahabuka


Chapter 34 **Advances in Radiographic Techniques Used in Dentistry 763** Zühre Zafersoy Akarslan and Ilkay Peker

#### Chapter 35 **Evidence-Based Control of Oral Malodor 801** Nao Suzuki, Masahiro Yoneda and Takao Hirofuji

#### Chapter 36 **Periodontal Changes and Oral Health 817** Petra Surlin, Anne Marie Rauten, Mihai Raul Popescu, Constantin Daguci and Maria Bogdan

Preface

Oral Health Science and Dentistry.

This is the second book on Oral Health Science. The first book resulted in publication of Oral Health Care-Pediatric, Research, Epidemology and clinical Practices and Oral Health Care-Prosthodontics, Periodontology, Biology, Research and systemic Conditions in February 2012. The present effort documents current developments in Oral Health Sciences in all major conti‐ nents of the world and has contribution from authors and researchers from all over the world. This makes the present book reflection of the progress in Oral Health Science and Practices

and indicates the direction in which this stream of education is likely to head forward.

The book covers areas of General Dentistry, Paediatric and Preventive Dentistry, Geriatric and Prosthodontics, Orthodontics, Periodontology, Conservative Dentistry and Radiology and Oral Medicine. The chapters of the book are grouped accordingly. The contributions to the book have been made from researchers and specialists from Europe, Americas and Asia. It is hoped that chapters of this book will act as reference and initiators of further research in

This effort has been possible by the interest and untiring effort by InTech and its very ener‐ getic Head of Book Publishing Ms Danijela Duric. I sincerely thank for their imitative and efforts in making this publication possible. I will be failing in my duty if I do not acknowl‐ edge the contribution of my family specially my wife Dr. Harnit K. Virdi and my son Dhar‐

> **Prof. (Dr.) Mandeep Singh Virdi** Department of Pediatric Dentistry

> > India

PDM Dental College and Research Institute

am Pratap for bearing with me during the development of this book.

## Preface

This is the second book on Oral Health Science. The first book resulted in publication of Oral Health Care-Pediatric, Research, Epidemology and clinical Practices and Oral Health Care-Prosthodontics, Periodontology, Biology, Research and systemic Conditions in February 2012.

The present effort documents current developments in Oral Health Sciences in all major conti‐ nents of the world and has contribution from authors and researchers from all over the world. This makes the present book reflection of the progress in Oral Health Science and Practices and indicates the direction in which this stream of education is likely to head forward.

The book covers areas of General Dentistry, Paediatric and Preventive Dentistry, Geriatric and Prosthodontics, Orthodontics, Periodontology, Conservative Dentistry and Radiology and Oral Medicine. The chapters of the book are grouped accordingly. The contributions to the book have been made from researchers and specialists from Europe, Americas and Asia.

It is hoped that chapters of this book will act as reference and initiators of further research in Oral Health Science and Dentistry.

This effort has been possible by the interest and untiring effort by InTech and its very ener‐ getic Head of Book Publishing Ms Danijela Duric. I sincerely thank for their imitative and efforts in making this publication possible. I will be failing in my duty if I do not acknowl‐ edge the contribution of my family specially my wife Dr. Harnit K. Virdi and my son Dhar‐ am Pratap for bearing with me during the development of this book.

#### **Prof. (Dr.) Mandeep Singh Virdi**

Department of Pediatric Dentistry PDM Dental College and Research Institute India

**Pediatric and Preventive Dentistry**

## **Fissure Sealing in Occlusal Caries Prevention**

## Kristina Goršeta

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59325

## **1. Introduction**

In the modern world there is still a problem of dental caries. Dental caries is still the most common chronic childhood disease and the primary cause of tooth loss. Over the past 30 years, significant progress has been made in the prevention of dental caries in children and adoles‐ cents. While caries has decreased on interproximal surfaces, occlusal pit and fissure caries have increased [1, 2]. In general, research has demonstrated that caries on occlusal and buccal/ lingual surfaces account for almost 90% of caries experienced in children and adolescents [3]. The caries process in the first and second molars usually starts soon after eruption. The occlusal surfaces of lateral teeth, especially molars have complicated morphology with many grooves (fissures) and pits on the occlusal surface and on the buccal and palatal surfaces (Figure 1). These molar teeth are considered the most susceptible teeth to dental caries due to the anatomy of the chewing surfaces of these teeth, which unfortunately inhibits protection from saliva and fluoride and instead favours plaque accumulation [4]. Pits and fissures don't cause caries process. They permit the entrance of microorganisms and food into this sheltered warm moist richly provided incubator and the dental plaque can be expected to form here. They instead provide a sanctuary to those agents, which cause caries. When carbohydrates in food come in contact with the plaque, acidogenic bacteria in the plaque create acid. This acid damages the enamel walls of the pits and fissures and caries results. Therefore, the most decay is concen‐ trated on the occlusal surfaces of posterior molars.

Pits and fissures have variations in their appearance in cross section. They were descri‐ bed based on the alphabetical description of shape. According to Nango (1960) there were 4 types of pits and fissures: V&U type: self cleansing and somewhat caries resistant; U type: narrow slit like opening with a larger base-susceptible to caries and a number of differ‐ ent ranches K type: also very susceptible to caries [5]. These are the sites most suscepti‐ ble to developing decay [6].

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

**Croatia** 

**Introduction** 

on the occlusal surfaces of posterior molars.

**Title: Fissure sealing in occlusal caries prevention Author: Kristina Gorseta, DMD, MS, PhD** 

**Affiliations: Department of Pediatric and Preventive Dentistry, School of Dental Medicine, University of Zagreb,** 

In the modern world there is still a problem of dental caries. Dental caries is still the most common chronic childhood disease and the primary cause of tooth loss. Over the past 30 years, significant progress has been made in the prevention of dental caries in children and adolescents. While caries has decreased on interproximal surfaces, occlusal pit and fissure caries have increased [1, 2]. In general, research has demonstrated that caries on occlusal and buccal/lingual surfaces account for almost 90% of caries experienced in children and adolescents [3]. The caries process in the first and second molars usually starts soon after eruption. The occlusal surfaces of lateral teeth, especially molars have complicated morphology with many grooves (fissures) and pits on the occlusal surface and on the buccal and palatal surfaces (Figure 1). These molar teeth are considered the most susceptible teeth to dental caries due to the anatomy of the chewing surfaces of these teeth, which unfortunately inhibits protection from saliva and fluoride and instead favours plaque accumulation [4]. Pits and fissures don't cause caries process. They permit the entrance of microorganisms and food into this sheltered warm moist richly provided

This acid damages the enamel walls of the pits and fissures and caries results. Therefore, the most decay is concentrated

description of shape. According to Nango (1960) there were 4 types of pits and fissures: V&U type: self cleansing and

**Figure 1 Occlusal morphology of molar teeth**  Pits and fissures have variations in their appearance in cross section. They were described based on the alphabetical **Figure 1.** Occlusal morphology of molar teeth

**Figure 2.** Caries lesions on the occlusal surface of molar tooth

In most cases the shape of the pit or fissure is such that it is impossible to clean, explaining the high susceptibility of pits and fissures to dental caries (Figure 2 and 3). Caries in the pits and fissures follows the direction of enamel rods and characteristically forms a triangular or cone shaped lesion with its apex at the outer surface and its base towards DEJ. Pits and fissures provide greater cavitations than smooth surface caries. Preventive measures for tooth decay include daily tooth brushing, topical fluoride application, chewing gums with xylitol and sealing of fissures which are applied by dental clinicians [7-10].

There have been many efforts made within past decades to prevent the development of caries, in particular occlusal caries as it was once generally accepted that pits and fissures of teeth

**Figure 3.** Caries lesion in the fissure of molar tooth

would become infected with bacteria within 10 years of erupting into the mouth [7-10]. G.V. Black, the creator of modern dentistry, informed that more than 40% of caries incidences in permanent teeth occurred in pits and fissures due to being able to retain food and plaque [9].There were many attempts to prevent occlusal caries. Willoughby D. Miller, a pioneer of dentistry, was applying silver nitrate with its antibacterial functions to surfaces of teeth to prevent occlusal caries in early 1905. It was chemically treating the biofilm against both Streptococcus mutans and Actinomyces naeslundii, which are both carious pathogens [7-9, 11]. Silver nitrate, which was also being practiced by H. Klein and J.W. Knutson in the 1940s, was being used in attempt to prevent and arrest occlusal caries [9,12].

In 1955, M.G. Buonocore gave insight to the benefits of etching enamel with phosphoric acid. [7-9] His studies demonstrated that resin could be bonded to enamel through acid etching, increasing adhesion whilst also creating an improved marginal integrity of resin restorative material [7,9]. Later, this bonding system leads to the future successful creation of fissure sealants [8-13].

By the late 1970s and early 1980s the clinical data on sealants and caries prevention was very positive. Studies have continued to demonstrate sealant success. One 4-year study showed an overall 43% decrease in the prevalence of caries effectiveness with significantly better sealant retention on premolars (84%) than molars (30%) [5]. A 7-year study reported 66% complete sealant retention and 14% partial retention [9]. Sealant loss was 20% while there was a 55% reduction in caries rate for the sealed teeth versus the unsealed teeth. One 10-year study showed that for over 8,000 sealants placed on permanent first molars, there was 41% complete sealant retention at 10 years and a 58%–63% retention rate over 7 to 9 years [10].

## **2. Sealants materials**

**Figure 2.** Caries lesions on the occlusal surface of molar tooth

**Figure 1.** Occlusal morphology of molar teeth

4 Emerging Trends in Oral Health Sciences and Dentistry

sealing of fissures which are applied by dental clinicians [7-10].

In most cases the shape of the pit or fissure is such that it is impossible to clean, explaining the high susceptibility of pits and fissures to dental caries (Figure 2 and 3). Caries in the pits and fissures follows the direction of enamel rods and characteristically forms a triangular or cone shaped lesion with its apex at the outer surface and its base towards DEJ. Pits and fissures provide greater cavitations than smooth surface caries. Preventive measures for tooth decay include daily tooth brushing, topical fluoride application, chewing gums with xylitol and

**Title: Fissure sealing in occlusal caries prevention Author: Kristina Gorseta, DMD, MS, PhD** 

on the occlusal surfaces of posterior molars.

Pits and fissures

**Figure 1 Occlusal morphology of molar teeth** 

**Croatia** 

**Introduction** 

**Affiliations: Department of Pediatric and Preventive Dentistry, School of Dental Medicine, University of Zagreb,** 

In the modern world there is still a problem of dental caries. Dental caries is still the most common chronic childhood disease and the primary cause of tooth loss. Over the past 30 years, significant progress has been made in the prevention of dental caries in children and adolescents. While caries has decreased on interproximal surfaces, occlusal pit and fissure caries have increased [1, 2]. In general, research has demonstrated that caries on occlusal and buccal/lingual surfaces account for almost 90% of caries experienced in children and adolescents [3]. The caries process in the first and second molars usually starts soon after eruption. The occlusal surfaces of lateral teeth, especially molars have complicated morphology with many grooves (fissures) and pits on the occlusal surface and on the buccal and palatal surfaces (Figure 1). These molar teeth are considered the most susceptible teeth to dental caries due to the anatomy of the chewing surfaces of these teeth, which unfortunately inhibits protection from saliva and fluoride and instead favours plaque accumulation [4]. Pits and fissures don't cause caries process. They permit the entrance of microorganisms and food into this sheltered warm moist richly provided incubator and the dental plaque can be expected to form here. They instead provide a sanctuary to those agents, which cause caries. When carbohydrates in food come in contact with the plaque, acidogenic bacteria in the plaque create acid. This acid damages the enamel walls of the pits and fissures and caries results. Therefore, the most decay is concentrated

Pits and fissures have variations in their appearance in cross section. They were described based on the alphabetical description of shape. According to Nango (1960) there were 4 types of pits and fissures: V&U type: self cleansing and somewhat caries resistant; U type: narrow slit like opening with a larger base-susceptible to cariesand a number of different

ranches K type: also very susceptible to caries [5]. These are the sites most susceptible to developing decay [6].

There have been many efforts made within past decades to prevent the development of caries, in particular occlusal caries as it was once generally accepted that pits and fissures of teeth Pit and fissure sealants proved to be an effective clinical intervention to prevent occlusal caries [13-15]. The aim of fissure sealants is to prevent or arrest the development of dental caries [15]. Preventing tooth decay from the pits and fissures of the teeth is achieved by the fissure sealants blocking these surfaces and therefore stopping food and bacteria from getting stuck in these grooves and fissures [15]. Fissure sealants also provide a smooth surface that is easily accessible for both our natural protective factor, saliva and the toothbrush bristles when cleaning our teeth. Fissure sealing prevents the growth of bacteria in fissures that cause tooth decay. There are several types of materials for fissure sealing.

**Figure 4.** Fissure sealed with resin based sealant material

Caries in pits and fissures has responded less to routine preventive methods than caries on smooth surfaces. Pit and fissure sealant use is an effective clinical regime available for preventing occlusal caries. The most widely used pit and fissure sealants are based on bisglycidyl methacrylate (Bis-GMA) resins. These resins were introduced in 1963 as restorative materials. The main types in use are resin-based sealants and glass ionomer cements [16, 17]. Cueto and Buonocore suggested the sealing of pits and fissures with an adhesive resin in 1967 [18,19]. E.I. Cueto created the first sealant material, which was methyl cyanoacrylate [7, 11,19]. However, this material was susceptible to bacterial breakdown over time, therefore was not an acceptable sealing material [18]. Bunonocore made further advances in 1970 by developing bisphenol-a glycidyl dimethacrylate, which is a viscous resin commonly known as BIS-GMA [13]. This material was used as the basis for many resin-based sealant/composite material developments in dentistry, as it is resistant to bacterial breakdown and forms a steady bond with etched enamel [13,19, 30].

A second group of materials used as fissure sealants are the glass ionomer cements (Figure 5). Glass ionomer cement is also the material of choice for fissure sealing. In 1974, glass ionomer cement fissure sealants (GIC) were introduced by J.W. McLean and A.D. Wilson [15,38]. GIC materials bond both to enamel and dentine after being cleaned with polyacrylic acid condi‐ tioner [15]. Some other advantages GIC's have is that they contain fluoride and are less moisture sensitive, with suggestions being made that despite having poor retention, they may prevent occlusal caries even after the sealant has fallen out due to their ability to release fluoride[7,13,14-16].

It has certain advantages over composite resins: less susceptible to moisture, easy handling and long-term release of fluoride ions [20,21]. These are all essential characteristics for materials handled in paediatric dentistry. However, various studies have shown a significantly lower level of retention compared with composite resins [22-25]. Mechanical properties of glass ionomer are significantly weaker than composite resin. Question about preventive effect of glass ionomer still gets controversial answers: Different studies have shown different preven‐ tive effects [22, 24, 21,26, 27].

Glass ionomer materials release fluoride over time and have the advantage of being less sensitive to moisture contamination than resin-based materials, making them a potential alternative to resin-based sealants when moisture control is an issue [28,29]. Hybrid materials which incorporate features of both resin and glass ionomer, e.g. polyacid-modified resins (compomers) and resin-modified glass ionomers, have also been developed and used as pit and fissure sealants [30].

**Figure 5.** Fissure sealed with glass ionomer sealant material

Preventing tooth decay from the pits and fissures of the teeth is achieved by the fissure sealants blocking these surfaces and therefore stopping food and bacteria from getting stuck in these grooves and fissures [15]. Fissure sealants also provide a smooth surface that is easily accessible for both our natural protective factor, saliva and the toothbrush bristles when cleaning our teeth. Fissure sealing prevents the growth of bacteria in fissures that cause tooth decay. There

Caries in pits and fissures has responded less to routine preventive methods than caries on smooth surfaces. Pit and fissure sealant use is an effective clinical regime available for preventing occlusal caries. The most widely used pit and fissure sealants are based on bisglycidyl methacrylate (Bis-GMA) resins. These resins were introduced in 1963 as restorative materials. The main types in use are resin-based sealants and glass ionomer cements [16, 17]. Cueto and Buonocore suggested the sealing of pits and fissures with an adhesive resin in 1967 [18,19]. E.I. Cueto created the first sealant material, which was methyl cyanoacrylate [7, 11,19]. However, this material was susceptible to bacterial breakdown over time, therefore was not an acceptable sealing material [18]. Bunonocore made further advances in 1970 by developing bisphenol-a glycidyl dimethacrylate, which is a viscous resin commonly known as BIS-GMA [13]. This material was used as the basis for many resin-based sealant/composite material developments in dentistry, as it is resistant to bacterial breakdown and forms a steady bond

A second group of materials used as fissure sealants are the glass ionomer cements (Figure 5). Glass ionomer cement is also the material of choice for fissure sealing. In 1974, glass ionomer cement fissure sealants (GIC) were introduced by J.W. McLean and A.D. Wilson [15,38]. GIC materials bond both to enamel and dentine after being cleaned with polyacrylic acid condi‐ tioner [15]. Some other advantages GIC's have is that they contain fluoride and are less moisture sensitive, with suggestions being made that despite having poor retention, they may prevent occlusal caries even after the sealant has fallen out due to their ability to release

are several types of materials for fissure sealing.

6 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 4.** Fissure sealed with resin based sealant material

with etched enamel [13,19, 30].

fluoride[7,13,14-16].

## **3. Properties of fissure sealing materials**

Resin-based fissure sealants are effective at preventing caries on pit and fissure surfaces in children and adolescents. A Cochrane systematic review of 16 trials found that first permanent molar teeth sealed with resin-based sealant had 78% less caries on occlusal surfaces after 2 years and 60% less after 4–4.5 years compared to unsealed molars [31]. Sealant retention is critical to the effectiveness of resin-based sealants and retention has become an important measure of sealant effectiveness. The Cochrane systematic review reported complete sealant retention rates and it ranged from 79% to 92% at 12 months, 71% to 85% at 24 months, 61% to 80% at 36 months, 52% at 48 months, 72% at 54 months and 39% at 9 years [31]. There was evidence of a clear trend for decreasing sealant retention with time. Some other systematic review on sealant effectiveness reported that the caries-preventive effect of sealants was influenced by sealant replacement, with relatively high reductions in caries risk found in those studies in which a sealant replacement strategy had been used [32].

To achieve effective caries prevention on occlusal surfaces, dental sealants should have several properties. Adhesion of material should be perfect during all kind of function and thermal challenges. Dimensional changes of material during setting should be minimal. Complete retention of sealant material in the occlusal fissures depends on the dimensional changes and resistance to wear and fracture. Good preventive effect today means substantial release of fluoride ions.

Glass ionomer cements (GICs) are also proposed for pit and fissure sealant materials. They have several advantages compared to classic resin sealant materials: easy handling, fluoride releasing at a continuous rate and they are not moisture sensitive.

For the best caries preventive effect in the fissures of lateral teeth, material for sealing should have the following properties:


Inclusion of fluoride ions in the material may be beneficial on the prevention of developing carious lesions, and the remineralization of any demineralized enamel adjacent to the sealant [33-37].

Some studies introduced additional treatment to improve mechanical properties of glass ionomer materials. So a few years ago a method of heating the glass ionomer was introduced. Material was heated with 60-70oC metal plates in order to improve the mechanical properties of materials [39]. Sidhu and colleagues have linked the contraction of the material and the loss of water from glass ionomer cement as a reason to improve the properties of materials[40]. Some studies have shown enhanced adhesion of glass ionomer for hard tissues [95].

Another study tried to increase the level of retention of glass ionomer sealants with heating during setting time of materials [41]. The results obtained for the resin sealing group as a control group in this study are consistent with previously published studies and their results [41-44]. Glass ionomer (Fuji VII) on the basis of the results obtained by monitoring of patient showed a relatively low percentage of retention after 12 months. The results did not differ when compared with the results obtained for the retention of classical (chemical) treated glass ionomer cement [45-50].

## **4. Caries preventive effect**

influenced by sealant replacement, with relatively high reductions in caries risk found in those

To achieve effective caries prevention on occlusal surfaces, dental sealants should have several properties. Adhesion of material should be perfect during all kind of function and thermal challenges. Dimensional changes of material during setting should be minimal. Complete retention of sealant material in the occlusal fissures depends on the dimensional changes and resistance to wear and fracture. Good preventive effect today means substantial release of

Glass ionomer cements (GICs) are also proposed for pit and fissure sealant materials. They have several advantages compared to classic resin sealant materials: easy handling, fluoride

For the best caries preventive effect in the fissures of lateral teeth, material for sealing should

**1.** Ideal adhesion of material should be maintained during setting and function, including

Inclusion of fluoride ions in the material may be beneficial on the prevention of developing carious lesions, and the remineralization of any demineralized enamel adjacent to the sealant

Some studies introduced additional treatment to improve mechanical properties of glass ionomer materials. So a few years ago a method of heating the glass ionomer was introduced. Material was heated with 60-70oC metal plates in order to improve the mechanical properties of materials [39]. Sidhu and colleagues have linked the contraction of the material and the loss of water from glass ionomer cement as a reason to improve the properties of materials[40].

Another study tried to increase the level of retention of glass ionomer sealants with heating during setting time of materials [41]. The results obtained for the resin sealing group as a control group in this study are consistent with previously published studies and their results [41-44]. Glass ionomer (Fuji VII) on the basis of the results obtained by monitoring of patient showed a relatively low percentage of retention after 12 months. The results did not differ when compared with the results obtained for the retention of classical (chemical) treated glass

Some studies have shown enhanced adhesion of glass ionomer for hard tissues [95].

studies in which a sealant replacement strategy had been used [32].

releasing at a continuous rate and they are not moisture sensitive.

the challenges of both thermal and mechanical cycling.

**2.** Complete retention of the sealant material in the occlusal fissures

fluoride ions.

have the following properties:

8 Emerging Trends in Oral Health Sciences and Dentistry

**3.** Resistance to wear and fracture

**4.** Ease to handling and placement

**5.** Caries preventive effects

**6.** Biocompatibility.

ionomer cement [45-50].

[33-37].

There is good evidence that teeth sealed very early after eruption require more frequent reapplication of the FS than teeth sealed later [51,52]. Therefore, FS placement may be delayed until the teeth are fully erupted, unless high caries activity is present. Placement of FS even in the absence of regular follow-up is beneficial [53, 54].

Caries prevalence is relatively low in high-income and relatively high in low-and middleincome countries. Children from high-income countries have benefited from the available established caries preventive measures; such as the use of fluoride-containing products and awareness among their parents and caretakers of the importance of keeping tooth surfaces free from plaque [55].

The studies show that sealants work if applied correctly. Sealant success is multifactorial [56, 57]. Technique, fissure morphology, and the characteristics of the sealant contribute to clinical success [58]. When one reviews published sealant data, a basic concept of 5%–10% of sealant loss per year has been seen demonstrated [31, 32]. This data reveal the importance of reevaluating teeth with sealants on a periodic basis and to reapply if necessary.

Discussion about caries preventive effect of glass ionomer sealants is still controversial: different studies have shown different preventive effects. It was reported that some material remnants in the fissures can maintain caries prevention. The treatment of glass ionomer material with thermo-curing was recently introduced and showed increase of the mechanical properties. Gorseta et al. showed increased bond strength of glass ionomers to hard dental tissues after thermo-curing during material setting [58]. Skrinjaric et al. investigated the retention rate of glass ionomer sealant material thermo-cured during setting time after 1-year clinical trial [41]. Some authors have pointed to the fact that the remains of SIC in the fissures may have some preventive effect in the development of caries [59, 60]. Skrinjaric et al. did not determine SIC remains in fissures. Increased cariostatic effect can be achieved by regular reapplication, but it increases the cost of such preventing procedure [61-64]. The Database Cochane Review could not find a conclusion on a comparison of glass ionomer sealants and resin sealants [63]. Therefore, it is an area that needs further investigation in order to obtain relevant conclusions.

Primary objective of the most studies is to evaluate the effectiveness of pit and fissure sealants in children and adolescents. It is very important that a different background level of caries in the population is related to obtained results. The diagnosis of the surface to be sealed was based on clinical examination in nine studies, one further study used also a DIAGNOdent device [65-68].

Studies which compare the retention of two or more nearly similar type of sealant materials and report the caries rates only on the sealed occlusal surfaces are not relevant. It is important to report on individual level. Information on the caries risk in the study population, the use of fluoridated water, toothpaste and general preventive methods as well as other preventive interventions should be reported in order to facilitate multivariate analysis of risk factors [69]. Comparing glass ionomers to resin sealants, where less than 10% of tooth surfaces had a small dentine caries lesion and most tooth surfaces were reported to be sound. Caries diagnosis of occlusal surfaces can be challenging. In general, using conventional visual, tactile and radio‐ graphic methods in occlusal caries lesion diagnosis, it is not accurate enough to identify whether a lesion extends into the dentine or not [70].

New technologies such as DIAGNOdent laser fluorescence devices may be more sensitive in detecting occlusal dentinal caries [71, 72]. However, the likelihood of false-positive diagnoses may increase when using laser-fluorescence compared with visual methods [71]. Regardless of the caries diagnostic method used, the condition of an occlusal surface to be sealed remains, however, in any case somewhat unclear.

## **5. Indications and contraindications**

Post eruption period of the tooth is most caries susceptible. According to EAPD guidelines, fissure sealant should be placed as soon as possible if there is an indication for placement. However, teeth can be sealed at any age depending on assessment of caries risk factors. [15].

Indications for the use of dental sealants are individual and it depends on patients or teeth that are at high risk of dental caries.

This includes patients with:


Contraindications for the use of dental sealants are individual patients or teeth that are at a low risk of dental caries:

This includes patients with:


## **6. Clinical procedure for fissure sealing**

It includes:

Comparing glass ionomers to resin sealants, where less than 10% of tooth surfaces had a small dentine caries lesion and most tooth surfaces were reported to be sound. Caries diagnosis of occlusal surfaces can be challenging. In general, using conventional visual, tactile and radio‐ graphic methods in occlusal caries lesion diagnosis, it is not accurate enough to identify

New technologies such as DIAGNOdent laser fluorescence devices may be more sensitive in detecting occlusal dentinal caries [71, 72]. However, the likelihood of false-positive diagnoses may increase when using laser-fluorescence compared with visual methods [71]. Regardless of the caries diagnostic method used, the condition of an occlusal surface to be sealed remains,

Post eruption period of the tooth is most caries susceptible. According to EAPD guidelines, fissure sealant should be placed as soon as possible if there is an indication for placement. However, teeth can be sealed at any age depending on assessment of caries risk factors. [15].

Indications for the use of dental sealants are individual and it depends on patients or teeth that

Contraindications for the use of dental sealants are individual patients or teeth that are at a

**•** Partially erupted teeth without adequate moisture control (operators may choose to use GIC

whether a lesion extends into the dentine or not [70].

however, in any case somewhat unclear.

10 Emerging Trends in Oral Health Sciences and Dentistry

are at high risk of dental caries.

**•** Patients with high risk of dental caries

**•** Enamel defects or hypomineralisation or hypoplasia

This includes patients with:

**•** Poor oral hygiene

**•** Deep pits and fissures

low risk of dental caries:

This includes patients with:

**•** Adequate oral hygiene

in these cases)

**•** Teeth with shallow, self-cleansing fissures

**•** A balanced diet with low carbohydrates intake

**•** Teeth with previously restored pits and fissures.[73]

**•** Initial lesion of dental caries

**•** Orthodontics appliances.[73]

**5. Indications and contraindications**

**1. Tooth selection** (Figure 6) and cleaning the occlusal surface (Figure 7).

Visual dental examination is the starting point for dental assessment and treatment planning. The assessment of occlusal surfaces is particularly challenging, due to their complex morphol‐ ogy. The basic prerequisites for visual caries detection are clean, dry teeth and good illumi‐ nation [72, 74, 75].

The difficulty in detecting and correctly assessing occlusal caries by visual examination alone has led to the development of various caries detection methods to refine the diagnostic process, and to enhance the identification of early caries lesions [68, 71, 73]. These methods include dental radiography, light-based technologies e.g. fibre-optic transillumination, quantitative laser fluorescence (DIAGNOdent) or light induced fluorescence (QLF). Given the importance of the visual examination, a system for detailed visual examination of teeth – the International Caries Detection and Assessment System (ICDAS) – has been developed, which promotes the recording of the earliest changes in enamel as well as dentinal caries [76].

**Figure 6.** Tooth selected for sealing

There are different approaches for surface cleaning and the way of cleaning pits and fissures before sealing. It may seem to be controversial. Raadal et al. suggested careful removal of pellicle and plaque with pumice in order to achieve optimal acid-etch pattern of the enamel [77]. On the other hand, Harris and Garcia-Godoy keep that the enamel acid etching alone is sufficient for surface cleaning and provided soft plaque removal [78]. The literature is extensive on the effectiveness of different methods for cleaning prior to bonding [15]. Air abrasion also has been suggested for preparation of the occlusal surface before sealant application [79]. In this case a high-speed stream of purified aluminium oxide particles propelled by air pressure is used to clean the tooth surface. They can remove debris and excavate incipient decay in the fissures. A widening of the fissures with rotary instrumentation in order to remove superficial enamel and open the fissure to have the resin penetrate into it has been recommended before

**Figure 7.** Cleaning the occlusal surface

etching and sealant application by Waggoner and Siegal. This is known as the invasive pitand fissure technique [80, 81]. However, although cleaning the fissures with a bur has given superior retention in some studies [82, 83]. There is evidence in other studies that it provides no additional benefit [84]. Furthermore, purpose full removal of enamel or enameloplasty just to widen the base of a fissure in a sound occlusal surface is an invasive technique, which disturbs the equilibrium of the fissure system and exposes a child unnecessarily to the use of a handpiece or air abrasion. It is concluded, therefore, that there is a need for removal of most organic substance in order to obtain sufficient bonding, but that the removal of sound tooth tissue by the use of instruments, such as a bur, is unnecessary and undesirable. There is a significant volume of evidence of high fissure sealants retention without the use of a bur. Hydrogen peroxide (3%) also has been suggested for cleaning the occlusal fissures before etching, but there is no evidence that this improves clinical retention [85].

#### **2. Moisture control**

Adequate isolation is the most critical aspect of the sealant application process [78]. Achieving good moisture control is one of the greatest challenges to successful sealant application. Salivary contamination of a tooth surface during or after acid etching will have a key effect on the bond quality between enamel and resin. Salivary contamination, also allows the precipi‐ tation of glycoprotein onto the enamel surface greatly decreasing bond strength. If the enamel porosity created by the etching procedure is filled by any kind of liquid, the formation of resin tags in the enamel is blocked or reduced [86, 87]. The circumstances that affect the control of moisture will vary from patient to patient, and may relate to the state of eruption of the tooth, the patient's ability to co-operate, the materials and equipment available for isolation, or a combination of these factors. The options considered by the Guideline Group for 'interim' treatment of teeth for which a sealant was indicated but for which adequate isolation could not be achieved were: resin-based sealant, fluoride varnish and glass ionomer sealant [15].

The rubber dam, when properly placed, provides the best, the safest way of moisture control, and for an operator working alone, it ensures properly isolation from start to finish. In young and partially erupted teeth this is usually not practical. There is evidence of difficulty in securely placing a clamp onto a partially erupted tooth, discomfort during clamp placement and it demands the use of local analgesia in some instances [7, 15]. On the other hand, there is sufficient evidence that careful isolation with cotton rolls gives similar retention results [83]. Cotton roll isolation offers some advantages over rubber dam isolation. No anaesthetic is necessary because no clamps are placed. Cotton rolls can be held in place with either cotton roll holders or fingers. The primary disadvantage to cotton roll isolation is that it is almost a practical necessity that an assistant be used to provide four-handed dentistry [88-90]. The maintenance of a dry field must therefore usually be achieved by the use of cotton rolls and isolation shields, in combination with a thoughtful use of the water spray and evacuation tip. The isolation procedure may frequently be extremely challenging, particularly in the partially erupted teeth or in those children with poor cooperation.

#### **3. Enamel cleaning**(Figure 8)

etching and sealant application by Waggoner and Siegal. This is known as the invasive pitand fissure technique [80, 81]. However, although cleaning the fissures with a bur has given superior retention in some studies [82, 83]. There is evidence in other studies that it provides no additional benefit [84]. Furthermore, purpose full removal of enamel or enameloplasty just to widen the base of a fissure in a sound occlusal surface is an invasive technique, which disturbs the equilibrium of the fissure system and exposes a child unnecessarily to the use of a handpiece or air abrasion. It is concluded, therefore, that there is a need for removal of most organic substance in order to obtain sufficient bonding, but that the removal of sound tooth tissue by the use of instruments, such as a bur, is unnecessary and undesirable. There is a significant volume of evidence of high fissure sealants retention without the use of a bur. Hydrogen peroxide (3%) also has been suggested for cleaning the occlusal fissures before

Adequate isolation is the most critical aspect of the sealant application process [78]. Achieving good moisture control is one of the greatest challenges to successful sealant application. Salivary contamination of a tooth surface during or after acid etching will have a key effect on the bond quality between enamel and resin. Salivary contamination, also allows the precipi‐ tation of glycoprotein onto the enamel surface greatly decreasing bond strength. If the enamel porosity created by the etching procedure is filled by any kind of liquid, the formation of resin tags in the enamel is blocked or reduced [86, 87]. The circumstances that affect the control of moisture will vary from patient to patient, and may relate to the state of eruption of the tooth, the patient's ability to co-operate, the materials and equipment available for isolation, or a combination of these factors. The options considered by the Guideline Group for 'interim' treatment of teeth for which a sealant was indicated but for which adequate isolation could not be achieved were: resin-based sealant, fluoride varnish and glass ionomer sealant [15].

The rubber dam, when properly placed, provides the best, the safest way of moisture control, and for an operator working alone, it ensures properly isolation from start to finish. In young and partially erupted teeth this is usually not practical. There is evidence of difficulty in

etching, but there is no evidence that this improves clinical retention [85].

**2. Moisture control**

**Figure 7.** Cleaning the occlusal surface

12 Emerging Trends in Oral Health Sciences and Dentistry

The goal of etching is to produce a dry, uncontaminated and frosted surface [91]. There are various etching materials available, but the most frequently used is orthophosphoric acid, provided that its concentration lies between 30% and 50% by weight. This is available as both a liquid solution and a gel. Small variations in the concentration do not appear to affect the quality of the etched surface [81]. Duggal et al. showed no significant difference in retention of fissure sealant after one year follow-up on second primary and first permanent molars when 15, 30, 45 or 60 seconds etching times were used [92]. Liquid etching, likewise, is often applied by brush or a small cotton pledget. The application of the gel is often done either directly from the gel dispenser with special applicator tips or with a small disposable brush [7].

**Figure 8.** Etching the occlusal surface

#### **4. Rinsing and drying**

Many of the sealant manufacturers recommend rinsing the tooth for 20 to 30 seconds to remove the etchant. The most important is ensuring that the rinse is long enough to remove all of the etchant from the surface. After drying the tooth with compressed air, the tooth exhibits a chalky, frosted appearance but if still no milky white appearance is seen, the tooth should be re-etched for 15 to 20 seconds [7, 81, 91].

#### **5. Sealant application** (Figure 9)

During sealant application, all the susceptible pits and fissures should be sealed for maximum caries protection. The long-term clinical success of fissure sealants is closely related to their poor handling [93]. The sealant material can be applied to the tooth in a variety of methods. It may be applied with a small brush or on the tip of an explorer. Some common problems occur during sealant application. Small bubbles may form in the sealant material. If these are present, they should be teased out with a brush before polymerization. Many sealant kits have their own dispensers, which directly apply the sealant to the tooth surface. When using a dispenser, the dentist should allow the sealant to flow ahead into the pits and fissures. It reduces air entrapment [7].

**Figure 9.** Application of glass ionomer fissure sealing material

**6. Application of surface gloss for glass ionomer sealants** (Figure 10)

**Figure 10.** Application of surface gloss

#### **7. Polymerization of resin sealants** or Thermo-curing of glass ionomer sealants (Figure 11)

For light cured sealants, polymerization should be initiated quickly after the sealant is placed on the etched surface to help minimize potential contamination. Some study found that the longer sealants were allowed to sit on the etched surface before being polymerized; the more the sealant penetrated the microporosities, creating longer resin tags, which are critical for micromechanical retention [94]. One of the key factors affecting polymerisation is the light intensity of the dental light curing unit. A Canadian study reported that 12.1% of light curing units tested in a sample of dental practices had intensities that would be considered inadequate (<300 mW/cm2 ) [70]. Other factors that may influence polymerisation include curing time, distance of the light guide from the material being cured, and thickness, shade and composition of the material being cured.

**Figure 11.** Thermo-curing with dental light

**5. Sealant application** (Figure 9)

14 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 9.** Application of glass ionomer fissure sealing material

**Figure 10.** Application of surface gloss

**6. Application of surface gloss for glass ionomer sealants** (Figure 10)

entrapment [7].

During sealant application, all the susceptible pits and fissures should be sealed for maximum caries protection. The long-term clinical success of fissure sealants is closely related to their poor handling [93]. The sealant material can be applied to the tooth in a variety of methods. It may be applied with a small brush or on the tip of an explorer. Some common problems occur during sealant application. Small bubbles may form in the sealant material. If these are present, they should be teased out with a brush before polymerization. Many sealant kits have their own dispensers, which directly apply the sealant to the tooth surface. When using a dispenser, the dentist should allow the sealant to flow ahead into the pits and fissures. It reduces air

There are some tips for better fissure sealants:


Sealant retention should be checked with a probe after application, and the sealant re-applied, if necessary, repeating each step of the sealant application procedure.

Regular evaluation of sealants for retention is critical to their success. During routine recall examinations, it is necessary to re-evaluate the sealed tooth surface both visually and tactually for loss of material, exposure of voids in the material and caries development. The need for reapplication of sealants is usually highest during the first six months after placement [95]. When sealants are partially lost and require repair, the clinician should vigorously attempt to dislodge the remaining sealant material with an explorer. If it remains intact to probing, there is no need to completely remove the old material before placing the new.

**Figure 12.** Occlusal view of fissure sealed with nano ionomer cement

## **7. Retention rates for the fissure sealing**

One of the major problems when considering the success rates of sealant restorations is the variation in techniques and materials used. Short term studies indicate a high degree of success for sealant restorations [96-105]. However, longer term studies appear to indicate that success is less predictable [106-110].

Recent study by Gorseta et al. investigated retention of Glass Carbomer fissure sealant after six and twelve months of clinical trial [111]. Glass Carbomer is relatively new material developed from glass ionomer (GIC) and contains nano-sized powder particles and fluorapa‐ tite. Advantages of Glass Carbomer comparing to GIC are better mechanical properties and command setting through application of heat. Materials included forty eight teeth with welldelineated fissure morphology divided in two groups which were sealed with Glass Carbomer Sealant (Glass Carbomer Products, Netherlands) and Helioseal F (Vivadent, Liechtenstein) using split mouth design. Investigated materials were placed and set according to manufac‐ turer's instruction using dental light Bluephase 16i (Vivadent, Liechtenstein) (Figure 10). Teeth in group A were sealed with Glass Carbomer material and in group B with Helioseal F. Evaluation criteria (Kilpatrick et al.) for retention of sealant was classified as: type 1: intact sealant; type 2: 1/3 of sealant missing; type 3: 2/3 of sealant missing; and type 4: whole sealant missing. Presence of new caries lesions was evaluated in two categories: 1-absent; 2-present.

Gorseta et al. used replicas for evaluation of fissure sealant retention rate. The impressions with polyvinylxyloxane impression material of Glass Carbomer-sealed teeth were taken in order to obtain replicas of occlusal surfaces (Figure 14). For that purpose, impression was taken and poured in acrylic resin (Citofix Kit, Struers) (Figure 13). The obtained replicas were analysed with SEM (Figure 15, 16).

**Figure 13.** Impression of occlusal surface of molar

for loss of material, exposure of voids in the material and caries development. The need for reapplication of sealants is usually highest during the first six months after placement [95]. When sealants are partially lost and require repair, the clinician should vigorously attempt to dislodge the remaining sealant material with an explorer. If it remains intact to probing, there

One of the major problems when considering the success rates of sealant restorations is the variation in techniques and materials used. Short term studies indicate a high degree of success for sealant restorations [96-105]. However, longer term studies appear to indicate that success

Recent study by Gorseta et al. investigated retention of Glass Carbomer fissure sealant after six and twelve months of clinical trial [111]. Glass Carbomer is relatively new material developed from glass ionomer (GIC) and contains nano-sized powder particles and fluorapa‐ tite. Advantages of Glass Carbomer comparing to GIC are better mechanical properties and command setting through application of heat. Materials included forty eight teeth with welldelineated fissure morphology divided in two groups which were sealed with Glass Carbomer Sealant (Glass Carbomer Products, Netherlands) and Helioseal F (Vivadent, Liechtenstein) using split mouth design. Investigated materials were placed and set according to manufac‐ turer's instruction using dental light Bluephase 16i (Vivadent, Liechtenstein) (Figure 10). Teeth in group A were sealed with Glass Carbomer material and in group B with Helioseal F. Evaluation criteria (Kilpatrick et al.) for retention of sealant was classified as: type 1: intact sealant; type 2: 1/3 of sealant missing; type 3: 2/3 of sealant missing; and type 4: whole sealant missing. Presence of new caries lesions was evaluated in two categories: 1-absent; 2-present.

is no need to completely remove the old material before placing the new.

16 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 12.** Occlusal view of fissure sealed with nano ionomer cement

**7. Retention rates for the fissure sealing**

is less predictable [106-110].

**Figure 14.** Replicas of occlusal surface of molar

Obtained data were statistically analyzed using non-parametric Mann-Whitney test.

Results showed that retention rate in-group A and B were 100% after six months of clinical service. There were no secondary caries lesions in either group. Results showed that complete retention in group A and B were 75% after 12 months of clinical service. There were two new caries lesions in each group. Mann-Whitney U test doesn't reveal significant statistical difference between groups. Glass Carbomer sealant material showed comparable retention rate to resin based sealant material and can also be recommended for every day practice [111].

In some studies which found statistically significantly more caries in group with glass ionomer sealed teeth at 36-48 months than in group with resin sealed teeth, the complete retention for resin sealants was about 80%, and for glass ionomers was very low (3%) [112, 113, 114].

Studies published by Karlzén-Reuterving and Williams reported similar retention rate did not show a difference between the materials in caries incidence [115, 116]. In next two studies, glass ionomers sealing were reported to be more effective regarding caries prevention [117, 118]. They reported retention of both sealant materials as low (resin-based sealants 28% to 40% and glass ionomers in 21% to 40% after 36 months). Conditioning with 10% polyacrylic acid as well as heating lamp polymerization during curing of cement had no effect on the level of retention of the tested glass ionomer cement (Fuji VII). Similar studies have been done in other parts of Europe, and all with the record of low retention rate of glass ionomer sealants, or the value does not significantly deviate from those of the observed in our study. The two-year Finnish study published the complete retention of polyalcenoic cement at 26% of the sealed teeth compared with 82% fully retained fissure sealants of bis-GMA materials [50].

**Figure 15.** SEM analysis of glass ionomer sealant

After 28 months, Poulsen et al [45] have noted retention of Fuji III of less than 10%, and Pardi et al [46] only 3.5%. After nine months Weerheijm et al. [60] showed an overall retention of Fuji IX in the amount of 51% and only 15% for Fuji III. The incidence of new carious lesions in the group of sealing with glass ionomer cements was not statistically significant. The duration of study is only one year because of the small percentage of retention rate of glass ionomer sealants. Regardless of what is known that the most people prefer chewing on the right side, a control group of sealants (Helioseal F) placed on the right side of the jaw showed a high percentage of retention of 80%.

months Weerheijm et al. [60] showed an overall retention of Fuji IX in the amount of 51% and only 15% for Fuji III. The

Studies published by Karlzén-Reuterving and Williams reported similar retention rate did not show a difference between the materials in caries incidence [115, 116]. In next two studies, glass ionomers sealing were reported to be more effective regarding caries prevention [117, 118]. They reported retention of both sealant materials as low (resin-based sealants 28% to 40% and glass ionomers in 21% to 40% after 36 months). Conditioning with 10% polyacrylic acid as well as heating lamp polymerization during curing of cement had no effect on the level of retention of the tested glass ionomer cement (Fuji VII). Similar studies have been done in other parts of Europe, and all with the record of low retention rate of glass ionomer sealants, or the value does not significantly deviate from those of the observed in our study. The two-year Finnish study published the complete retention of polyalcenoic cement at 26% of the sealed teeth compared with 82% fully retained fissure

sealants of bis-GMA materials [50].

After 28 months, Poulsen et al [45] have noted retention of Fuji III of less than 10%, and Pardi et al [46] only 3.5%. After nine **Figure 16.** SEM analysis of glass ionomer sealant-higher magnification

difference between groups. Glass Carbomer sealant material showed comparable retention rate to resin based sealant material and can also be recommended for every day practice [111]. In some studies which found statistically significantly more caries in group with glass ionomer sealed teeth at 36-48 months than in group with resin sealed teeth, the complete retention for resin sealants was about 80%, and for glass ionomers was very low (3%) [112, 113, 114].

Studies published by Karlzén-Reuterving and Williams reported similar retention rate did not show a difference between the materials in caries incidence [115, 116]. In next two studies, glass ionomers sealing were reported to be more effective regarding caries prevention [117, 118]. They reported retention of both sealant materials as low (resin-based sealants 28% to 40% and glass ionomers in 21% to 40% after 36 months). Conditioning with 10% polyacrylic acid as well as heating lamp polymerization during curing of cement had no effect on the level of retention of the tested glass ionomer cement (Fuji VII). Similar studies have been done in other parts of Europe, and all with the record of low retention rate of glass ionomer sealants, or the value does not significantly deviate from those of the observed in our study. The two-year Finnish study published the complete retention of polyalcenoic cement at 26% of the sealed

teeth compared with 82% fully retained fissure sealants of bis-GMA materials [50].

After 28 months, Poulsen et al [45] have noted retention of Fuji III of less than 10%, and Pardi et al [46] only 3.5%. After nine months Weerheijm et al. [60] showed an overall retention of Fuji IX in the amount of 51% and only 15% for Fuji III. The incidence of new carious lesions in the group of sealing with glass ionomer cements was not statistically significant. The duration of study is only one year because of the small percentage of retention rate of glass ionomer sealants. Regardless of what is known that the most people prefer chewing on the right side, a control group of sealants (Helioseal F) placed on the right side of the jaw showed a high

**Figure 15.** SEM analysis of glass ionomer sealant

18 Emerging Trends in Oral Health Sciences and Dentistry

percentage of retention of 80%.

Sidhu et al. studied contraction SIC after heating [40]. They concluded that the degree of contraction of the material depends on the porosity within the SIC. These dimensional changes can affect not only the marginal integrity between the enamel and the material, but also compromise the quality of adhesion between the glass ionomer and enamel. As the viscosity of glass ionomers used for sealing fissures greater than the viscosity of the resin sealants, Simonsen, McLean recommend use SIC only fissure having a diameter greater than 100 microns [119]. Also, solutions and gels for fluoridation may affect the surface SIC causing greater roughness [120]. This may induce microfractures on the surface of the material, then the fractures in the material and chained lead to loss of retention of material in the fissure. incidence of new carious lesions in the group of sealing with glass ionomer cements was not statistically significant. The

**Figure 16 SEM analysis of glass ionomer sealant-higher magnification** 

The study of Pardi analyzed following sealant materials: flowable resin composite (Revolu‐ tion), resin-modified glass ionomer (Vitremer) and compomer (DyractFlow) [121]. All occlusal surfaces were conditioned with 37% phosphoric acid. After 2 years, sealants were totally retained on 76% of the teeth sealed with Revolution, on 58% of teeth sealed with Dyract Flow and on 47% of the occlusal surfaces sealed with Vitremer. Recent studies comparing resins to resin-modified glass ionomers at 36 months, reported clearly better complete retention rates for resins (94%) than for resin-modified glass ionomers (5%) [122,123].

There might be many different causes behind the inconsistent results between the studies comparing resin-based materials to glass ionomers as sealants. Therefore, conclusion cannot be drawn based only on retention rate of material as sealants. However, information about caries prevalence in population is very important as diet and oral hygiene [122, 123].

Recent studies showed that the level of retention of glass ionomer sealants treated by heating during setting time is considerably lower than retention of conventional composite resin for sealing. Reduced time manipulation and adhesion of glass ionomer material for the wet surface of the tooth, unequivocally favours glass ionomer material as the material of choice for sealing partially erupted molars [124-130]. This procedure is especially warranted in high caries risk patients, uncooperative patients and those with special needs [121].

Griffin et al. evaluated the effectiveness of sealants in managing caries lesions in a metaanalysis, and found their effectiveness in preventing dentin caries to be in the range of 62% to 100% (median 74% for all; 83% for non-cavitated and 65% for cavitated lesions). They recommended the placement of sealants to arrest lesions in the early carious stages and also to surfaces where caries status is uncertain. The progression of non-cavitated occlus‐ al lesions was slow also for surfaces that were not sealed indicating that such surfaces could either be monitored or sealed. Invasive treatment methods were not recommended [124, 126-131].

Sealant maintenance is an integrated part of the sealant approach – all sealed surfaces should be regularly monitored clinically and radiographically [132-133]. Bitewing radiographs are suggested to be taken at a frequency consistent with the patient's risk status especially in cases where there has been doubt about the surface caries status prior to sealant application [124]. Defective or lost sealants should be reapplied in order to maintain the marginal integrity of sealants.

## **8. Conclusion**

A fissure sealant is a material that is placed in the pits and fissures of teeth in order to prevent or arrest the development of dental caries. As the integrity and retention of a sealant is considered crucial to the success of sealants in the long-term, resin based is the material of choice. Sealing over incipient caries lesions is both effective and practical – the dental profes‐ sion should be encouraged to use sealants more in an interceptive manner rather than in a preventive or operative manner.) They recommended the placement of sealants to arrest lesions in the early carious stages and also to surfaces where caries status is uncertain. The progression of non-cavitated occlusal lesions was slow also for surfaces that were not sealed indicating that such surfaces could either be monitored or sealed.

## **Author details**

Kristina Goršeta\*

Address all correspondence to: kgorseta@sfzg.hr

Department of Pediatric and Preventive Dentistry, School of Dental Medicine, University of Zagreb, Croatia

## **References**

of the tooth, unequivocally favours glass ionomer material as the material of choice for sealing partially erupted molars [124-130]. This procedure is especially warranted in high caries risk

Griffin et al. evaluated the effectiveness of sealants in managing caries lesions in a metaanalysis, and found their effectiveness in preventing dentin caries to be in the range of 62% to 100% (median 74% for all; 83% for non-cavitated and 65% for cavitated lesions). They recommended the placement of sealants to arrest lesions in the early carious stages and also to surfaces where caries status is uncertain. The progression of non-cavitated occlus‐ al lesions was slow also for surfaces that were not sealed indicating that such surfaces could either be monitored or sealed. Invasive treatment methods were not recommended [124,

Sealant maintenance is an integrated part of the sealant approach – all sealed surfaces should be regularly monitored clinically and radiographically [132-133]. Bitewing radiographs are suggested to be taken at a frequency consistent with the patient's risk status especially in cases where there has been doubt about the surface caries status prior to sealant application [124]. Defective or lost sealants should be reapplied in order to maintain the marginal integrity of

A fissure sealant is a material that is placed in the pits and fissures of teeth in order to prevent or arrest the development of dental caries. As the integrity and retention of a sealant is considered crucial to the success of sealants in the long-term, resin based is the material of choice. Sealing over incipient caries lesions is both effective and practical – the dental profes‐ sion should be encouraged to use sealants more in an interceptive manner rather than in a preventive or operative manner.) They recommended the placement of sealants to arrest lesions in the early carious stages and also to surfaces where caries status is uncertain. The progression of non-cavitated occlusal lesions was slow also for surfaces that were not sealed

Department of Pediatric and Preventive Dentistry, School of Dental Medicine, University of

indicating that such surfaces could either be monitored or sealed.

Address all correspondence to: kgorseta@sfzg.hr

patients, uncooperative patients and those with special needs [121].

20 Emerging Trends in Oral Health Sciences and Dentistry

126-131].

sealants.

**8. Conclusion**

**Author details**

Kristina Goršeta\*

Zagreb, Croatia


[28] Yengopal V, Mickenautsch S, Bezerra A, Leal S. Caries-preventive effect of glass ion‐ omer and resin-based fissure sealants on permanent teeth: a meta analysis. J Oral Sci 2009;51(3):373–82.

[14] Weintraub JA. The effectivness of pit and fissure sealants. J of Public Health Dent.

[15] Welbury R, Raadal M, Lygidakis N. Guidelines on the use of Pit and Fissures Seal‐ ants in Paediatric Dentistry. An EAPD policy document. Eur J Paediatr Dent.

[16] Simonsen RJ. Pit and fissure sealant: review of the literature. Pediatr Dent 2002;24:

[17] Adair SM. The role of sealants in caries prevention programs. J Calif Dent Assoc

[18] Cueto EI, Buonocore MG. Sealing pits and fissures with an adhesive resin. Its use in

[19] Gwinnett AJ, Buonocore MG. Adhesives and caries prevention. A preliminary report.

[20] Taifour D, Frencken JE, van't Hof MA, Beiruti N, Truin GJ. Effects of glass ionomer sealants in newly erupted first molars after 5 years: a pilot study. Community Dent

[21] Poulsen S, Laurberg L, Vaeth M, Jensen U, Haubek D. A field trial of resin-based and glass-ionomer fissure sealants: clinical and radiographic assessment of caries. Com‐

[22] Pardi V, Pereira AC, Mialhe FL, Meneghim MC, Ambrosano GMB. A 5-year evalua‐ tion of two glass-ionomer cements used as fissure sealants. Community Dent Oral

[23] Forss H, Halme E. Retention of a glass ionomer cement and a resin-based fissure sealant and effect on carious outcome after 7 years. Community Dent Oral Epide‐

[24] Poulsen S, Beiruti N, Sadat N. A comparison of retention and the effect on caries of fissure sealing with a glass-ionomer and a resin-based sealant. Community Dent Oral

[25] Williams B, Laxton L, Holt RD, Winter GB. Fissure sealants: a 4-year clinical trial comparing an experimental glass polyalkenoate cement with a bis glycidyl metacry‐

[26] Mejare I, Major IA. Glass ionomer and resin based fissure sealants: a clinical study.

late resin used as fissure sealants. Br Dent J. 1996;180:104-8.

[27] Uribe S. The effectiveness of fissure sealants. Evid Based Dent. 2004;5:92.

caries prevention. J Am Dent Assoc. 1967;75(1):121-128.

1989;49(5 Spec No):317-30.

22 Emerging Trends in Oral Health Sciences and Dentistry

2004;3:179-84.

2003;31:221-7.

Br Dent J. 1965;119:77-80.

Oral Epidemiol. 2003;31:314-9.

Epidemiol. 2003;31:386-91.

Epidemiol. 2001;29:298-301.

Scand J Dent Res. 1990;98:345-50.

miol. 1998;26:21-5.

munity Dent Oral Epidemiol. 2006;34:36-40.

393-414.


[42] Morphis TL, Toumba KJ. Retention of two fluoride pit-and-fissure sealants in com‐

[43] Walker J, Floyd K, Jakobsen J. The effectiveness of sealants in pediatric patients. J

[44] Lygidakis NA, Oulis KI, Christodoulidis A. Evaluation of fissure sealants retention following four different isolation and surface preparation techniques: four years clin‐

[45] Poulsen S, Laurberg L, Vaeth M, Jensen U, Haubek D. A field trial of resin-based and glass-ionomer fissure sealants: clinical and radiographic assessment of caries. Com‐

[46] Pardi V, Pereira AC, Mialhe FL, Meneghim MC, Ambrosano GMB. A 5-year evalua‐ tion of two glass-ionomer cements used as fissure sealants. Community Dent Oral

[47] Forss H, Halme E. Retention of a glass ionomer cement and a resin-based fissure sealant and effect on carious outcome after 7 years. Community Dent Oral Epide‐

[48] Poulsen S, Beiruti N, Sadat N. A comparison of retention and the effect on caries of fissure sealing with a glass-ionomer and a resin-based sealant. Community Dent Oral

[49] Williams B, Laxton L, Holt RD, Winter GB. Fissure sealants: a 4-year clinical trial comparing an experimental glass polyalkenoate cement with a bis glycidyl metacry‐

[50] Forss H, Saarni M, Seppa L. Comparison of glass ionomer and resin based sealants.

[51] Dennison JB, Straffon LH, More FG. Evaluating tooth eruption on sealant efficacy. J

[52] Walker J, Floyd K, Jakobsen J, Pinkham JR. The effectiveness of preventive resin re‐ storations in pediatric patients. ASDC J Dent Child 1996 Sep-Oct;63(5):338-40.

[53] Cueto EI, Buonocore MG. Sealing of pits and fissures with an adhesive resin: its use

[54] Chestnutt IG, Schafer F, Jacobson AP, Stephen KW. The prevalence and effectiveness of fissure sealants in Scottish adolescents. Br Dent J 1994 Aug 20;177(4):125-9.

[55] Jo E. Frencken. The ART approach using glass-ionomers in relation to global oral

[56] Simonsen RJ. Retention and effectiveness of a single application of white sealant after

late resin used as fissure sealants. Br Dent J. 1996;180:104-8.

in caries prevention. J Am Dent Assoc 1967Jul;75(1):121-8.

Community Dent Oral Epidemiol. 1994;22:21-4.

Am Dent Assoc 1990 Nov;121(5):610-4.

health care. Dental materials 2010;26:1–6.)

10 years. J Am Dent Assoc. 1987115(1):31-36.

parison to a conventional sealant. Int J Paediatr Dent. 1998;8:203-8.

Dent Child. 1996;63:268-70.

24 Emerging Trends in Oral Health Sciences and Dentistry

Epidemiol. 2003;31:386-91.

Epidemiol. 2001;29:298-301.

miol. 1998;26:21-5.

ical trial. J Clin Pediatr Dent. 1994;19:23-5.

munity Dent Oral Epidemiol. 2006;34:36-40.


[85] Christensen GJ. Fluoride made it: why haven't sealants? JADA 1992;123(2):89-90.

[71] Bader JD, Shugars DA. A systematic review of the performance of a laser fluores‐ cence device for detecting caries. Journal of the American Dental Association

[72] Lussi A, Hibst R, Paulus R. DIAGNOdent: an optical method for caries detection.

[73] Beauchamp J. CPW, Crall J.J., Donly K., Feigal R., Gooch B., Ismail A., Kohn W., Sie‐ gal M., Simonsen R. Evidence-based clinical recommendations for the use of pit-andfissure sealants: A report of the American Dental Association Council on Scientific

[74] Ekstrand KR, Martignon S, Ricketts DJN, Qvist V. Detection and activity assessment of primary coronal caries lesions: a methodologic study. Oper Dent 2007;32(3):225–

[75] Bader JD, Shugars DA, Bonito AJ. A systematic review of the performance of meth‐ ods for identifying carious lesions. J Public Health Dent 2002;62(4):201–13.

[76] Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, et al. The International Ca‐ ries Detection and Assessment System (ICDAS): an integrated system for measuring

[77] Raadal M, Espelid I, Mejare I. The caries lesion and its management in children and adolescents. In: Pediatric Dentistry: a clinical approach. Koch G, Poulsen S (eds). Co‐

[78] Harris NO, Garcia-Godoy F. Primary preventive dentistry. 5th edition. London: Asi‐

[79] Goldstein RE, Parkins FM. Air-abrasive technology: its new role in restorative den‐

[80] De Craene GP, Martens C, Dermaut R. The invasive pit and fissure sealing technique in pediatric dentistry: an SEM study of a preventive restoration. ASDC J Dent Child

[81] Waggoner WF, Siegal M. Pit and fissure sealant application: updating the technique.

[82] Shapira J, Eidelman E. Six-year clinical evaluation of fissure sealants placed after me‐ chanical preparation: a matched pair study. Pediatr Dent 1986 Sep;8(3):204-5.

[83] Lygidakis NA, Oulis KI, Christodoulidis A. Evaluation of fissure sealants retention following four different isolation and surface preparation techniques: four years clin‐

[84] Blackwood JA, Dilley DC, Roberts MW, Swift EJ Jr. Evaluation of pumice, fissure en‐ ameloplasty and air abrasion on sealant microleakage. Pediatr Dent 2002 May-Jun;

dental caries. Community Dent Oral Epidemiol 2007;35(3):170–8.

penhagen: Munksgaard; 2001. pp. 173-212.

J Am Dent Assoc 1996 Mar;127(3):351-61, quiz 391-2.

ical trial. J Clin Pediatr Dent 1994 Fall;19(1):23-5.

mon and Schuster Company; 1999.

tistry. JADA 1994;125:551-7.

1988;55(1):34-42.

24(3):199-203.

Journal of Dental Research 2004;83(Spec Iss C):C80–3.

2004;135 (10):1413–26.

26 Emerging Trends in Oral Health Sciences and Dentistry

Affairs. JADA. 2008; 139

35.


[115] Karlzén-Reuterving G, van Dijken JW. A three-year followup of glass ionomer ce‐ ment and resin fissure sealants. Journal of Dentistry for Children 1995;62(2):108–10.

[101] Walls AWG, Murray JJ, McCabe JF. The management of occlusal caries in permanent molars. A clinical trial comparing a minimal composite restoration with an occlusal

[102] Simonsen RJ, Jensen ME. Preventive resin restorations utilizing a diluted filled com‐ posite resins: 30 months results. J Dent Res 1979;58(special issue A):330(abstract No.

[103] Raadal M. Follow-up study of sealing and filling with composite resins in the pre‐ vention of occlusal caries. Community Dent Oral Epidemiol 1978;6:176-180.

[105] Houpt M, Eidelman E, Shey EZ. Occlusal restoration using fissure sealant instead of

[106] Houpt M, Eidelman E, Shey EZ. Occlusal composite restorations:4 year results. J Am

[107] Welbury RR, Walls AGW, Murray JJ, McCabe JF. The management of occlusal caries in permanent molars. A 5-year clinical trial comparing a minimal composite with an

[108] Houpt M, Fuks A, Eidelman E. Composite/sealant restoration: 6.5 year results. Paed

[109] Simonsen RJ, Landy NA. Preventive Resin Restorations: fracture resistance and 7 year clinical results. J Dent Res 1984; 63(special issue): 261(abstract No.175).

[110] Houpt M, Fuks A, Eidelman E. The preventive resin (composite resin/sealant) resto‐

[111] K. Gorseta, D. Glavina, A. Borzabadi-Farahani, R.N. Van Duinen, I. Skrinjaric, R.G. Hill and E. Lynch. One-Year Clinical Evaluation of a Glass Carbomer Fissure Sealant, a Preliminary Study European Journal of Prosthodontics and Restorative Dentistry.

[112] Kervanto-Seppälä S, Lavonius E, Pietilä I, Pitkäniemi J, Meurman J, Kerosuo E. Com‐ paring the caries-preventive effect of two fissure sealing modalities in public health care: a single application of glass ionomer and a routine resin-based sealant pro‐ gramme. A randomized split-mouth clinical trial. International Journal of Paediatric

[113] Poulsen S, Beiruti N, Sadat N. A comparison of retention and the effect on caries of fissure sealing with a glassionomer and a resin-based sealant. Community Dentistry

[114] Rock WP, Foulkes EE, Perry H, Smith AJ. A comparative study of fluoride-releasing composite resin and glass ionomer materials used as fissure sealants. Journal of Den‐

[104] Simonsen RJ. Preventive resin restorations. J Am Dent Assoc 1980;100:535-539.

'extension for prevention'. ASCD J Dent Child 1984;51:270-273.

amalgam restoration. Br Dent J 1988;164:288-292.

amalgam restoration. Br Dent J 1990;169:361-366.

ration:Nine-year results. Quintessence Int 1994;25:155-159.

Dent Assoc 1985;110:351-353.

28 Emerging Trends in Oral Health Sciences and Dentistry

Dent 1988; 10: 304-306.

22 (2014), 2; 67-71.

Dentistry 2008;18(1):56–61.

tistry 1996;24(4):275–80.

and Oral Epidemiology 2001;29(4):298–301.

952).


**Chapter 2**

## **Early Childhood Caries (ECC) — Etiology, Clinical Consequences and Prevention**

[128] Beiruti N, Frencken JE, van't Hof MA, Taifour D, van Palenstein Helderman WH. Ca‐ ries-preventive effect of one-time application of composite resin and glass ionome‐

[129] Antonson SA, Antonson DE, Brener S, Crutchfield J, Larumbe J, Michaud C, et al.Twenty-four month clinical evaluation of fissure sealants on partially erupted per‐ manent first molars: glass ionomer versus resin-based sealant. Journal of the Ameri‐

[130] Yilmaz Y, Beldüz N, Eyübo lu O. A two-year evaluation of four different fissure seal‐ ants. European Archives of Paediatric Dentistry: Official Journal of the European

[131] Yildiz E, Dörter C, Efes B, Koray F. A comparative study of two fissure sealants: a 2 year clinical follow-up. Journal of Oral Rehabilitation 2004;31(10):979–84.

[132] Yakut N, Sönmez H. Resin composite sealant vs. polyacidmodified resin composite applied to post eruptive mature and immature molars: two year clinical study. The

[133] Taifour D, Frencken JE, van't Hof MA, Beiruti N, Truin GJ. Effects of a glass ionomer sealant in newly erupted first molars after 5 years: a pilot study. Community Dentist‐

sealants after 5 years. Caries Research 2006;40(1):52–9.

can Dental Association 2012;143(2): 115–22.

30 Emerging Trends in Oral Health Sciences and Dentistry

Academy of Paediatric Dentistry 2010;11(2):88–92.

Journal of Clinical Pediatric Dentistry 2006;30(3):215–8.

ry and Oral Epidemiology 2003;31(4):314–9.

Agim Begzati, Merita Berisha, Shefqet Mrasori, Blerta Xhemajli-Latifi, Rina Prokshi, Fehim Haliti, Valmira Maxhuni, Vala Hysenaj-Hoxha and Vlera Halimi

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59416

## **1. Introduction**

Primary teeth are also known as milk or deciduous teeth. The 20 primary teeth start to appear in a baby's mouth around the sixth month and they stay in the mouth until they are gradually replaced by the permanent teeth between the ages of six to twelve years.

Primary teeth start to develop from the 6th to 7th week of fetal life from epithelial cells of the mouth that form the tooth buds. The cells of these initial tooth germs continue to differentiate during pregnancy, and, when the baby is born most teeth are already partially formed in the jaws.

The primary teeth play an important role in giving facial fullness and aesthetically pleasant facial shapes. Absence of teeth, due to any reason, not only hampers the masticatory activity of the individual, but also affect the facial features to great extent, affecting the concerned person physiologically, emotionally and socially.

Unfortunately, the primary teeth's function is disrupted when the demineralization process of hard tooth structures is involved – dental caries.

The oral health of children is especially aggravated with the occurrence of the so-called early childhood caries(ECC). ECC is an acute, rapidly developing dental disease occurring initially in the cervical third of the maxillary incisors, destroying the crown completely.

The presence of dental caries, especially of ECC, may reflect on the oral health status of children in countries with insufficient health system and inefficient primary dentistry. Early Childhood Caries (ECC) is a public health problem with biological, social and behavioral determinants.

The preventive activities must start at an early age. Home-care methods are more than necessary.

#### **1.1. Primary Teeth**

The eruption of the primary teeth starts around the sixth month with the central incisors of the lower jaw and it is fully completed by the 3rd year of age with the appearance of the upper second molar. Normally, the first teeth that erupt are the two front teeth of the lower jaw (mandibular central incisors). After a few of months they are followed by the four front teeth of the upper jaw (maxillary central and lateral incisors). The last primary teeth that erupt are the upper second molars which are expected to appear around the age of 2½ years and not later than the completion of the 3rd year.

Teeth eruption is the process during which they move towards the surface of the jawbone and break through the gums, until they take their final position in the mouth with their crown fully visible. At this point the crown is completely formed, but the root of the tooth will continue to form for one more year.

The process of tooth eruption is usually accompanied with pain and discomfort for the baby. The associated symptoms such as drooling, disruptions in eating or sleeping patterns, irritability, swollen gums are referred as 'teething'.

When the primary dentition is completed, children have a set of 20 primary teeth, ten at every jaw. They belong to 3 different teeth types: 8 incisors, 4 canines, and 8 molars.

Eruption of the first permanent molar (age of 6 years), marks the end of the primary dentition period and the start of mixed dentition.

The anatomy and morphology of the primary teeth is also generally similar with that of permanent teeth. Externally the tooth is covered by a layer of enamel at the crown area and by cementum at the root area. Under the enamel there is a layer of dentine which surrounds the soft and alive dental pulp at the center of the tooth.

However some distinctive features of primary teeth are: smaller size, thinner and more translucent enamel, less mineralized enamel (which makes primary teeth more vulnerable to cavities, especially for early childhood caries), larger pulp chambers, narrower and smaller roots, etc.

#### **1.2. Role/importance of the primary teeth**

Parents commonly ask why they should worry about cavities in baby, since they will be replaced by the permanent teeth? The role of the primary teeth is just as important as the role of the permanent ones.

Humans use teeth to tear, grind, and chew food in the first step of digestion. Teeth also play a role in human speech. Additionally, teeth also provide structural support to muscles in the face and form the human smile and other facial expressions. So, broadly the main functions of the teeth can be summarized as follows: role in mastication (helps eating), aids in articulation and speech, role in aesthetics (gives shape and beauty to the face).

One of the main functions of teeth is the mastication of the food. The first step of digestion involves the mouth and teeth. Each type of tooth serves a different function in the chewing process. Depending on the shape, teeth enable cutting, grinding, chewing and preparing food for swallow and further digestion in the digestive tract. The Incisors cut foods when you bite into them. The sharper and longer canines tear food, while the wider molars grind the food.

The preventive activities must start at an early age. Home-care methods are more than

The eruption of the primary teeth starts around the sixth month with the central incisors of the lower jaw and it is fully completed by the 3rd year of age with the appearance of the upper second molar. Normally, the first teeth that erupt are the two front teeth of the lower jaw (mandibular central incisors). After a few of months they are followed by the four front teeth of the upper jaw (maxillary central and lateral incisors). The last primary teeth that erupt are the upper second molars which are expected to appear around the age of 2½ years and not

Teeth eruption is the process during which they move towards the surface of the jawbone and break through the gums, until they take their final position in the mouth with their crown fully visible. At this point the crown is completely formed, but the root of the tooth will continue to

The process of tooth eruption is usually accompanied with pain and discomfort for the baby. The associated symptoms such as drooling, disruptions in eating or sleeping patterns,

When the primary dentition is completed, children have a set of 20 primary teeth, ten at every

Eruption of the first permanent molar (age of 6 years), marks the end of the primary dentition

The anatomy and morphology of the primary teeth is also generally similar with that of permanent teeth. Externally the tooth is covered by a layer of enamel at the crown area and by cementum at the root area. Under the enamel there is a layer of dentine which surrounds

However some distinctive features of primary teeth are: smaller size, thinner and more translucent enamel, less mineralized enamel (which makes primary teeth more vulnerable to cavities, especially for early childhood caries), larger pulp chambers, narrower and smaller

Parents commonly ask why they should worry about cavities in baby, since they will be replaced by the permanent teeth? The role of the primary teeth is just as important as the role

Humans use teeth to tear, grind, and chew food in the first step of digestion. Teeth also play a role in human speech. Additionally, teeth also provide structural support to muscles in the face and form the human smile and other facial expressions. So, broadly the main functions of the teeth can be summarized as follows: role in mastication (helps eating), aids in articulation

jaw. They belong to 3 different teeth types: 8 incisors, 4 canines, and 8 molars.

necessary.

**1.1. Primary Teeth**

form for one more year.

roots, etc.

of the permanent ones.

later than the completion of the 3rd year.

32 Emerging Trends in Oral Health Sciences and Dentistry

period and the start of mixed dentition.

**1.2. Role/importance of the primary teeth**

irritability, swollen gums are referred as 'teething'.

the soft and alive dental pulp at the center of the tooth.

and speech, role in aesthetics (gives shape and beauty to the face).

Masticatory function, besides stimulating the development of the jaws, allows the child to learn the right way of eating. Toothache during mastication can affect the child's nutrition. Accord‐ ing to some studies it has been found that children with more decayed teeth have less than 80% of average weight, which they are expected to have for their age (Acs et al 1999, Acs et al 1992). Children with toothache often after their recovery reach their normal weight and have tranquility during their sleep (Elice & Fields 1990).

The role of healthy primary teeth consists in clearly speaking and emphasizing the correct letters and sounds. The mouth, especially the teeth, lips, and tongue are essential for speech, one of the very important functions of teeth. The teeth, lips, and tongue are used to form words by controlling airflow through the mouth. Especially, the front teeth enable correct pronunci‐ ation of consonants: t, th, d, f, etc.

Primary teeth, among other roles, have one more extremely important role. As long as they are in the oral cavity, until their physiological loss, they will serve as space retention for permanent teeth. Their premature loss can be a cause of malocclusions in children. If we achieve to prevent their premature loss, malocclusion frequency will be reduced for 30%. Although early loss of primary incisors would not have a major consequence, a premature loss of primary molar and canine will be marked by a significant disorder in the development of occlusion during the eruption of the permanent teeth (Marković 1976).

Healthy teeth and full realization of their function, in fact, will allow a normal psycho-physical development of children, which for their age, is very important.

## **2. Dental caries — Definition, etiology and epidemiology**

Dental caries is one of the most prevalent diseases in children worldwide. The Center for Disease Control and Prevention reports that dental caries is perhaps the most prevalent infectious diseases in children. Dental caries is five times more common than asthma and seven times more common than hay fever in children (US Department of Health and Human Services 2000).

Tooth decay is localized progressive disease, whose character consists in the destruction of tooth structures mainly under the influence of metabolic products of the oral microflora.

Dental caries is pathological destruction of tooth hard tissue with progressive effluence. Initially it appears in enamel, the dentin is involved after that, and later the pulp and the periodontium, with the possibility of complications that will affect the general health. The consequences of caries may be numerous, ranging from the morphological changes to functional ones, e.g. complete crown destruction (early childhood caries), chewing difficul‐ ties, speech impediments, digestive tract disorders, odentogenic focal points (Raiç 1985, Stosic 1991).

Dental caries usually begins as small, shallow holes; if left untreated, these holes can become larger and deeper and potentially lead to tooth destruction or loss. Complications of dental caries include: pain, dental abscess, difficulties during chewing, tooth damage or loss, tooth sensitivity.

There are numerous definitions on caries, depending on what is taken in consideration: etiology, pathogenesis, clinical features.

Dental caries may be defined as a bacterial disease of the hard tissues of the teeth characterized by demineralization of the inorganic and destruction of the organic substance of tooth (Soames & Southam 1999).

According to Douglas, dental caries is the most common chronic infectious disease of child‐ hood, caused by the interaction of bacteria, mainly *Streptococcus mutans*, and sugary foods on tooth enamel. *S. mutans* breaks down sugars for energy, causing an acidic environment in the mouth and result in demineralization of the enamel of the teeth and dental caries (Douglass et al. 2004).

Since *S. mutans* is transmitted to the child, another definition is based in the transmissibility. Dental caries is defined as a transmissible localized infection caused by a multi-factorial etiology. In order for dental caries to develop, four interrelated factors must occur: the patient (host), substrate (carbohydrates), dental plaque (*S. mutans*), and the time factor.

#### **2.1. Etiology**

Dental caries is a disease that is not caused by one factor. If only one factor would cause this disease, its prevention would have been much easier and more controllable. Many studies like clinical studies, but mostly longitudinal epidemiological studies, show convincing evidence for a multi-factorial nature of this disease. Numerous factors affecting the appearance of caries act team-wise and not separately, make caries pathogenesis very complex but also hinder the possibility to undertake effective preventive measures.

There are several important factors that make up the dental caries etiological circle. Host respectively tooth, dental plaque respectively bacteria, and substrate respectively saliva carbohydrates, all in co-operation with the time factor, are vicious chain of dental caries development.

The hard tooth structure, the enamel, is the forefront part that undergoes the demineralization process, respectively caries. The development of caries in enamel surface as much as it is affected by the internal structure of the hard tissue build of the tooth, equally, perhaps even more it depends on the strength of external factors affect.

Sometimes for various reasons: local, general or even hereditary, tooth structure can be so poorly mineralized, that it would need a very small amount of external factors to cause dental caries.

The general opinion regarding the etiology of dental caries nowadays is that it is a very complex multifactorial disease, presented with high prevalence in all age groups. It has already been established that dental caries is a chronic infectious process with a multifactorial etiology. Dietary factors, oral microorganisms that can produce acids from sugars, and host suscepti‐ bility all need to coexist for caries to develop (Konig & Navia 1995).

functional ones, e.g. complete crown destruction (early childhood caries), chewing difficul‐ ties, speech impediments, digestive tract disorders, odentogenic focal points (Raiç 1985,

Dental caries usually begins as small, shallow holes; if left untreated, these holes can become larger and deeper and potentially lead to tooth destruction or loss. Complications of dental caries include: pain, dental abscess, difficulties during chewing, tooth damage or loss, tooth

There are numerous definitions on caries, depending on what is taken in consideration:

Dental caries may be defined as a bacterial disease of the hard tissues of the teeth characterized by demineralization of the inorganic and destruction of the organic substance of tooth (Soames

According to Douglas, dental caries is the most common chronic infectious disease of child‐ hood, caused by the interaction of bacteria, mainly *Streptococcus mutans*, and sugary foods on tooth enamel. *S. mutans* breaks down sugars for energy, causing an acidic environment in the mouth and result in demineralization of the enamel of the teeth and dental caries (Douglass

Since *S. mutans* is transmitted to the child, another definition is based in the transmissibility. Dental caries is defined as a transmissible localized infection caused by a multi-factorial etiology. In order for dental caries to develop, four interrelated factors must occur: the patient

Dental caries is a disease that is not caused by one factor. If only one factor would cause this disease, its prevention would have been much easier and more controllable. Many studies like clinical studies, but mostly longitudinal epidemiological studies, show convincing evidence for a multi-factorial nature of this disease. Numerous factors affecting the appearance of caries act team-wise and not separately, make caries pathogenesis very complex but also hinder the

There are several important factors that make up the dental caries etiological circle. Host respectively tooth, dental plaque respectively bacteria, and substrate respectively saliva carbohydrates, all in co-operation with the time factor, are vicious chain of dental caries

The hard tooth structure, the enamel, is the forefront part that undergoes the demineralization process, respectively caries. The development of caries in enamel surface as much as it is affected by the internal structure of the hard tissue build of the tooth, equally, perhaps even

Sometimes for various reasons: local, general or even hereditary, tooth structure can be so poorly mineralized, that it would need a very small amount of external factors to cause dental

(host), substrate (carbohydrates), dental plaque (*S. mutans*), and the time factor.

possibility to undertake effective preventive measures.

more it depends on the strength of external factors affect.

Stosic 1991).

sensitivity.

& Southam 1999).

et al. 2004).

**2.1. Etiology**

development.

caries.

etiology, pathogenesis, clinical features.

34 Emerging Trends in Oral Health Sciences and Dentistry

There are some important factors that comprise the etiological circles of the dental caries: host or the tooth, dental or bacterial plaque, substrate – carbohydrates and saliva, and altogether co-react with the time factor. The hard dental structures, initially the enamel, undergo the demineralization process, respectively the caries. The caries development in the enamel surface is equally dependent from the inner hard dental structure and from the intensity of the extrinsic factors' action.

The newest concept in dentistry explains the cause of dental caries as a consequence of disruption of "Caries Balance" (Featherstone 2004). Dr. John Featherstone introduced the concept of the Caries Balance in 2002. The theory of "Caries Balance" defines dental caries as a disease of hard dental tissues, and the destruction of the enamel surface as a result of the disruption of the balance of demineralization and remineralization.

This misbalance may be manifested in the beginning of demineralization or during the process of remineralization. The defect in the enamel surface is a result of the domination of the demineralization process and such process has progressive course directed towards pulpar space. Which process will dominate depends on the proportions of the factors that constitute "Caries Balance", i.e. protective and pathological factors.

The balance disorder will be manifested with early demineralization process or eventually with remineralization process. This concept is that dental caries can be viewed as a balance of healthy or protective factors (factor of remineralization), and disease or pathogenic factors (factor of demineralization). Cavities are caused by an imbalance between risk factors for the disease and protective factors.

Pathological factors (risk factors) are: acid-producing bacteria, frequent eating/drinking of fermentable carbohydrates, sub-normal saliva flow and "function".

Protective factors are: saliva flow and its components; fluoride, calcium, phosphate reminer‐ alization; antibacterials (chlorhexidine, xylitol), etc.

The level of risk for dental caries depends on the domination of the certain group of factors that participate in the "Caries Balance". If there is domination of the pathological factors, the risk for dental caries will be higher and the treatment needs will require larger restorative interventions, as well as other consequences. If there is a domination of protective factors, then the invasive restorative dentistry will have fewer burdens, and concentrate in minimal restorations of superficial caries. Biological factors tend to be similar within all cultures and populations, although habit/environmental factors tend to be influenced specifically by the culture in place.

#### **2.2. The prevalence of dental caries**

It has already been mentioned that dental caries is the mostly spread disease in the world. Dental caries is a disease that affects all age groups, most commonly children.

Epidemiological data derived from the Oral Health Promotion Group of Kosovo showed a high prevalence of caries among children in Kosovo (89.2% among preschool children and 94.4% among school children). The mean dmft/DMFT index was 5.6 for preschool children and 4.9 for all school children (Begzati et al. 2011).

The results from the same previous study show that dental health of these children in Kosovo is worse than that of children in other European countries. Specifically, the mean dmft of fiveyear-olds at preschools in Kosovo (8.1) was found to be higher than the same value of preschool children in USA (1.7) and in many other European countries (1991-1995), including Ireland (0.9), Spain (1.0), Denmark (1.3), Norway (1.4), Finland (1.4), Netherlands (1.7), United Kingdom (2.0), France (2.5), and Germany (2.5). Our results are only comparable to the rates in Belarus (7.4), Sarajevo, Bosnia (7.53) (ages 5-7) and Albania (8.5), (Marthaler 1996, Kobaslia 2000). The low treatment rate of children in Kosovo (<2%) indicates a high treatment need. Also, the mean DMFT (5.8) of school children in Kosovo (age 12) was higher in comparison with school children (age 12) of the following developed countries: Netherlands (1.1), Finland (1.2), Denmark (1.3), USA (1.4), United Kingdom (1.4), Sweden (1.5), Norway (2.1), Ireland (2.1), Germany (2.6) and Croatia (2.6) (16). The mean DMFT of Kosovo's children (age 12) was similar to the mean values in Latvia (7.7), Poland (5.1) and a group of 12- to 14-year-olds in Sarajevo, Bosnia (7.18), (Marthaler 1996, Kobaslia 2000).

## **3. Early Childhood Caries (ECC)-definition**

ECC is an acute, rapidly developing dental disease occurring initially in the cervical third of the maxillary incisors, destroying the crown completely. Early onset and rampant clinical progression makes ECC a serious public health problem. Due to varying clinical, etiological,

localization, and course features, this pathology is found under different names such as labial caries (LC), caries of incisors, nursing bottle mouth, rampant caries (RC), nursing bottle caries (NBC), nursing caries, baby bottle tooth decay (BBTD), early childhood caries (ECC), rampant early childhood dental decay, and severe early childhood caries (SECC) (James 1957, Goose 1967, Fass 1962, Winter et al.1966, Derkson & Ponti 1982, Ripa 1988, Arkin 1986, Bruered et al. 1989, Kaste & Gift 1995, Tinanoff et al. 1998, Horowitz 1998, Drury et al. 1999).

According to Davis, the definition of this pathology has always been complex and "difficult to be described, but when it is seen, you know what it's about" (Davis 1998).

In 1862, an American physician, Abraham Jacobi (Jacobi 1862) was the first to describe the clinical appearance of early childhood caries, which he observed in one of his own patients. Whereas, in 1932 Beltrami described this form of caries, as "Les dentes noires des tout petits" (black teeth in small children), (Beltrami 1952). Author Fass, created the term *nursing bottle mouth* (Fass 1962).

The literature contains a variety of other terms used to describe early childhood caries and its diagnostic criteria. Most of them relate to the use of a feeding bottle or prolonged breastfeeding (feeding bottle tooth decay, feeding bottle syndrome, nursing caries, nursing bottle mouth, and so on). The authors wish to highlight the danger of excessive drinking from a baby bottle, if it contains sweetened liquids, or prolonged on-demand breastfeeding (Schroth et al. 2007).

To inform the scientific community with internationally comparable data on the incidence of early childhood caries, delegates to a conference at the Centers for Disease Control and Prevention, invented the term *early childhood caries* in order to better the multi-factorial pathogenesis of the disease" (Kaste & Gift 1995).

Unfortunately, this term was seen to have its limitations. Three years later, a further conference on early childhood caries, organized by the National Health Institute (USA), added two further definitions/descriptions, which were *rampant infant caries* and *early childhood dental decay* (RIE, CDD), (Quartey & Williamson 1998). These differences in definition were due above all to diversity in diagnostic criteria.

#### **3.1. Clinical diagnostic criteria of Early Childhood Caries (ECC)**

**2.2. The prevalence of dental caries**

36 Emerging Trends in Oral Health Sciences and Dentistry

4.9 for all school children (Begzati et al. 2011).

Sarajevo, Bosnia (7.18), (Marthaler 1996, Kobaslia 2000).

**3. Early Childhood Caries (ECC)-definition**

*mouth* (Fass 1962).

It has already been mentioned that dental caries is the mostly spread disease in the world.

Epidemiological data derived from the Oral Health Promotion Group of Kosovo showed a high prevalence of caries among children in Kosovo (89.2% among preschool children and 94.4% among school children). The mean dmft/DMFT index was 5.6 for preschool children and

The results from the same previous study show that dental health of these children in Kosovo is worse than that of children in other European countries. Specifically, the mean dmft of fiveyear-olds at preschools in Kosovo (8.1) was found to be higher than the same value of preschool children in USA (1.7) and in many other European countries (1991-1995), including Ireland (0.9), Spain (1.0), Denmark (1.3), Norway (1.4), Finland (1.4), Netherlands (1.7), United Kingdom (2.0), France (2.5), and Germany (2.5). Our results are only comparable to the rates in Belarus (7.4), Sarajevo, Bosnia (7.53) (ages 5-7) and Albania (8.5), (Marthaler 1996, Kobaslia 2000). The low treatment rate of children in Kosovo (<2%) indicates a high treatment need. Also, the mean DMFT (5.8) of school children in Kosovo (age 12) was higher in comparison with school children (age 12) of the following developed countries: Netherlands (1.1), Finland (1.2), Denmark (1.3), USA (1.4), United Kingdom (1.4), Sweden (1.5), Norway (2.1), Ireland (2.1), Germany (2.6) and Croatia (2.6) (16). The mean DMFT of Kosovo's children (age 12) was similar to the mean values in Latvia (7.7), Poland (5.1) and a group of 12- to 14-year-olds in

ECC is an acute, rapidly developing dental disease occurring initially in the cervical third of the maxillary incisors, destroying the crown completely. Early onset and rampant clinical progression makes ECC a serious public health problem. Due to varying clinical, etiological, localization, and course features, this pathology is found under different names such as labial caries (LC), caries of incisors, nursing bottle mouth, rampant caries (RC), nursing bottle caries (NBC), nursing caries, baby bottle tooth decay (BBTD), early childhood caries (ECC), rampant early childhood dental decay, and severe early childhood caries (SECC) (James 1957, Goose 1967, Fass 1962, Winter et al.1966, Derkson & Ponti 1982, Ripa 1988, Arkin 1986, Bruered et al.

According to Davis, the definition of this pathology has always been complex and "difficult

In 1862, an American physician, Abraham Jacobi (Jacobi 1862) was the first to describe the clinical appearance of early childhood caries, which he observed in one of his own patients. Whereas, in 1932 Beltrami described this form of caries, as "Les dentes noires des tout petits" (black teeth in small children), (Beltrami 1952). Author Fass, created the term *nursing bottle*

1989, Kaste & Gift 1995, Tinanoff et al. 1998, Horowitz 1998, Drury et al. 1999).

to be described, but when it is seen, you know what it's about" (Davis 1998).

Dental caries is a disease that affects all age groups, most commonly children.

Due to the early appearance, typical localization, rapid destruction of the hard tissue of tooth, early childhood caries is a specific form of primary tooth decay. Childhood caries appears in caries resistant regions, such as: labial surfaces of the upper incisors, in the upper and lower molars, more rarely in the upper canine, and even less or not at all in the lower canine and incisors. In addition, during bottle-feeding with sugar-containing drinks, the upper incisors bathe in these sugar-containing drinks but the saliva from minor salivary glands in the area of these teeth has only limited remineralising properties, whereas the lower incisors remain largely protected by the tongue during bottle-feeding.

Different authors propose different criteria to define or describe the early childhood caries. Author Amidi, studying the publications about ECC, has concluded that: in 27 publications, the criteria for defining ECC was the presence of labial surface caries in at least one frontal maxillary tooth, in 23 studies at least two frontal maxillary teeth while in 9 studies three frontal maxillary teeth (Soames & Southam 1999).

Below are some criteria's for defining early childhood caries from various researchers cited by authors Amid & Woosung 1999:


In the literature we still can find some criteria's, for example:


Author Wynne 1999, classifies early childhood caries into three types:

Type I (moderately easy) - usually involves two upper central incisors.

Type II (moderate, severe) - includes incisors, first molar, canine, and does not include the lower incisors.

Type III (widespread, severe) - including the mandibular incisors.

#### **3.2. ECC — Prevalence**

Prevalence of ECC is different and it largely depends on the criteria set by the researcher and the place where the examination takes place. There are differences between the data for urban or rural places, rich or poor places, "flourished" or "non-flourished" places. Furthermore, the prevalence of ECC varies in different countries, which may depend on the diagnostic criteria. While in some developed countries having advanced programs for oral health protection, the prevalence of ECC is around 5% (Derkson & Ponti 1982, Ripa 1988, Kaste et al. 1996, Davenport 1990, Hinds & Gregory 1995). In some countries of Southeastern Europe (neighboring countries of Kosovo) this prevalence reaches 20% (Bosnia) and 14% (Macedonia) (Huseinbegović 2001, Apostolova et al. 2003). Much higher ECC prevalence has been reported for such places as Quchan, Iran (59%) (Mazhari et al. 2007) and Alaska (66.8%) (Kelly & Bruerd 1987). At American Indian children the preva‐ lence is 41.8% (Kelly & Bruerd 1987). Similarly, in North American populations, the prevalence at high-risk children ranges from 11% to 72% (Berkowitz 2003).

Data from relevant literature show different prevalence in different countries, cited by various authors (Berkowitz et al. 1993, McDonald 2000, Wendet 1995, Begzati et al. 2011, Barbakov et al. 1985, Harris & Garsia 1999, Huseinbegović 2001, Holt et al. 1996, Kaste 1991, Pettit et al. 2001, Bruered et al.1989, Reisine 1998, Wyne 1999, Apostolova 2003).

#### **3.3. Etiology**

Dental caries is an infectious and transmissible disease. Therefore, early childhood caries is an extremely aggressive form of the disease.

It was suggested that from the biological determinants, the three key causal factors for dental caries were: microorganisms, substrate, and host (Keyes 1962).

However, in the etiology of early childhood caries very special role given to dental plaque, respectively cariogenic bacteria. Of the great interest in the cariogenesis process are only two


**•** one or more frontal maxillary teeth that has evidence that the child was fed with a bottle

**•** at least one carious maxillary incisor with the involvement of labial and proximal surface

Type II (moderate, severe) - includes incisors, first molar, canine, and does not include the

Prevalence of ECC is different and it largely depends on the criteria set by the researcher and the place where the examination takes place. There are differences between the data for urban or rural places, rich or poor places, "flourished" or "non-flourished" places. Furthermore, the prevalence of ECC varies in different countries, which may depend on the diagnostic criteria. While in some developed countries having advanced programs for oral health protection, the prevalence of ECC is around 5% (Derkson & Ponti 1982, Ripa 1988, Kaste et al. 1996, Davenport 1990, Hinds & Gregory 1995). In some countries of Southeastern Europe (neighboring countries of Kosovo) this prevalence reaches 20% (Bosnia) and 14% (Macedonia) (Huseinbegović 2001, Apostolova et al. 2003). Much higher ECC prevalence has been reported for such places as Quchan, Iran (59%) (Mazhari et al. 2007) and Alaska (66.8%) (Kelly & Bruerd 1987). At American Indian children the preva‐ lence is 41.8% (Kelly & Bruerd 1987). Similarly, in North American populations, the

Data from relevant literature show different prevalence in different countries, cited by various authors (Berkowitz et al. 1993, McDonald 2000, Wendet 1995, Begzati et al. 2011, Barbakov et al. 1985, Harris & Garsia 1999, Huseinbegović 2001, Holt et al. 1996, Kaste 1991, Pettit et al.

Dental caries is an infectious and transmissible disease. Therefore, early childhood caries is an

It was suggested that from the biological determinants, the three key causal factors for dental

However, in the etiology of early childhood caries very special role given to dental plaque, respectively cariogenic bacteria. Of the great interest in the cariogenesis process are only two

**•** maxillar incisors and the mesial surface of canine (O'Sallivan 1993);

**•** one or more maxillary incisor with cervical crown caries (Lopez 1998).

Author Wynne 1999, classifies early childhood caries into three types: Type I (moderately easy) - usually involves two upper central incisors.

Type III (widespread, severe) - including the mandibular incisors.

prevalence at high-risk children ranges from 11% to 72% (Berkowitz 2003).

2001, Bruered et al.1989, Reisine 1998, Wyne 1999, Apostolova 2003).

caries were: microorganisms, substrate, and host (Keyes 1962).

or only proximale surface (Kaste et al. 1996);

38 Emerging Trends in Oral Health Sciences and Dentistry

(Al-Dashti 1995);

lower incisors.

**3.3. Etiology**

extremely aggressive form of the disease.

**3.2. ECC — Prevalence**

bacterial genera: mutant streptococci and lactobacills (Norman & Franklin 1999). A very important role is attributed to the bacterium Streptococcus mutans-called "the window of infection" (Caufield et al. 1993), in that it is responsible for the primary oral infection in the first phase of ECC (Berkowitz 1980; Berkowitz et al. 1996).

The most important requirement is an early infection, usually with the mother's cariogenic bacteria, for example, between the age of 19-31 months. However, earlier and later infection is a possibility (Caufield et al. 1993, Wan 2001).

After transmission of cariogenic bacteria and a frequent supply of substrate (sucrose) to the plaque, usually given as a sugary drink (juices and so on from a feeding bottle) or in older children, in snacks in the form of solid-cariogenic foods such as sweets, chocolates, cakes, biscuits, the development of early childhood caries occurs. If this loading of the plaque with sugars occurs at bedtime (night) and there is no tooth brushing, caries can progress rapidly.

In addition to the other severe types of early childhood caries, feeding on demand with cariogenic food and liquids is regarded as a co-factor for early childhood caries (Wendt & Birkhed 1995). As mentioned earlier, many social and behavioral determinants are risk factors for early childhood caries.

Favoring risk factors are as follows: low socio-economic status, low educational attainment in parents, chronic non-communicable diseases, inadequate health literacy, are all risk factors for a early childhood caries. Social and behavioral factors have been described in association with early childhood caries in numerous publications (FDI 1988, Horowitz 1998, Reisine & Douglass 1998, Seow 1998).

#### *3.3.1. Cariogenic bacteria*

In one of our studies conducted in the clinic of Paediatric Dentistry, it was found that S.mutans had a crucial role in ECC. The prevalence of S.mutans at our children was around 90% (Begzati et al. 2014). These facultative anaerobes are commonly found in the human oral cavity, and are a major contributor of tooth decay. The result of decay can greatly affect the overall health of the individual (Whiley & Beighton 2013).

The mutans streptococci and some Lactobacillus species are the two groups of infectious agents most strongly associated with dental caries. Earlier clinical studies reported that MS could not be detected in the mouths of normal predentate infants (Berkowitz et al. 1975, Berkowitz et al. 1980, Stiles et al. 1976, Catalanotto et al. 1975, Caufield et al. 1993, Karn et al 1998).

More recent clinical investigations have demonstrated that MS can colonize in the mouths of predentate infants (Tanner et al. 2002; Wan et al. 2001).

According to Berkowitz transmission of S.mutans happens in two ways: vertical and horizon‐ tal transmission. Vertical transmission is the transmission of microbes from caregiver to child. The major reservoir from which infants acquire S.mutans is their mothers. A study conducted by Berkowitz and co-authors reported that, when mothers harbored greater than 105 colony forming units (cfu) of MS per mL of saliva, the frequency of infant infection was 58%. When mothers harbored 103 cfu of MS per mL of saliva or more, however, the frequency of infant infection was 9 times less (6%) (Berkowitz et al 1981). These data clearly demonstrate that mothers with dense salivary reservoirs of MS are at high risk for infecting their infants early in life.

Vertical transmission is not the only vector by which MS are perpetuated in human populations.

Horizontal transmission also occurs. Horizontal transmission is the transmission of microbes between members of a group (eg, family members of a similar age or students in a classroom). Based on appearance, ways of transmission and prevention, Berkowitz concludes that: primary oral infection by mutans streptococci (MS) may occur in predentate infants. Infants may acquire MS via vertical and horizontal transmission. Improvements in the prevention of dental caries may likely be realized through intervention strategies that focus on the natural history of this infectious disease.

#### **Streptococcus mutans (SM)**

In addition to the other severe types of early childhood caries, feeding on demand with cariogenic food and liquids is regarded as a co-factor for early childhood caries (Wendt & Birkhed 1995). As mentioned earlier, many social and behavioral determinants are risk factors

Favoring risk factors are as follows: low socio-economic status, low educational attainment in parents, chronic non-communicable diseases, inadequate health literacy, are all risk factors for a early childhood caries. Social and behavioral factors have been described in association with early childhood caries in numerous publications (FDI 1988, Horowitz 1998, Reisine & Douglass

In one of our studies conducted in the clinic of Paediatric Dentistry, it was found that S.mutans had a crucial role in ECC. The prevalence of S.mutans at our children was around 90% (Begzati et al. 2014). These facultative anaerobes are commonly found in the human oral cavity, and are a major contributor of tooth decay. The result of decay can greatly affect the overall health

The mutans streptococci and some Lactobacillus species are the two groups of infectious agents most strongly associated with dental caries. Earlier clinical studies reported that MS could not be detected in the mouths of normal predentate infants (Berkowitz et al. 1975, Berkowitz et al.

More recent clinical investigations have demonstrated that MS can colonize in the mouths of

According to Berkowitz transmission of S.mutans happens in two ways: vertical and horizon‐ tal transmission. Vertical transmission is the transmission of microbes from caregiver to child. The major reservoir from which infants acquire S.mutans is their mothers. A study conducted by Berkowitz and co-authors reported that, when mothers harbored greater than 105 colony forming units (cfu) of MS per mL of saliva, the frequency of infant infection was 58%. When

infection was 9 times less (6%) (Berkowitz et al 1981). These data clearly demonstrate that mothers with dense salivary reservoirs of MS are at high risk for infecting their infants early

Vertical transmission is not the only vector by which MS are perpetuated in human

Horizontal transmission also occurs. Horizontal transmission is the transmission of microbes between members of a group (eg, family members of a similar age or students in a classroom). Based on appearance, ways of transmission and prevention, Berkowitz concludes that: primary oral infection by mutans streptococci (MS) may occur in predentate infants. Infants may acquire MS via vertical and horizontal transmission. Improvements in the prevention of dental caries may likely be realized through intervention strategies that focus on the natural

cfu of MS per mL of saliva or more, however, the frequency of infant

1980, Stiles et al. 1976, Catalanotto et al. 1975, Caufield et al. 1993, Karn et al 1998).

for early childhood caries.

40 Emerging Trends in Oral Health Sciences and Dentistry

1998, Seow 1998).

*3.3.1. Cariogenic bacteria*

mothers harbored 103

history of this infectious disease.

in life.

populations.

of the individual (Whiley & Beighton 2013).

predentate infants (Tanner et al. 2002; Wan et al. 2001).

*Streptococcus mutans* are gram-positive cocci shaped bacteria. SM is isolated from all tissues of the oral cavity and constitutes the largest number of inhabitants of the oral microflora. This bacteria belongs to the Viridans group of streptococci (Galdvin 2004). Traditionally oral streptococci are differentiated on the basis of simple biochemical and physiological tests. Many recent studies comparing homologous DNA, gave description of the whole protein content and detection of glicosidasis activity clarifying the relationship between many species.

Mutant streptococci represent a group of bacterial species that had previously been classified as serotypes of the same species. These bacteria are characterized by their ability to ferment manitol and sorbitol, producing extracellular glicanes from sucrose with cariogenic activity in animal models. Important for the human population are two species: S. mutans and S. sobrinus. Streptococcus mutans has got this name in 1924 when Clarke in England isolated the micro‐ organisms from human carious lesions. He noted that they are more oval shaped, not round and assumed that they are mutants of streptococcus.

Mutant streptococci, are now considered as the main pathogenic species involved in the caries process. It is noted that if they are seeded in the mouth of animals, including rats, rodents and monkeys, are able to cause caries. Some detailed studies have shown a correlation between the presence of S.mutans and caries. These findings are repeated in longitudinal studies of microbiology and caries incidence. Mutant streptococci are usually found in relatively large numbers in plaque formed immediately after the development of lesions at the superficial soft surfaces. During a longitudinal study samples are taken periodically for analysis of separate parts for S.mutans and teeth were examined simultaneously. Teeth destined to become decayed, showed a significant increase of the ratio of S.mutans 6 to 24 months before the eventual diagnosis of caries. In similar conditions SM isolated from dental plaque terrains on stained white lesions are characterized by a ratio greater than plaque by SM while probing enamel grounds. The increased number of SM in saliva has also gone hand in hand with the development of lesions in smooth surface. In another study of saliva analysis of 200 children showed that 93 percent of them were positive for caries evident S. mutant, while uninfected children were almost always unaffected by decay (Russell 2003).

S. mutans position as the primary agent of caries formation in favor of their certain physio‐ logical characteristics. These features include the ability to adhere in tooth surface, producing insoluble polysaccharides from sucrose, rapidly producing lactic acid substrates by a number of sugars, acid tolerance and formation of intracellular stores of polysaccharides. These features help cariogenic SM survival in an environment not suitable in terms of so-called "feast or famine" cycles or due to the low concentration of substrate (i.e between meals) or excess substrate concentrations (e.g during consumption of food rich in sugar). As a general rule, cariogenic bacteria metabolize sugars to produce energy they need for growth and multipli‐ cation. The products of this metabolism are acids, which are derived from bacteria in plaque fluid. Damage caused by S.mutans is mainly due to lactic acid, although other acids such as butyric and propionic was found within the plaque. Generally, S.mutans is the most common streptococcal mutant infectious agent in humans and strong evidences are presented as the most virulent cause of odontogenic infections. Another mutans bacteria from the group of socalled S.sobrinus, differs from S.mutans because they require sucrose for adherence and growth in the dental plaque.

Correlation between caries and S. mutans, based on the data described in the literature and based on experimental models that are performed, and based on certain conclusions (Russell 2003):


#### **S.mutans, sugar and caries**

Taking large amounts of sugar combined with low values of pH frequently leads to an increased number of S. mutans.These bacteria are characterized by these features:


#### **S. mutans sugar transportation**

S. mutans is equipped with a conveyor system more efficient to carry sugars within their cells. During the metabolic process in the cell, they produce different substances, which contribute sufficiently to their pathogenicity. When it received the greatest amount of sugars S. mutans produce mainly Lactic Acid (Hamada and Slade, 1980). Streptococcus mutans produces extracellular and intracellular polysaccharides. Extracellular polysaccharides are also pro‐ duced during the enzymatic reactions. Their sticky properties are favorable for bacterial adherence capabilities on the surface of the teeth, helping their placement on smooth surfaces (Koga 1986, Loesch 1986).

Polysaccharides also help connectivity and multiplication of dental plaque. Moreover, their insolubility prevents natural protective effect of saliva. Polysaccharides ensure the survival of intracellular bacteria in nutritionally poor intervals, and are used by bacteria to produce acids (Hamada and Slade 1980).

#### **S. mutans, tolerance to acidic environment**

called S.sobrinus, differs from S.mutans because they require sucrose for adherence and

Correlation between caries and S. mutans, based on the data described in the literature and based on experimental models that are performed, and based on certain conclusions (Russell

**•** Animal experiments: S. mutans causes caries among gnatobiotik animals in the presence of

**•** Virulence: S. mutans has properties that contribute to caries development. These properties are acidogenety, uric acid production, extarcelular production of glicanes and intracellular

**•** Cross-sectional studies in humans: an increase in the number of S. mutans found in the initial

**•** Longitudinal studies in humans: a large number of S. mutans in a number of tooth decays

Taking large amounts of sugar combined with low values of pH frequently leads to an

S. mutans is equipped with a conveyor system more efficient to carry sugars within their cells. During the metabolic process in the cell, they produce different substances, which contribute sufficiently to their pathogenicity. When it received the greatest amount of sugars S. mutans produce mainly Lactic Acid (Hamada and Slade, 1980). Streptococcus mutans produces extracellular and intracellular polysaccharides. Extracellular polysaccharides are also pro‐ duced during the enzymatic reactions. Their sticky properties are favorable for bacterial adherence capabilities on the surface of the teeth, helping their placement on smooth surfaces

Polysaccharides also help connectivity and multiplication of dental plaque. Moreover, their insolubility prevents natural protective effect of saliva. Polysaccharides ensure the survival of intracellular bacteria in nutritionally poor intervals, and are used by bacteria to produce acids

**•** Streptococci other "non mutans" with similar properties can also be cariogenic.

increased number of S. mutans.These bacteria are characterized by these features:

growth in the dental plaque.

42 Emerging Trends in Oral Health Sciences and Dentistry

storage of polysaccharides;

correlates with subsequent caries;

**•** Capacity to adhere to tooth structure

**•** Production of lactic acid from sugars

**•** Tolerance in acidic environment

**S. mutans sugar transportation**

(Koga 1986, Loesch 1986).

(Hamada and Slade 1980).

**•** Production of intra and extracellular polysaccharide

**•** Sugar Transportation system

carious lesions;

**S.mutans, sugar and caries**

2003):

sugar;

Bacteria multiply under certain environmental conditions and they have obvious advantages compared with other micro-organisms. Diet and lack of suppressive factors determine the composition of the oral flora.

The decrease in pH prevents many bacteria from growth, while streptococci are multiplying in this particular environment (Harper & Loesch 1984). Changes in bacterial flora are in favor of bacteria which can survive in acidic conditions on account of acid no-tolerant microorgan‐ isms and acidic production. Pathogenic micro-organisms produce acid, the pH of which is lower enough than the value below which the tooth enamel begins to melt. S. mutans is recognized as the initiator of caries. They affect the initiation of the process leading to loss of minerals, and this facilitates the bacteria to penetrate the tooth structure (Burne 1998).

#### *3.3.2. Substrate (Carbohydrates)*

The human body uses glucose as substrate food, while other carbohydrates under the action of relevant enzymes converted into glucose. Cariotic action of sugars depends on their fermenting potential, respectively as far as the highest level of acids produced by the their fermentation. It was found that carbohydrates are the major class fermentabile affecting ecological changes in the mouth. While carbohydrates are transformed into acids, sucrose under the action of bacterial enzymes (glykosiltransferasa-GTF, and fruktosyltransferasa-FTF) turns into two classes polymers (glukan and fruktan).

Glukan plays the role of infectious matter to the surface of the tooth, not dissolved in water. This attribute enables attachment of dental plaque and S.mutans for tooth surface. Levan under the influence of enzymes derived from S. mutans fermented in the acidic product (Pincaham 1994).

Dairy products (milk, cheese) has an influence in the ecology of the area of the mouth. Dairy products can protect teeth from decay. This can happen as a result of buffer capacity of milk proteins or because of decarboxylation of amino acids after proteolysis some bacteria can metabolise kazein. Milk protein (casein) and its derivatives can be absorbed on the surface of the tooth, modify the structure of pelicula which make it unsuitable for adhesion of S. mutans, but also enable establishing of calcium phosphate and initiate the process of remineralisation.

Some sugar substitutes that do not turn into acid, as xilitoli for example you add sweets, have a role in inhibiting the development of S. Mutans (Pincaham 1994, Marsh 2000).

#### **Correlation between SM and consumption of sugars**

Studies on the correlation between presence of SM in saliva and sweet diet is not entirely clear, even data from the literature are sometimes contradictory. While some studies such as those of Polish authors has shown that children with a SM presence is 94% while 56% LB and daily frequency of sweets consumption exceeds 5 times a day (Wierzbicka, 1987). But, so it does not happen with children in Mozambique where annual consumption of sugar for school children is very low (11 kg), while the presence of SM is 98%, 40% of their high value. Sudan is also similar in that although annual consumption is about 18 kg, SM was identified in 90%, moderate values and higher than 50% (Carlsson 1989).

## **4. Study report**

In our previous study (Begzati et al. 2010), the prevalence of ECC and various caries risk factors such as quantity of cariogenic S mutans colonies, was evaluated.

#### *Methods*

In the study there were included 1,008 children of both sexes, from 1 to 6 years of age, from 9 kindergartens of Prishtina, capital city of Kosovo. The sample was random, representing 80% of all kindergarten children. The sample size was calculated with a confidence level of 95% and a confidence interval of 2.

#### *Bacterial sampling — Determination of S.mutans*

In our study the presence of S mutans was determined using the CRT bacteria test (Ivoclar Vivadent, Liechtenstein) on the saliva previously stimulated by chewing paraffin. Bacterial counts were recorded as colony-forming units per milliliter (CFU/mL) of saliva. The number of bacterial colonies was graded as follows: Class 0 and Class 1 (CFU < 105/mL saliva), and Class 2 and Class 3 (CFU ≥ 105/mL saliva), according to the manufacturers' scoring-card (Ivoclar-Vivadent, Lichtenstein). In younger subjects, with less saliva collected, the modified spatula method was used.

#### *Dental examination and diagnostic criteria*

The children were examined in well-lit premises, using a flashlight as the light source, and a dental mirror and dental probe. Diagnostic criteria were calibrated (Hunt 1986), with interexaminer reliability resulting in kappa = 0.91, based on the examination of 35 children of different ages. Dental caries was scored as the number of decayed, missing, or filled primary teeth (dmft).

ECC was defined as "initial occurrence of caries in cervical region of at least two maxillary incisors." Using a careful lift-the-lip examination, the presence or absence of ECC was recorded depending on the presence of "noncavity caries/white spot lesions" or "cavity caries."

In order to study the clinical and etiological aspects of ECC, a sub-sample of children with ECC was included for further analysis. The latter part of the examination, which included the clinical study of ECC development (according to ECC stages), determination of bacterial colony sampling, oral hygiene index (OHI), and filling out of the questionnaire, was conducted in the Pediatric Dentistry Clinic of the School of Dentistry.Children with ECC were examined using the light of the dental unit, with dental mirror and probe.

#### *Clinical course of ECC*

In order to explain the clinical course of ECC, we propose the following stages in the occurrence and progression of carious lesions in ECC: ECCi (initial stage), ECCc (circular stage), ECCd (destructive stage) and ECCr (*radix relicta* stage).

Early Childhood Caries (ECC) — Etiology, Clinical Consequences and Prevention http://dx.doi.org/10.5772/59416 45

**Figure 1.** ECCi (initial stage)—white spot lesion or initial defect in enamel of cervix.

**4. Study report**

44 Emerging Trends in Oral Health Sciences and Dentistry

and a confidence interval of 2.

spatula method was used.

teeth (dmft).

*Clinical course of ECC*

*Dental examination and diagnostic criteria*

*Bacterial sampling — Determination of S.mutans*

*Methods*

In our previous study (Begzati et al. 2010), the prevalence of ECC and various caries risk factors

In the study there were included 1,008 children of both sexes, from 1 to 6 years of age, from 9 kindergartens of Prishtina, capital city of Kosovo. The sample was random, representing 80% of all kindergarten children. The sample size was calculated with a confidence level of 95%

In our study the presence of S mutans was determined using the CRT bacteria test (Ivoclar Vivadent, Liechtenstein) on the saliva previously stimulated by chewing paraffin. Bacterial counts were recorded as colony-forming units per milliliter (CFU/mL) of saliva. The number of bacterial colonies was graded as follows: Class 0 and Class 1 (CFU < 105/mL saliva), and Class 2 and Class 3 (CFU ≥ 105/mL saliva), according to the manufacturers' scoring-card (Ivoclar-Vivadent, Lichtenstein). In younger subjects, with less saliva collected, the modified

The children were examined in well-lit premises, using a flashlight as the light source, and a dental mirror and dental probe. Diagnostic criteria were calibrated (Hunt 1986), with interexaminer reliability resulting in kappa = 0.91, based on the examination of 35 children of different ages. Dental caries was scored as the number of decayed, missing, or filled primary

ECC was defined as "initial occurrence of caries in cervical region of at least two maxillary incisors." Using a careful lift-the-lip examination, the presence or absence of ECC was recorded depending on the presence of "noncavity caries/white spot lesions" or "cavity caries."

In order to study the clinical and etiological aspects of ECC, a sub-sample of children with ECC was included for further analysis. The latter part of the examination, which included the clinical study of ECC development (according to ECC stages), determination of bacterial colony sampling, oral hygiene index (OHI), and filling out of the questionnaire, was conducted in the Pediatric Dentistry Clinic of the School of Dentistry.Children with ECC were examined

In order to explain the clinical course of ECC, we propose the following stages in the occurrence and progression of carious lesions in ECC: ECCi (initial stage), ECCc (circular stage), ECCd

using the light of the dental unit, with dental mirror and probe.

(destructive stage) and ECCr (*radix relicta* stage).

such as quantity of cariogenic S mutans colonies, was evaluated.

**Figure 2.** ECCc (circular stage)—lesion in the dentin and circular distribution of this lesion proximally.

**Figure 3.** ECCd (destructive stage)—destruction of more than half the crown without affecting the incisal edge.

**Figure 4.** ECCr (*radix relicta* stage)—total destruction of the crown.

#### *Results of study*

From the total 1,008 examined children aged 1-6 years, the caries prevalence expressed in terms of the caries index per person, or dmft > 0, was 86.31%, with a mean dmft of 5.8. The prevalence of ECC was 17.36%, or 175 out of 1,008 examined children (Figure 1). The sub-sample of children with diagnosed ECC consisted of 150 children out of 175 invited for further analysis. Twentyfive children of this group from different kindergartens didn't show up in the Depart‐ ment. The mean age of children with ECC was 3.8 ± 1.2 years. The mean dmft in children with ECC was 11 ± 3.6. There was no statistical difference of ECC prevalence between genders (t test = 1.81, P = 0.07).

As expected, the lowest mean dmft score was found at age 2 (6.47 ± 2.13), with an age-related increase in dmft of 12.8 at age 6 (Table 1). In comparing the mean dmft in ECC children with respect to age, there was a significant statistical difference between age 2 and ages 4, 5, and 6. (One-Way ANOVA test F = 16, P < 0.001).

#### *ECC stages*

The ECC stages were not equally distributed. The most common stage present was that of radix relicta (41.7%), while the stage appearing least frequently was the initial stage (15.4%), or 27 out of 150 children with ECC.

There was a significant difference between the stages of ECC (c2 = 211.1, P < 0.0001). Twentyfive of the 27 children with ECC in the initial stage were reexamined 1 year after the baseline examination (2 children did not appear for reexamination dueto address change). The 1-year reexamination showed that the initial stage had advanced to the circular stage in 28% of cases, destructive stage in 20%, radix relicta stage in 36%, and having been extracted due to ECC in 16% of cases (Table 2). Mean age of subjects with initial stage of ECC was 2 ± 0.7. Mean dmft on reexamination showed an increase from 5.1 to 8.8 (P < 0.001).

### **4.1. Clinical specificities and progress**

Even before the child is 2 years, in the gingival third of the labial surface of the upper front teeth, as a result of the enamel decalcification process a chalk colored stain ("white spot lesions") appears, which expands in the enamel of the cervical region of the tooth and for a short time it covers the entire tooth, destroying the whole hard tooth tissue. During this process, initially the enamel on the incisal region of the frontal tooth is resistant, especially canine, that shows that those parts of tooth enamel which are mineralized before birth, are more resistant to caries than the parts that are mineralized after birth (Thomas et al. 1999).

In the initial stage(Fig.1) there is a small loss of minerals from the hydroxylapatite crystals of enamel. As a result of tooth's hard tissue demineralization micropores start forming, which refract the light, and as a result it comes to the formation of so-called *white spots lesions*. Such spots are localized where the concentration of dental plaque is higher. If the destruction continues as a result of the demineralization effect of acids on enamel and apatite removal, the cavity starts to form. (Reisine & Douglass 1998).

This quick progress, helps the caries to quickly affect even the dentin layer, so for a short time the entire tooth crown is destroyed and all that remain are the roots (radix relicta)(Fig.4). Often it happens in 3 year old children, in the upper frontal region, where they have only roots remaining that resemble stumps.

Iritative formation of dentin, which makes the carious lesion get a brown color is a result of permanent irritation in the revealed dentin, while sclerotic tissue can make a full obliteration of tooth canal. The formation of iritative – sclerotic dentin can have an effect in this disease without symptoms, but with difficulties in feeding, speech and aesthetics. Also as a result of reflexive reaction (gums, tongue, lips injury etc.), a number of general symptoms is provoked such as digestive disorders, raised body temperature, increased saliva production, etc. The dental pain starts when the tooth pulp is revealed, in gangrenous teeth or when the infectious pathological process appears in periodoncium.

#### **4.2. Complications and consequences**

**Figure 4.** ECCr (*radix relicta* stage)—total destruction of the crown.

46 Emerging Trends in Oral Health Sciences and Dentistry

From the total 1,008 examined children aged 1-6 years, the caries prevalence expressed in terms of the caries index per person, or dmft > 0, was 86.31%, with a mean dmft of 5.8. The prevalence of ECC was 17.36%, or 175 out of 1,008 examined children (Figure 1). The sub-sample of children with diagnosed ECC consisted of 150 children out of 175 invited for further analysis. Twentyfive children of this group from different kindergartens didn't show up in the Depart‐ ment. The mean age of children with ECC was 3.8 ± 1.2 years. The mean dmft in children with ECC was 11 ± 3.6. There was no statistical difference of ECC prevalence between genders (t

As expected, the lowest mean dmft score was found at age 2 (6.47 ± 2.13), with an age-related increase in dmft of 12.8 at age 6 (Table 1). In comparing the mean dmft in ECC children with respect to age, there was a significant statistical difference between age 2 and ages 4, 5, and 6.

The ECC stages were not equally distributed. The most common stage present was that of radix relicta (41.7%), while the stage appearing least frequently was the initial stage (15.4%),

There was a significant difference between the stages of ECC (c2 = 211.1, P < 0.0001). Twentyfive of the 27 children with ECC in the initial stage were reexamined 1 year after the baseline examination (2 children did not appear for reexamination dueto address change). The 1-year reexamination showed that the initial stage had advanced to the circular stage in 28% of cases, destructive stage in 20%, radix relicta stage in 36%, and having been extracted due to ECC in 16% of cases (Table 2). Mean age of subjects with initial stage of ECC was 2 ± 0.7. Mean dmft

on reexamination showed an increase from 5.1 to 8.8 (P < 0.001).

*Results of study*

test = 1.81, P = 0.07).

*ECC stages*

(One-Way ANOVA test F = 16, P < 0.001).

or 27 out of 150 children with ECC.

#### *Early crown destruction – root remaining (radix relicta)*

Sometimes, in the upper fornix we can see several changes that, in a quick glance, can lead us to the wrong diagnosis. Since the permanent teeth have palatine position, during their eruption process they put internal pressure in the apical part of the deciduous teeth, so that the deciduous tooth root tip can penetrate the bone and mucosa and erupt in the upper level of vestibular fornix (Fig.5). The erupted roots can make deep and painful decubitus at the upper lip (Fig. 8)

If in the root canal a purulent or gangrenous inflammatory process is present, then in the upper fornix we may encounter isolated purulent process (encapsulated) - abscess. (Fig. 6)

**Extension of the inflammatory process** - sometimes purulent inflammatory process involves gingiva, on all remaining roots, where the clinical symptoms become much more difficult.

**Figure 5.** Radix relicta and bone penetration

**Figure 6.** Abscess and fistula

**Local situation –** the gingiva is edematic, hyperemic and under pressure it is painful. Also while applying a slightly harder pressure from the gingival pocket purulent secret will come out. The tooth is extremely sensitive to palpation and percussion. (Fig.7)

**Figure 7.** Edematic and hyperemic gingiva

**Local situation** *–* the gingiva is edematic, hyperemic and under pressure it is painful. Also while applying a slightly harder pressure from the gingival pocket purulent secret will come out. The tooth is extremely sensitive to palpation and percussion. (Fig.7)

*General condition -* pain, elevated temperature, fever, loss of appetite, the patient is pale and frightened. The patient cannot be fed as a result of edema of the lip and the gum inflammation. The food intake is affected due to the great sensitivity of the gangrenous roots **Figure 8.** Spread of infection- result of ECC complications

the clinical symptoms become much more difficult.

in the upper front. (Fig.8)

**Fig.7**

*Early Extraction* 

serial if it is decided by the therapist.

*Dental eruption disorders as a result of the remaining roots*  As a result of root persistence, among others, it may have an effect in the eruption disorders of permanent teeth causing orthodontic abnormality (fig. 9.10.) **General condition -** pain, elevated temperature, fever, loss of appetite, the patient is pale and frightened. The patient cannot be fed as a result of edema of the lip and the gum inflammation. The food intake is affected due to the great sensitivity of the gangrenous roots in the upper front. (Fig.8)

#### **Fig.9 Fig.10** *Dental eruption disorders as a result of the remaining roots*

As a result of root persistence, among others, it may have an effect in the eruption disorders of permanent teeth causing orthodontic abnormality (Fig. 9, 10.)

**Figure 9.** Persistence of radix relicta and disorders of permanent tooth eruption

#### *Early Extraction*

**Local situation –** the gingiva is edematic, hyperemic and under pressure it is painful. Also while applying a slightly harder pressure from the gingival pocket purulent secret will come

out. The tooth is extremely sensitive to palpation and percussion. (Fig.7)

**Figure 7.** Edematic and hyperemic gingiva

**Figure 5.** Radix relicta and bone penetration

48 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 6.** Abscess and fistula

9 Fig.11 Fig.112 Consequence of an early childhood caries is the "loss" or extraction of teeth (Figure 11 & 12). Extraction of the teeth is approved when the clinical conditions become more serious, as a result of complications. But also: extraction may be due to unprofessional interference from the insisting parent, and the acceptance by the physician to do the extraction. The extraction, for example may be serial if it is decided by the therapist.

Consequences of Early extraction can be:

**Figure 10.** Orthodontic abnormality-result of radix relicta persistence

**Figure 11.** Early extraction of teeth


Avoidance of these effects is done by prosthetic work, whose role would be: space mainte‐ nance, the normal pronunciation of letters, aesthetic improvement, etc.

### **5. Discussion**

**•** *Risk factors of ECC*

Considering the data from the literature, the role of S mutans in the etiology of ECC, especially in the initial phase, is very crucial. These data also demonstrate the high prevalence of this

**Figure 12.** Total extraction of teeth-result of ECC complications

**•** abnormalities in the tooth eruption,

**Figure 11.** Early extraction of teeth

**•** barriers in eating, poor aesthetics, etc.

**5. Discussion**

**•** *Risk factors of ECC*

**•** speech impediment (incorrect pronunciation of letters),

**Figure 10.** Orthodontic abnormality-result of radix relicta persistence

50 Emerging Trends in Oral Health Sciences and Dentistry

nance, the normal pronunciation of letters, aesthetic improvement, etc.

Avoidance of these effects is done by prosthetic work, whose role would be: space mainte‐

Considering the data from the literature, the role of S mutans in the etiology of ECC, especially in the initial phase, is very crucial. These data also demonstrate the high prevalence of this bacterium in preschool children. S mutans is found at the earliest ages, with the prevalence of 53% in 6- to 12-month-old children (Milgrom 2000), 60% in 15-month-olds (Karn 1998), 67% in 18-month-old Swedes (Hallonsten et al. 1995), and 94.7% in 3- to 4-year-old Chinese (Li et al. 1994). Almost all preschool urban Icelandic children were found to carry S mutans (Holbrook 1993). According to the studies of Ge and Caufield, all S-ECC children were S mutans–positive (Ge 2008). Borutta 2002, found that in 80% of children (3 years old) diagnosed with caries, the presence of S mutans was demonstrated, while higher counts of this bacterium were found in children with ECC.

The high prevalence of S mutans was also demonstrated in our study: 98% of preschool children. Expressed in colony-forming units (CFU/mL saliva), 93% of the ECC children in our study had a high S. mutans counts (CFU > 105 ). Higher salivary counts of *S. mutans* have been correlated with high dmft values (11.5) in our study. This significant correlation between high dmft or caries experience and high S mutans counts has been demonstrated in other studies (Köhler et al. 1995, Twetman & Frostner 1991, Maciel 2001).

In our study, the sweets consumption of children with ECC was very high. Almost 4/5 of ECC children have sweet snacks more than twice a day. It is of great concern that kindergartens as educational institutions do not have a more serious approach to a healthy diet and reduction of sugary food. On the contrary, at least once a day, sweet food (jam, chocolate, cream, biscuits, or cake) is served to children. Also, serving of this food is very common between meals. The literature also shows a high consumption of sweets between meals (Ölmez 2003) and high caries values in children who have frequent sweets (Holbrook 1989).

Another important factor in the etiology of ECC is bottle feeding, which is accompanied by high salivary counts of *S mutans.* The relationship between bottle usage and salivary counts of S mutans (Mohan 1998) has been reported. In the children that were in the study, the duration of bottle feeding with sweetened milk or juice was very long, wherein nearly 4/5 of children were bottle fed from 1 to 3 and more years.

Another harmful practice is putting children to sleep with a juice-filled bottle, which is practiced in 2/3 of children with ECC, although Johnsen has reported that 78% of parents of children with ECC had attempted to substitute water for a cariogenic liquid (e.g., apple juice, formula) in the bedtime nursing bottle [Johnsen]. A review of the literature from the etiological point of view of ECC shows that "the use of a bottle at night" is not the only cause of ECC (Plat 2000).

Oral hygiene habits established at the age of 1 can be maintained throughout early childhood (Wendt 1995). There is a high level of negligence in the oral hygiene of our children. More than half do not brush their teeth at all, exhibiting a very high oral hygiene index-OHI (1.52). The importance of the primary dentition of oral health promotion must be focused on the education of mothers to motivate their children for oral hygiene. Unfortunately, we found "bad convic‐ tion" of mothers regarding primary teeth that they will be replaced, thus neglecting the care for children's teeth. Data from the literature show that cooperation of mothers is very impor‐ tant in overcoming the belief that the deciduous dentition can be neglected (Rosamund 2003).

Mothers' knowledge and behaviours of oral hygiene are the key components for chil‐ dren's oral health care. The child imitates parental behaviours, including oral hygiene habits; thus, tooth brushing at an early age depends on maternal knowledge and behav‐ iours. In our study, 38% of the mothers stated that their children did not brush their teeth at all. Only 11% of the interviewed mothers demonstrated proper techniques of tooth brushing. Unfortunately, a relatively low percentage of mothers (24%) stated that tooth brushing should last at least 2 to 3 minutes. The interviewed mothers rarely assisted their children during tooth brushing (5%).Even though fluoride and antimicrobial agents have a beneficial role in preventing caries, an insignificant number of interviewed mothers stated that they had knowledge regarding fluoride and they did not practice these preventive methods with their children (Begzati et al. 2014).

Besides fluoride treatments, an antimicrobial treatment option has become a serious consid‐ eration for many dental professionals. The data from the literature have confirmed the positive antibacterial role of chlorhexidine in the destruction of S. mutans colonies and inhibiting caries (Featherstone 2004, Zhang et al. 2006).

From the answers of mothers concerning fluoride use, we ascertained a marked lack of knowledge about the benefits of this agent in maintaining healthy tooth structure. This information gap can be inferred from their answers. When asked, "Do you give fluoride tablets to your child?" their answers were stated as if they have been asked about some medication: "I give those tablets to my child as needed." The absence of fluoride in Kosovo's municipal drinking water may highly influence caries prevalence rates in children.

Nutritional counseling, fluoride therapy, and oral hygiene may be required to prevent development of carious lesions in children. In the case of high-risk patients such as ECC children with a predominance of high salivary counts of S mutans, the use of either the antibacterial rinse chlorhexidine gluconate or the oral health care gel chlorhexidine has been suggested (Featherstone 2004).

The oral health promotion and preventive measures are also influenced by social and economic factors. Statistical data from Kosovo are as follows: large families (with average size of 6.5 members), high unemployment rate (in 2008 it marked 45.4%, for female 56.4%), high birth rate (16%) and the lowest economic growth in the region [56], represent some of the aggra‐ vating factors when dealing with the health issues of the population, including oral health issues (Ministry of Public Administration. Statistical Office of Kosovo 2010).

Given the complexity of factors associated with ECC, it is unfortunate that most of the interest has only been from dental organizations. The critical change needed to accomplish the necessary research related to prevention of ECC is to expand our network through inclusion other health professionals, community leaders, national organizations serving children, and political leaders (Ismaili 1998).

**•** *Consequences of ECC*

Another harmful practice is putting children to sleep with a juice-filled bottle, which is practiced in 2/3 of children with ECC, although Johnsen has reported that 78% of parents of children with ECC had attempted to substitute water for a cariogenic liquid (e.g., apple juice, formula) in the bedtime nursing bottle [Johnsen]. A review of the literature from the etiological point of view of ECC shows that "the use of a bottle at night" is not the only cause of ECC

Oral hygiene habits established at the age of 1 can be maintained throughout early childhood (Wendt 1995). There is a high level of negligence in the oral hygiene of our children. More than half do not brush their teeth at all, exhibiting a very high oral hygiene index-OHI (1.52). The importance of the primary dentition of oral health promotion must be focused on the education of mothers to motivate their children for oral hygiene. Unfortunately, we found "bad convic‐ tion" of mothers regarding primary teeth that they will be replaced, thus neglecting the care for children's teeth. Data from the literature show that cooperation of mothers is very impor‐ tant in overcoming the belief that the deciduous dentition can be neglected (Rosamund 2003).

Mothers' knowledge and behaviours of oral hygiene are the key components for chil‐ dren's oral health care. The child imitates parental behaviours, including oral hygiene habits; thus, tooth brushing at an early age depends on maternal knowledge and behav‐ iours. In our study, 38% of the mothers stated that their children did not brush their teeth at all. Only 11% of the interviewed mothers demonstrated proper techniques of tooth brushing. Unfortunately, a relatively low percentage of mothers (24%) stated that tooth brushing should last at least 2 to 3 minutes. The interviewed mothers rarely assisted their children during tooth brushing (5%).Even though fluoride and antimicrobial agents have a beneficial role in preventing caries, an insignificant number of interviewed mothers stated that they had knowledge regarding fluoride and they did not practice these preventive

Besides fluoride treatments, an antimicrobial treatment option has become a serious consid‐ eration for many dental professionals. The data from the literature have confirmed the positive antibacterial role of chlorhexidine in the destruction of S. mutans colonies and inhibiting caries

From the answers of mothers concerning fluoride use, we ascertained a marked lack of knowledge about the benefits of this agent in maintaining healthy tooth structure. This information gap can be inferred from their answers. When asked, "Do you give fluoride tablets to your child?" their answers were stated as if they have been asked about some medication: "I give those tablets to my child as needed." The absence of fluoride in Kosovo's municipal

Nutritional counseling, fluoride therapy, and oral hygiene may be required to prevent development of carious lesions in children. In the case of high-risk patients such as ECC children with a predominance of high salivary counts of S mutans, the use of either the antibacterial rinse chlorhexidine gluconate or the oral health care gel chlorhexidine has been

drinking water may highly influence caries prevalence rates in children.

methods with their children (Begzati et al. 2014).

(Featherstone 2004, Zhang et al. 2006).

suggested (Featherstone 2004).

(Plat 2000).

52 Emerging Trends in Oral Health Sciences and Dentistry

Scientific research suggests that the development of ECC occurs in 3 stages. The first stage is characterized by a primary infection of the oral cavity with ECC. The second stage is the proliferation of these organisms to pathogenic levels as a consequence of frequent and prolonged exposure to cariogenic substrates. Finally, a rapid demineralization and cavitation of the enamel occurs, resulting in rampant dental caries (Wyne 1998). A 1-year follow-up of ECC development from the initial stage, representing decay at the enamel level and its progression to more destructive stages, shows even development in all affected teeth. It is quite an acute development, because in 2/3 of the children, the ECC has progressed to more complicated stages (destructive and radix relicta stages). Within 1 year, the dmft values have increased to 3.7. Consecutively, these children commonly experience pain from pulpitis, gangrene, and apical periodontitis. Also, these conditions are often followed by abscesses and cellulitis, sometimes with phlegmona, seriously endangering the child's general health. De Grauwe, in describing the progression of ECC, has noticed that the development of caries from the enamel to the dentin level can occur within 6 months (De Grauwe et al. 2004). The rapid development of ECC and its clinical appearance, especially in primary incisors, identifies it in its initial stages as a risk factor for future caries in the primary and permanent dentitions (Al-Shalan et al. 1997).

Children with congenital heart anomalies are frequent patients in our departments, some of them exhibiting severe ECC. There is strong evidence that untreated dental disease is an important etiological factor in the pathogenesis of infective endocarditis, a condition that still carries a high risk of mortality (Child 1996).

#### **Preventive measures for ECC** (Begzati et al. 2012)

Early childhood caries (ECC) is a health problem with biological, social and behavioral determinants. Intervention treatment does not resolve this problem. It is difficult, sometimes impossible and expensive.

The only safest way is prevention of this complex pathology. European Academy of Pediatric Dentistry (2008) has recommended general strategies for ECC prevention:


Based on these recommendations, we will describe detailed preventive measures: primary prevention – prenatal and postnatal care; and secondary prevention – parents' and dental professionals' role.

#### **• Primary prevention**

It should begin during prenatal period and it consists of pregnant woman's needs' fulfillment with necessary and healthy products;

Proper quality of food for the newborn during the enamel maturation phase;

Fluoridation of newly-erupted teeth;

Antimicrobial therapy with chlorhexidine.

#### **• Secondary prevention**

Mothers' education on recognizing the first signs of ECC using "lift-the-lip" technique. The aim of this measure is early detection of the so-called "white spot".

Parents should be encouraged to avoid bad feeding habits of their children and give effort for proper feeding:


Necessary consultations with the dentist -

Professional education activity targeting primary care health providers (pediatricians, internists, family physicians, obstetricians, mid-level medical practitioners):


## **6. Conclusions**

**•** Oral health assessments with counseling at regularly scheduled visits during the first year

**•** Children's teeth should be brushed daily with a smear of fluoride toothpaste as soon as they

**•** Professional applications of fluoride varnish are recommended at least twice yearly in

**•** Parents of infants and toddlers should be encouraged to reduce behaviours that promote

Based on these recommendations, we will describe detailed preventive measures: primary prevention – prenatal and postnatal care; and secondary prevention – parents' and dental

It should begin during prenatal period and it consists of pregnant woman's needs' fulfillment

Mothers' education on recognizing the first signs of ECC using "lift-the-lip" technique. The

Parents should be encouraged to avoid bad feeding habits of their children and give effort for

Proper quality of food for the newborn during the enamel maturation phase;

aim of this measure is early detection of the so-called "white spot".

**•** the use of cup instead of the bottle as early as possible;

**•** reduce the liquid in the bottle, gradually by night,

**•** the use of natural, a little sweetened, juice or tea, or just water;

**•** avoid the discontinuation of bottle use by the method "bottle is gone";

**•** daily tooth brushing, at least twice a day, obligatory before going to bed.

of life are an important strategy to prevent ECC

the early transmission of mutans streptococci.

groups or individuals at risk.

54 Emerging Trends in Oral Health Sciences and Dentistry

with necessary and healthy products;

Fluoridation of newly-erupted teeth;

Antimicrobial therapy with chlorhexidine.

erupt

professionals' role.

**• Primary prevention**

**• Secondary prevention**

**•** breast-feeding of the baby;

**•** not sleeping with bottle in mouth;

**•** reduce sweets as much as possible;

Necessary consultations with the dentist -

**•** no sweets between meals;

**•** avoid the use of fabricated juices or soda;

proper feeding:

Oral health is integral to general health and should not be considered in isolation. Oral diseases have detrimental effects on an individual's physical and psychological well-being and reduce quality of life. The commonest disease is dental caries. Caries progression or reversal is determined by the balance between protective and pathological factors in the mouth. The most important component in the treatment of the caries disease is prevention. Understanding the balance between pathological factors and protective factors is the key to successful prevention of caries. Analyzing the etiology, prevalence, clinical specifics, consequences and complica‐ tions, caries in general and ECC in particular are estimated as serious diseases, which represent not only health problem, but also a great serious social and economic problem.

Consequence of an early childhood caries, especially in underdeveloped countries, can be very severe, spanning from tooth loss to general health disorders. One of the complications of untreated ECC is the "loss" or extraction of teeth. Consequences of early extraction can be: abnormalities in the tooth eruption, speech impediment (incorrect pronunciation of letters), barriers in eating, poor aesthetics, etc.

The rapid development of ECC, especially in primary incisors, identifies it in its initial stages as a risk factor for future caries in the primary and permanent dentitions. There is strong evidence that untreated dental disease is an important etiological factor in the pathogenesis of infective endocarditis, a condition that still carries a high risk of mortality.

The risk factors for early childhood caries include a number of social and behavioural deter‐ minants.

Primary prevention must start in the prenatal stage to fulfill the needs of pregnancy. Parents should be encouraged to avoid bad feeding habits and to instruct and supervise their children in tooth brushing. Mothers should be instructed to use the lift-the-lip technique to spot the white-spot lesions as first signs of dental caries. Newly erupted teeth must be treated with fluoride agents, and, as needed, antimicrobial agents containing chlorhexidine and thymol. Further investigation is needed to assess the effectiveness of new intervention strategies beyond traditional measures that are not strictly dependent on access to dental professional providers.

Permanent and sustained oral health promotion organized with the participation of the entire civil society, with the mandatory presence of key stakeholders in the areas of education and healthcare, represent one of the highest priorities. The WHO strategies and objectives imple‐ mentation regarding oral health promotion should be understood in the right manner and should be implemented continuously.

## **Author details**

Agim Begzati1\*, Merita Berisha3 , Shefqet Mrasori2 , Blerta Xhemajli-Latifi1 , Prokshi1 , Haliti1 , Valmira Maxhuni1 , Vala Hysenaj-Hoxha1 and Vlera Halimi1

\*Address all correspondence to: agimbegzati@yahoo.com

1 Department of Pedodontics and Preventive Dentistry, School of Dentistry, Medical Facul‐ ty, University of Prishtina, Prishtina, Republic of Kosovo

2 Department of Endodnintic, Medical Faculty, University of Prishtina, Prishtina, Republic of Kosovo

3 National Institute of Public Health of Kosovo, Department of Social Medicine, Medical Faculty, University of Prishtina, Prishtina, Republic of Kosovo

## **References**


[6] Al-Shalan, T.A., Erickson, P.R. & Hardie, N.A.(1997). Primary incisor decay before age 4 as a risk factor for future dental caries. *Paediatric Dentistry*,Vol.19, No.1, pp. 37-41.

Permanent and sustained oral health promotion organized with the participation of the entire civil society, with the mandatory presence of key stakeholders in the areas of education and healthcare, represent one of the highest priorities. The WHO strategies and objectives imple‐ mentation regarding oral health promotion should be understood in the right manner and

, Shefqet Mrasori2

and Vlera Halimi1

1 Department of Pedodontics and Preventive Dentistry, School of Dentistry, Medical Facul‐

2 Department of Endodnintic, Medical Faculty, University of Prishtina, Prishtina, Republic

3 National Institute of Public Health of Kosovo, Department of Social Medicine, Medical

[1] Arkin, E.B. (1986). The Healthy Mothers, Healthy Babies Coalition: four years of

[2] Acs, G., Shulman, R., Wai, M. & Chussid' S. (1999). The effect of dental rehabilitation on the body weight of children with early childhood caries. *Pediatric Dentistry*, Vol.

[3] Acs, G., Lodolini, G., Kaminsky, S. & Cisneros, G.J.(1992). Effect of nursing caries on body weight in a pediatric population. *Pediatric Dentistry*, Vol. 14, pp:302-305.

[4] Al-Dashti, A.A., Williams, S.A. & Curzon, M.E.(1995). Breast feeding, bottle feeding and dental caries in Kuwait, a country with low-fluoride levels in the water supply.

[5] Apostolova, D., Asprovsa, V. & Simovska N (2003). Circular caries-ECC-a problem at the earliest age. *8th Congress of the Balkan Stomatological Society,* (Abstract Book) Tira‐

, Vala Hysenaj-Hoxha1

\*Address all correspondence to: agimbegzati@yahoo.com

ty, University of Prishtina, Prishtina, Republic of Kosovo

Faculty, University of Prishtina, Prishtina, Republic of Kosovo

progress. *Public Health Repository,* Vol. 101, pp. 147-156.

*Community Dental Health*. Vol.12, pp.42–47.

, Blerta Xhemajli-Latifi1

, Prokshi1

, Haliti1 ,

should be implemented continuously.

56 Emerging Trends in Oral Health Sciences and Dentistry

Agim Begzati1\*, Merita Berisha3

**Author details**

Valmira Maxhuni1

of Kosovo

**References**

21, pp.109-113.

na, 2003.


[34] Ge. Y., Caufield, P.W., Fisch, G.S. & Li. Y.(2008). Streptococcus mutans and Strepto‐ coccus sanguinis Colonization Correlated with Caries Experience in Children. *Caries Res,* Vol.42, pp.444-448.

[20] Carlsson, P.(1989). Distribution of mutans streptococci in populations with different levels of sugar consumption. *Scandinavian journal of dental research*, Vol.97 No.2, pp.

[21] Centers for Disease Control and Prevention (CDCP), conference. Atlanta, GA, Sep‐

[22] Caufield, P.W., Cutter, G.R. & Dasanayake A.P.(1993). Initial acquisition of mutans streptococci by infants: evidence for a discrete window of infectivity. *Journal of Dental*

[23] Catalanotto, F.A., Shklair, I.I. & Keene, H.J.(1975). Prevalence and localization of Streptococcus mutans in infants and children. *Journal of the American Dental Associa‐*

[24] Child, J.S. (1996). Risks for and prevention of infective endocarditis. In: Child JS, ed. *Cardiology Clinics—Diagnosis and Management of Infective Endocarditis*. Philadelphia,

[25] Drury, Th.F., Horowitz, A.M., Ismail, A.I., Maertens, M.P., Rozier, R.G. & Selwitz, R.H. (1999). Diagnosing and reporting Early Childhood Caries for Research Purpos‐

[26] Davis, G.N. (1998). Early childhood caries-a synopsis. *Community Dentistry and Oral*

[27] Derkson, G.D. & Ponti, P. (1982). Nursing bottle syndrome: prevalence end etiology in a non fluoridated city. *Journal of the Canadian Dental Association*, Vol. 6, pp. 389-393.

[28] Douglass, J.M., Douglass, A.B. & Silk HJ.(2004). A practical guide to infant oral

[29] Elice, C.E. & Fields, C.W.(1990). Failure to thrive: Rewire of literature, case reports and implications for dental treatment. *Pediatric Dentistry*, Vol.12, pp.185-189.

[30] European Academy of Paediatric Dentistry (EAPD 2008). *Guidelines on Prevention of*

[31] Featherstone, J.D.B. (2004). The Caries Balance: The Basis for Caries Management by Risk Assessment. *Oral Health and Preventive Dentistry*, Vol. 2, No 1, pp. 259-264 [32] Fass, E.(1962). Is bottle feeding of milk a factor in dental caries? *Journal of Dentistry for*

[33] Fédération Dentaire Internationale –FDI(1988). Technical report No. 31. Review of methods of identification of high caries groups and individuals. *International Dental*

*Early Childhood Caries: An EAPD Policy Document.* Dublin, Ireland.

120-125.

tember 1994.

*Research* , Vol.72, pp. 37-45.

58 Emerging Trends in Oral Health Sciences and Dentistry

*tion*, Vol.91, pp:606-609.

Pa: WB Saunders Co, Vol. 14, pp. 327-343.

es. *Journal of Public Health Dentistry*, Vol. 59, pp. 192-197.

*Epidemiology*,Munksgaard , Vol. 26, pp.106-116.

health. *Am Fam Physician.* Vol.70, pp.2113–2120.

*Children* Vol.29, pp. 245-251.

*Journal, Vol.*38, pp. 177-189.


[64] Li, Y., Navia, J.M. & Caufield, P.W.(1994). Colonization by mutans streptococci in mouths of 3- and 4- year -old Chinese children with or without enamel hypoplasia. *Archives of Oral Biology,* , Vol.39, N.12, pp.1057-1062.

[50] Ismail, A.I. (1998). Prevention of early childhood caries. *Community Dentistry and Oral*

[51] Johnsen, D.C. (1982). Characteristics and backgrounds of children with "nursing ca‐

[52] Jacobi, A. (1862). Dentition. *Its Derangements. A Course of Lectures Delivered in the New*

[53] James, P.M.C., Parfitt, G.J. & Falkner, F. (1957). A study of the aetiology of labial ca‐ ries of the deciduous incisor teeth in small children. *British Dental Journal*, Vol. 103,

[54] Kobaslia, S., Maglaic, N. & Begovic, A. (2000). Caries prevalence of Sarajevo children.

[55] Konig, K.G. & Navia, E.M. (1995). Nutritional role of sugars in oral health. *American*

[56] Keyes, P.H.(1962). Recent advances in dental caries research. *International Dental Jour‐*

[57] Kaste, L.M. & Gift, H.C. (1995). Inappropriate infant bottle feeding: Status of the Healthy People 2000 Objective. *Archives of Pediatrics & Adolescent Medicine.* Vol. 149,

[58] Kaste, L.M., Selwitz, R.H., Oldakowski, R.J., Brunelle, J.A., Win, D.M. & Brown, L.J. (1996). Coronal Caries in the Primary and Permanent Dentition of Children and Ado‐ lescents 1-17 Years of Age: United States, 1988-1991, *Journal of Dental Research*,Vol. 75,

[59] Karn, T.A., O'Sullivan, D.M. & Tinannoff N. (1988). Colonization of mutans strepto‐ cocci in 8- to 15- month-old children. *Journal of Public Health Dentistry,*, Vol. 58, No.3.

[60] Köhler, B., Andreen, I. & Jonsson, B. (1988). The earlier the colonization by mutans streptococci, the higher the caries prevalence at 4 years of age. *Oral Microbiology and*

[61] Köhler, B., Bjarnason, S., Care, R., Mackevica, I. & Rence, I. (1995). Mutans strepto‐ cocci and dental caries prevalence in a group of Latvian preschool children. *European*

[62] Koga, T., Asakawa, H., Okahashi, N. & Hamada, S.(1986). Sucrose –dependent cell adherence and cariogenicity of serotype-c streptococcus mutans *Journal of general mi‐*

[63] Lopez, L., Berkowitz, R.J., Moss, M.E. & Weinstein, P. (2000). Mutans streptotocci prevalence in Puerto Rican babies with cariogenic feeding behaviors. *Pediatric Den‐*

*Epidemiology*, Vol. 26, No.1, pp. 49-61.

60 Emerging Trends in Oral Health Sciences and Dentistry

No. 2, pp.37–40.

*nal, Vol.* 12, pp. 443-464.

pp.786-791.

pp. 631-641.

pp. 248-249.

*Immunology,* Vol. 3, pp. 14-17.

*crobiology,* . Vol.132, pp.2873-2883.

*tistry,* Vol. 22, No. 4, pp. 299–301.

*Journal of Oral Sciences*, Vol. 103, No. 4, pp. 264-266.

ries." *Pediatric Dentistry*, Vol. 4, No. 3, pp. 218–224.

*York Medical College.* New York: Ballière Brothers

*Acta Stomatologica Croatica*, Vol. 34, pp. 83-85

*Journal of Clinical Nutrition,* Vol. 62, Suppl. pp. 275S-83S.


year old children in Rome who were not included in population prevention pro‐ grams. Ann Ig. Vol.13, No.4, pp.329-38.


[94] Thomas, A.K., David, M.O. & Norman, T.(1998). Colonization of Mutans Streptococci in 8 to 15 month-old Children. *Journal of Public Health Dentistry*, Vol.58, pp:248-249.

year old children in Rome who were not included in population prevention pro‐

[78] Quartey, J.B. & Williamson, D.D.(1998). Prevalence of early childhood caries at Har‐

[80] Reisine, S., Douglass, J.M. ( 1998). Psychosocial and behavioral issues in early child‐ hood caries. *Community Dentistry and Oral Epidemiology*; Vol. 26, No.1, pp. 32-44.

[81] Rosamund, L.H. & Tracy, W. (2003). An oral health promotion program for an urban minority population of preschool children. *Community Dentistry and Oral Epidemiolol‐*

[82] Russell, R.(2003). Microbiological aspects of caries prevention, Prevention of oral dis‐

[83] Ripa, L.W. (1988). Nursing caries: a comprehensive review. *Pediatric Dentistry*, Vol.

[84] Soames, J.V. & Southam, J.C. (1999). Oral Pathology-book, by Oxford University

[85] Stile, H.M., Loesche, W.J. & O'Brien T.C. (1976). Microbial Aspects of Dental Caries.

[86] Schroth, R.J., Brothwell, D.J. & Moffatt, M.E.K.(2007). Caregiver knowledge and atti‐ tudes of preschool oral health and early childhood caries (ECC). *International Journal*

[89] Seow, W.K.(1998). Biological mechanisms of early childhood caries. *Community Den‐*

[90] Tinanoff, N., Kaste, L.M. & Corbin, S.B. (1998). Early childhood caries: a positive be‐ ginning. *Community Dentistry and Oral Epidemiolology*, Vol. 26, No. 1, pp. 117-119.

[91] Twetman, S. & Frostner, N. (1991). Salivary mutans streptococci and caries preva‐ lence in 8-year-old Swedish schoolchildren. *Swedish Dental Journal*, Vol. 15, No. 3, pp.

[92] Tanner, ACR.(2002). The microbiota of young children from tooth and tongue sam‐

[93] Thomas, F.D., Alice, M.H., Amidi, I.I., Marco, P.M., Rozier, G.R. & Robert, H.( 1999). Diagnosing and Reporting Early Childhood Caries for Research Purposes, *Journal of*

ris County clinics. *Journal of Dentistry for Children. Vol.* 7, pp.127-131.

[79] Raiç, Z.(1985). Deçija i preventivna stomatologija-book, Zagreb.

London, England: Information Retrieval; Vol. 1. pp:187-199.

[87] Stosiç, P.(1991). Deçja i preventivna stomatologija-book. Beograd.

[88] Soames, J.V. & Southam, J.C. (1999). Oral Pathology. 3rd ed. Oxford

*of Circumpolar Health* Vol. 66, pp. 153-167.

*tistry and Oral Epidemiology, Vol.* 26, pp. 8-27.

ples. *Journal of Dental Research,* Vol.81, pp:53-57.

*Public Health Dentistry,* Vol.59, pp.192-197.

grams. Ann Ig. Vol.13, No.4, pp.329-38.

62 Emerging Trends in Oral Health Sciences and Dentistry

*ogy*, Vol. 31, No. 5, pp. 392-399.

ease, Oxford.

10, pp. 268-282.

press.

145-151.


## **Improving Antimicrobial Activity of Dental Restorative Materials**

J.M.F.A. Fernandes, V.A. Menezes, A.J.R. Albuquerque, M.A.C. Oliveira, K.M.S. Meira, R.A. Menezes Júnior and F.C. Sampaio

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59252

## **1. Introduction**

The oral cavity harbors a great diversity of microbial species that have a strong tendency to colonize dental surfaces, tongue and oral mucosa [1,2]. These accumulations of oral bacteria on dental surfaces are natural forms of biofilm growth in humans. They are also known as dental plaque and in spite of several favorable conditions (e.g. temperature, humidity) these biofilms are constantly challenged by host factors. It is recognized that structural organization of a dental biofilm are influenced by the interplay of many unfavorable and also several favorable ones such as the chemical nature of the substrate and the type of the surface where the biofilm develops [3].

In dentistry, restoration failure is generally attributed to a combination of oral bacteria and inappropriate features of dental materials. Efficient dental restorative materials are important for an adequate recovery of masticatory and esthetic functions. However, these materials are prone to biofilm formation, affecting oral health. It is well accepted that under *in vivo* condi‐ tions, rough surfaces attract more biofilm than smooth ones, but the variables that influence bacterial adhesion to dental materials are still a matter of debate.

Dental caries is the most prevalent disease found in the oral cavity of humans. It is regarded as multifactorial chronic and complex disease which is dependent of a cariogenic biofilm [4,5]. Thus, a carious lesion takes some time to develop. However, initial carious lesions are easily and rapidly formed during a three-day of high sucrose regime and poor oral hygiene conditions. So, as long as there is a cariogenic microbial biofilm attached to a dental surface there is a great chance to find a carious lesion on this tooth spot [6]. Growth of oral

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

bacteria on dental surfaces requires adhesion strategies because there is a constant flow of host secretions (e.g. saliva) that can interfere on the ability of planktonic cells (nonattached bacteria). As a result, the formation of the oral biofilm is not homogenous and it contains multiple bacterial species [4,7,8].

Oral bacteria can adhere to hydrophobic as well as to hydrophilic surfaces and many explan‐ atory theories are suggested including the influence of complex electrostatic mechanisms such as van der Waals energy. After biofilm establishment on restorations, surface deterioration of materials (e.g.: resin composites and glass-ionomer cements) will take place facilitating the development of a mature biofilm resulting in dental carious lesions. The microflora from these diseased teeth sites is significantly different from healthy sites on a tooth [10]. The frequent changes in environmental conditions can lead to shifts in biofilm microflora and as a result the microbial homeostasis breaks down in dental plaque (e.g. low pH), and disease occurs.

It must be pointed out that the presence of these oral microbes in the mouth is natural, and is also essential for the normal development of the physiology of the oral cavity [9]. Hence, any antimicrobial strategy has to consider the perspective of restoring some microbial equilibrium and not a complete depletion of oral bacterial from the mouth. Many antimicrobial substances, compounds or mixture of antibacterial agents (e.g. bisbiguanides, metal ions, quaternary ammonium compounds, essential oils) have been successfully formulated into home care products to control oral biofilms. Several investigations have proved their efficacy in control‐ ling the development of oral biofilms despite important drawbacks as tooth staining, bad taste, etc. [3,4]. Moreover, at moderate or high concentrations, these antimicrobial mouthwashes and toothpastes can inhibit bacterial growth in many different modes and truly affect biofilmforming capacity of some pathogenic traits. Hence, to be considered a successful antimicrobial agent a substance, compound or the mixture of both must be able of maintaining the oral biofilm at "normal" cariogenic bacterial levels which are compatible with the individual oral health. Simultaneously, the material must be effective without any interference on the beneficial properties of the resident oral microflora.

Mouthwashes and toothpastes are accepted methods to deliver antimicrobials into the oral mouth. However, they are completely dependent on the discipline and compliance of the patient to the oral treatment. In addition, many of these antimicrobials are prescribed for short periods to avoid any risk of disturbing the resident oral microflora [3,10]. Hence, one strategy is to incorporate antimicrobials into dental materials. The possibility that dental restorative material may release antimicrobial compounds are regarded as an interesting strategy for overcoming the development of cariogenic dental biofilms and the risk for secondary dental caries. In addition, there is a chance that under less biofilm stress dental materials could increase longevity. This strategy is of great importance since dental restorations properties may be improved if an antibiotic-dental material is used.

The aim of the present review is to shed light on the techniques and effectiveness on improving antibacterial activities of dental restorative materials. The main focus is on incorporation and subsequent slow-release of antimicrobial chemical species, molecules, compounds and low molecular weight antibacterial agents such as metal ions, iodine, antibiotics, chlorhexidine and natural products such as essential oils. The *in vitro* and *in vivo* techniques used in microbiology are also explored taking into account that main bacteria involved are Gram-positive cocci shaped bacteria such as *Streptococcus sobrinus, Streptococcus mutans* and Lactobacillus sp.

## **2.** *In vitro* **and** *in vivo* **techniques for studying biofilms**

bacteria on dental surfaces requires adhesion strategies because there is a constant flow of host secretions (e.g. saliva) that can interfere on the ability of planktonic cells (nonattached bacteria). As a result, the formation of the oral biofilm is not homogenous and it

Oral bacteria can adhere to hydrophobic as well as to hydrophilic surfaces and many explan‐ atory theories are suggested including the influence of complex electrostatic mechanisms such as van der Waals energy. After biofilm establishment on restorations, surface deterioration of materials (e.g.: resin composites and glass-ionomer cements) will take place facilitating the development of a mature biofilm resulting in dental carious lesions. The microflora from these diseased teeth sites is significantly different from healthy sites on a tooth [10]. The frequent changes in environmental conditions can lead to shifts in biofilm microflora and as a result the microbial homeostasis breaks down in dental plaque (e.g. low pH), and disease occurs.

It must be pointed out that the presence of these oral microbes in the mouth is natural, and is also essential for the normal development of the physiology of the oral cavity [9]. Hence, any antimicrobial strategy has to consider the perspective of restoring some microbial equilibrium and not a complete depletion of oral bacterial from the mouth. Many antimicrobial substances, compounds or mixture of antibacterial agents (e.g. bisbiguanides, metal ions, quaternary ammonium compounds, essential oils) have been successfully formulated into home care products to control oral biofilms. Several investigations have proved their efficacy in control‐ ling the development of oral biofilms despite important drawbacks as tooth staining, bad taste, etc. [3,4]. Moreover, at moderate or high concentrations, these antimicrobial mouthwashes and toothpastes can inhibit bacterial growth in many different modes and truly affect biofilmforming capacity of some pathogenic traits. Hence, to be considered a successful antimicrobial agent a substance, compound or the mixture of both must be able of maintaining the oral biofilm at "normal" cariogenic bacterial levels which are compatible with the individual oral health. Simultaneously, the material must be effective without any interference on the

Mouthwashes and toothpastes are accepted methods to deliver antimicrobials into the oral mouth. However, they are completely dependent on the discipline and compliance of the patient to the oral treatment. In addition, many of these antimicrobials are prescribed for short periods to avoid any risk of disturbing the resident oral microflora [3,10]. Hence, one strategy is to incorporate antimicrobials into dental materials. The possibility that dental restorative material may release antimicrobial compounds are regarded as an interesting strategy for overcoming the development of cariogenic dental biofilms and the risk for secondary dental caries. In addition, there is a chance that under less biofilm stress dental materials could increase longevity. This strategy is of great importance since dental restorations properties

The aim of the present review is to shed light on the techniques and effectiveness on improving antibacterial activities of dental restorative materials. The main focus is on incorporation and subsequent slow-release of antimicrobial chemical species, molecules, compounds and low molecular weight antibacterial agents such as metal ions, iodine, antibiotics, chlorhexidine and natural products such as essential oils. The *in vitro* and *in vivo* techniques used in microbiology

contains multiple bacterial species [4,7,8].

66 Emerging Trends in Oral Health Sciences and Dentistry

beneficial properties of the resident oral microflora.

may be improved if an antibiotic-dental material is used.

In 1940´s microbiologists described an interesting phenomenon that occurs when fresh sea water is kept in a glass bottle, the so-called "bottle effect". It was observed that the number of microorganisms attached a glass surface increase while at the same time there is a reduction in free-living microorganisms [11]. This is a relevant historical landmark because it represents the starting point of a paradigm shift that is still valid these days. In fact, only 30 years later, scientific community understood that the biofilm mode of life is the rule rather the exception when bacteria and fungi species are collected, studied and investigated in nature under real life conditions. Biofilms are defined as complex consortia of microorganisms that are attached to a surface that can be of biotic or abiotic nature [12].

The microbial biofilm formation involves a multi-stage process in which bacterial and fungi adhere to the surface. For more details see figure 1 which is based in several reports [13-16].

**Figure 1.** The multi-stage process of biofilm formation by oral microorganisms.

At this stage only weak forces are operating. Therefore it is also known as the initial reversible attachment stage. Subsequently, there is a production of an extracellular matrix (containing polysaccharides, proteins and DNA) that results in a stronger attachment which is also known as the irreversible attachment stage [16]. In general, after attachment, biofilm growth follows two other distinct phases or behavior: spreading and dispersal of microorganisms.

Basically, the attachment process involves equilibrium of electrostatic forces. Microbes and tooth surfaces are negatively charged. As they are immersed in a fluid (saliva) system which is rich in calcium and other counterions, these negative charged surfaces attract and mobilize cations. As a result, a double charged layer is formed (electrical double layer) and this overlap causes a repulsive electrostatic force. Simultaneously, as the bacterium approaches the tooth surface, they also experience a repulsive force (van der Waals force). Finally, the combinations of repulsive and attraction forces known as DLVO theory modulate the microorganism adherence to dental surfaces. This is valid for dental restorative materials as well, and one must consider the fact that it can be more favorable if a porous or irregular surface is facilitating bacterial adherence [3,13-16].

The first bacteria to attach to the acquired pellicle (layer of glycoproteins) on the tooth surface are called the pioneer species (*Streptococcus oralis*, *Streptococcus mitis*, *Streptococcus sanguis*). Surprisingly, *S. mutans* is not a first colonizer despite its high cariogenic nature. In fact, *S. mutans* is the most studied bacteria in oral microbiology but under clinical environment one must consider that a multispecies biofilm is operating [3,9].

Historically, in Dentistry, the examination of mature oral biofilms started when electron microscope became available for microbiologists [19]. Later, molecular biological tools became popular and new insights about how microbes attach and develop on tooth surfaces were finally confirmed. One "striking" observation was actually a confirmation of an obvious theory that microbes stick to a surface many benefits are obtained: a) selection of sites where they stay in favorable environments, b) these surfaces may have enough substrate or can contribute to diffuse some nutrient and c) the different species often work together and this consortium provides physical support and protection [20-29].

More recently, zeta potential, confocal laser scanning microscopy (CLSM) together with fluorescence techniques received attention and became useful techniques to study bacteria adhesion to surfaces [29]. In spite of the great evolution in techniques, many limitations have to be considered when comes to the evaluation of an antimicrobial substances against biofilms development. First, there is still the gap of *in vitro* and *in vivo* environments. *In situ* studies can overcome some of these limitations but other drawbacks cannot be ruled out. Most studies on bacteria adhesion to surfaces were carried out under *in vitro* conditions which do not reflect the real life. Secondly, there is the paradox of testing planktonic cells but interpretations are generalized to conditions of biofilm formation. It is well established that biofilms express genes different from those of planktonic cells. Moreover, it has been observed that biofilm cells are generally believed to closely resemble planktonic cells in stationary phase. However, biofilms were found to more closely resemble to planktonic cells at exponentially growing than those of planktonic cells in the stationary phase [19,20]. In addition, it cannot be ruled out the differences between single species biofilm versus multispecies biofilms since under laboratory Improving Antimicrobial Activity of Dental Restorative Materials http://dx.doi.org/10.5772/59252 69

At this stage only weak forces are operating. Therefore it is also known as the initial reversible attachment stage. Subsequently, there is a production of an extracellular matrix (containing polysaccharides, proteins and DNA) that results in a stronger attachment which is also known as the irreversible attachment stage [16]. In general, after attachment, biofilm growth follows

Basically, the attachment process involves equilibrium of electrostatic forces. Microbes and tooth surfaces are negatively charged. As they are immersed in a fluid (saliva) system which is rich in calcium and other counterions, these negative charged surfaces attract and mobilize cations. As a result, a double charged layer is formed (electrical double layer) and this overlap causes a repulsive electrostatic force. Simultaneously, as the bacterium approaches the tooth surface, they also experience a repulsive force (van der Waals force). Finally, the combinations of repulsive and attraction forces known as DLVO theory modulate the microorganism adherence to dental surfaces. This is valid for dental restorative materials as well, and one must consider the fact that it can be more favorable if a porous or irregular surface is facilitating

The first bacteria to attach to the acquired pellicle (layer of glycoproteins) on the tooth surface are called the pioneer species (*Streptococcus oralis*, *Streptococcus mitis*, *Streptococcus sanguis*). Surprisingly, *S. mutans* is not a first colonizer despite its high cariogenic nature. In fact, *S. mutans* is the most studied bacteria in oral microbiology but under clinical environment one

Historically, in Dentistry, the examination of mature oral biofilms started when electron microscope became available for microbiologists [19]. Later, molecular biological tools became popular and new insights about how microbes attach and develop on tooth surfaces were finally confirmed. One "striking" observation was actually a confirmation of an obvious theory that microbes stick to a surface many benefits are obtained: a) selection of sites where they stay in favorable environments, b) these surfaces may have enough substrate or can contribute to diffuse some nutrient and c) the different species often work together and this consortium

More recently, zeta potential, confocal laser scanning microscopy (CLSM) together with fluorescence techniques received attention and became useful techniques to study bacteria adhesion to surfaces [29]. In spite of the great evolution in techniques, many limitations have to be considered when comes to the evaluation of an antimicrobial substances against biofilms development. First, there is still the gap of *in vitro* and *in vivo* environments. *In situ* studies can overcome some of these limitations but other drawbacks cannot be ruled out. Most studies on bacteria adhesion to surfaces were carried out under *in vitro* conditions which do not reflect the real life. Secondly, there is the paradox of testing planktonic cells but interpretations are generalized to conditions of biofilm formation. It is well established that biofilms express genes different from those of planktonic cells. Moreover, it has been observed that biofilm cells are generally believed to closely resemble planktonic cells in stationary phase. However, biofilms were found to more closely resemble to planktonic cells at exponentially growing than those of planktonic cells in the stationary phase [19,20]. In addition, it cannot be ruled out the differences between single species biofilm versus multispecies biofilms since under laboratory

two other distinct phases or behavior: spreading and dispersal of microorganisms.

bacterial adherence [3,13-16].

68 Emerging Trends in Oral Health Sciences and Dentistry

must consider that a multispecies biofilm is operating [3,9].

provides physical support and protection [20-29].

**Figure 2.** Schematic representation of the development of an oral biofilm and the potential of antimicrobials to inter‐ fere on this process when releasing some antimicrobial element or substance [13-18]

conditions monospecies biofilm can survive for only 72 hours in absence of sugar. The duration of survival can be extended with addition of mucin, but how close is this to the real oral mouth of a patient? [21] Another flow systems versus static models, pre-treatment of acquired pellicle or no pre-treatment at all. [22]. Finally, a crucial point is: how to validate microbial growth? BacLight staining techniques only measure the presence of intact membranes and may not correlate with the culturability or viability of bacteria from oral biofilms [23].

After all these relevant methodological points, more questions marks can be attributed on how to evaluate antimicrobial agents against biofilms. In addition to evaluate the effects in biofilms itself, one must consider the understanding of suitable methods related to the incorporation of antimicrobials into these dental restorative materials. For instance, the concentration of the antimicrobial agent, the volume or amount of material to be included and how far these substances can interfere on mechanical and esthetic features of a restoration [21-26].

Considering the presence of a mature biofilm covering a dental restoration, it must be pointed out that a major requirement of the final formulation is to deliver sufficient concentration of the inhibitor in the surroundings. Moreover, the antimicrobial effect must be kept on a prolonged time or at least for a enough period of time that will maintain an effective dose operating. This point is quite important since oral bacteria do not live as independent entities. So, as highlighted previously, a high resistance to antibiotics is likely to occur [27-30].

Along the last decades biofilms have been studied extensively because they are present in several surfaces, such as all solid surfaces in the oral cavity, in biomateriais implanted in the human body, in catheter surfaces, in water pipes [24]. After the establishment of a biofilm on dental restorations, deterioration of the outer layer surface of these materials will take place and facilitate bacteria adhesion [25]. On the other hand, the possibility that dental restoring materials can deliver antimicrobials may reduce considerably the risk of secondary caries in spite of the limitations of some dental materials.

## **3. Antimicrobials in dental materials: How much is enough versus how much is safe?**

Oral bacteria can attach to many restorative materials like amalgam, gold, ceramics, resin composite, glass ionomer cements. In order to achieve long-term success of dental fillings there are many requirements. Some are related to the professional ability in manipulating and polishing these materials. However, some considerations rely on physical, chemical and biological characteristics of the dental material used. Surface roughness is not the focus of this review, but it may be influenced by the interplay of professionals' ability as well as dental materials features.

The incorporation of 5, 10, 15 up to 30% of antimicrobial compounds or substances into dental materials have been proposed [24-30]. However, the higher amount of antimicrobial agents, the higher is the risk to loose important features in dental restoration as biocompatibility and resistance. Hence, how much is enough and how much is safe? In the literature, addition of 1.5% can be effective if the antimicrobial is potent enough [27].

Figure 3 presents this dilemma related to the interference of "extra" substances to be incorpo‐ rated into dental materials and limitations regarding the loss of important features of the material.

An interesting report showed that incorporation of 1% chlorhexidine (CHX) diacetate in GIC (glass ionomer cements) is optimal for clinical use. This is valid in terms of antimicrobial activities, CHX-release pattern, physical properties and bonding ability to tooth surfaces [28]. An additional valuable information was the conclusion that incorporation of CHX diacetate at 2% or greater values of percentage participation significantly decreased compressive strength and adversely affected bond strength to dentin.

It has been observed that some dental materials (e.g. gold and its alloys) are naturally able to kill bacteria in the adhering biofilms [29]. Glass ionomer cements (GIC) are recognized for releasing fluoride ions that can modulate biofilm formation [27,30]. The point is that this is not enough since GIC reduces its ability to release fluoride in short periods. So, it is expected that dental restoration with antimicrobial properties may have extended potential for inhibiting biofilm formation in a long-term basis.

operating. This point is quite important since oral bacteria do not live as independent entities.

Along the last decades biofilms have been studied extensively because they are present in several surfaces, such as all solid surfaces in the oral cavity, in biomateriais implanted in the human body, in catheter surfaces, in water pipes [24]. After the establishment of a biofilm on dental restorations, deterioration of the outer layer surface of these materials will take place and facilitate bacteria adhesion [25]. On the other hand, the possibility that dental restoring materials can deliver antimicrobials may reduce considerably the risk of secondary caries in

**3. Antimicrobials in dental materials: How much is enough versus how**

Oral bacteria can attach to many restorative materials like amalgam, gold, ceramics, resin composite, glass ionomer cements. In order to achieve long-term success of dental fillings there are many requirements. Some are related to the professional ability in manipulating and polishing these materials. However, some considerations rely on physical, chemical and biological characteristics of the dental material used. Surface roughness is not the focus of this review, but it may be influenced by the interplay of professionals' ability as well as dental

The incorporation of 5, 10, 15 up to 30% of antimicrobial compounds or substances into dental materials have been proposed [24-30]. However, the higher amount of antimicrobial agents, the higher is the risk to loose important features in dental restoration as biocompatibility and resistance. Hence, how much is enough and how much is safe? In the literature, addition of

Figure 3 presents this dilemma related to the interference of "extra" substances to be incorpo‐ rated into dental materials and limitations regarding the loss of important features of the

An interesting report showed that incorporation of 1% chlorhexidine (CHX) diacetate in GIC (glass ionomer cements) is optimal for clinical use. This is valid in terms of antimicrobial activities, CHX-release pattern, physical properties and bonding ability to tooth surfaces [28]. An additional valuable information was the conclusion that incorporation of CHX diacetate at 2% or greater values of percentage participation significantly decreased compressive

It has been observed that some dental materials (e.g. gold and its alloys) are naturally able to kill bacteria in the adhering biofilms [29]. Glass ionomer cements (GIC) are recognized for releasing fluoride ions that can modulate biofilm formation [27,30]. The point is that this is not enough since GIC reduces its ability to release fluoride in short periods. So, it is expected that dental restoration with antimicrobial properties may have extended potential for inhibiting

1.5% can be effective if the antimicrobial is potent enough [27].

strength and adversely affected bond strength to dentin.

biofilm formation in a long-term basis.

So, as highlighted previously, a high resistance to antibiotics is likely to occur [27-30].

spite of the limitations of some dental materials.

70 Emerging Trends in Oral Health Sciences and Dentistry

**much is safe?**

materials features.

material.

**Figure 3.** Schematic representation for understanding the effects of external substances and compounds when incorpo‐ rated into regular dental materials.

In addition to chemical changes due to incorporation of antimicrobials into dental restorative materials, there is also the problem of chemical changes also interfere in the distribution of masticatory forces applied on a tooth. For instance, the presence of a carious lesion in molar tooth can demand fast treatment protocol for the affected area and depending on the lesion extension, it must receive a temporary filling [31-34]. In general, temporary filling materials are typically made from a combination of zinc oxide and eugenol which has good antimicrobial activity. Eugenol is also important due to its sedative properties. The zinc oxide powder is a very versatile compound that can present different properties when combined with various agents. When mixed together, the material starts off soft and in few minutes it becomes more hard and brittle. However, this mixture is not harder enough to be compared to regular dental fillings and its far from restoring tooth hardness. This material is classified as intermediate restorative material (IRM) and it is a good example that the beneficial aspects of antimicrobial and anti-inflammatory properties are achieved while mechanical properties of resistance become very low. Therefore, this material must be accepted as a temporary and not a definite filling material. Under the influence of masticatory forces, as previously mentioned, there will be a stress in the remaining parts of the dental element that will certainly compromise the longevity of the restoration as well as the whole tooth structure [31-34].

A comparative study analysing deformations done through Finite Element Method (FEM) and applying the software ANSYS shows the differences in compressive loads between sound and restored teeth with intermediate restorative materials (IRM), see figure 4A and 4B. It is shown that the restored tooth IRM (figure 4B) is deformed in a different way when compared to the sound tooth (4A). Figure 5 shows this simulation evaluating a map of tension for both conditions: A (sound tooth) and B (restored).

**Figure 4.** Sites of deformations in sound and IRM restored teeth.

**Figure 5.** Sites of tensions in sound and IRM restored teeth.

As expected, the analysis shows that the distribution of forces in the interior of the teeth flows in different patterns. As a result, the restored tooth experiences a higher stress in some parts. Basically, these maps show compressive forces throughout the whole sound tooth (A) whereas for restored teeth tensile stress forces are observed.

It well is established that development of a numerical model as FEM makes it possible to quantify and evaluate masticatory loads [34]. However, few studies have considered the influence of antimicrobials in dental restorations. One must bear in mind that a good balance has to be achieved between the beneficial aspects of having an "antibacterial restoration" compared do a regular one. Certainly the size and shape of the restoration are important variables but interesting results can be obtained by these simulations.

It is important to realize that the changes in the map of tensions are directly related to the changes in the physical constitution of the tooth because in this case, the dental enamel was substituted by a restorative material. This change cannot necessarily be attributed to a change of forces because the molar frequently will be constantly submitted to the same masticatory forces it was receiving before the carious lesion. As shown in figure 5, the red colour of the figure 5B indicates a significant higher tension the 5A. The structural fatigue is the main mechanism of collapse of the reminiscent dental tissue and this process can be aggravated when it is submitted to long treatment periods, particularly if IRM is used. In other words, the IRM used as temporary fillings must have a short life because they reduce the mechanical efficiency of the teeth in spite of its beneficial support to control biofilm formation.

According to Noort (2013) [35], there is a subtle distinction between safety and biocompatibility two important features of dental materials. Safety is concerned with the fact that materials when in contact with the human body should not cause any adverse effect, whereas biocom‐ patibility is the quality of being non-destructive in the biological environment maintaining the beneficial effect to the patient. So far, few materials can be regarded as completely safe and fully biocompatible in the oral environment. Most dental materials interact with the oral environment and this interaction might be a release of components with undesirable side effects for oral tissues.

## **4. Dental restorative materials with antimicrobials**

sound tooth (4A). Figure 5 shows this simulation evaluating a map of tension for both

As expected, the analysis shows that the distribution of forces in the interior of the teeth flows in different patterns. As a result, the restored tooth experiences a higher stress in some parts. Basically, these maps show compressive forces throughout the whole sound tooth (A) whereas

It well is established that development of a numerical model as FEM makes it possible to quantify and evaluate masticatory loads [34]. However, few studies have considered the influence of antimicrobials in dental restorations. One must bear in mind that a good balance has to be achieved between the beneficial aspects of having an "antibacterial restoration"

conditions: A (sound tooth) and B (restored).

72 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 4.** Sites of deformations in sound and IRM restored teeth.

**Figure 5.** Sites of tensions in sound and IRM restored teeth.

for restored teeth tensile stress forces are observed.

Dental materials must simulate dental structure and have to restore the anatomy and the function of affected dental surfaces due to dental caries or trauma. However, the desirable aesthetics and the concerns with biocompatibility have not been forgotten and this is valid for resin composite, glass ionomer cements and IRM (MJÖR et al., 1990). It must be highlighted that bone and dentin can be considered as natural composites, whose main constituents are collagen (polymer) and apatite (a ceramic) [35].

Metals have been used for centuries as antimicrobial agents and they continue to be useful at the present time. Silver, copper, gold, titanium and zinc are the most common exam‐ ples in Dentistry [36]. Dioxide of titanium has been used as whitening agent. However, silver and copper has been receiving larger attention due to their antimicrobial proper‐ ties. As a result, these metals are incorporate to several dental products to control halito‐ sis and dental biofilms [5].

As for dental resins, GIC and IRM, these materials are probably the best examples of improve‐ ment of restorative materials that has contributed to the recovery of ideal anatomical form and function with less removal of tooth structure. The use of "fluoride-release" materials, "smartmaterials" and "bio-active" materials are some desirable features that are becoming necessary in many clinical situations because minimally invasive treatment of carious lesions is much more acceptable nowadays. Probably, the first experiences to produce a useful "smartmaterial" were related to the concept that fluoride-releasing materials. Glass ionomer cements do not undergo great dimensional changes in a moist environment and exhibit noticeable shrinkage in a dry environment at temperatures higher than 50°C, which is similar to the behavior of dentin [37]. This is a good example of biocompatibility.

Attempts to improve GIC have been quite successful. There is one report indicating that zinc addition to GIC can decrease microorganisms growth and improve fluoride release, without significantly affecting the materials' flexural strength and solubility [38]. In another report, conventional glass ionomer cement (GIC) liner was mixed with different antibiotics such as metronidazole, ciprofloxacin and cefaclor to produce an antibacterial GIC. After an *in vitro* evaluation of infected dentin sealed with this product, there was a 98.6% decrease in micro‐ organisms, bacterial aggregates, and intertubular dentin with exposed collagen fibers and dentinal tubules [41]. When conventional GIC was added with 1.5, 3.0 and 4.5% of ciproflox‐ acin, metronidazole and minocycline this material was effective for inhibiting *S. mutans* and *L. casei*, and the addition of a 1.5% antibiotic mixture was optimal to provide appropriate physical and bonding properties [39]. For more than a decade, several reports in the literature has been demonstrating antibacterial activity against *S. mutans*, *S. oralis*, *S. salivarius* and Streptococcus sp when GIC are reinforced with antimicrobials or due to fluoride or pH equilibrium [7, 40-44]. It has been claimed that GIC has the ability to increase pH and this is likely to be an important mechanism of caries protection under clinical conditions since oral bacteria can produce lactic acid [43].

The resin composites have been used, frequently, as restoring material due to its great aesthetics and physiologic properties [44]. More recently, incorporation of 12-methacryloy‐ loxydodecylpyridinium bromide, a monomer also known as MDPB showed good results for its antibacterial activity when incorporated in bonding agents [28].

However, instead of releasing an antimicrobial substance, the strategy to incorporate them to act as part of its structure is also possible. In this perspective, nanoparticles can provide good optical properties for conventional and hybrid composites [45]. However, there is still a lack of studies in the literature showing the beneficial aspects for placing such material in a dental cavity. For instance, it is still unknown how effective these materials can inhibit caries activity close to restorations when active bioparticles are incorporated into these resins [46-48]. As a general observation, it must be highlighted that there are many in vitro studies but very few clinical trials to support their use under regular clinical activity [46].

Finally, it can be stated that two main approaches can be presented when antimicrobial bioactive materials are prepared. One approach is to prepare a substance-release material (e.g. GIC). Another perspective is to incorporate the antimicrobial to be active being part of its structure without any release of active component. Basically, this latter option is of outmost importance since the release of a substance implies in loss of matter and in theoretical basis this means some loss in mechanical properties. Taking into account that GIC acts as battery charges for fluoride, it must be pointed out that "recovery" of fluoride ions does not reach original levels [47-49]. Hence, other advantages have to be operating to consider this material as a good option for dental restorations.

Another point to be considered is the fact concentrations of substances released from some dental materials such as GIC materials were not different, regardless of the amount of antimicrobial substance incorporated. Thus, as long as the antimicrobial is not interfering in the mechanical properties, an increase in the amount of antimicrobial drug will not provide additional benefits.

## **5. Dental restorative materials with nanoparticles**

more acceptable nowadays. Probably, the first experiences to produce a useful "smartmaterial" were related to the concept that fluoride-releasing materials. Glass ionomer cements do not undergo great dimensional changes in a moist environment and exhibit noticeable shrinkage in a dry environment at temperatures higher than 50°C, which is similar to the

Attempts to improve GIC have been quite successful. There is one report indicating that zinc addition to GIC can decrease microorganisms growth and improve fluoride release, without significantly affecting the materials' flexural strength and solubility [38]. In another report, conventional glass ionomer cement (GIC) liner was mixed with different antibiotics such as metronidazole, ciprofloxacin and cefaclor to produce an antibacterial GIC. After an *in vitro* evaluation of infected dentin sealed with this product, there was a 98.6% decrease in micro‐ organisms, bacterial aggregates, and intertubular dentin with exposed collagen fibers and dentinal tubules [41]. When conventional GIC was added with 1.5, 3.0 and 4.5% of ciproflox‐ acin, metronidazole and minocycline this material was effective for inhibiting *S. mutans* and *L. casei*, and the addition of a 1.5% antibiotic mixture was optimal to provide appropriate physical and bonding properties [39]. For more than a decade, several reports in the literature has been demonstrating antibacterial activity against *S. mutans*, *S. oralis*, *S. salivarius* and Streptococcus sp when GIC are reinforced with antimicrobials or due to fluoride or pH equilibrium [7, 40-44]. It has been claimed that GIC has the ability to increase pH and this is likely to be an important mechanism of caries protection under clinical conditions since oral

The resin composites have been used, frequently, as restoring material due to its great aesthetics and physiologic properties [44]. More recently, incorporation of 12-methacryloy‐ loxydodecylpyridinium bromide, a monomer also known as MDPB showed good results for

However, instead of releasing an antimicrobial substance, the strategy to incorporate them to act as part of its structure is also possible. In this perspective, nanoparticles can provide good optical properties for conventional and hybrid composites [45]. However, there is still a lack of studies in the literature showing the beneficial aspects for placing such material in a dental cavity. For instance, it is still unknown how effective these materials can inhibit caries activity close to restorations when active bioparticles are incorporated into these resins [46-48]. As a general observation, it must be highlighted that there are many in vitro studies but very few

Finally, it can be stated that two main approaches can be presented when antimicrobial bioactive materials are prepared. One approach is to prepare a substance-release material (e.g. GIC). Another perspective is to incorporate the antimicrobial to be active being part of its structure without any release of active component. Basically, this latter option is of outmost importance since the release of a substance implies in loss of matter and in theoretical basis this means some loss in mechanical properties. Taking into account that GIC acts as battery charges for fluoride, it must be pointed out that "recovery" of fluoride ions does not reach original levels [47-49]. Hence, other advantages have to be operating to consider this material

behavior of dentin [37]. This is a good example of biocompatibility.

its antibacterial activity when incorporated in bonding agents [28].

clinical trials to support their use under regular clinical activity [46].

bacteria can produce lactic acid [43].

74 Emerging Trends in Oral Health Sciences and Dentistry

as a good option for dental restorations.

Nanoparticles are generally defined as particles that are smaller than 100 nanometers in diameter. So, in order to provide a good perspective, it can be emphasized that nanotechnology deals with structures as small as 10-9 m while oral bacteria reach a size of 10-6 m. Although there is a large difference in size, the improvements of many technologies in the 1980s made possible the combination of these two worlds. Many researchers' points out that nanotech‐ nology has been applied for dental materials as an innovative concept for the development of materials with better properties including the anti-caries effect [5,45,49].

It is recognized that many nanoparticles do have a great antimicrobial activity, particularly if it is a metallic nanoparticles. The antimicrobial activity of many types of nanoparticle is certainly a function of their size but other features are important such as high surface area, unusual crystal morphologies (edges and corners) and reactive sites.There is a great difference of a regular metal and a 10-9 m particles when incorporated into dental materials. Consequent‐ ly, their properties can radically change, as hardness, area of active surface, chemical reactivity and biological activity [26].

The inverse relationship between the size of some particles and its antimicrobial activity has been demonstrated for particles of up to 10 nm were tested against *Escherichia coli* [50]. Thus, this might be valid for nanoparticles as well. The main mechanism or mechanisms behind the antimicrobial activity of nanoparticles are not fully elucidated. Hence, several studies focusing on the antimicrobial activity of different metals and metallic nanoparticles against oral microorganisms have to be performed for a clear picture on this matter. Another point to be considered is the effectiveness of these nanoparticles to control the development of a biofilm. Considering that biofilms are rather organized and can avoid the penetration of big molecules (e.g. chlorhexidine) the small size of these particles can be advantageous. However, so far these particles have been introduced into prosthetic devices coatings and oral care products. The strategy for placing them within dental materials is currently being explored in vitro and more research is needed to consider their regular use in the dental clinic.

Basically, the most promising nanoparticles are: silver, zinc oxide, calcium-phosphates [5]. Nevertheless, is must be also known that an interesting systematic map demonstrated that there is currently a limited amount of information concerning the release of nanoparticles from polymer-based dental materials. After reviewing 140 full-text articles on this matter, only 3 were regarded as methodological sound. Actually, a passive release of nanoparticles from a polymer-based dental material was not observed by the investigated reports. [51]. Table 1 summarizes some important features of these materials when present within dental materials.


**Table 1.** Observations and conclusions related to nanoparticles incorporated into dental materials.

### **6. Final considerations**

The oral environment imposes difficulties when it is designed a study for evaluating dental materials [3,9,10,25]. Since 1950´s it is know that microbial microleakage at the cavity wall/ material interface is a problem to restoration survival. The persistence of microorganisms underneath fillings is also recognized as a serious problem in restorative dentistry. The antibacterial properties of restorative materials can substantially influence the success of a dental filling in the oral cavity. The frequent problem is that dental materials "natural" antibacterial properties are not enough to cope with the facility of biofilm formation. Thus, the incorporation of antimicrobials in restorative materials has to take into account the properties of each dental material. For instance, restorations of glass-ionomer cements are based on an acid-base reaction between a polyacrylic acid solution and fluoroaminosilicate glass particles. This reaction yields a structure that is more stable than composites. As a result, by adhering to tooth structure the glass-ionomer cements potentially reduces microleakage. This is an important property since it can enhance fluoride release. So, why not incorporating antibiotics as well? Hence, glass ionomer cements are strong candidates to have antimicrobials incorpo‐ rated as long as it does not disturb the acid-base reaction. On the other hand, resin composites are much better materials considering aesthetic properties. Finally, coatings killing bacteria upon contact seems to be more promising than antimicrobial-releasing coatings. However, many in vitro studies cannot support the findings that are observed *in vivo*. This observation suggests that more clinical research is needed to clarify this issue. Hence, clinical research on this topic is of outmost relevance for minimum intervention restorative techniques in dentistry and for promoting oral health. Another point to consider is the challenge for the future dental materials with antimicrobials properties: to develop even more effective materials that are able to improve clinical antimicrobial efficacy while still preserving the benefits of the normal, resident oral microflora.

## **Author details**

**Nanoparticles Observations References**

• Incorporated into dental adhesives could reduce *S. mutans* close to

• Concentrations of 0.5-1% provided antimicrobial activity with preservation of aesthetic and mechanical properties of dental materials (resin composites). • Future research must focus on silver-biofilm interaction and silver-

• The mechanism of action may be attributed to oxidative stress by H2O2 and

• Incorporated into dental materials ZnO may release Zn2+ which interferes in sucrose metabolism and magnesium depletion that is important for biofilm

• Future research must focus on the determination of ideal concentrations of nanoparticles in order to have antimicrobial activity without compromising

• This compound was selected due to its good antimicrobial activity and because it can be copolymerized with other monomers providing a strong bonding system with the material. However, difficulties in controlling the

• The hydrophobic nature and positive charge of these nanoparticles may

• These compounds can interfere on adherence and growth of *Streptococcus*

• The resin composites with these nanoparticles can increase up to four times the capacity of remineralization of the enamel in comparison with the

• Hydroxyapatite nanocrystals may interact with bacterial adhesins and can

The oral environment imposes difficulties when it is designed a study for evaluating dental materials [3,9,10,25]. Since 1950´s it is know that microbial microleakage at the cavity wall/

• Future research must focus on efficacy of products that are already available in the market such as casein phosphopeptide (CPP)-amorphous and

**Table 1.** Observations and conclusions related to nanoparticles incorporated into dental materials.

• Future research must focus on kinetics to optimize the release

[5,26,49, 52-59]

[5,26,49, 58, 60, 61]

[5,26,63-65]

[5,26,66-71]

resulting in cell death.

76 Emerging Trends in Oral Health Sciences and Dentistry

orthodontic brackets.

polimerization processes of dental materials.

structural changes in cell wall.

mechanical properties of the materials.

enhance the antimicrobial activity.

release of such agents may be a potential drawback.

equilibrium.

characteristics.

composites with fluoride.

reduce bacterial adherence to dental surfaces.

calcium phosphate (ACP) nanocomplex.

*mutans*.

**6. Final considerations**

• It may provoke structural changes and damage bacterial membranes,

Silver

Zinc oxide

Quaternary Ammonium

Calciumphosphates J.M.F.A. Fernandes1 , V.A. Menezes1 , A.J.R. Albuquerque2 , M.A.C. Oliveira3 , K.M.S. Meira3 , R.A. Menezes Júnior4 and F.C. Sampaio2,3\*

\*Address all correspondence to: fcsampa@gmail.com

1 Post-graduation in Pediatric Dentistry, Faculty of Dentistry, University of Pernambuco, Camaragibe, Pernambuco, Brazil

2 RENORBIO, Northeast Network of Biotechnology, Federal University of Paraiba, Biotech‐ nology Centre, Campus I, Joao Pessoa, Paraiba, Brazil

3 Post-graduation in Dentistry, Health Science Center, University of Paraíba, João Pessoa, Paraíba, Brazil

4 Alternative and Renewable Energy Center, Department of Renewable Energy Engineering, Federal University of Paraíba, João Pessoa, Paraíba, Brazil

#### **References**


[17] Bowen WH, Koo H. Biology of Streptococcus mutans-Derived Glucosyltransferases: Role in Extracellular Matrix Formation of Cariogenic Biofilms. Caries Research 2011; 45:69-86.

**References**

2009.

2010; 89:1175–86.

78 Emerging Trends in Oral Health Sciences and Dentistry

4:131-48.

46:39-56.

2011 May; 36(5):347-55.

[1] Gharechahi M, Moosavi H, Forghani M. Effect of surface roughness and materials

[3] Marsh PD, Martin M. Oral microbiology, 5th ed. Oxford, UK: Churchill; Livingstone;

[4] Fejerskov O, Kidd E. Dental caries: the disease and its clinical management. 2nd ed.

[5] Allaker RP. The use of nanoparticles to control oral biofilm formation. J Dent Res

[6] von der Fehr FR, Löe H, Theilade E. Experimental caries in man. Caries Res 1970;

[7] Naik S, Sureshchandra B. Antimicrobial efficacy of glass ionomers, composite resin, liners & polycarboxylates against selected stock culture microorganisms: an in vitro

[9] Marsh PD. Dental plaque: biological significance of a biofilm and community life-

[10] Fine DH, Markowitz K, Furgang D, Goldsmith D, Ricci-Nittel D, Charles CH, et al. Effect of rinsing with an essential oil-containing mouthrinse on subgingival perio‐

[11] Zobell CE. The effect of solid surfaces upon bacterial activity. J Bacteriol 1943;

[12] Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of per‐

[14] Renner LD, Weibel DB. Physicochemical regulation of biofilm formation. MRS Bull

[15] Petersen FC, Tao L, Scheie AA. DNA binding-uptake system: a link between cell-to-

[16] Witchurch CB, Tolker-Nielsen T, Ragas PC, Mattick JS. Extracellular DNA required

cell communication and biofilm formation. J. Bacteriol 2005; 187:4392.

for bacterial biofilm formation. Science 2002; 295:1487.

[13] Tuson HH, Weibel DB. Bacteria–surface interactions. Soft Matter 2013; 9:4368-80.

[8] Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007; 369:51-9.

[2] Marsh PD. Contemporary perspective on plaque control. Br Dent J 2012; 22:601-6

composition on biofilm formation. JBNB 2012; 3:541-6.

Oxford, UK: Blackwell Munksgaard; 2011.

study. Endodontology 2012; 24(2):21-8.

style. J Clin Periodontol 2005; 32:7−15.

dontopathogens. J Periodontol 2007; 78:1935−42.

sistent infections. Science 1999; 284:1318-22.


[45] Hamouda IM. Current perspectives of nanoparticles in medical and dental biomate‐ rials. J Biomed Res 2012;26:143–151. http://www.readcube.com/articles/10.7555/JBR. 26.20120027 (accessed 02 September 2014).

[31] Lin CL, Chang CH, Wang CH, Ko CC, Lee HE. Numerical investigation of the factors affecting interfacial stresses in an MOD restored tooth by auto-meshed finite element

[32] Toparli M, Gokay N, Aksoy T. Analysis of a restored maxillary second premolar tooth by using three-dimensional finite element method. J Oral Rehabil 1999;

[33] Farah JW, Craig RG. Finite element stress analysis of restored axisymmetric first mo‐

[34] Williams KR, Edmundson JT, Rees JS. Finite element stress analysis of restored teeth.

[35] Noort R. Introduction to dental materials. 4th ed. Edinburgh; New York: Mosby

[36] Giertsen E. Effects of mouthrinses with triclosan, zinc ions, copolymer, and sodium lauryl sulphate combined with fluoride on acid formation by dental plaque in vivo.

[37] Khoroushi M, Keshani F. A review of glass-ionomers: From conventional glass-ion‐

[38] Osinaga PW, Grande RH, Ballester RY, Simionato MR, Delgado Rodrigues CR, Muench A. Zinc sulfate addition to glass-ionomer-based cements: Influence on phys‐ ical and antibacterial properties, zinc and fluoride release. Dent Mater. 2003; 19:212–7

[39] Yesilyurt C, Er K, Tasdemir T, Buruk K, Celik D. Antibacterial activity and physical properties of glass-ionomer cements containing antibiotics. Oper Dent 2009; 1:18-23.

[40] Nakajo K, Imazato S, Takahashi Y, Kiba W, Ebisu S, Takahashi N. Fluoride Released from Glass-Ionomer Cement Is Responsible to Inhibit the Acid Production of Caries-

[41] Ferreira JMS, Pinheiro SL, Sampaio FC, Menezes VA. Use of glassionomer cement containing antibiotics to seal off infected dentin: a randomized clinical trial. Brazilian

[42] Jedrychowski JR, Caputo AA, Kerper S. Antibacterial and mechanical properties of restorative materials combined with chlorhexidines. J Oral Rehabil 1983; 10:373-381.

[43] Nicholson JW, Aggarwal A, Czarnecka B, Li-manowska-Shaw H. The rate of change of pH of lactic acid exposed to glass-ionomer dental cements. Biomaterials 2000;

[44] Konradsson K. Influence of a dental ceramic and a calcium aluminate cement on den‐ tal biofilm formation and gingival inflammatory response. Dissertation (Master De‐

omer to bioactive glass-ionomer. Dent Res J. 2013; 10(4): 411-20.

Related Oral Streptococci. Dental Materials 2009; 25(6):703-8.

gree in Odontology). Umeå University, Sweden; 2007.

method. J Oral Rehabil 2001; 28:517-25.

lar. J Dent Res 1974; 53:859-66.

Dent Mater 1987; 3:200-6.

80 Emerging Trends in Oral Health Sciences and Dentistry

Caries Res 2004; 38(5):430-5.

Dental Journal. 2013; 24(1):68-73.

21(19):1989-93.

26:157-64.

Elsevier, 2013.


## **Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of Recent Evidences in This Field**

Mariana Minatel Braga, Isabela Floriano, Fernanda Rosche Ferreira, Juliana Mattos Silveira, Alessandra Reyes, Tamara Kerber Tedesco, Daniela Prócida Raggio, José Carlos Pettorossi Imparato and Fausto Medeiros Mendes

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59600

## **1. Introduction**

[61] Gu H, et al. Effect of ZnCl2 on plaque growth and biofilm vitality. Arch Oral Biol

[62] Vaidyanathan M, et al. Antimicrobial properties of dentine bonding agents deter‐

[63] Imazato S, et al. Antibacterial resin monomers based on quaternary ammonium and

[64] Zhang K, et al. Effect of water-ageing on dentine bond strength and anti-biofilm ac‐ tivity of bonding agent containing new monomer dimethylaminododecyl methacry‐

[65] Cheng L, Weir MD, Xu HHK, Antonucci JM, Kraigsley AM, Lin NJ, Lin-Gibson S, Zhou X. Antibacterial amorphous calcium phosphate nanocomposites with a quater‐ nary ammonium dimethacrylate and silver nanoparticles. Dent Mater 2012;

[66] Xu HHK, Moreau JL, Sun L, Chow LC. Strength and fluoride release characteristics of a calcium fluoride based dental nanocomposite. Biomaterials Nov 2008; 9(32):

[67] Moreau JL, Sun L, Chow LC, Xu HHK. Mechanical and acid neutralizing properties and bacteria inhibition of amorphous calcium phosphate dental nanocomposite. J Bi‐

[68] Hannig C, Hannig M. Natural enamel wear: a physiological source of hydroxylapa‐ tite nanoparticles for biofilm management and tooth repair? Medical Hypothese.

[69] Venegas SC, Palacios JM, Apella MC, Morando PJ, Blesa MA. Calcium modulates in‐ teractions between bacteria and hydroxyapatite. J Dent Res 2006; 85:1124-8.

[70] Arcís RW, López-Macipe A, Toledano M, Osorio E, Rodríguez-Clemente R, Murtra J, Fanovich MA, Pascual CD. Mechanical properties of visible light-cured resins rein‐ forced with hydroxyapatite for dental restoration. Dent Mater Jan 2002; 18(1):49-57.

[71] Chen M. Novel strategies for the prevention and treatment of biofilm related infec‐

omed Mater Res B Appl Biomater Jul 2011; 98(1):80-8.

tions. Int J Mol Sci 2013; 14(9):18488-501.

mined using *in vitro* and *ex vivo* methods. J Dent 2009; 37:514-21.

their benefits in restorative dentistry. Jpn Dent Sci Rev 2012; 48:115–25.

2012; 57:369-75.

82 Emerging Trends in Oral Health Sciences and Dentistry

28:561-72.

4261-7.

2010; 74:670-2.

late. J Dent 2013; 41:504-13.

Approximal surfaces have been pointed as a challenge regarding the control of caries lesions in primary teeth, specially due to the larger area of contact between adjacent teeth and limited salivary access [1, 2]. In addition, children can present less dexterity to using dental floss and depend on parent's collaboration to remove interproximal dental plaque [3]. Therefore, poor compliance to flossing by children [4] seems to contribute to make the arrestment of approx‐ imal caries lesions more difficult. Consequently, identifying and understanding attitudes towards flossing are very important tasks to aid health professionals for flossing orientation and its incentive [4].

Several evidences have been published recently as promising alternatives in order to deal with approximal caries lesion in primary teeth and minimize the effects of poor compliance with flossing and/or repair eventual irreversible dental decay caused by caries progression.

Minimally invasive interventions have been proposed to caries lesion management, compris‐ ing early detection, preventive procedures and minimal invasion [5]. This approach also proposes to minimize the discomfort of patient [6], specially to deal with pediatric patients' dental anxiety and fear [7]. However, even considering minimal invasive treatments, there are operational differences among them that could interfere on children's discomfort and accept‐ ability. Indeed, when exploring options for dental treatment, not only the efficacy/effectiveness

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

but also the cost-efficacy/effectiveness and the patient's discomfort/satisfaction should also be comparatively investigated for available approaches.

Based on the exposed above, this chapter aims to present the particularities of dealing with approximal caries lesions and make a critical appraisal concerning effectiveness/efficacy, applicability, utility and clinical relevance of recent published studies and their findings. In this way, we expect to permit the clinicians to choose the best option for treating initial and advanced approximal caries lesions in primary teeth basing your decision-making process on relevant scientific evidences.

## **2. Approximal caries**

Caries lesions (clinical signs of the disease) are developed on the biofilm-tooth interface [8-10] and the key factor of their formation is the presence acid-producing biofilm of the tooth surface [11]. Usually, minerals from oral fluids and tooth are in balance. However, when a tooth surface has biofilm accumulated for some period, changes in pH occur, caused by biofilm bacterial metabolism [8]. These pH fluctuations at biofilm-tooth interface may cause tooth mineral loss when the pH is decreasing (demineralization) or mineral gain when the pH is increasing (remineralization) [12]. When there is a prevalence of demineralization over remineralization, mineral loss is observed and this leads to a caries lesion [8, 13]. Thus, caries lesions start with mineral loss from the tooth surface and, if the biofilm is not removed, they progress until cavitation and tooth destruction.

Considering that the demineralization/remineralization processes occur on the biofilmtooth interface, special attention should be given to the main biofilm stagnation areas, as occlusal surfaces, approximal surfaces and smooth surfaces along the gingival margin. These areas are relatively protected from mechanical wear by tongue, cheeks, abrasive food, and toothbrushing [13].

Since mechanical removal of the stagnated biofilm does not occur, the lactic acid produced by this biofilm acts on enamel and may cause demineralization. As the enamel is constituted by hydroxyapatite crystals, separated from each other by small intercrystalline spaces filled with water and organic material [14], the mineral loss due to caries results on an increase of these intercrystalline spaces, increasing the enamel porosity [15]. The mineral loss is higher in the subsurface of caries lesions and the surface layer thickness of the lesions ranged from 35 to 130 µm. The maximum mineral content in this layer corresponds to 74% to 100% of that of sound enamel [16]. This histopathological process is observed clinically as the formation of white spot lesions. The mentioned mineral loss results in the loss of translucence of the enamel and the opaque appearance of the white-spot lesion [17]. On the approximal surfaces, these lesions developed between the contact point and the gingival margin, resulting in a kidney-shaped white spot lesion (Figure 1). This area is the one most prone to biofilm accumulation on approximal surfaces (Figure 2).

Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of… http://dx.doi.org/10.5772/59600 85

but also the cost-efficacy/effectiveness and the patient's discomfort/satisfaction should also be

Based on the exposed above, this chapter aims to present the particularities of dealing with approximal caries lesions and make a critical appraisal concerning effectiveness/efficacy, applicability, utility and clinical relevance of recent published studies and their findings. In this way, we expect to permit the clinicians to choose the best option for treating initial and advanced approximal caries lesions in primary teeth basing your decision-making process on

Caries lesions (clinical signs of the disease) are developed on the biofilm-tooth interface [8-10] and the key factor of their formation is the presence acid-producing biofilm of the tooth surface [11]. Usually, minerals from oral fluids and tooth are in balance. However, when a tooth surface has biofilm accumulated for some period, changes in pH occur, caused by biofilm bacterial metabolism [8]. These pH fluctuations at biofilm-tooth interface may cause tooth mineral loss when the pH is decreasing (demineralization) or mineral gain when the pH is increasing (remineralization) [12]. When there is a prevalence of demineralization over remineralization, mineral loss is observed and this leads to a caries lesion [8, 13]. Thus, caries lesions start with mineral loss from the tooth surface and, if the biofilm is not removed, they progress until

Considering that the demineralization/remineralization processes occur on the biofilmtooth interface, special attention should be given to the main biofilm stagnation areas, as occlusal surfaces, approximal surfaces and smooth surfaces along the gingival margin. These areas are relatively protected from mechanical wear by tongue, cheeks, abrasive food, and

Since mechanical removal of the stagnated biofilm does not occur, the lactic acid produced by this biofilm acts on enamel and may cause demineralization. As the enamel is constituted by hydroxyapatite crystals, separated from each other by small intercrystalline spaces filled with water and organic material [14], the mineral loss due to caries results on an increase of these intercrystalline spaces, increasing the enamel porosity [15]. The mineral loss is higher in the subsurface of caries lesions and the surface layer thickness of the lesions ranged from 35 to 130 µm. The maximum mineral content in this layer corresponds to 74% to 100% of that of sound enamel [16]. This histopathological process is observed clinically as the formation of white spot lesions. The mentioned mineral loss results in the loss of translucence of the enamel and the opaque appearance of the white-spot lesion [17]. On the approximal surfaces, these lesions developed between the contact point and the gingival margin, resulting in a kidney-shaped white spot lesion (Figure 1). This area is the one most prone to biofilm accumulation on

comparatively investigated for available approaches.

84 Emerging Trends in Oral Health Sciences and Dentistry

relevant scientific evidences.

**2. Approximal caries**

cavitation and tooth destruction.

approximal surfaces (Figure 2).

toothbrushing [13].

**Figure 1.** Approximal caries lesions. Note the shape of this lesion, located contouring the contact point, which is the area where the biofilm usually stagnates.

**Figure 2.** Biofilm accumulation on approximal surfaces. Note other dental surfaces are clean, but the biofilm remains stagnated in approximal areas.

The progression of enamel caries takes place along the enamel prisms, and in the approximal surfaces results on a conical shape [18] (Figure 3 and 4). If the plaque stagnation on caries lesions does not succeed, the lesion may reach the dentinoenamel junction and progress into the dentin [11] (Figure 3). The progression of an enamel lesion into dentine in primary teeth is faster than the observed in permanent ones [19].

There is no consensus in the literature about how does the progression of caries lesions when it reaches the dentinoenamel junction [11, 20]. Nevertheless, it is known that in lesions that reach the dentinoenamel junction, demineralized dentine is present, as part of the progression of enamel lesions [21]. On the other hand, the level of bacterial invasion is very low [22], especially because there is no cavitation. Therefore, it is expected a lower progression com‐ pared to cavitated lesions [23]. As dentine is composed of about 50% of mineral [24], caries progression into dentine tends to be faster than in enamel. As the less demineralized areas are the intertubular dentin composed of a matrix of collagen reinforced by apatite, the deminer‐ alization process tends to follow the direction of dentine tubules, resulting in the typical histology of dentine caries lesions, as you can see in Figure 3.

**Figure 3.** Schematic diagram of approximal caries progression. Different numbers symbolize different areas observed during caries lesion progression. (1- tertiary or reparative dentine, 2 - dentine tubules, 3- affected layer of carious den‐ tine, 4-infected layer of carious dentine 5- enamel lesion) - adapated from Fejerskov et al., 2008 [14].

of enamel lesions [21]. On the other hand, the level of bacterial invasion is very low [22], especially because there is no cavitation. Therefore, it is expected a lower progression com‐ pared to cavitated lesions [23]. As dentine is composed of about 50% of mineral [24], caries progression into dentine tends to be faster than in enamel. As the less demineralized areas are the intertubular dentin composed of a matrix of collagen reinforced by apatite, the deminer‐ alization process tends to follow the direction of dentine tubules, resulting in the typical

**Figure 3.** Schematic diagram of approximal caries progression. Different numbers symbolize different areas observed during caries lesion progression. (1- tertiary or reparative dentine, 2 - dentine tubules, 3- affected layer of carious den‐

tine, 4-infected layer of carious dentine 5- enamel lesion) - adapated from Fejerskov et al., 2008 [14].

histology of dentine caries lesions, as you can see in Figure 3.

86 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 4.** Histological exam of an enamel caries lesion. Note its conical shape, since progression follows the interpris‐ matic spaces.

Substantial demineralization into dentin may be observed despite the absence of cavitation [25]. Nevertheless, if caries lesion progresses continuously into dentine, demineralized enamel may collapse and the intact surface may become cavitated. Thus, bacterial invasion into enamel and proteolytic action of bacterial enzymes mainly on the collagen may occur. If the biofilm stagnation is not controlled, an increase of the cavity size and further biofilm invasion could be expected [26]. When the cavity is present, a most infected dentine could be expected [23], which contribute to faster caries progression.

Two altered zones of dentine could be found in a dentine caries lesion: a superficial infected and a deeper affected layer [27] (Figure 3). The infected dentine consists of irreversibly aciddemineralized dentine, with its collagen degraded and highly contaminated with bacteria [28]. The affected dentine is only minimally infected and has potential to repair under suitable conditions, since their collage structure is maintained [29, 30]. Clinically, the main difference between these zones is the consistency due to the amount of collagen degradation observed in each one. The infected dentine tends to be soft and easily removed with excavators, while the affected dentine is usually harder [29] (Figure 5).

Since the progression of caries lesions is slow, the dentine may react in order to minimize the chance of occurrence of pulp exposition/inflammation. Therefore, highly mineralized peri‐ tubular dentin is secreted and reduces the tubules diameter, decreasing the dentine permea‐ bility and the chance for bacterial contamination [11]. This reaction is usually started since the caries lesion reaches the dentinoenamel junction. However, even considering the slow progression of caries lesions and pulp mechanisms for preventing pulp damage, it is not always possible to avoid the pulp exposure. When the reaction takes time to succeed, this

**Figure 5.** Clinical aspect of infected (a) and affected dentine (b) in dentine caries lesion.

highly mineralized dentine (Figure 6), also called as sclerotic dentine [31], is found in the bottom of the cavities, showing a hard consistency and usually a darker coloration.

**Figure 6.** Histological appearance of sclerotic dentine. Note the different appearance of dentine, evidencing the hyper‐ mineralization of peritubular dentine.

Despite the stage of caries lesion, the presence of biofilm at the tooth surface determines caries progression [32]. Since this biofilm may be controlled, the lesion may be arrested. Therefore, both for non-cavitated and cavitated lesions, the inactivation of caries lesions would be possible, when the control of the biofilm is possible [33]. Since the biofilm control is achieved, the redeposition of mineral is facilitated. This mineral gain tend to reduce enamel porosities [34, 35]. Therefore, active lesions generally exhibits a more porous surface layer than the inactive lesions [16]. In addition, the surface wear/polishing may occur and differences in enamel surface roughness may occur [34, 35]. Due to that, active and inactive lesions tend to be different due to enamel porosity and surfaces wear/polishing (Figure 7). Besides, dentine caries may also be arrested. In these cases, there is an increase in the mineral content in the surface layer of the dentine lesions. The arrested dentine caries lesion presents more mineral‐ ized dentine, the surface is not always infected surface layer and may present sclerotic, harder

highly mineralized dentine (Figure 6), also called as sclerotic dentine [31], is found in the

(a) (b)

**Figure 6.** Histological appearance of sclerotic dentine. Note the different appearance of dentine, evidencing the hyper‐

mineralization of peritubular dentine.

bottom of the cavities, showing a hard consistency and usually a darker coloration.

**Figure 5.** Clinical aspect of infected (a) and affected dentine (b) in dentine caries lesion.

88 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 7.** Active enamel caries on mesial surface of a second primary molar. Note characteristics usually associated with active lesions caused by biofilm stagnation in this area. Despite the absence of the adjacent primary molar, note the remained fragments that make the plaque removal and lesion arrestment more difficult.

**Figure 8.** Active dentine caries on mesial surface of a second primary molar. Note characteristics usually associated with active lesions caused by biofilm stagnation in this area. Despite the absence of the adjacent primary molar, which will permit the mechanical control of local biofilm, this lesion did not have time enough to arrest. In this situation (ab‐ sence of the adjacent tooth), this lesion tend to be arrested. That is why the picture still evidences characteristics of a dentine active lesion.

consistency and, usually, dark colour [36] (Figure 8). Changes observed in inactive dentine lesions may be detected after 6 months. However, hard consistency is usually observed after total arrestment of the lesion, which generally takes years [36].On the other hand, it is worth to state that due to difficulties in controlling the biofilm on approximal lesions, few assessed lesions present the characteristic above, as we are going to discuss in further sections of this chapter (Figures 7 and 8).

## **3. The challenge: Controlling approximal caries lesions**

Approximal surfaces of primary molars present some particularities that expose them to a greater risk of developing caries [1, 37], and, consequently, it is a challenge when controlling caries lesion is needed.

Firstly, approximal surfaces in primary teeth present a large area of contact between them, favoring stagnation of carbohydrates and hindering biofilm removing [1, 2]. Moreover, the salivary access is limited, which contributes to further reduction of the biofilm pH compared to more accessible surfaces, promoting a more acidogenic environment and propitious to the development of caries lesions [1]. In addition, the limited salivary access reduces the exposition of these surfaces to fluorides.

Despite young children usually present wider approximal spaces [38], in most children, the anatomical conditions do not allow that approximal surfaces are cleaned only with brushing, requiring the use of dental floss to remove the biofilm. Besides, the patients' adherence to using dental floss seems to be low [39], mainly regarding children, since they could present less dexterity to flossing and depend on parent's collaboration to remove interproximal biofilm [3, 40]. In fact, a systematic review showed that interproximal caries risk decrease when children's flossing is performed by professional. However, authors suggest these findings cannot be extrapolated, since flossing has only failed when used by the children by themselves [41]. A recent study of our group showed motivational issues are more associated with non compli‐ ance with flossing by children (Figure 9).

The challenge becomes even greater when the initial lesion progresses to cavitated lesion (Figure 10). In addition, the biofilm accumulates inside the lesion and it is not possible to be removed by flossing. Consequently, the dentine inside this cavity tend to become more infected [23] and caries progression is faster. Indeed, the inactivation of cavitated lesions (only by self-removal of biofilm) is usually more observed in smooth or occlusal surfaces. We usually observe that in very small cavities or very large decays, for example. On approximal surfaces, most cavitated caries lesions hardly ever present favorable condi‐ tions to be arrested (Figure 10).

For all these reasons the approximal surfaces of primary molars are the most affected by caries lesions in some populations [1, 42]. Even in regions where this is not occurring, controlling interproximal caries lesions is still a challenge, especially due to the difficulty of the mechanical control of biofilm on such surfaces. That is why many approximal lesions are active lesions, Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of… http://dx.doi.org/10.5772/59600 91

consistency and, usually, dark colour [36] (Figure 8). Changes observed in inactive dentine lesions may be detected after 6 months. However, hard consistency is usually observed after total arrestment of the lesion, which generally takes years [36].On the other hand, it is worth to state that due to difficulties in controlling the biofilm on approximal lesions, few assessed lesions present the characteristic above, as we are going to discuss in further sections of this

Approximal surfaces of primary molars present some particularities that expose them to a greater risk of developing caries [1, 37], and, consequently, it is a challenge when controlling

Firstly, approximal surfaces in primary teeth present a large area of contact between them, favoring stagnation of carbohydrates and hindering biofilm removing [1, 2]. Moreover, the salivary access is limited, which contributes to further reduction of the biofilm pH compared to more accessible surfaces, promoting a more acidogenic environment and propitious to the development of caries lesions [1]. In addition, the limited salivary access reduces the exposition

Despite young children usually present wider approximal spaces [38], in most children, the anatomical conditions do not allow that approximal surfaces are cleaned only with brushing, requiring the use of dental floss to remove the biofilm. Besides, the patients' adherence to using dental floss seems to be low [39], mainly regarding children, since they could present less dexterity to flossing and depend on parent's collaboration to remove interproximal biofilm [3, 40]. In fact, a systematic review showed that interproximal caries risk decrease when children's flossing is performed by professional. However, authors suggest these findings cannot be extrapolated, since flossing has only failed when used by the children by themselves [41]. A recent study of our group showed motivational issues are more associated with non compli‐

The challenge becomes even greater when the initial lesion progresses to cavitated lesion (Figure 10). In addition, the biofilm accumulates inside the lesion and it is not possible to be removed by flossing. Consequently, the dentine inside this cavity tend to become more infected [23] and caries progression is faster. Indeed, the inactivation of cavitated lesions (only by self-removal of biofilm) is usually more observed in smooth or occlusal surfaces. We usually observe that in very small cavities or very large decays, for example. On approximal surfaces, most cavitated caries lesions hardly ever present favorable condi‐

For all these reasons the approximal surfaces of primary molars are the most affected by caries lesions in some populations [1, 42]. Even in regions where this is not occurring, controlling interproximal caries lesions is still a challenge, especially due to the difficulty of the mechanical control of biofilm on such surfaces. That is why many approximal lesions are active lesions,

**3. The challenge: Controlling approximal caries lesions**

chapter (Figures 7 and 8).

90 Emerging Trends in Oral Health Sciences and Dentistry

caries lesion is needed.

of these surfaces to fluorides.

ance with flossing by children (Figure 9).

tions to be arrested (Figure 10).

**Figure 9.** Child using dental floss. Sometimes, children present difficulties in dexterity for flossing. However, motiva‐ tion is often the biggest problem.

**Figure 10.** Cavitated lesion on distal surface of the first primary molar. Note the plaque stagnation inside the cavity, which makes difficult the control of such lesions.

although other surfaces have presented higher rates of caries progression [43]. In fact, smooth surfaces are cleaned easily [43] and lesions are easier to be controlled [44]. Besides, the occlusal surfaces, despite their morphology, are favored by the attrition [43]. In the Figure 2, it is possible to notice the remained biofilm on approximal surface, despite presenting smooth and occlusal surfaces with absence of visible plaque, complicating the control of approximal caries, even in initial stages.

Rates ranging from 70% to 90% of approximal caries progression have been shown for primary teeth after 1 or 2-year-follow-up [45, 46]. These figures have been superior to rates found for permanent teeth [47], that is comprehensible since a faster progression is expected in these teeth [48].

Based on the rationale detailed above, it is evident that controlling approximal caries lesions is really an actual challenge in pediatric clinic. Further, we will discuss about important aspects concerning detection and management of approximal caries lesions in primary teeth.

## **4. How may approximal caries be accurately detected? — Difficulties and important aspects**

Detection of approximal caries lesions has not been a simple task. The simplest and most accepted method for caries detection among children is the visual inspection [49]. On the other hand, it is obvious that the contact between adjacent teeth makes caries detection by visual inspection more difficult. Ideally, approximal surfaces should be examined after cleaning by dental floss (Figure 11). When assessing approximal surfaces looking for caries lesions, it is important to examine, firstly, by an occlusal view. In this view, the dentist will observe the integrity and appearance of the marginal ridge. If a caries lesion is present (usually more advanced ones), cavities (Figure 10) or shadows (Figure 12) may be seen in this area. Further, the surface should be examined by buccal and lingual/palatal view. If caries lesion reaches these areas, it may be also detected by visual inspection (Figure 13). The direct examination of this surface is rare and may only occur when the adjacent tooth is not present (Figure 14).

**Figure 11.** Cleaning the approximal surface before visual examination – note the use of dental floss.

Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of… http://dx.doi.org/10.5772/59600 93

**Figure 12.** Approximal caries lesion evidenced by the shadow we can see above the marginal bridge.

Rates ranging from 70% to 90% of approximal caries progression have been shown for primary teeth after 1 or 2-year-follow-up [45, 46]. These figures have been superior to rates found for permanent teeth [47], that is comprehensible since a faster progression is expected in these

Based on the rationale detailed above, it is evident that controlling approximal caries lesions is really an actual challenge in pediatric clinic. Further, we will discuss about important aspects

**4. How may approximal caries be accurately detected? — Difficulties and**

Detection of approximal caries lesions has not been a simple task. The simplest and most accepted method for caries detection among children is the visual inspection [49]. On the other hand, it is obvious that the contact between adjacent teeth makes caries detection by visual inspection more difficult. Ideally, approximal surfaces should be examined after cleaning by dental floss (Figure 11). When assessing approximal surfaces looking for caries lesions, it is important to examine, firstly, by an occlusal view. In this view, the dentist will observe the integrity and appearance of the marginal ridge. If a caries lesion is present (usually more advanced ones), cavities (Figure 10) or shadows (Figure 12) may be seen in this area. Further, the surface should be examined by buccal and lingual/palatal view. If caries lesion reaches these areas, it may be also detected by visual inspection (Figure 13). The direct examination of this surface is rare and may only occur when the adjacent tooth is not present (Figure 14).

**Figure 11.** Cleaning the approximal surface before visual examination – note the use of dental floss.

concerning detection and management of approximal caries lesions in primary teeth.

teeth [48].

**important aspects**

92 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 13.** Buccal view – lesion may be detected since is extended from mesial into buccal surface.

The visual inspection using a scoring visual system has shown high specificity in caries detection on approximal surfaces [50]. However, lower values of sensitivity should be expected [50]. In other words, most part of non-cavitated approximal caries, as well other several cavitated lesions, cannot be detected when visual inspection is used. Radiographs have shown to increase the sensitivity of caries detection [50, 51]. On the other hand, although some clinical guidelines have recommend taking bitewing radiographs in all children to detect caries lesions in primary molars[52], its utility has been recently questioned, since no additional benefit was observed in comparison to only the visual inspection being performed [53].

**Figure 14.** Direct examination of an approximal caries lesion due to the absence of the adjacent tooth.

Actually, using only visual inspection may lead to higher number of false negatives (some non-evident lesions may be missed). However, these lesions may be arrested by preventive measurements. On the other hand, the radiographs may result in higher number of false positive results, what may be worse, since it might lead to unnecessary operative treatment [53]. In addition, several non-cavitated lesions may have the radiographic appearance of a cavitated lesion (Figure 15). As a consequence of radiographic examination, they might receive unnecessary operative treatment. Weighing the pros and cons of bitewing radiographs for caries detection, it seems more useful to take bitewing radiographs in order to confirm the presence of approximal caries, in cases in which visual signs have been identified (instead of detecting non-evident caries) or to help the choice for the best option for treating an approximal caries [54]. In the last situation, radiographs may help in caries depth assessment and also, in evaluation of the periapical tissue [54].

The presence of cavities has been another concern regarding approximal caries detection, since the cavitation has been considered an important point in the prognosis of these caries lesions. As mentioned, some cavities are not detected by visual examination. Besides, radiographs do not aid in this issue, as exposed before. The temporary separation using orthodontic rubbers is an available alternative [55, 56], which permit the direct visual inspection and tactile examination of the approximal surfaces (Figures 15 to 17). This technique is well-accepted by children [49]. However, it is necessary two appointments to permit the conclusion of diagnostic using this method. Even visuo-tactile assessment of approximal surface is possible; doubts in diagnosis may remain. The inderdental space created after temporary separation is around 0.8 mm [38] and may not always be large enough to guarantee there is no cavity on the surface, nor to affirm the cavity is clinically within enamel. In fact, several dentine lesions are not cavitated. Other dentine lesions may may be associated with microcavities; however, without exposing the dentine. On the other hand, we believe that some cavitations which present radiographic image into dentine may be wrongly scored as cavity clinically restricted to enamel. This is why the limited space reached after teeth separation may be not enough to the Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of… http://dx.doi.org/10.5772/59600 95

**Figure 15.** Direct visual inspection (a) and radiograph (b) of the same surface (distal surface of the second primary mo‐ lar). Clinically, we can see a white spot on the approximal surface (absence of shadows in the marginal bridge) – (a). Radiographically, we evidence a radiolucid image suggestive of caries lesion in dentine. The image might also suggest the presence of cavity (b), that is definitely not evidenced in clinical examination (a). This case represents a false-posi‐ tive result for caries in dentine that could occur in some radiographic examinations.

Actually, using only visual inspection may lead to higher number of false negatives (some non-evident lesions may be missed). However, these lesions may be arrested by preventive measurements. On the other hand, the radiographs may result in higher number of false positive results, what may be worse, since it might lead to unnecessary operative treatment [53]. In addition, several non-cavitated lesions may have the radiographic appearance of a cavitated lesion (Figure 15). As a consequence of radiographic examination, they might receive unnecessary operative treatment. Weighing the pros and cons of bitewing radiographs for caries detection, it seems more useful to take bitewing radiographs in order to confirm the presence of approximal caries, in cases in which visual signs have been identified (instead of detecting non-evident caries) or to help the choice for the best option for treating an approximal caries [54]. In the last situation, radiographs may help in caries depth assessment and also, in

**Figure 14.** Direct examination of an approximal caries lesion due to the absence of the adjacent tooth.

The presence of cavities has been another concern regarding approximal caries detection, since the cavitation has been considered an important point in the prognosis of these caries lesions. As mentioned, some cavities are not detected by visual examination. Besides, radiographs do not aid in this issue, as exposed before. The temporary separation using orthodontic rubbers is an available alternative [55, 56], which permit the direct visual inspection and tactile examination of the approximal surfaces (Figures 15 to 17). This technique is well-accepted by children [49]. However, it is necessary two appointments to permit the conclusion of diagnostic using this method. Even visuo-tactile assessment of approximal surface is possible; doubts in diagnosis may remain. The inderdental space created after temporary separation is around 0.8 mm [38] and may not always be large enough to guarantee there is no cavity on the surface, nor to affirm the cavity is clinically within enamel. In fact, several dentine lesions are not cavitated. Other dentine lesions may may be associated with microcavities; however, without exposing the dentine. On the other hand, we believe that some cavitations which present radiographic image into dentine may be wrongly scored as cavity clinically restricted to enamel. This is why the limited space reached after teeth separation may be not enough to the

evaluation of the periapical tissue [54].

94 Emerging Trends in Oral Health Sciences and Dentistry

dentist being able to actually felt the bottom of these cavities, in order to confirm if he/she is felling enamel or dentine surface. These are limitations of this method. However, since there is no other available possibility to detect the presence of cavities, we have used the temporary separation when we suspect that a cavity is present, especially if dentine involvement is confirmed by visual signs or radiographs.

**Figure 16.** Temporary tooth separation using orthodontic rubbers. (a) before placing the rubber between adjacent teeth; (b) after placing the rubber; (c) after removing the rubber – note the wide space for direct examination.

**Figure 17.** Temporary tooth separation using orthodontic rubbers – visual and tactile assessment of separated surfaces (a); WHO probe (ballpoint probe) used to tactile assessment of surfaces.

The activity status is not usually a differential in caries lesions assessment, especially in children. In fact, as exposed before, most part of detected approximal lesions tend to be active [43]. It is not impossible to find inactive approximal caries. However, especially among children, the interproximal plaque control is still very deficient and make the lesions arrest‐ ment more difficult. Thus, activity assessment is not a real concern in primary teeth. In some situations, when the adjacent tooth have exfoliated, we may observe a natural process of lesion inactivation of an approximal caries due to the possibility of controlling biofilm only by toothbrushing such area (see Figures 8 and 14).

## **5. Is it possible to control approximal caries lesions?**

In theory, controlling dental caries in any surface is related to controlling of dental plaque over the lesion [32]. As the activity status of approximal caries is not usually a differential factor, we will not discuss it here. However, it is obvious that, if an approximal caries lesion is arrested, it would not demand any measure to be controlled. Considering this situation, we may guide the management of approximal caries lesions basically according to depth and severity, assessed during examination of caries lesions. The conceptual tree for managing caries lesions on approximal surfaces is presented below (Figure 18).

Non-cavitated approximal caries lesions tend to be easier to be controlled since there is no cavity to complicate biofilm removal. Besides, if these lesions are restricted to the enamel, they have a slower progression compared to dentine [45]. Therefore, several possibilities are available in order to controlling them, from the dental flossing to the use of resin infiltration.

Cavitated enamel lesions (Figure 19) are expected to progress faster than those which present intact surface. However, most part of these lesions cannot be detected clinically, neither by visual, nor by tactile assessment. If detected by tooth separation, both non-invasive and invasive treatments would be available for such cases, but there is no strong evidence of the best option in this case. Choosing the non-invasive treatment may permit to postpone invasive interventions. Otherwise, since the presence of cavity is detected, the use of restoration as a Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of… http://dx.doi.org/10.5772/59600 97

(a) (b)

(a); WHO probe (ballpoint probe) used to tactile assessment of surfaces.

96 Emerging Trends in Oral Health Sciences and Dentistry

toothbrushing such area (see Figures 8 and 14).

**5. Is it possible to control approximal caries lesions?**

on approximal surfaces is presented below (Figure 18).

**Figure 17.** Temporary tooth separation using orthodontic rubbers – visual and tactile assessment of separated surfaces

The activity status is not usually a differential in caries lesions assessment, especially in children. In fact, as exposed before, most part of detected approximal lesions tend to be active [43]. It is not impossible to find inactive approximal caries. However, especially among children, the interproximal plaque control is still very deficient and make the lesions arrest‐ ment more difficult. Thus, activity assessment is not a real concern in primary teeth. In some situations, when the adjacent tooth have exfoliated, we may observe a natural process of lesion inactivation of an approximal caries due to the possibility of controlling biofilm only by

In theory, controlling dental caries in any surface is related to controlling of dental plaque over the lesion [32]. As the activity status of approximal caries is not usually a differential factor, we will not discuss it here. However, it is obvious that, if an approximal caries lesion is arrested, it would not demand any measure to be controlled. Considering this situation, we may guide the management of approximal caries lesions basically according to depth and severity, assessed during examination of caries lesions. The conceptual tree for managing caries lesions

Non-cavitated approximal caries lesions tend to be easier to be controlled since there is no cavity to complicate biofilm removal. Besides, if these lesions are restricted to the enamel, they have a slower progression compared to dentine [45]. Therefore, several possibilities are available in order to controlling them, from the dental flossing to the use of resin infiltration.

Cavitated enamel lesions (Figure 19) are expected to progress faster than those which present intact surface. However, most part of these lesions cannot be detected clinically, neither by visual, nor by tactile assessment. If detected by tooth separation, both non-invasive and invasive treatments would be available for such cases, but there is no strong evidence of the best option in this case. Choosing the non-invasive treatment may permit to postpone invasive interventions. Otherwise, since the presence of cavity is detected, the use of restoration as a

**Figure 18.** Conceptual tree for managing approximal caries, correlating the caries detection and activity assessment based on ICDAS and clinical decision-making. (\* situations in which is usually difficult to affirm caries lesions are real‐ ly inactive; \*\* the ICDAS activity assessment always considers lesions score 4 as probably active)

manner to control biofilm at the lesion would be necessary [57]. On the other hand, high amount of sound tissue would be acceptable in order to restore this surface adequately. Therefore, depending on patients' and professional's preferences and particularities of the clinical case, both options are possible. Considering the minimal invasive philosophy, maybe, opting for the non-restorative approach would be interesting since the children's comfort and preservation of dental structures would be maximized.

For approximal dentine caries lesions, the detection of cavities may be more relevant. If the cavitation is not easily visible or not felt by probing, the temporary separation could aid in seeking for cavities (see Figure 15). A dentine lesion progress faster than an enamel lesion. However, if the lesion is not cavitated, this progression is slower than for cavitated lesions [23], since the level of bacterial invasion is very low [22]. Based on that, we may argue the control of several outer non-cavitated dentine lesions would be possible. However, this is not so frequent. Actually, most dentine caries lesions in primary teeth are cavitated [58]. On the other hand, when the cavity is present, some approach that avoids the stagnation of the biofilm over the lesion seems to be indispensable. In this sense, any intervention which prevents biofilm accumulation on these lesions or facilitates is removal could be useful. Otherwise, it is important to clarify that mechanical removal of biofilm by flossing might not be a good choice in these cases, since the cavity may hide the plaque and interfere with caries lesion control.

**Figure 19.** a) Cavitated caries lesion into enamel (direct examination). This cavity probably would not be seen when surface was assessed in the oral cavity due to the presence of the adjacent tooth. Using the temporary separation might help in detecting this cavity. Regarding treatment, we have to ponder if this lesion was detected and the option was operative treatment, a high amount of sound tissue would have to be removed. (b) Schematic representation of how accessing the mentioned cavity if the tooth was actually in the arch.

## **6. Options (interventions) to control initial approximal caries**

Despite flossing is the most suitable method for mechanical removal of biofilm from the interproximal area [59, 60], controlling approximal caries just by flossing has not been shown to be effective [41], probably because its flossing by children and adolescents is not constant and adequate [4]. Controlling approximal caries by just flossing is a simple intervention, however, patient might be instructed and constantly motivated by professional [61]. Although dentist should never give up instructing and motivating to floss, choosing only this approach could be not enough for some approximal caries lesions. In fact, depending on children's compliance with flossing this option may not succeed, especially considering problems with motivation to flossing discussed earlier in this chapter. Thus, early interventions to initial caries lesions become even more important to arrest these lesions and prevent cavitations or lesions progression into dentine.

Initial caries lesion may be managed by remineralizing agents. A recent systematic review has shown the fluorides, in its different vehicles, present the most consistent benefit in controlling progression of initial caries lesions [62]. However, this review did not include any study which had used fluorides for approximal caries lesions in primary teeth. Actually, few studies have been performed aiming to investigate the management of initial caries in primary teeth and the evidence is inconclusive when we consider the most effective vehicle to be used, the frequence of use and the cost-effectiveness of using fluorides in primary teeth[63]. The fluoride varnish reduced in 25% the caries progression on approximal caries of primary molars [45] (Figure 20). Other fluorides vehicles, as gels and foams, have been associated with caries reduction on approximal surfaces [64]. However, they were tested in permanent teeth. The use of interdental brush or dental floss dipped in fluoride gel has been also advocated to using fluorides for approximal areas [65, 66] (Figure 21).

Another option tested for the same purpose was an association AgF followed by SnF2, resulting in a arrestment of 74% of approximal caries lesions [46]. At the moment, our group is testing Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of… http://dx.doi.org/10.5772/59600 99

**Figure 20.** Application of fluoride varnish on approximal surfaces which present initial caries lesions.

**6. Options (interventions) to control initial approximal caries**

accessing the mentioned cavity if the tooth was actually in the arch.

98 Emerging Trends in Oral Health Sciences and Dentistry

progression into dentine.

fluorides for approximal areas [65, 66] (Figure 21).

Despite flossing is the most suitable method for mechanical removal of biofilm from the interproximal area [59, 60], controlling approximal caries just by flossing has not been shown to be effective [41], probably because its flossing by children and adolescents is not constant and adequate [4]. Controlling approximal caries by just flossing is a simple intervention, however, patient might be instructed and constantly motivated by professional [61]. Although dentist should never give up instructing and motivating to floss, choosing only this approach could be not enough for some approximal caries lesions. In fact, depending on children's compliance with flossing this option may not succeed, especially considering problems with motivation to flossing discussed earlier in this chapter. Thus, early interventions to initial caries lesions become even more important to arrest these lesions and prevent cavitations or lesions

**Figure 19.** a) Cavitated caries lesion into enamel (direct examination). This cavity probably would not be seen when surface was assessed in the oral cavity due to the presence of the adjacent tooth. Using the temporary separation might help in detecting this cavity. Regarding treatment, we have to ponder if this lesion was detected and the option was operative treatment, a high amount of sound tissue would have to be removed. (b) Schematic representation of how

Initial caries lesion may be managed by remineralizing agents. A recent systematic review has shown the fluorides, in its different vehicles, present the most consistent benefit in controlling progression of initial caries lesions [62]. However, this review did not include any study which had used fluorides for approximal caries lesions in primary teeth. Actually, few studies have been performed aiming to investigate the management of initial caries in primary teeth and the evidence is inconclusive when we consider the most effective vehicle to be used, the frequence of use and the cost-effectiveness of using fluorides in primary teeth[63]. The fluoride varnish reduced in 25% the caries progression on approximal caries of primary molars [45] (Figure 20). Other fluorides vehicles, as gels and foams, have been associated with caries reduction on approximal surfaces [64]. However, they were tested in permanent teeth. The use of interdental brush or dental floss dipped in fluoride gel has been also advocated to using

Another option tested for the same purpose was an association AgF followed by SnF2, resulting in a arrestment of 74% of approximal caries lesions [46]. At the moment, our group is testing

**Figure 21.** Use of fluoride gel on approximal initial caries lesions. (a) dental floss dipped in fluoride gel. (b) interdental toothbrush dipped in fluoride gel. (c) interdental toothbrush (note some natural space/separation is need for its intro‐ duction into approximal areas.

the use of the silver diamine fluoride (SDF) to control approximal caries in primary teeth [67] (Figure 22 and 23). A previous study of our group pointed to the possibility of using the silver diamine fluoride (SDF) in children for arrestment of enamel caries lesions on occlusal surfaces of permanent erupting molar [68]. As erupting occlusal surfaces, approximal surfaces chal‐ lenge by making the mechanical control biofilm more difficult. In addition, some studies have shown that the SDF is more effective than fluoride varnish to prevent and arrest caries [69-71]. Even showing success since 1960 [69], its effectiveness had not been tested in approximal lesions of primary teeth. It is expected after SDF application, some staining may be seen on treated surfaces. The staining is probably caused by the precipitation of insoluble silver phosphates [72] (Figure 23).

Besides the remineralizing agents, another possibility in order to treat initial caries is sealing or infiltrating caries lesions [74]. Sealants have been used for several years in prevention of dental caries [75]. However, its therapeutic effect may be more expressive than the preventive one [76]. Sealing a caries lesion avoid its contact with biofilm, permitting its arrestment.

Another option tested for the same purpose was an association AgF followed by SnF2, resulting in a arrestment of 74% of approximal caries lesions (46). At the moment, our group is testing the use of the silver diamine fluoride (SDF) to control approximal caries in primary teeth (67) (Figure 22 and 23). A previous study of our group pointed to the possibility of using the silver diamine fluoride (SDF) in children for arrestment of enamel caries lesions on occlusal surfaces of permanent erupting molar (68). As erupting occlusal surfaces, approximal surfaces challenge by making the

been tested in approximal lesions of primary teeth. It is expected after SDF application, some staining may be seen on

treated surfaces. The staining is probably caused by the precipitation of insoluble silver phosphates (72).

Figure 22 – Application of silver diamine fluoride (SDF) in approximal caries lesions of primary teeth. (a) 30% SDF (Cariestop 30%,Biodinâmica Química e Farmacêutica LTDA, Ibiporã, Paraná, Brazil); (b) and (c) Extra-oral and intraoral protection of soft tissues with petroleum jelly to avoid staining and mucosal irritation (73); (d) application of SDF using a small disposable brush for 3 min – moisture was controlled by using cotton rolls and saliva ejectors. (e) washing **Figure 22.** Application of silver diamine fluoride (SDF) in approximal caries lesions of primary teeth. (a) 30% SDF (Car‐ iestop 30%,Biodinâmica Química e Farmacêutica LTDA, Ibiporã, Paraná, Brazil); (b) and (c) Extra-oral and intra-oral protection of soft tissues with petroleum jelly to avoid staining and mucosal irritation [73]; (d) application of SDF using a small disposable brush for 3 min – moisture was controlled by using cotton rolls and saliva ejectors. (e) washing for 30s to remove soluble final products of reaction between SDF and hydroxapatite.

for 30s to remove soluble final products of reaction between SDF and hydroxapatite.

**Figure 23.** Staining caused by the SDF application after follow-up. The staining is probably due to deposition of silver phosphate that is a insoluble salt, responsible to the dark colour when exposed to the light [72]. Note the staining is hardly visible on treated approximal surfaces.

Sealants were initially devised for occlusal surfaces, which present a complex morphology and difficult mechanical plaque removal, especially in non-motivated or collaborative patients. However, the principle of sealing has been extended to other surfaces in which controlling the biofilm is a challenge, as approximal surfaces [77]. The idea is the same: preventing caries lesion progression by eliminating the direct contact between the lesion and the biofilm. A previous study showed a 25% reduction in caries progression on approximal surfaces of primary teeth when sealed (comparatively to surfaces in which patients only flossed) [42]. These findings were comprehensible since when sealants are used, the poor children's compliance with flossing tends to be minimized.

Resin infiltration is other available option to "seal" caries lesions [78]. The infiltrant is a lowviscosity resin that promotes sealing into the lesion [78]. Differently from sealing, for infiltrat‐ ing caries lesions,the superficial layer of caries lesion is removed by acid conditioning. Further, the lesion is infiltrated with a low-viscosity resin. Therefore, the barrier against biofilm would be created inside the lesions, instead ofin the surface of caries lesions [79].In addition, the tooth separation is not required for infiltrating caries lesions. On the other hand, if tooth separation is not performed, some doubts concerning diagnosis may remain. Besides, a kit for resin infiltration is sold containing all products used in the process and specifically designed applicators for approximal surfaces. (Figure 24). Despite these differences compared to the traditional sealants, we believe they exert similar roles in controlling caries lesions progres‐ sion, since the contact between lesion and biofilm is avoided. Infiltration has been showed as an efficacious treatment for permanent teeth [79-81], but only one study was conducted in primary teeth [82]. In this study, resin infiltration was more efficacious than fluoride varnish in the arrestment of proximal lesions [82]. Although no study has compared sealing and infiltrat‐ ing caries lesions on approximal surfaces of primary teeth, results in permanent teeth permit to guess that sealants andinfiltrants tendto have similar efficacy when thedeal is treating initial caries lesions [81].

Besides effectiveness/efficacy in controlling caries lesions, the patients' acceptance regarding the available treatments should be considered in clinical decision-making, especially treating children. Few studies have assessed patient-centered outcomes related to enamel caries lesions treatments. Sealing using relative isolation was well-accepted by most children [42]. In this study, the non-use of rubber dam was pointed as a possible concern [42]. On the other hand, when local anesthesia and rubber dam were used for infiltrating lesions in primary teeth, children reported higher levels of discomfort than when other non-invasive approaches were used [83]. Therefore, we consider that those techniques that cause less discomfort should be preferred and considered by clinicians. In addition, patient's and parents' satisfaction with treatments for initial caries lesions have not been evaluated. Staining caused by inactivation of caries lesions and/or using of SDF has not been systematically assessed. That is one of our concerns when testing the SDF as a possibility to treat initial caries [67]. Based on some preliminary findings, we believe this consequence of the mentioned treatment will not impact on patient's and parent's perceptions, especially due to the position of the surface, which hides the effect of SDF application (see Figure 23).

Finally, cost-efficacy of the mentioned treatment should be considered. More complex treatments as sealing or infiltrating caries lesions are more time-consuming [83], which will certainly lead to higher costs. Thus, even being equally effective, simpler procedures tend to

Sealants were initially devised for occlusal surfaces, which present a complex morphology and

**Figure 23.** Staining caused by the SDF application after follow-up. The staining is probably due to deposition of silver phosphate that is a insoluble salt, responsible to the dark colour when exposed to the light [72]. Note the staining is

Figure 23 – Staining caused by the SDF application after follow-up. The staining is probably due to deposition of silver phosphate that is a insoluble salt, responsible to the dark colour when exposed to the light (72). Note the staining is

Figure 22 – Application of silver diamine fluoride (SDF) in approximal caries lesions of primary teeth. (a) 30% SDF (Cariestop 30%,Biodinâmica Química e Farmacêutica LTDA, Ibiporã, Paraná, Brazil); (b) and (c) Extra-oral and intraoral protection of soft tissues with petroleum jelly to avoid staining and mucosal irritation (73); (d) application of SDF using a small disposable brush for 3 min – moisture was controlled by using cotton rolls and saliva ejectors. (e) washing

**Figure 22.** Application of silver diamine fluoride (SDF) in approximal caries lesions of primary teeth. (a) 30% SDF (Car‐ iestop 30%,Biodinâmica Química e Farmacêutica LTDA, Ibiporã, Paraná, Brazil); (b) and (c) Extra-oral and intra-oral protection of soft tissues with petroleum jelly to avoid staining and mucosal irritation [73]; (d) application of SDF using a small disposable brush for 3 min – moisture was controlled by using cotton rolls and saliva ejectors. (e) washing for

for 30s to remove soluble final products of reaction between SDF and hydroxapatite.

30s to remove soluble final products of reaction between SDF and hydroxapatite.

hardly visible on treated approximal surfaces.

hardly visible on treated approximal surfaces.

(a) <sup>A</sup>

100 Emerging Trends in Oral Health Sciences and Dentistry

Another option tested for the same purpose was an association AgF followed by SnF2, resulting in a arrestment of 74% of approximal caries lesions (46). At the moment, our group is testing the use of the silver diamine fluoride (SDF) to control approximal caries in primary teeth (67) (Figure 22 and 23). A previous study of our group pointed to the possibility of using the silver diamine fluoride (SDF) in children for arrestment of enamel caries lesions on occlusal surfaces of permanent erupting molar (68). As erupting occlusal surfaces, approximal surfaces challenge by making the mechanical control biofilm more difficult. In addition, some studies have shown that the SDF is more effective than fluoride varnish to prevent and arrest caries (69-71). Even showing success since 1960 (69), its effectiveness had not been tested in approximal lesions of primary teeth. It is expected after SDF application, some staining may be seen on

(b) <sup>A</sup>

(d) <sup>A</sup> (e) <sup>A</sup>

(c) <sup>A</sup>

treated surfaces. The staining is probably caused by the precipitation of insoluble silver phosphates (72).

difficult mechanical plaque removal, especially in non-motivated or collaborative patients.

**Figure 24.** Resin infiltration of an initial caries lesion – (a) direct visual inspection after tooth separation - distal surface of element 54 presented a white spot lesion without any cavity. (b) After local anesthesia and adaptation of the rubber dam, 15%hydrochloric acid was applied on the lesion for 120s, followed by washing and air-drying. (c) Dehydration using 95% ethanol, followed by air-drying. (d) Resin infiltrant application on the lesion for 120s, followed by excess removal and light-curing for 40s. Further, resin is applied for more 30s and light-cured again. (e) All products used in resin infiltration are included in a specific kit commercialized for this purpose by the manufacturers (Icon® - Dental Milestones Guaranteed – DMG, Germany). *Note: For caries sealing, the steps A, B and D will be the same, but without the use of special applicators and using other materials (dental adhesives and resin sealants).*

be more cost-efficacious than complex ones. This is another point to be weighed in the decisionmaking process. Although our investigation is ongoing, we believe the SDF may be a more cost-efficacious/effective approach to be used in treating initial caries compared to other available treatments.

In summary, the scientific evidence regarding the effectiveness for treating initial caries on approximal surfaces in primary teeth is still scarce. However, some possible alternatives may be used until stronger evidences may be available. Additionally, it is important to consider the simplest techniques are cheaper and seem to be more accepted by children. Therefore, all these properties of the technique chosen for treating enamel caries on approximal surfaces in primary teeth should be considered conjointly.

## **7. Options to be used when cavitated**

As discussed earlier, the greater susceptibility to caries experience of the approximal surface [1] linked to the faster progression rate for enamel to reach the dentin in primary teeth [19] results in a high prevalence of cavitated dentin caries lesions. These lesions need procedures that allow to arrest them and, especially, to reestablish the previous anatomy.

The treatments recommended to cavitated dentin lesion in approximal surfaces can be assigned according to depth and extent of the lesions.

Initially, when observed one cavitated lesion reaching outer dentin of approximal surface in primary teeth, without breaking the marginal ridge (see Figure 15), the utilization of infiltrating technique [82] or the sealing with adhesive system [42] or fissure sealants [77] has been proposed. These materials, as discussed for initial lesions, mechanically block the biofilm accumulation over the lesion. Previous studies have shown that both treatments seem to be good option to control caries progression in outer third of dentin [42, 82]. These previous studies included cavitated caries lesions clinically into enamel (despite their radiographic extension into dentin) [42, 82]. However, as few lesions with this severity were included in the samples, we could not draw definitive conclusions on the efficacy of these techniques or dental materials for cavitated lesions.

Sealing has been proved to be an option for small occlusal cavities exposing dentine [84]. Once more, the purpose of preventing the contact with cariogenic biofilm and enabling plaque removal from the surface instead is performing operative procedure care [84]. The same approach, if used on approximal surfaces, would avoid removal of sound enamel to access small lesions into dentine with preserved marginal bridge (Figure 25). A pilot study that compared the sealing to restoration for approximal cavitated dentin lesions showed almost 70% of sealed lesions have failed after 18 months compared to 11% of the restorations [85]. Besides, 54% of sealed lesions showed progression [85]. This finding seems to be linked with the technical difficulties in performing approximal caries sealing. Since the resin-based sealant is hydrophobic, there is a need to use rubber dam; however, sometimes there is a difficulty to maintain the work area without water (saliva, fluid) contamination [85]. Moreover, inserting both acid phosphoric and resin-based sealant into approximal cavities may have been a challenge which may justify the high proportion of observed failures [85]. Thus, although resinbased sealing represents the most conservative option to control cavitated dentin lesions, until the present moment, it is still not a satisfactory option to treat approximal cavitated caries lesions.

be more cost-efficacious than complex ones. This is another point to be weighed in the decisionmaking process. Although our investigation is ongoing, we believe the SDF may be a more cost-efficacious/effective approach to be used in treating initial caries compared to other

(a) (b) (c)

(d) (e)

**Figure 24.** Resin infiltration of an initial caries lesion – (a) direct visual inspection after tooth separation - distal surface of element 54 presented a white spot lesion without any cavity. (b) After local anesthesia and adaptation of the rubber dam, 15%hydrochloric acid was applied on the lesion for 120s, followed by washing and air-drying. (c) Dehydration using 95% ethanol, followed by air-drying. (d) Resin infiltrant application on the lesion for 120s, followed by excess removal and light-curing for 40s. Further, resin is applied for more 30s and light-cured again. (e) All products used in resin infiltration are included in a specific kit commercialized for this purpose by the manufacturers (Icon® - Dental Milestones Guaranteed – DMG, Germany). *Note: For caries sealing, the steps A, B and D will be the same, but without the use*

In summary, the scientific evidence regarding the effectiveness for treating initial caries on approximal surfaces in primary teeth is still scarce. However, some possible alternatives may be used until stronger evidences may be available. Additionally, it is important to consider the simplest techniques are cheaper and seem to be more accepted by children. Therefore, all these properties of the technique chosen for treating enamel caries on approximal surfaces in

As discussed earlier, the greater susceptibility to caries experience of the approximal surface [1] linked to the faster progression rate for enamel to reach the dentin in primary teeth [19]

available treatments.

primary teeth should be considered conjointly.

*of special applicators and using other materials (dental adhesives and resin sealants).*

102 Emerging Trends in Oral Health Sciences and Dentistry

**7. Options to be used when cavitated**

Depending on the size of the cavity and its location, it is also possible to improve the plaque removal from the cavity in order to promote caries lesions arrestment. This choice is especially interesting in areas in which restoration may be a greater challenge to deal than the mechanical control of the biofilm. Small approximal cavities in anterior primary teeth may be one indication for that, since restorations in these teeth may require sound tissue removal in order to access the cavity (Figure 26). Slicing has been also tested to approximal caries in posterior primary teeth [86]. Although, this technique seems to be a most conservative option for such cases, strongest evidences are necessary concerning it.

A recent systematic review showed that there is no difference concerning the choice of restorative material to treat occlusoproximal dentin cavities [87]. In this study, both conven‐ tional approaches as amalgam and composite resin were compared to Atraumatic Restorative

**Figure 25.** Cavitated dentine caries lesions (a-b). To restore these lesions, sound tissues should have to be removed, as schematically drawn (c-d).

Treatment (ART) performed with high-viscous glass ionomer cement (GIC), demonstrating similar results and satisfactory options to treating these lesions in primary teeth, until 3 years of follow up. However, when we think about the minimal intervention, which has the partial caries removal as one of its concepts, there is no reason to perform the amalgam restoration. Due to that, this procedure will not be discussed in this chapter.

Worldwide, the composite resin associated to adhesive system is, in approximately 25% of cases, the material of choice for restoring primary teeth [88-90]. This material shows satisfac‐ tory efficacy when used under local anesthesia and rubber dam, regardless of the brand of composite resin [91], demonstrating a success rate around 90% on occlusal and occlusalproximal surface of primary teeth [92]. On the other hand, when it is considered the adhesive system, a systematic review reported that both three-step etch-and-rinse and two-step selfetching adhesive system present the best clinical performances [93]. However, this systematic review only considered the clinical trials performed in permanent teeth and these results should be interpreted with caution to primary teeth.

Some specific protocols to be applied in primary teeth in order to obtain similar results that observed to permanent teeth have been suggested. One of the proposals is shortening the etching time in dentin, for etch-and-rinse adhesive systems in order to increase the bond

Are the Approximal Caries Lesions in Primary Teeth a Challenge to Deal With? — A Critical Appraisal of… http://dx.doi.org/10.5772/59600 105

**Figure 26.** Small cavity on distal surface of upper primary central incisor – buccal (a) and palatal (b) view. Treatment: (c) access to the cavity to facilitate the mechanical removal of the biofilm; (d) application of fluoride varnish to enhance the remineralization. (e/f) follow-up after two weeks evidences the best control of the biofilm in the region.

stability of the restorations in primary teeth [94]. This protocol is based on previous studies that demonstrated the primary dentin is more reactive to acid etching [95, 96] and showed good results *in vitro* studies [94, 97]. Thus, the authors suggest the dentin etching of 35-37% acid phosphoric for 7 seconds before the adhesive system application [94]. Etching enamel remains in 15 seconds.

Treatment (ART) performed with high-viscous glass ionomer cement (GIC), demonstrating similar results and satisfactory options to treating these lesions in primary teeth, until 3 years of follow up. However, when we think about the minimal intervention, which has the partial caries removal as one of its concepts, there is no reason to perform the amalgam restoration.

**Figure 25.** Cavitated dentine caries lesions (a-b). To restore these lesions, sound tissues should have to be removed, as

Worldwide, the composite resin associated to adhesive system is, in approximately 25% of cases, the material of choice for restoring primary teeth [88-90]. This material shows satisfac‐ tory efficacy when used under local anesthesia and rubber dam, regardless of the brand of composite resin [91], demonstrating a success rate around 90% on occlusal and occlusalproximal surface of primary teeth [92]. On the other hand, when it is considered the adhesive system, a systematic review reported that both three-step etch-and-rinse and two-step selfetching adhesive system present the best clinical performances [93]. However, this systematic review only considered the clinical trials performed in permanent teeth and these results

Some specific protocols to be applied in primary teeth in order to obtain similar results that observed to permanent teeth have been suggested. One of the proposals is shortening the etching time in dentin, for etch-and-rinse adhesive systems in order to increase the bond

Due to that, this procedure will not be discussed in this chapter.

schematically drawn (c-d).

104 Emerging Trends in Oral Health Sciences and Dentistry

should be interpreted with caution to primary teeth.

One important point to be pondered is that the main reason to failure of resin composite restorations is caries around restorations [92]. Due to that, other options of restorative materials may be considered. A previous study evidenced the effect of the resin-modified GIC restora‐ tion in prevention of secondary caries when compared to resin composite [98], probably due to fluoride release and uptake of the glass ionomer cements. The resin-modified GIC may be a good alternative, since presents a similar behavior of resin composite in clinical situation [91]. Its longevity is on average 5 years in occlusoproximal cavities [99]. However, this material contains resin monomers in its composition and may increase susceptibility to the presence of humidity compared to other ionomers. This characteristic associated to the need of a light source to polymerization of the material can be pointed as disadvantages of using resinmodified GIC.

On the other hand, similar trend regarding the protection of the margin of restorations can be observed with ART (Figure 26), since this treatment has high-viscous GIC as the material of choice. The GIC shows results such like the RMGIC in prevention of new caries lesion [100]. Moreover, studies have considered GIC as a viable alternative due to the similar survival rates compared to others restorative materials/techniques [87]. Other proprieties of GIC may also contribute to this choice, i.e., ability to chemically bond to enamel and dentine with insignifi‐ cant heat formation or shrinkage, biocompatibility with the pulp and periodontal tissues and a similar coefficient of thermal expansion to tooth structure [101].

More recently, a new advantage related to GIC in occlusoproximal restoration has been addressed. Studies have claimed the contact with an approximal cavity offers a higher risk to the adjacent surfaces developing caries lesion [1]. In these cases, GIC restoration could prevent the new lesions and even to arrest the initial ones [102]. This hypothesis has been confirmed by a practice-based research, which showed that the progression rate of caries lesion on tooth surfaces adjacent to amalgam restorations was 30%, whilst to GIC restorations was only 16% [103]. These premises associated with no need of local anesthesia and rubber dam application have contributed for indicating GIC restoration associated to partial caries removal as the best option to treat cavitated lesions in children (Figure 27). On the other hand, similar trend regarding the protection of the margin of restorations can be observed with ART (Figure 26), since this treatment has high-viscous GIC as the material of choice. The GIC shows results such like the RMGIC in prevention of new caries lesion (100). Moreover, studies have considered GIC as a viable alternative due to the similar survival rates compared to others restorative materials/techniques (87). Other proprieties of GIC may also contribute to this choice, i.e., ability to chemically bond to enamel and dentine with insignificant heat formation or shrinkage, biocompatibility with the pulp and periodontal tissues and a similar coefficient of thermal expansion to tooth structure (101). More recently, a new advantage related to GIC in occlusoproximal restoration has been addressed. Studies have claimed the contact with an approximal cavity offers a higher risk to the adjacent surfaces developing caries lesion (1). In these cases, GIC restoration could prevent the new lesions and even to arrest the initial ones (102). This hypothesis has been confirmed by a practice-based research, which showed that the progression rate of caries lesion on tooth surfaces adjacent to amalgam restorations was 30%, whilst to GIC restorations was only 16% (103). These premises associated with no need of local anesthesia and rubber dam application have contributed for indicating GIC

restoration associated to partial caries removal as the best option to treat cavitated lesions in children (Figure 26).

into dentine; (b) accessing the cavity using a manual instrument; (c) preparing for restoration – to restore the contact point and avoid marginal excess; (d) after inserting the GIC and using finger pressure over the material; (e) final restoration; (f) checking the occlusal contacts. *(images gently donated by Dr. Isabel Olegario)*  **Figure 27.** Step-by-step of an occlusoproximal restoration based on atraumatic restorative treatment, using partial ca‐ ries removal and high-visous glass ionomer cement (GIC). (a) cavity into dentine; (b) accessing the cavity using a man‐ ual instrument; (c) preparing for restoration – to restore the contact point and avoid marginal excess; (d) after inserting the GIC and using finger pressure over the material; (e) final restoration; (f) checking the occlusal contacts. *(images gen‐ tly donated by Dr. Isabel Olegario)*

It is evident, based on topics discussed in this paper, that approximal caries lesions are an actual challenge to

bitewings) or result in a greater doubt regarding options for treating those lesions (e.g. temporary tooth separation), since weak scientific evidences have been found for corroborating some available for clinical decision-making for approximal

#### dentists deal with. Indeed, the detection of caries lesion on these surfaces presents a duality. On one hand, the surfaces position in oral cavity makes the direct visual inspection almost impossible. On the other hand, if additional caries detection methods are used sequentially, they may lead to overtreatment in some situations (e.g. indiscriminate use of **8. Final considerations**

*Final considerations* 

cavities clinically restricted to enamel. Even if caries detection has been an overcome stage, treating approximal caries is not a simple task. Unfortunately, few strong evidences are available to support these treatments. Therefore, clinicians should try to use the best available evidences at the occasion. Based on that, we tried to contribute to clinical decision-making process joining the description of present evidences to a critical appraisal of them. We believe the critical judgment of the published evidences is crucial to guide the better clinicians' conduct to their patients. Nowadays, the adoption of the minimal intervention philosophy has been a reality. Based on that, we have looked into evidences that may support our clinical decision-making not only based on effectiveness or efficacy of therapies used. We have also looked for manners of treating our children minimizing destruction/loss of healthy or It is evident, based on topics discussed in this paper, that approximal caries lesions are an actual challenge to dentists deal with. Indeed, the detection of caries lesion on these surfaces presents a duality. On one hand, the surfaces position in oral cavity makes the direct visual inspection almost impossible. On the other hand, if additional caries detection methods are used sequentially, they may lead to overtreatment in some situations (e.g. indiscriminate use of bitewings) or result in a greater doubt regarding options for treating those lesions (e.g. temporary tooth separation), since weak scientific evidences have been found for corroborat‐ ing some available for clinical decision-making for approximal cavities clinically restricted to enamel.

Even if caries detection has been an overcome stage, treating approximal caries is not a simple task. Unfortunately, few strong evidences are available to support these treatments. Therefore, clinicians should try to use the best available evidences at the occasion. Based on that, we tried to contribute to clinical decision-making process joining the description of present evidences to a critical appraisal of them. We believe the critical judgment of the published evidences is crucial to guide the better clinicians' conduct to their patients.

Nowadays, the adoption of the minimal intervention philosophy has been a reality. Based on that, we have looked into evidences that may support our clinical decision-making not only based on effectiveness or efficacy of therapies used. We have also looked for manners of treating our children minimizing destruction/loss of healthy or reparable structures and guaranteeing higher levels of comfort and satisfaction to them. Due to that, we have insisted on situations in which treatments present similar effectiveness/efficacy, the simplest, the most cost-effective/efficacious or the most acceptable approaches should be preferable by dentists for treating their patients. We believe the conjoint critical appraisal of these requisites may be helpful when dealing with the challenge that approximal caries lesions in primary teeth represents.

## **Acknowledgements**

cant heat formation or shrinkage, biocompatibility with the pulp and periodontal tissues and

More recently, a new advantage related to GIC in occlusoproximal restoration has been addressed. Studies have claimed the contact with an approximal cavity offers a higher risk to the adjacent surfaces developing caries lesion [1]. In these cases, GIC restoration could prevent the new lesions and even to arrest the initial ones [102]. This hypothesis has been confirmed by a practice-based research, which showed that the progression rate of caries lesion on tooth surfaces adjacent to amalgam restorations was 30%, whilst to GIC restorations was only 16% [103]. These premises associated with no need of local anesthesia and rubber dam application have contributed for indicating GIC restoration associated to partial caries removal as the best

into dentine; (b) accessing the cavity using a manual instrument; (c) preparing for restoration – to restore the contact point and avoid marginal excess; (d) after inserting the GIC and using finger pressure over the material; (e) final

**Figure 27.** Step-by-step of an occlusoproximal restoration based on atraumatic restorative treatment, using partial ca‐ ries removal and high-visous glass ionomer cement (GIC). (a) cavity into dentine; (b) accessing the cavity using a man‐ ual instrument; (c) preparing for restoration – to restore the contact point and avoid marginal excess; (d) after inserting the GIC and using finger pressure over the material; (e) final restoration; (f) checking the occlusal contacts. *(images gen‐*

 It is evident, based on topics discussed in this paper, that approximal caries lesions are an actual challenge to dentists deal with. Indeed, the detection of caries lesion on these surfaces presents a duality. On one hand, the surfaces position in oral cavity makes the direct visual inspection almost impossible. On the other hand, if additional caries detection methods are used sequentially, they may lead to overtreatment in some situations (e.g. indiscriminate use of bitewings) or result in a greater doubt regarding options for treating those lesions (e.g. temporary tooth separation), since weak scientific evidences have been found for corroborating some available for clinical decision-making for approximal

It is evident, based on topics discussed in this paper, that approximal caries lesions are an actual challenge to dentists deal with. Indeed, the detection of caries lesion on these surfaces presents a duality. On one hand, the surfaces position in oral cavity makes the direct visual inspection almost impossible. On the other hand, if additional caries detection methods are used sequentially, they may lead to overtreatment in some situations (e.g. indiscriminate use of bitewings) or result in a greater doubt regarding options for treating those lesions (e.g. temporary tooth separation), since weak scientific evidences have been found for corroborat‐

Even if caries detection has been an overcome stage, treating approximal caries is not a simple task. Unfortunately, few strong evidences are available to support these treatments. Therefore, clinicians should try to use the best available evidences at the occasion. Based on that, we tried to contribute to clinical decision-making process joining the description of present evidences to a critical appraisal of them. We believe the critical judgment of the published

Nowadays, the adoption of the minimal intervention philosophy has been a reality. Based on that, we have looked into evidences that may support our clinical decision-making not only based on effectiveness or efficacy of therapies used. We have also looked for manners of treating our children minimizing destruction/loss of healthy or

restoration; (f) checking the occlusal contacts. *(images gently donated by Dr. Isabel Olegario)* 

evidences is crucial to guide the better clinicians' conduct to their patients.

*Final considerations* 

*tly donated by Dr. Isabel Olegario)*

**8. Final considerations**

cavities clinically restricted to enamel.

On the other hand, similar trend regarding the protection of the margin of restorations can be observed with ART (Figure 26), since this treatment has high-viscous GIC as the material of choice. The GIC shows results such like the RMGIC in prevention of new caries lesion (100). Moreover, studies have considered GIC as a viable alternative due to the similar survival rates compared to others restorative materials/techniques (87). Other proprieties of GIC may also contribute to this choice, i.e., ability to chemically bond to enamel and dentine with insignificant heat formation or shrinkage, biocompatibility with the pulp and periodontal tissues and a similar coefficient of thermal expansion to tooth

More recently, a new advantage related to GIC in occlusoproximal restoration has been addressed. Studies have claimed the contact with an approximal cavity offers a higher risk to the adjacent surfaces developing caries lesion (1). In these cases, GIC restoration could prevent the new lesions and even to arrest the initial ones (102). This hypothesis has been confirmed by a practice-based research, which showed that the progression rate of caries lesion on tooth surfaces adjacent to amalgam restorations was 30%, whilst to GIC restorations was only 16% (103). These premises associated with no need of local anesthesia and rubber dam application have contributed for indicating GIC restoration associated to partial caries removal as the best option to treat cavitated lesions in children (Figure 26).

> Figure 26 – Step-by-step of an occlusoproximal restoration based on atraumatic restorative treatment, using partial caries removal and high-visous glass ionomer cement (GIC). (a) cavity

a similar coefficient of thermal expansion to tooth structure [101].

option to treat cavitated lesions in children (Figure 27).

structure (101).

106 Emerging Trends in Oral Health Sciences and Dentistry

Authors would like to thank the CNPq, Capes and Fapesp (Protocol 2012/50716-0 and 2014/00271-7), which have given financial support for investigations performed in this field. They were also very thankful to Dr. O´Such for English revision and to Dr. Olegario to donation of some images for illustrating this chapter.

## **Author details**

Mariana Minatel Braga1\*, Isabela Floriano1 , Fernanda Rosche Ferreira1 , Juliana Mattos Silveira1 , Alessandra Reyes1 , Tamara Kerber Tedesco1 , Daniela Prócida Raggio1 , José Carlos Pettorossi Imparato2 and Fausto Medeiros Mendes1,2

\*Address all correspondence to: mmbraga@usp.br

1 Dental School, Department of Pediatric Dentistry, University of São Paulo, São Paulo, Brazil

2 University Camilo Castelo Branco, São Paulo, Brazil and CPO São Leopoldo Mandic, Campinas, Brazil

## **References**


[13] Kidd EA, Fejerskov O. What constitutes dental caries? Histopathology of carious en‐ amel and dentin related to the action of cariogenic biofilms. Journal of dental re‐ search. 2004;83 Spec No C:C35-8. PubMed PMID: 15286119.

**References**

PMID: 20731733. eng.

108 Emerging Trends in Oral Health Sciences and Dentistry

2003/05/09. eng.

21698350. ENG.

21894873. eng.

9088687.

[1] Cagetti MG, Campus G, Sale S, Cocco F, Strohmenger L, Lingström P. Association between interdental plaque acidogenicity and caries risk at surface level: a cross sec‐ tional study in primary dentition. Int J Paediatr Dent. 2011 Mar;21(2):119-25. PubMed

[2] Seki M, Karakama F, Terajima T, Ichikawa Y, Ozaki T, Yoshida S, et al. Evaluation of mutans streptococci in plaque and saliva: correlation with caries development in pre‐ school children. J Dent. 2003 May;31(4):283-90. PubMed PMID: 12735923. Epub

[3] Choo A, Delac DM, Messer LB. Oral hygiene measures and promotion: review and considerations. Aust Dent J. 2001 Sep;46(3):166-73. PubMed PMID: 11695154. eng.

[4] Ashkenazi M, Bidoosi M, Levin L. Factors associated with reduced compliance of children to dental preventive measures. Odontology. 2011 Jun. PubMed PMID:

[5] Longbottom CL, Huysmans MC, Pitts NB, Fontana M. Glossary of key terms. Mon‐

[6] Rao A, Malhotra N. The role of remineralizing agents in dentistry: a review. Com‐ pend Contin Educ Dent. 2011 2011 Jul-Aug;32(6):26-33; quiz 4, 6. PubMed PMID:

[7] Milsom KM, Tickle M, Humphris GM, Blinkhorn AS. The relationship between anxi‐ ety and dental treatment experience in 5-year-old children. Br Dent J. 2003 May;

[8] Fejerskov O. Concepts of dental caries and their consequences for understanding the disease. Community Dent Oral Epidemiol. 1997 Feb;25(1):5-12. PubMed PMID:

[9] Fejerskov O. Changing paradigms in concepts on dental caries: Consequences for or‐

[10] Featherstone JD. The continuum of dental caries--evidence for a dynamic disease process. J Dent Res. 2004;83 Spec No C:C39-42. PubMed PMID: 15286120. eng.

[11] Bjørndal L, Mjör IA. Pulp-dentin biology in restorative dentistry. Part 4: Dental ca‐ ries--characteristics of lesions and pulpal reactions. Quintessence Int. 2001 Oct;32(9):

[12] Manji F, Fejerskov O, Nagelkerke NJ, Baelum V. A random effects model for some epidemiological features of dental caries. Community Dent Oral Epidemiol. 1991

ogr Oral Sci. 2009;21:209-16. PubMed PMID: 19494688. eng.

194(9):503-6; discussion 495. PubMed PMID: 12835786. eng.

al health care. Caries research. 2004;38(3):182-91.

717-36. PubMed PMID: 11695140. eng.

Dec;19(6):324-8. PubMed PMID: 1764899. eng.


[38] Novaes TF, Matos R, Celiberti P, Braga MM, Mendes FM. The influence of interden‐ tal spacing on the detection of proximal caries lesions in primary teeth. Brazilian oral research. 2012 Jul-Aug;26(4):293-9. PubMed PMID: 22790495.

[25] Pitts NB, Rimmer PA. An in vivo comparison of radiographic and directly assessed clinical caries status of posterior approximal surfaces in primary and permanent

[26] González-Cabezas C. The chemistry of caries: remineralization and demineralization events with direct clinical relevance. Dent Clin North Am. 2010 Jul;54(3):469-78.

[27] Almahdy A, Downey FC, Sauro S, Cook RJ, Sherriff M, Richards D, et al. Microbio‐ chemical analysis of carious dentine using Raman and fluorescence spectroscopy.

[28] Banerjee A, Watson TF, Kidd EA. Dentine caries: take it or leave it? Dent Update.

[29] Fusayama T. Two layers of carious dentin; diagnosis and treatment. Operative den‐

[30] Bjørndal L, Larsen T, Thylstrup A. A clinical and microbiological study of deep cari‐ ous lesions during stepwise excavation using long treatment intervals. Caries Res.

[31] Schupbach P, Lutz F, Guggenheim B. Human root caries: histopathology of arrested

[32] Kidd EA. How 'clean' must a cavity be before restoration? Caries research. 2004 May-

[33] Mejare I, Stenlund H, Zelezny-Holmlund C. Caries incidence and lesion progression from adolescence to young adulthood: a prospective 15-year cohort study in Sweden.

[34] Holmen L, Thylstrup A, Artun J. Surface changes during the arrest of active enamel carious lesions in vivo. A scanning electron microscope study. Acta odontologica

[35] Artun J, Thylstrup A. A 3-year clinical and SEM study of surface changes of carious enamel lesions after inactivation. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 1989 Apr;95(4):327-33.

[36] Nyvad B, Fejerskov O. Assessing the stage of caries lesion activity on the basis of clinical and microbiological examination. Community Dent Oral Epidemiol. 1997

[37] Igarashi K, Lee IK, Schachtele CF. Comparison of in vivo human dental plaque pH changes within artificial fissures and at interproximal sites. Caries Res. 1989;23(6):

lesions. Caries research. 1992;26(3):153-64. PubMed PMID: 1628289.

Caries research. 2004 Mar-Apr;38(2):130-41. PubMed PMID: 14767170.

Scandinavica. 1987 Dec;45(6):383-90. PubMed PMID: 3481156.

teeth. Caries Res. 1992;26(2):146-52. PubMed PMID: 1521308. eng.

Caries Res. 2012;46(5):432-40. PubMed PMID: 22739587. eng.

2000 2000 Jul-Aug;27(6):272-6. PubMed PMID: 11218463. eng.

tistry. 1979 Spring;4(2):63-70. PubMed PMID: 296808.

1997;31(6):411-7. PubMed PMID: 9353579. eng.

Jun;38(3):305-13. PubMed PMID: 15153704.

PubMed PMID: 2705413.

Feb;25(1):69-75. PubMed PMID: 9088694.

417-22. PubMed PMID: 2598230. Epub 1989/01/01. eng.

PubMed PMID: 20630190. eng.

110 Emerging Trends in Oral Health Sciences and Dentistry


[62] Tellez M, Gomez J, Kaur S, Pretty IA, Ellwood R, Ismail AI. Non-surgical manage‐ ment methods of noncavitated carious lesions. Community dentistry and oral epi‐ demiology. 2013 Feb;41(1):79-96. PubMed PMID: 23253076.

[50] Abazov VM, Abbott B, Abolins M, Acharya BS, Adams M, Adams T, et al. Search for resonant pair production of neutral long-lived particles decaying to bb in pp colli‐ sions at square root(S)=1.96 TeV. Phys Rev Lett. 2009 Aug 14;103(7):071801. PubMed

[51] Bader JD, Shugars DA, Bonito AJ. A systematic review of the performance of meth‐ ods for identifying carious lesions. J Public Health Dent. 2002 Fall;62(4):201-13.

[52] Espelid I, Mejare I, Weerheijm K, Eapd. EAPD guidelines for use of radiographs in children. European journal of paediatric dentistry : official journal of European Acad‐

[53] Mendes FM, Novaes TF, Matos R, Bittar DG, Piovesan C, Gimenez T, et al. Radio‐ graphic and laser fluorescence methods have no benefits for detecting caries in pri‐

[54] Braga MM, Mendes FM, Ekstrand KR. Detection activity assessment and diagnosis of dental caries lesions. Dental clinics of North America. 2010 Jul;54(3):479-93. PubMed

[55] Rimmer PA, Pitts NB. Temporary elective tooth separation as a diagnostic aid in gen‐ eral dental practice. British dental journal. 1990 Aug 11-25;169(3-4):87-92. PubMed

[56] Mialhe FL, Pereira AC, Pardi V, de Castro Meneghim M. Comparison of three meth‐ ods for detection of carious lesions in proximal surfaces versus direct visual examina‐ tion after tooth separation. The Journal of clinical pediatric dentistry. 2003 Fall;28(1):

[57] Ridell K, Olsson H, Mejàre I. Unrestored dentin caries and deep dentin restorations in Swedish adolescents. Caries Res. 2008;42(3):164-70. PubMed PMID: 18446024. eng.

[58] Mendes FM, Braga MM. Caries detection in primary teeth is less challenging than in

[59] Corby PM, Biesbrock A, Bartizek R, Corby AL, Monteverde R, Ceschin R, et al. Treat‐ ment outcomes of dental flossing in twins: molecular analysis of the interproximal microflora. J Periodontol. 2008 Aug;79(8):1426-33. PubMed PMID: 18672992. Epub

[60] Merchant AT. Flossing for 2 weeks reduces microbes associated with oral disease. J Evid Based Dent Pract. 2009 Dec;9(4):223-4. PubMed PMID: 19913742. Epub

[61] Schüz B, Wiedemann AU, Mallach N, Scholz U. Effects of a short behavioural inter‐ vention for dental flossing: randomized-controlled trial on planning when, where and how. J Clin Periodontol. 2009 Jun;36(6):498-505. PubMed PMID: 19453572. eng.

emy of Paediatric Dentistry. 2003 Mar;4(1):40-8. PubMed PMID: 12870988.

mary teeth. Caries research. 2012;46(6):536-43. PubMed PMID: 22907166.

PMID: 19792632. Epub 2009/10/02. eng.

PubMed PMID: 12474624.

112 Emerging Trends in Oral Health Sciences and Dentistry

PMID: 20630191.

PMID: 2206652.

2008/08/05. eng.

2009/11/17. eng.

59-62. PubMed PMID: 14604144.

permanent teeth. Dental Hypotheses. 2013;4:17-20.


[85] Celiberti P. Novas possibilidades de manejo e monitoramento de lesões de cárie em superfícies proximais.. São Paulo: Dental School, University of São Paulo; 2011.

[74] Ammari MM, Soviero VM, da Silva Fidalgo TK, Lenzi M, Ferreira DM, Mattos CT, et al. Is non-cavitated proximal lesion sealing an effective method for caries control in primary and permanent teeth? A systematic review and meta-analysis. Journal of

[75] Ahovuo-Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A, Makela M, et al. Seal‐ ants for preventing dental decay in the permanent teeth. The Cochrane database of

[76] Heller KE, Reed SG, Bruner FW, Eklund SA, Burt BA. Longitudinal evaluation of sealing molars with and without incipient dental caries in a public health program. J Public Health Dent. 1995 Summer;55(3):148-53. PubMed PMID: 7562727. Epub

[77] Gomez SS, Basili CP, Emilson CG. A 2-year clinical evaluation of sealed noncavitated approximal posterior carious lesions in adolescents. Clinical oral investigations. 2005

[78] Phark JH, Duarte S, Jr., Meyer-Lueckel H, Paris S. Caries infiltration with resins: a novel treatment option for interproximal caries. Compend Contin Educ Dent. 2009

[79] Paris S, Hopfenmuller W, Meyer-Lueckel H. Resin infiltration of caries lesions: an ef‐ ficacy randomized trial. Journal of dental research. 2010 Aug;89(8):823-6. PubMed

[80] Meyer-Lueckel H, Bitter K, Paris S. Randomized controlled clinical trial on proximal caries infiltration: three-year follow-up. Caries Res. 2012;46(6):544-8. PubMed PMID:

[81] Martignon S, Ekstrand KR, Gomez J, Lara JS, Cortes A. Infiltrating/sealing proximal caries lesions: a 3-year randomized clinical trial. Journal of dental research. 2012 Mar;

[82] Ekstrand KR, Bakhshandeh A, Martignon S. Treatment of proximal superficial caries lesions on primary molar teeth with resin infiltration and fluoride varnish versus flu‐ oride varnish only: efficacy after 1 year. Caries research. 2010;44(1):41-6. PubMed

[83] Mattos-Silveira J, Floriano I, Ferreira FR, Vigano ME, Mendes FM, Braga MM. Child‐ ren's discomfort may vary among different treatments for initial approximal caries lesions: preliminary findings of a randomized controlled clinical trial. Int J Paediatr

[84] Hesse D, Bonifacio CC, Mendes FM, Braga MM, Imparato JC, Raggio DP. Sealing versus partial caries removal in primary molars: a randomized clinical trial. BMC Or‐ al Health. 2014;14:58. PubMed PMID: 24884684. Pubmed Central PMCID: 4045925.

91(3):288-92. PubMed PMID: 22257664. Epub 2012/01/20. eng.

Oct;30 Spec No 3:13-7. PubMed PMID: 19891346. Epub 2009/11/07. eng.

dentistry. 2014 Oct;42(10):1217-27. PubMed PMID: 25066832.

systematic reviews. 2013;3:CD001830. PubMed PMID: 23543512.

1995/01/01. eng.

114 Emerging Trends in Oral Health Sciences and Dentistry

22922306. eng.

Dec;9(4):239-43. PubMed PMID: 16167153.

PMID: 20505049. Epub 2010/05/28. eng.

PMID: 20090327. Epub 2010/01/22. eng.

Dent. 2014 Sep 17. PubMed PMID: 25229641.


**Chapter 5**

## **Dental Caries and Quality of Life Among Preschool Children**

Joana Ramos-Jorge, Maria Letícia Ramos-Jorge, Saul Martins de Paiva, Leandro Silva Marques and Isabela Almeida Pordeus

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59515

## **1. Introduction**

[97] Lenzi TL, Mendes FM, Rocha Rde O, Raggio DP. Effect of shortening the etching time on bonding to sound and caries-affected dentin of primary teeth. Pediatr Dent.

[98] Yengopal V, Mickenautsch S. Caries-preventive effect of resin-modified glass-ionom‐ er cement (RM-GIC) versus composite resin: a quantitative systematic review. Eur

[99] Qvist V, Laurberg L, Poulsen A, Teglers PT. Class II restorations in primary teeth: 7 year study on three resin-modified glass ionomer cements and a compomer. Eur J

[100] Mickenautsch S, Tyas MJ, Yengopal V, Oliveira LB, Bonecker M. Absence of carious lesions at margins of glass-ionomer cement (GIC) and resin-modified GIC restora‐ tions: a systematic review. Eur J Prosthodont Restor Dent. 2010 Sep;18(3):139-45.

[101] Anusavice KJ. Phillips' Science of Dental Materials. 12.ed. ed. Philadelphia: Saunders;

[102] Guglielmi CA. Efeito de materiais restauradores em contato proximal com lesões de cárie em dentes decíduos São Paulo: Dental School, University of São Paulo, 2013.

[103] Qvist V, Laurberg L, Poulsen A, Teglers PT. Eight-year study on conventional glass ionomer and amalgam restorations in primary teeth. Acta odontologica Scandinavi‐

Arch Paediatr Dent. 2011 Feb;12(1):5-14. PubMed PMID: 21299939.

Oral Sci. 2004 Apr;112(2):188-96. PubMed PMID: 15056118.

ca. 2004 Feb;62(1):37-45. PubMed PMID: 15124781.

PubMed PMID: 21077424.

116 Emerging Trends in Oral Health Sciences and Dentistry

2012.

2013 Sep-Oct;35(5):E129-33. PubMed PMID: 24290541.

Dental caries (tooth decay) is an adverse oral condition with a multifactor etiology involving genetic, behavioral and environmental aspects (Reisine and Psoter, 2001; Petersen *et al.*, 2005). Socioeconomic factors have been associated with caries experience and the distribu‐ tion of this condition among individuals (Pereira *et al.*, 2007; Traebert *et al.*, 2009). Under‐ standing the influence of lifestyle and social aspect on the occurrence and progression of dental caries can contribute to improvements in preventive and restorative treatment (Petersen *et al.*, 2005).

Although not a fatal condition, dental caries can lead to pain as well as problems with sleeping, eating, socializing and self-esteem. Thus, tooth decay can exert a negative impact on activities of daily living and, consequently, quality of life (Patel *et al.*, 2007). Quality of life is often evaluated by means of the investigation into the consequences of an adverse health condition and its treatment from the standpoint of the affected individual (Tamani‐ ni *et al.*, 2004). The association between oral health and quality of life is considered by many researchers to be a complement to clinical indicators (Martins-Júnior *et al.*, 2012a).

There are few assessment tools for measuring the impact of oral problems on the quality of life of children. As adults are responsible for decisions involving the health of their children (Pahel *et al.*, 2007), evaluating the perceptions of parents/caregivers regarding oral health problems that affect the quality of life of children is fundamental to planning health promotion strategies.

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

## **2. Problem statement**

The concept of oral health-related quality of life (OHRQoL) regards the impact that oral problems have on the performance of activities of daily living, wellbeing and quality of life (Slade, 1997). It is therefore important to assess OHRQoL in different populations to understand the oral health problems that affect individuals and design public health programs and strategies directed at prevention and treatment.

Despite the growing interest and consequent increase in the number of publications on this issue, the evaluation of the impact of dental caries in preschool children has only recently been the focus of investigation. As young children may not be capable of remembering events that occurred more than 24 hours earlier (Rebok *et al.*, 2001) and have limitations regarding the expression of emotions and anguish (Talekar *et al.*, 2005), this investigation is often performed with the aid of parents/caregivers. It is therefore important to explore the perceptions of parents/caregivers that affect the preventive care children receive at home as well as the use of dental services (Filstrup *et al.*, 2003). Moreover, the perceptions of parents/caregivers may offer insight into some of the reasons why preschool children often do not receive the dental treatment they need.

The Early Childhood Oral Health Impact Scale (ECOHIS) was developed for parents/caregiv‐ ers of young children (Pahel *et al.*, 2007). The use of this questionnaire in epidemiological studies has allowed broadening knowledge on adverse oral conditions that affect the quality of life of children as well as strengthening scientific evidence on this issue and demonstrating the need for oral health programs directed at preschool children.

Based on evidence that children aged four to six years can reliably report on their own quality of life (Filstrup *et al.*, 2003), the Scale of Oral Health Outcomes for Five-Year-Old Children (SOHO-5) has recently been developed in the United Kingdom (Tsakos *et al.*, 2012). However, studies employing this instrument have been limited to evaluating its reliability and validity.

Dental caries is the oral condition most often associated with a negative impact on the quality of life of preschool children (Abanto *et al.*, 2011; Scarpelli *et al.*, 2012; Ramos-Jorge *et al.*, 2014), the consequences of which include pain, decreased appetite, difficulty chewing, difficulty eating some foods and drinking hot or cold beverages, weight loss, difficulty sleeping, changes in behavior and a poor academic performance (Abanto *et al.*, 2011; Acs *et al.*, 1992; Ayhan *et al.*, 1996; Filstrup *et al.*, 2003; Feitosa *et al.*, 2005; Oliveira *et al.*, 2008; Martins-Júnior *et al.*, 2012b). Studies carried out in China (Wong *et al.*, 2011) and Brazil (Abanto *et al.*, 2011; Scarpelli *et al.*, 2012; Martins-Júnior *et al.*, 2012b) using the ECOHIS report that dental caries has a negative impact on the quality of life of preschool children and their parents/caregivers and this impact is greater in the presence of six or more carious lesions.

A study conducted in Canada found that dental surgery is the most common surgical proce‐ dure at most pediatric hospitals (Canadian Paediatric Decision Support Network, 2004), which indicates that the treatment of dental caries in children is costly. Moreover, the need for restorative treatment can lead to the establishment of a repetitive restorative cycle (Elderton *et al.*, 1990), which further raises treatment costs (Zero *et al.*, 2011). However, caries can be detected in the early stages, when restorative treatment is not necessary. The International Caries Detection and Assessment System (ICDAS) allows the standardization and diagnosis of dental caries in different settings and situations (Pitts, 2004). The integration of criteria from other caries detection and diagnostic systems involving non-cavitated enamel lesions and the staging of the disease process (Ekstrand *et al.*, 1997; Fyffe *et al.*, 2000; Chesters *et al.*, 2002; Rickets *et al.*, 2002) led to the current system, denominated ICDAS II (Shoaib *et al.*, 2009), which contributes to the preventive management of tooth decay.

**2. Problem statement**

118 Emerging Trends in Oral Health Sciences and Dentistry

treatment they need.

The concept of oral health-related quality of life (OHRQoL) regards the impact that oral problems have on the performance of activities of daily living, wellbeing and quality of life (Slade, 1997). It is therefore important to assess OHRQoL in different populations to understand the oral health problems that affect individuals and design public health

Despite the growing interest and consequent increase in the number of publications on this issue, the evaluation of the impact of dental caries in preschool children has only recently been the focus of investigation. As young children may not be capable of remembering events that occurred more than 24 hours earlier (Rebok *et al.*, 2001) and have limitations regarding the expression of emotions and anguish (Talekar *et al.*, 2005), this investigation is often performed with the aid of parents/caregivers. It is therefore important to explore the perceptions of parents/caregivers that affect the preventive care children receive at home as well as the use of dental services (Filstrup *et al.*, 2003). Moreover, the perceptions of parents/caregivers may offer insight into some of the reasons why preschool children often do not receive the dental

The Early Childhood Oral Health Impact Scale (ECOHIS) was developed for parents/caregiv‐ ers of young children (Pahel *et al.*, 2007). The use of this questionnaire in epidemiological studies has allowed broadening knowledge on adverse oral conditions that affect the quality of life of children as well as strengthening scientific evidence on this issue and demonstrating

Based on evidence that children aged four to six years can reliably report on their own quality of life (Filstrup *et al.*, 2003), the Scale of Oral Health Outcomes for Five-Year-Old Children (SOHO-5) has recently been developed in the United Kingdom (Tsakos *et al.*, 2012). However, studies employing this instrument have been limited to evaluating its reliability and validity. Dental caries is the oral condition most often associated with a negative impact on the quality of life of preschool children (Abanto *et al.*, 2011; Scarpelli *et al.*, 2012; Ramos-Jorge *et al.*, 2014), the consequences of which include pain, decreased appetite, difficulty chewing, difficulty eating some foods and drinking hot or cold beverages, weight loss, difficulty sleeping, changes in behavior and a poor academic performance (Abanto *et al.*, 2011; Acs *et al.*, 1992; Ayhan *et al.*, 1996; Filstrup *et al.*, 2003; Feitosa *et al.*, 2005; Oliveira *et al.*, 2008; Martins-Júnior *et al.*, 2012b). Studies carried out in China (Wong *et al.*, 2011) and Brazil (Abanto *et al.*, 2011; Scarpelli *et al.*, 2012; Martins-Júnior *et al.*, 2012b) using the ECOHIS report that dental caries has a negative impact on the quality of life of preschool children and their parents/caregivers and

A study conducted in Canada found that dental surgery is the most common surgical proce‐ dure at most pediatric hospitals (Canadian Paediatric Decision Support Network, 2004), which indicates that the treatment of dental caries in children is costly. Moreover, the need for restorative treatment can lead to the establishment of a repetitive restorative cycle (Elderton *et al.*, 1990), which further raises treatment costs (Zero *et al.*, 2011). However, caries can be

programs and strategies directed at prevention and treatment.

the need for oral health programs directed at preschool children.

this impact is greater in the presence of six or more carious lesions.

Despite the decline in the prevalence of dental caries beginning in the 1970s, the control of this condition continues to pose a challenge to public health authorities (Petersen *et al.*, 2005; Dye *et al.*, 2007). Moreover, increasing polarization is seen due to social inequalities in oral health (Sabbah *et al.*, 2007), which has led to a greater prevalence rate of dental caries in some minorities (Antunes *et al.*, 2004).

The difficulty in controlling dental caries affects both developed and developing nations. Successive national child dental health surveys in the United Kingdom have shown little change in the prevalence of caries among five-year-old children over the last 20 years (Lader *et al.*, 2004). Data from the United States of America tells a similar story, as no significant changes in the prevalence of dental caries among children aged two to 11 years was found from 1988-1994 to 1999-2002 (Beltran-Aguilar *et al.*, 2005).

The monitoring of the early stages of caries progression requires the assessment of a dentist. However, this is not a common occurrence among preschool children. Indeed, a Brazilian study found that only 13.3% of a sample of 1092 children aged zero to five years had visited a dentist at least once (Kramer *et al.*, 2008). This low rate of access to dental treatment can contribute to the greater prevalence of severe tooth decay in comparison to less advanced stages of pro‐ gression (Ramos-Jorge *et al.*, 2014). Furthermore, among older preschoolers, the negative impact on OHRQoL (Ramos-Jorge *et al.*, 2014) seems to stem from the fact that these individuals have caries in more advanced stages of decay and also have a greater capacity to communicate the effect of oral health conditions on their quality of life to parents/caregivers (Ramos-Jorge *et al.*, 2014). Consequently, the prevention and management of dental caries should begin at an early age, as this is an evident public health problem among preschool children.

The diminished appetite, difficulty chewing, weight loss and difficulty sleeping stemming from dental caries can compromise growth and development. Moreover, children with severe caries appear to be at significantly greater odds of having low vitamin D status compared to their caries-free counterparts and are likely malnourished, as they display significantly lower levels of calcium and serum albumin as well as higher levels of PTH compared to a control group (reference).

OHRQoL assessment tools designed for preschool children are useful for the evaluation of public oral health strategies and interventions. Such tools should have properties that enable the detection of clinical changes following treatment. Responsiveness is a key technical property that allows researchers to choose the most appropriate measures for clinical trials, provides a basis for estimating sample sizes and facilitates the interpretation of changes occurring after treatment (Guyatt *et al.*, 2002; Malden *et al.*, 2008).

The aim of health interventions should be to improve quality of life. Despite the tendency to consider oral health as a separate concept, it is an integral part of general health (Cunningham and Hunt, 2001). Thus, the complex multidimensional interrelationship between general and oral health is essential to quality of life (Kieffe and, Hoogstraten, 2008). In this context, the use of subjective measures considering individual viewpoints has become increasingly important to the evaluation of general and oral health (Kieffer and Hoogstraten, 2008).

## **3. Application area**

The findings of studies on OHRQoL and dental caries in preschool children are useful to the fields of pediatrics and pediatric dentistry and can be employed by public health administra‐ tors for the definition of strategies directed at improving the oral health status of this popula‐ tion.

## **4. Research course**

According to a large number of the aforementioned studies, scientific evidence indicates that dental caries has a negative impact on quality of life among preschool children, especially those with six or more carious lesions or lesions in a more advanced stage of progression. The aim of the study reported herein was to evaluate the association between different stages of dental caries and the impact on the quality of life of preschool children.

## **5. Method used**

A population-based, cross-sectional study was conducted involving preschool children. The inclusion criteria age between three and five years, enrolment in a preschool/daycare center in the city of Diamantina, Brazil, and parents/guardians fluent in Brazilian Portuguese who live with the child at least 12 hours per day. The exclusion criteria were current orthodontic treatment, systemic disease, having all carious lesions treated satisfactorily and the presence of tartar. The sample size was calculated using a 37.8% prevalence rate of impact from dental caries on the quality of life of preschool children (Martins-Júnior *et al.*, 2013), a 95% confidence interval and 5% standard error. The minimum sample was defined as 346 preschool children. A 1.2 correction factor was applied to enhance the precision and an additional 84 children were added to compensate for possible losses, resulting in a sample of 499 preschool children. To ensure representativeness, the sample was stratified based on the type of preschool (public or private) and the distribution of the sample was proportional to the total population enrolled in private and public preschools in the city.

Parents/caregivers were asked to answer the Brazilian version of the ECOHIS (B-ECOHIS) (Martins-Júnior *et al.*, 2012) and fill out a form addressing socio-demographic information, such as mother's schooling (years of study), whether the mother worked outside the home, monthly household income (categorized based on the Brazilian minimum wage = US\$304.38), duration of salary (in weeks), family provider and number of individuals who depend on the income.

The aim of health interventions should be to improve quality of life. Despite the tendency to consider oral health as a separate concept, it is an integral part of general health (Cunningham and Hunt, 2001). Thus, the complex multidimensional interrelationship between general and oral health is essential to quality of life (Kieffe and, Hoogstraten, 2008). In this context, the use of subjective measures considering individual viewpoints has become increasingly important

The findings of studies on OHRQoL and dental caries in preschool children are useful to the fields of pediatrics and pediatric dentistry and can be employed by public health administra‐ tors for the definition of strategies directed at improving the oral health status of this popula‐

According to a large number of the aforementioned studies, scientific evidence indicates that dental caries has a negative impact on quality of life among preschool children, especially those with six or more carious lesions or lesions in a more advanced stage of progression. The aim of the study reported herein was to evaluate the association between different stages of dental

A population-based, cross-sectional study was conducted involving preschool children. The inclusion criteria age between three and five years, enrolment in a preschool/daycare center in the city of Diamantina, Brazil, and parents/guardians fluent in Brazilian Portuguese who live with the child at least 12 hours per day. The exclusion criteria were current orthodontic treatment, systemic disease, having all carious lesions treated satisfactorily and the presence of tartar. The sample size was calculated using a 37.8% prevalence rate of impact from dental caries on the quality of life of preschool children (Martins-Júnior *et al.*, 2013), a 95% confidence interval and 5% standard error. The minimum sample was defined as 346 preschool children. A 1.2 correction factor was applied to enhance the precision and an additional 84 children were added to compensate for possible losses, resulting in a sample of 499 preschool children. To ensure representativeness, the sample was stratified based on the type of preschool (public or private) and the distribution of the sample was proportional to the total population enrolled

Parents/caregivers were asked to answer the Brazilian version of the ECOHIS (B-ECOHIS) (Martins-Júnior *et al.*, 2012) and fill out a form addressing socio-demographic information,

caries and the impact on the quality of life of preschool children.

to the evaluation of general and oral health (Kieffer and Hoogstraten, 2008).

**3. Application area**

120 Emerging Trends in Oral Health Sciences and Dentistry

**4. Research course**

**5. Method used**

in private and public preschools in the city.

tion.

The B-ECOHIS was used to assess the negative impact of the progression stage and activity of dental caries on the quality of life of the preschool children. This questionnaire is composed of 13 items distributed in a Child Impact Section (CIS) and Family Impact Section (FIS). The former section has four domains (symptoms, function, psychology and self-image/social interaction) and the latter has two domains (parental distress and family function). The scale has five response options for recording how often an event has occurred in a child's life. The CIS and FIS scores are calculated through a simple sum of the scores on all items in each section, ranging from 0 to 36 and 0 to 16, respectively. The total score ranges from 0 to 52, with higher scores denoting greater oral health impact and poorer OHRQoL.

The clinical oral examination of the children was performed by a single dentist who had undergone a calibration exercise at a public preschool, during which inter-examiner and intraexaminer Kappa values were greater than 0.8 for all oral conditions evaluated. The examination was carried out after brushing performed by the dentist, with the aid of a head lamp (PETZL®, Tikka XP, Crolles, France), mouth mirrors (PRISMA, São Paulo, SP, Brazil), WHO probes (Golgran Ind. e Com. Ltda., São Paulo, SP, Brazil) and dental gauze for drying the teeth. During the examination, the children remained lying on a portable stretcher.

The ICDAS II criteria and Activity Lesion Assessment, which measures visual appearance, local susceptibility to plaque buildup and surface texture, were used for the determination of dental caries. Dental caries was recorded as follows: distinct visual change in enamel – ICDAS code 2 (active and inactive); localized enamel breakdown – ICDAS code 3 (active and inactive); underlying dentin shadow – ICDAS code 4 (active and inactive); distinct cavity within visible dentin – ICDAS code 5 (active and inactive); and extensive cavity within visible dentin – ICDAS code 6, without pulp exposure (active and inactive), with pulp exposure (with absence or presence of fistula and root remnants). The first visual change in enamel (ICDAS code 1, when there is no pigmentation) is detected only after drying with compressed air. As drying was performed with dental gauze in the present study, the decision was made to exclude the evaluation of this condition. When the characteristic pigmentation of this stage of carious lesion was detected on any face with the tooth either wet or dried with gauze, the tooth was recorded as "sound".

Malocclusion, traumatic dental injury (TDI) and physiological tooth mobility were evaluated as possible confounding variables. Malocclusion was recorded in the presence of anterior open bite, posterior open bite, increased overjet, deep bite, anterior crossbite or posterior crossbite. The clinical diagnosis of TDI was performed using the criteria proposed by Andreasen (Andreasen et al., 2007) and the assessment of tooth discoloration. Physiological tooth mobility was considered only when the tooth was nearing exfoliation. All confounding variables were categorized as absent or present.

Statistical analysis was performed using the SPSS 20.0 program for Windows (SPSS Inc, Chicago, IL, USA). Descriptive analysis (including frequency distribution) was performed for mean total B-ECOHIS scores. Scores for the individual domains were analyzed for differences between oral conditions and socioeconomic/demographic factors. In cases of children with a tooth exhibiting different stages of dental caries, the worst condition was considered. Poisson regression analysis with robust variance was performed to associate the mean total B-ECOHIS score with each clinical oral condition, socioeconomic factor and characteristic of the child. Prevalence rates (PR) and 95% confidence intervals (95% CI) were calculated.

## **6. Status**

This study was completed and published in Community Dentistry and Oral Epidemiology.

## **7. Results**

A total of 499 preschool children were initially enrolled in the study, 451 (90.4%) of whom participated through to the end of the study. The main reason for losses was the absence of a questionnaire filled out by the parents. Mean age (standard deviation) of the preschool children was 4.25 (0.83) years. The female sex accounted for 53.9% of the sample. The prevalence of untreated caries was 51.2%. A total of 60.6% of the teeth with caries exhibited severe decay. Malocclusion, TDI and physiological tooth mobility were present in 28.4%, 17.5% and 2.0% of the preschool children, respectively.

The majority of parents/caregivers reported no impact on quality of life (52.8%) (i.e., B-ECOHIS score: 0). The most frequently reported items were pain, difficulty eating and drinking, irritability, trouble sleeping and smiling.

In the final multivariate model, negative impact on quality of life was associated with the age of the child and a lower level of mother's schooling. More advanced stages of caries were associated with an increased negative impact on the quality of life of the children. Among inactive lesions, only extensive cavity without pulp exposure had an increased negative impact on quality of life (PR = 3.68; 95% CI: 1.74 to 7.81; p = 0.001).

## **8. Further research**

Future investigations should be conducted to evaluate the results of intervention strategies on both the individual and population levels.

## **9. Conclusion**

Statistical analysis was performed using the SPSS 20.0 program for Windows (SPSS Inc, Chicago, IL, USA). Descriptive analysis (including frequency distribution) was performed for mean total B-ECOHIS scores. Scores for the individual domains were analyzed for differences between oral conditions and socioeconomic/demographic factors. In cases of children with a tooth exhibiting different stages of dental caries, the worst condition was considered. Poisson regression analysis with robust variance was performed to associate the mean total B-ECOHIS score with each clinical oral condition, socioeconomic factor and characteristic of the child.

This study was completed and published in Community Dentistry and Oral Epidemiology.

A total of 499 preschool children were initially enrolled in the study, 451 (90.4%) of whom participated through to the end of the study. The main reason for losses was the absence of a questionnaire filled out by the parents. Mean age (standard deviation) of the preschool children was 4.25 (0.83) years. The female sex accounted for 53.9% of the sample. The prevalence of untreated caries was 51.2%. A total of 60.6% of the teeth with caries exhibited severe decay. Malocclusion, TDI and physiological tooth mobility were present in 28.4%, 17.5% and 2.0% of

The majority of parents/caregivers reported no impact on quality of life (52.8%) (i.e., B-ECOHIS score: 0). The most frequently reported items were pain, difficulty eating and drinking,

In the final multivariate model, negative impact on quality of life was associated with the age of the child and a lower level of mother's schooling. More advanced stages of caries were associated with an increased negative impact on the quality of life of the children. Among inactive lesions, only extensive cavity without pulp exposure had an increased negative impact

Future investigations should be conducted to evaluate the results of intervention strategies on

Prevalence rates (PR) and 95% confidence intervals (95% CI) were calculated.

**6. Status**

**7. Results**

the preschool children, respectively.

122 Emerging Trends in Oral Health Sciences and Dentistry

irritability, trouble sleeping and smiling.

both the individual and population levels.

**8. Further research**

on quality of life (PR = 3.68; 95% CI: 1.74 to 7.81; p = 0.001).

Dental caries exerts a negative impact on the quality of life of preschool children, especially those with a greater number of carious lesions or lesions in a more advanced stage of progres‐ sion.

## **Author details**

Joana Ramos-Jorge1\*, Maria Letícia Ramos-Jorge1 , Saul Martins de Paiva2 , Leandro Silva Marques1 and Isabela Almeida Pordeus2

\*Address all correspondence to: joanaramosjorge@gmail.com

1 Universidade Federal dos Vales do Jequitinhonha e Mucuri, Diamantina, Minas Gerais, Brazil

2 Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

## **References**


retention, edentulism, and enamel fluorosis--United States, 1988-1994 and 1999-2002. MMWR Surveill Summ. 2005;54:1-43.


[20] Malden PE, Thomson WM, Jokovic A, Locker D: Changes in parente assessed oral health-related quality of life among young children following dental treatment under general anaesthetic. Community Dent Oral Epidemiol 2008, 36:108–117.

retention, edentulism, and enamel fluorosis--United States, 1988-1994 and 1999-2002.

[8] Chesters RK, Pitts NB, Matuliene G, Kvedariene A, Huntington E, Bendinskaite R, Balciuniene I, Matheson JR, Nicholson JA, Gendvilyte A, Sabalaite R,Ramanauskiene J, Savage D, Mileriene J. An abbreviated caries clinical trial design validated over 24

[9] Cunningham SJ, Hunt NP. Quality of life and its importance in orthodontics. J Or‐

[10] Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, Eke PI, Beltrán-Aguilar ED, Horowitz AM, Li CH. Trends in oral health status: United States,

[11] Elderton RJ. Clinical studies concerning re-restoration of teeth. Adv Dent Res 1990;

[12] Ekstrand KR, Ricketts DN, Kidd EA. Reproducibility and accuracy of three methods for assessment of demineralization depth of the occlusal surface: an in vitro examina‐

[13] Feitosa S, Colares V, Pinkham J: The psychosocial effects of severe caries in 4-yearold children in Recife, Pernambuco, Brazil. Cad Saude Publica 2005;21:1550-6.

[14] Filstrup SL, Briskie D, da Fonseca M, Lawrence L, Wandera A, Inglehart MR: Early childhood caries and quality of life: child and parent perspectives. Pediatr Dent 2003;

[15] Fyffe HE, Deery C, Nugent ZJ, Nuttall NM, Pitts NB. Effect of diagnostic threshold on the validity and reliability of epidemiological caries diagnosis using the Dundee Selectable Threshold Method for caries diagnosis (DSTM). Community Dent Oral Ep‐

[16] Guyatt G, Osoba D, Wu A, Wyrwich K, Norman G: Methods to explain the signifi‐ cance of health status measures. Hamilton, Ontario: Clinical Significance Consensus

[17] Kramer PF, Ardenghi TM, Ferreira S, Fischer LA, Cardoso L, Feldens CA. Use of dental services by preschool children in Canela, Rio Grande do Sul State, Brazil. Cad.

[18] Kieffer JM, Hoogstraten J. Linking oral health, general health, and quality of life. Eur

[19] Lader D, Chadwick B, Chestnutt, Harker R, Morris J, Nuttal N, Pitts N, Steele J, White D: Children's Dental Health in the United Kingdom, 2003 London: Office for

1988-1994 and 1999-2004. Vital Health Stat 2007; 11:1-92.

MMWR Surveill Summ. 2005;54:1-43.

months. J Dent Res 2002; 81:637-40.

tion. Caries Res 1997; 31:224-31.

thod 2001; 28:152-8.

124 Emerging Trends in Oral Health Sciences and Dentistry

4:4-9.

25:431-40.

idemiol 2000; 28: 42-51.

Saúde Pública 2008;24:150-6.

J Oral Sci. 2008;116:445-50

National statistics; 2004.

Meeting Group, Unpublished paper; 2002.


## **Chapter 6**

## **Herbal Dentifrices for Children**

Marisa Alves Nogueira Diaz, Isabela de Oliveira Carvalho and Gaspar Diaz

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59812

## **1. Introduction**

[33] Sabbah W, Tsakos G, Chandola T, Sheiham A, Watt RG. Social gradients in oral and

[34] Scarpelli AC, Paiva SM, Viegas CM, Carvalho AC, Ferreira FM, Pordeus IA: Oral health-related quality of life among Brazilian preschool children. Community Dent

[35] Schroth RJ, Levi JA, Sellers EA, Friel J, Kliewer E, Moffatt ME. Vitamin D status of children with severe early childhood caries: a case-control study. BMC Pediatr

[36] Shoaib L, Deery C, Ricketts DN, Nugent ZJ. Validity and reproducibility of ICDAS II

[37] Slade GD. Derivation and validation of a short-form oral health impact profile. Com‐

[38] Tamanini JTN, Dambros M, D'ancona CAL, Palma PCR, Netto Jr NR. Validation of the International Consultation on Incontinence Questionnaire – Short Form"

[39] Talekar BS, Rozier RG, Slade GD, Ennett ST. Parental perceptions of their preschool-

[40] Traebert J, Guimarães LA, Durante EZ, Serratine AC. Low maternal schooling and severity of dental caries in Brazilian preschool children. Oral Health Prev Dent 2009;

[41] Tsakos G, Blair YI, Yusuf H, Wright W, Watt RG, Macpherson LMD. Developing a new self-reported scale of oral health outcomes for 5-year-old children (SOHO-5).

[42] Wong HM, McGrath CP, King NM, Lo EC: Oral health-related quality of life in Hong

[43] Zero DT, Zandona AF, Vail MM, Spolnik KJ: Dental caries and pulpal disease. Dent

general health. J Dent Res 2007;86:992-6.

in primary teeth. Caries Res 2009;43:442-8.

munity Dent Oral Epidemiol 1997; 25:284-90.

Health Qual Life Outcomes 2012;10:62.

Clin North Am 2011;55:29-46.

Kong preschool children. Caries Res 2011;45:370-6.

(ICIQSF) for Portuguese. Rev Saude Publica 2004; 38:438-444.

aged children's oral health. J Am Dent Assoc 2005;136:364-72.

Oral Epidemiol 2012;41:336-44.

126 Emerging Trends in Oral Health Sciences and Dentistry

2013;13:174.

7:39-45.

The use of plant extracts as antimicrobial agents has been increasing every daily. Currently, these applications are mainly found in dentistry with the increased use of plant extracts in toothpastes for both adults and children. This finding results from the fact that the oral cavity is considered a favorable environment for the colonization and growth of a wide range of microorganisms, bacteria being the most common [1, 2]. One of the core arguments for the pharmaceutical industry to use toothpastes made from plant extracts is that they can act as antibiotics, analgesics, sedatives, and anti-inflammatories, in addition to being less likely to cause side effects. In the case of toothpastes for children's use where the presence of fluoride can lead to fluorosis, the presence of extracts with antimicrobial activity is quite interesting, given that these combat microorganisms by preventing the formation of biofilms [3].

The presence of microorganisms in the physiology of the oral cavity is essential for normal development, since most species are commensal microorganisms. In some cases, these microorganisms contribute to preventing the establishment of pathogenic microorganisms [4]. However, some of these microorganisms are considered to be opportunistic pathogens that play an important role in the etiology of periodontitis and dental caries, which are believed to be the most prevalent diseases in the world [5]. These microorganisms have also regularly been involved in the etiology of a number of systemic diseases, such as respiratory infections, infective endocarditis, and cardiovascular diseases [6, 7].

Dental caries is a complex oral disease, caused mainly by dental plaque. Dental plaque has been described as an ordered structure in which the primary colonizers are *Actinomyces* and *Streptococci*. These microorganisms bind tightly to one another, in addition to the solid tooth surface, by means of an extracellular matrix consisting of polymers of both host and microbial origin [8-10]. The formation of dental plaque includes a series of steps that begins with the

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

initial colonization of the pellicle and ends with the complex formation of a mature biofilm. Additionally, through the growth process of the biofilm, the microbial composition changes from one that is primarily Gram-positive and *Streptococcus*-rich to a structure filled with Gramnegative anaerobes in its more mature state [11]. It is widely accepted that the accumulation of microorganisms plays a key role in the initiation and progression of gingivitis and other oral diseases [12].

Gram-positive bacteria, such as *Lactobacilli* and the *Streptococci* species are associated with the formation of dental caries. As a result, strategies for treating this disease must concentrate on controlling the growth of these bacteria [13-15].

According to data from the World Health Organization (WHO), the prevalence of caries in schoolchildren is 60-90%, while among adults it is universal in most countries [16]. Biofilm formation is a natural process in the oral environment, and its control should be done through chemical and mechanical means. Brushing is a preventive measure considered essential for the prevention of caries and periodontal diseases, and can be effectively increased by using the toothpaste formulations containing antimicrobial agents [17-19].

### **1.1. Dental fluorosis**

Dental fluorosis is the exposure of the tooth germ during its formation process at high concentrations of fluoride, resulting in defects of enamel mineralization with severity directly linked to the amount ingested. Clinically, the formation of opaque spots on the enamel of homologous teeth turning to a yellow or brown color, can be observed in more severe cases. In addition to the high dosage of fluoride, other factors contribute to the onset of fluorosis: low body weight, nutritional status, rate of skeletal growth and bone remodeling periods. In this sense, dental fluorosis is a more common disease in teeth of late mineralization (permanent teeth) in children with a low weight or poor nutritional state, occurring mainly at the ages of the first to second stages of childhood where there is a high incidence of systemic fluoride intake and subsequent harmful effects [20].

The decrease in the prevalence of dental caries has been attributed in large part to the use of fluoride toothpastes when brushing, one of the most accepted measures for the control of dental caries [21, 22]. By contrast, the prevalence of dental fluorosis has increased worldwide. The use of fluoride toothpaste before 6 years of age has been identified as one of the main risk factors for dental fluorosis [23]. However, other factors have also been found to cause fluorosis, especially commercially sold drinks, such as mineral water and soft drinks, among others, a fact that has increased the incidence of fluorosis in both places with fluoridated water consumption as well as in areas with non-fluoridated water consumption. This finding indicates that there is an intake of fluoride from other sources as well, in addition to the public water supply. Several studies have been conducted in many countries to determine the amount of fluoride in mineral waters, especially in soft drinks. The values obtained range from 0.007 mg/L to more than 4.1 mg/L for mineral waters and from 0.02 to 1.28 ppm, an average level of 0.72 ppm, for soft drinks, with no significant difference when the tastes of diet sodas are compared [24].

Depending on its severity, dental fluorosis may not only have aesthetic consequences, but it may also cause pain and affect masticatory efficiency [25]. Due to these facts, it is necessary to develop alternative formulations of toothpaste based on plant extracts with proven antimi‐ crobial activity for use in children's dentistry to minimize the risk of dental fluorosis in infants and children from 1 to 6 years of age. Thus, many plant extracts with antimicrobial activity have been incorporated into toothpastes to prevent oral diseases. The plant extracts of the *Chordata macleya* and *Prunella vulgaris* species are examples of plants with an anti-inflammatory activity used in the international toothpaste market [26].

## **2. Toothpastes and antimicrobial agents**

initial colonization of the pellicle and ends with the complex formation of a mature biofilm. Additionally, through the growth process of the biofilm, the microbial composition changes from one that is primarily Gram-positive and *Streptococcus*-rich to a structure filled with Gramnegative anaerobes in its more mature state [11]. It is widely accepted that the accumulation of microorganisms plays a key role in the initiation and progression of gingivitis and other

Gram-positive bacteria, such as *Lactobacilli* and the *Streptococci* species are associated with the formation of dental caries. As a result, strategies for treating this disease must concentrate on

According to data from the World Health Organization (WHO), the prevalence of caries in schoolchildren is 60-90%, while among adults it is universal in most countries [16]. Biofilm formation is a natural process in the oral environment, and its control should be done through chemical and mechanical means. Brushing is a preventive measure considered essential for the prevention of caries and periodontal diseases, and can be effectively increased by using

Dental fluorosis is the exposure of the tooth germ during its formation process at high concentrations of fluoride, resulting in defects of enamel mineralization with severity directly linked to the amount ingested. Clinically, the formation of opaque spots on the enamel of homologous teeth turning to a yellow or brown color, can be observed in more severe cases. In addition to the high dosage of fluoride, other factors contribute to the onset of fluorosis: low body weight, nutritional status, rate of skeletal growth and bone remodeling periods. In this sense, dental fluorosis is a more common disease in teeth of late mineralization (permanent teeth) in children with a low weight or poor nutritional state, occurring mainly at the ages of the first to second stages of childhood where there is a high incidence of systemic fluoride

The decrease in the prevalence of dental caries has been attributed in large part to the use of fluoride toothpastes when brushing, one of the most accepted measures for the control of dental caries [21, 22]. By contrast, the prevalence of dental fluorosis has increased worldwide. The use of fluoride toothpaste before 6 years of age has been identified as one of the main risk factors for dental fluorosis [23]. However, other factors have also been found to cause fluorosis, especially commercially sold drinks, such as mineral water and soft drinks, among others, a fact that has increased the incidence of fluorosis in both places with fluoridated water consumption as well as in areas with non-fluoridated water consumption. This finding indicates that there is an intake of fluoride from other sources as well, in addition to the public water supply. Several studies have been conducted in many countries to determine the amount of fluoride in mineral waters, especially in soft drinks. The values obtained range from 0.007 mg/L to more than 4.1 mg/L for mineral waters and from 0.02 to 1.28 ppm, an average level of 0.72 ppm, for soft drinks, with no

significant difference when the tastes of diet sodas are compared [24].

oral diseases [12].

**1.1. Dental fluorosis**

controlling the growth of these bacteria [13-15].

128 Emerging Trends in Oral Health Sciences and Dentistry

intake and subsequent harmful effects [20].

the toothpaste formulations containing antimicrobial agents [17-19].

Common antimicrobial compounds added to toothpastes include: triclosan, stannous fluoride, and chlorhexidine. Nevertheless, despite the effectiveness of many formulations of toothpaste with antibacterial properties, the search for natural products with these properties has been increasing. Thus, plant extracts are being investigated as potential sources of new antibacterial compounds [27-29]. Dental plaque is considered an essential factor linked to the onset of caries, thus justifying the measures taken to control it. It is well-known that many metabolites produced by plants, such as tannins, terpenoids, flavonoids, and alkaloids, may represent a new source of antimicrobial substances [30, 31].

Natural toothpastes are considered to be those that do not incorporate the antimicrobial triclosan and fluoride. These toothpastes contain natural ingredients, such as the salts of sodium fluoride and sodium chloride and plant extracts, such as lemon, eucalyptus, rosemary, chamomile, sage, and myrrh [32]. Chamomile extract, for example, exhibits anti-inflammatory properties. By contrast, salvia extract decreases the tissue bleeding, whereas the extract of myrrhis, a natural antiseptic and extract of mentha, presents antiseptic, anti-inflammatory, and antimicrobial activities [33, 34]. Terpenoid compounds derived from medicinal plants and natural products, such as ursolic acid (UA) and oleanolic acid (OA), inhibited the growth of cariogenic microorganisms in a study conducted by Zhou and co-workers [35], suggesting that both compounds have the potential for use as antibacterial agents in the prevention of dental caries. Oral care products that are incorporated together with plant extracts are widely used due to their low toxicity, as compared to oral care products that contain antimicrobials, such as triclosan, cetyl pyridinium chloride, chlorhexidine, and fluoride [36, 37].

Toothpastes for children's use have had their contents changed in the name of progress and development in dentistry. In the past, toothpastes consisted of creams with a high fluorine content, masked by packaging illustrated with children's themes and flavored goodies that attracted children to the product. Nowadays, the cosmetics industry has reduced the fluorine content in these toothpastes to minimize the risk of fluorosis in children of less than 5 years of age, where fluorosis primarily affects the aesthetic appearance of their teeth [38].

## **3. Medicinal plants with antibacterial activity used in dentistry**

The use of medicinal plants for the treatment of dental problems has widely been discussed by many researchers. Many cultures still use medicinal plants for the treatment of oral diseases, including caries for the cleaning and brushing of teeth, especially in rural areas of underde‐ veloped countries where people still brush their teeth without toothpaste [39]. The scientific field that uses the knowledge of medicinal plants for use in oral health is called Ethno-dentistry, which combines the knowledge of plants used by rural populations, indigenous populations, and communities in general. A brief description of some of the most common plants used in oral health was compiled, as described below.

### **3.1.** *Myristica fragrans*

*Myristica fragrans* (Myristicaceae) is grown to be used as a spice and for medicinal purposes [40]. Its main constituents include alkylbenzenes (myristicin, elemicin, safrole, etc.); terpenes (α-pinene, β-pinene, myristic acid, trimyristin); and neolignans (myrislignan and macelignan) [41-43]. Its seed (known as nutmeg) is widely used in traditional medicine as an antithrombotic and antifungal drug, for the treatment of nausea and dyspepsia, and as an anti-inflammatory drug [44-46].

Studies have shown that *M. fragrans* has a great potential benefit in the field of dentistry, as its ethanol extract has proven to provide antibacterial activity against cariogenic bacteria [47]. According to Chung [42], the macelignan, an active compound isolated from *M. fragrans*, also presents an antibacterial activity against *Streptococcus mutans* and other oral microorganisms, such as *Streptococcus sobrinus*, *Streptococcus salivarius, Streptococcus sanguinis, Lactobacillus acidophilus*, and *Lactobacillus casei*, which indicates that it can be used as a natural antibacterial agent in oral hygiene products.

#### **3.2. Propolis**

Propolis, a natural antibiotic, is a resinous yellowish-brown to dark-brown substance collected by bees (*Apis mellifera*) from tree buds and is mixed with secreted beeswax. Bees use propolis as a glue to seal the opening of the hives protecting it from outside contaminants, which features over 300 compounds in its composition [48]. Among these constituents, one can find: flavonoids, steroids, sugars, and amino acids. The composition depends on the vegetation of the place from which it was collected and the season [48-50]. Thus, its biological activity is related to the plant ecology of the region visited by bees [51, 52]. Propolis has been outstanding for its anesthetic anti-inflammatory, healing, anti-trypanosome, and anti-cariogenic activities [53-56]. Brazilian propolis is one of the most active resinous substance, whose major compo‐ nents include diterpenes, lignans, *p*-coumaric acid, and flavonoids. A flavonoid is a compound with a wide range of biological activities, mainly antioxidant, anti-inflammatory, and antimi‐ crobial activities [57, 58, 49].

Ikeno *et al.* [59] and Park *et al.* [60], respectively, have shown that propolis has *in vitro* effects on bacterial growth as well as on the activity of the glucosyltransferase enzyme (GTF), responsible for the formation of *S. sobrinus*, *S. mutans*, and *S. cricetus* biofilms in caries developed in rats. These studies demonstrate that propolis may well become a promising alternative for the prevention of caries and other oral diseases [61-63].

#### **3.3. Chitosan**

**3. Medicinal plants with antibacterial activity used in dentistry**

oral health was compiled, as described below.

130 Emerging Trends in Oral Health Sciences and Dentistry

**3.1.** *Myristica fragrans*

agent in oral hygiene products.

crobial activities [57, 58, 49].

drug [44-46].

**3.2. Propolis**

The use of medicinal plants for the treatment of dental problems has widely been discussed by many researchers. Many cultures still use medicinal plants for the treatment of oral diseases, including caries for the cleaning and brushing of teeth, especially in rural areas of underde‐ veloped countries where people still brush their teeth without toothpaste [39]. The scientific field that uses the knowledge of medicinal plants for use in oral health is called Ethno-dentistry, which combines the knowledge of plants used by rural populations, indigenous populations, and communities in general. A brief description of some of the most common plants used in

*Myristica fragrans* (Myristicaceae) is grown to be used as a spice and for medicinal purposes [40]. Its main constituents include alkylbenzenes (myristicin, elemicin, safrole, etc.); terpenes (α-pinene, β-pinene, myristic acid, trimyristin); and neolignans (myrislignan and macelignan) [41-43]. Its seed (known as nutmeg) is widely used in traditional medicine as an antithrombotic and antifungal drug, for the treatment of nausea and dyspepsia, and as an anti-inflammatory

Studies have shown that *M. fragrans* has a great potential benefit in the field of dentistry, as its ethanol extract has proven to provide antibacterial activity against cariogenic bacteria [47]. According to Chung [42], the macelignan, an active compound isolated from *M. fragrans*, also presents an antibacterial activity against *Streptococcus mutans* and other oral microorganisms, such as *Streptococcus sobrinus*, *Streptococcus salivarius, Streptococcus sanguinis, Lactobacillus acidophilus*, and *Lactobacillus casei*, which indicates that it can be used as a natural antibacterial

Propolis, a natural antibiotic, is a resinous yellowish-brown to dark-brown substance collected by bees (*Apis mellifera*) from tree buds and is mixed with secreted beeswax. Bees use propolis as a glue to seal the opening of the hives protecting it from outside contaminants, which features over 300 compounds in its composition [48]. Among these constituents, one can find: flavonoids, steroids, sugars, and amino acids. The composition depends on the vegetation of the place from which it was collected and the season [48-50]. Thus, its biological activity is related to the plant ecology of the region visited by bees [51, 52]. Propolis has been outstanding for its anesthetic anti-inflammatory, healing, anti-trypanosome, and anti-cariogenic activities [53-56]. Brazilian propolis is one of the most active resinous substance, whose major compo‐ nents include diterpenes, lignans, *p*-coumaric acid, and flavonoids. A flavonoid is a compound with a wide range of biological activities, mainly antioxidant, anti-inflammatory, and antimi‐

Ikeno *et al.* [59] and Park *et al.* [60], respectively, have shown that propolis has *in vitro* effects on bacterial growth as well as on the activity of the glucosyltransferase enzyme (GTF), Chitin and chitosan are copolymers consisting of *N*-acetyl-D-glucosamine and D-glucosamine units in varying proportions. Chitin is the second most abundant polysaccharide in nature and is the main component of the exoskeleton of crustaceans and insects, but can also be found in nematodes, fungal cell walls, and yeasts. Chitosan has interesting medicinal properties, especially the antimicrobial activity *in vitro* against oral biofilm formations. This finding was reported in studies conducted by Verkaik *et al.* [64-66], who found that chitosan-based toothpaste, when compared with chlorhexidine-based toothpaste, traditionally used as an antimicrobial agent in toothpastes, may be equally as effective.

Chitosan showed a significant action in reducing dental plaque and presented antimicrobial activity *in vitro* against several pathogens in the oral cavity associated with the formation of dental plaque and periodontal disease, such as *Actinobacillus*, *S. mutans*, and *P. gingivalis* [67, 68]. Tarsie *et al.* [69] demonstrated that chitosan could influence the adherence of *S. mutans* to tooth surfaces, thus confirming the possibility of using this polysaccharide as a preventive agent in the formation of biofilms. According to the literature [70, 71], chitosan mouthwash was quite effective in reducing plaque that adheres to the teeth and reducing the count of *S. mutans* in saliva.

According to Mohiree Yadav [72], the addition of chitosan to toothpastes reduced plaque levels by 70% and caries caused by bacteria by 85%, respectively. Thus, toothpastes containing plant extracts and chitosan present an antibacterial efficacy comparable to those containing chlo‐ rhexidine [65]. The proven antimicrobial, anti-inflammatory, and healing effects of chitosan, coupled with their ability to inhibit the formation of biofilms, may well represent a formidable advantage in the treatment of diseases associated with the oral cavity [73].

#### **3.4.** *Punica granatum* **Linn.**

*Punica granatum* Linn. (Punicaceae), known in Brazil as "romã", is a small shrub cultivated worldwide in tropical and subtropical climates, has been used in traditional medicine as an astringent, hemostatic agent, and in the control of diabetes [74]. It is also commonly used to treat throat infections, cough and fever due to its anti-inflammatory and antimicrobial potential [75]. The antibiotic activity of the *P. granatum* extract is associated with its chemical constituents, including tannins and alkaloids found in the leaves, roots, stems and fruits [76, 77]. The alcoholic extract obtained from the fruit of *P. granatum* has shown effective antimi‐ crobial activity against cariogenic bacteria, such as *S*. *mitis*, *S. mutans, S. sanguinis, S. sobrinus*, and *L. casei* [78, 79]. Toothpaste obtained from the alcoholic extract of *P. granatum* showed activity against cariogenic *S. mutans*, *S. sanguinis*, and *S. mitis* bacteria, demonstrating its antibacterial effect, suggesting the effective use of this herbal agent in the control of the adherence of different microorganisms within the oral cavity [80].

### **3.5.** *Lentinus edodes* **and** *Cichorium intybus*

*Lentinula edodes* is the second most cultivated species of edible mushroom in the world, behind only champignon (*Agaricus bisporus*) [81]. It can be grown on tree trunks or on prepared substrates, and has attracted the interest of researchers, as it presents scientifically proven nutritional and therapeutic qualities [82].

*Cichorium intybus* (Compositae) has been used by humans as food since the dawn of civiliza‐ tion. It is a native plant of Europe that can be grown virtually everywhere [83, 84]. Studies have shown that various plant foods contain components with antibacterial and anti-dental plaque activity [85], including the alcoholic extracts of edible mushrooms, namely *L. edodes* and *C. intybus*, which can be used in products formulated for daily oral hygiene, such as mouthwashes and toothpastes [86-88].

#### **3.6.** *Copaifera officinalis* **L.**

*Copaifera officinalis* L. (Fabaceae) is a tree found mainly in Latin America and West Africa, also known as "Copaiba", copaiba balsam, Jesuit's balsam, copal, and capivi [89-91]. The copaiba oil has been documented to contain antibacterial activity. It corresponds to an excretion product, whose purpose is most likely to protect the plant against animals, fungi, and bacteria [92]. It is a liquid of varying viscosity and color, which can vary from yellow to brown [93, 94]. The extracted oil can vary in relation to its concentration of diterpenes and sesquiterpenes [95]. It is popularly used as an anti-inflammatory and healing agent whose actions are related to the presence of diterpenes within its composition [96]. Pieri *et al.* [97] studied the antimi‐ crobial activity of copaiba oil on plaque-forming bacteria in dogs. The results showed that the oil was active against cariogenic bacteria, presenting an inhibitory effect on the adhesion of plaque-forming bacteria.

#### **3.7.** *Rosmarinus officinalis* **Linn.**

*Rosmarinus officinalis* Linn. (Labiatae) is a small shrub whose leaves have small glands containing essential oils. Tests performed *in vitro* with the essential oil showed an inhibito‐ ry effect on the adherence of *S. mutans* and the inhibitory growth activity of Gramnegative bacteria [98-100]. This plant has great potential in inhibiting bacterial growth and in the synthesis of glucan, suggesting its potential use in the control of cariogenic bacte‐ ria, whose activities were observed when its hydro-alcoholic extract showed significant activity on the glucosyltransferase enzyme produced by *S. mutans* [101-103]. It could also be observed that the alcoholic extract proved to be efficient in inhibiting the adherence of *S. mitis, S. mutans* and *S. sobrinus*, which suggests that it contains compounds with antibacterial activity against oral bacteria [104].

#### **3.8.** *Lippia sidoides* **Cham.**

*Lippia sidoides* Cham. (Verbenaceae) is a shrub originating from northeastern Brazil, popularly known as "alecrim pimenta". It is used in the treatment of allergic rhinitis, sore throat, gum inflammation, and the treating of skin wounds and cuts [105, 106]. *L. sidoides* contains an essential oil rich in thymol, which contains bactericidal properties [107, 108]. Tests performed *in vivo* have proven the effectiveness of a mouthwash and toothpaste-based essential oil of *L. sidoides*. An inhibition of approximately 12% of the microorganisms could be observed, with a 6% of reduction in the biofilm formation rate, thus demonstrating the efficiency of this essential oil in oral-based hygiene products [109, 110].

#### **3.9.** *Calendula officinalis* **L.**

**3.5.** *Lentinus edodes* **and** *Cichorium intybus*

132 Emerging Trends in Oral Health Sciences and Dentistry

nutritional and therapeutic qualities [82].

and toothpastes [86-88].

**3.6.** *Copaifera officinalis* **L.**

plaque-forming bacteria.

**3.8.** *Lippia sidoides* **Cham.**

**3.7.** *Rosmarinus officinalis* **Linn.**

antibacterial activity against oral bacteria [104].

*Lentinula edodes* is the second most cultivated species of edible mushroom in the world, behind only champignon (*Agaricus bisporus*) [81]. It can be grown on tree trunks or on prepared substrates, and has attracted the interest of researchers, as it presents scientifically proven

*Cichorium intybus* (Compositae) has been used by humans as food since the dawn of civiliza‐ tion. It is a native plant of Europe that can be grown virtually everywhere [83, 84]. Studies have shown that various plant foods contain components with antibacterial and anti-dental plaque activity [85], including the alcoholic extracts of edible mushrooms, namely *L. edodes* and *C. intybus*, which can be used in products formulated for daily oral hygiene, such as mouthwashes

*Copaifera officinalis* L. (Fabaceae) is a tree found mainly in Latin America and West Africa, also known as "Copaiba", copaiba balsam, Jesuit's balsam, copal, and capivi [89-91]. The copaiba oil has been documented to contain antibacterial activity. It corresponds to an excretion product, whose purpose is most likely to protect the plant against animals, fungi, and bacteria [92]. It is a liquid of varying viscosity and color, which can vary from yellow to brown [93, 94]. The extracted oil can vary in relation to its concentration of diterpenes and sesquiterpenes [95]. It is popularly used as an anti-inflammatory and healing agent whose actions are related to the presence of diterpenes within its composition [96]. Pieri *et al.* [97] studied the antimi‐ crobial activity of copaiba oil on plaque-forming bacteria in dogs. The results showed that the oil was active against cariogenic bacteria, presenting an inhibitory effect on the adhesion of

*Rosmarinus officinalis* Linn. (Labiatae) is a small shrub whose leaves have small glands containing essential oils. Tests performed *in vitro* with the essential oil showed an inhibito‐ ry effect on the adherence of *S. mutans* and the inhibitory growth activity of Gramnegative bacteria [98-100]. This plant has great potential in inhibiting bacterial growth and in the synthesis of glucan, suggesting its potential use in the control of cariogenic bacte‐ ria, whose activities were observed when its hydro-alcoholic extract showed significant activity on the glucosyltransferase enzyme produced by *S. mutans* [101-103]. It could also be observed that the alcoholic extract proved to be efficient in inhibiting the adherence of *S. mitis, S. mutans* and *S. sobrinus*, which suggests that it contains compounds with

*Lippia sidoides* Cham. (Verbenaceae) is a shrub originating from northeastern Brazil, popularly known as "alecrim pimenta". It is used in the treatment of allergic rhinitis, sore throat, gum inflammation, and the treating of skin wounds and cuts [105, 106]. *L. sidoides* contains an *Calendula officinalis* L. (Asteraceae) is an herbaceous plant that is widely cultivated in many parts of the world for ornamental, medicinal, and cosmetic purposes [111]. In the dental field, this plant has been tested as regards its capacity to control the growth of biofilm-forming bacteria. Tests performed *in vivo* have demonstrated the effect of a 10% tincture of *C. officina‐ lis* against chronic gingivitis, presenting significant improvement in the gingival tissues, with no apparent side effects [112, 19]. From these results, a toothpaste and a mouthwash containing 10% tincture of *C. officinalis* was developed. Tests performed *in vivo* using the type of toothpaste have demonstrated the effectiveness of this dental cream on gingival inflammation and the reduction of biofilm formation caused by *S. mutans* [113, 103]. Tests performed *in vivo* using a mouthwash containing 10% tincture of *C. officinalis* verified its efficiency in improving periodontal health, concluding that the performance was similar to mouthwashes prepared with 0.12% chlorhexidine in most evaluated parameters [114]. Another test performed *in vivo* using a toothpaste containing hydroalcoholic extracts of *C. officinalis* and *C. sylvestris* also showed bacteriostatic and fungistatic actions against microorganisms, such as *S. aureus, S. mutans*, and *C. albicans*, showing the associated therapeutic properties of these extracts [115].

### **3.10.** *Schinus terebinthifolius* **Raddi and** *Myracrodruon urundeuva* **Fr. All.**

*Schinus terebinthifolius* Raddi and *Myracrodruon urundeuva* Fr. All. (Anacardiaceae), known in Brazil as "aroeira da praia" and "aroeira do sertão", respectively, are plants that are commonly found in South America. These plants are still used in traditional medicine in the northeastern regions of Brazil [116-119]. A 10% tincture of *S. terebinthifolius* showed efficacy in controlling biofilms formed by *S. mutans*, with a significant reduction in colony-forming units, as well as in the treatment of chronic gingivitis, presenting similar results when compared to 0.12% chlorhexidine-based toothpastes. This tincture also showed anti-inflammatory and antifungal activities against *Candida albicans*, suggesting its potential as an antibacterial agent, especially in the prevention oral cavity disease [120-123]. By contrast, the alcoholic extract of *M. urun‐ deuva* also showed significant antimicrobial and anti-adherent activities against microorgan‐ isms that form biofilms [124].

#### **3.11.** *Matricaria recutita* **Linn.**

*Matricaria recutita* Linn. (Compositae) is a native plant of Europe and western Asia and is known for its variety of active flavonoids as well as for its essential oil, which is rich in terpenoids and is responsible for its anti-inflammatory and antibacterial activities [125, 126]. This plant has been widely used in inflammatory and infectious processes of the oral cavity [127]. Costa *et al.* [128] found that the alcoholic extract of *M. recutita* has antibacterial and antiadherent activities against cariogenic bacteria *S. mutans, S. sanguinis* and *L. casei* [129]. Ac‐ cording to studies performed by Lins *et al.* [130], a simple application of a mouthwash based on the hydroalcoholic extract of *M. recutita* proved effective in controlling biofilm formations caused by microorganisms, such as *S. mutans* and *S. sanguinis*, found in the oral cavity. In addition, this plant has been used in commercial toothpastes formulations for adults and children.

#### **3.12.** *Eugenia uniflora* **L.**

*Eugenia uniflora* L. (Myrtaceae), popularly known as "pitangueira", is a fruitful plant that is native to Brazil but can also be found in northern Argentina and Uruguay. [131]. Its leaves have been related to the treatment of various ailments, including fever, stomach ailments, hypertension, and obesity [132]. Antimicrobial activity was observed in this plant's leaves and cherries against *S. mutans*, *S. sanguinis*, *S. salivarius*, *S. mitis*, and *S. oralis* bacteria*.* Toothpastes containing the alcoholic extract of the ripe fruit of *E. uniflora* showed a similar efficacy to the Colgate Total 12 toothpaste, used as controlling agents in tests performed *in vivo* by Jovito *et al.* [133]. Castro *et al.* [134] demonstrated that hydroalcoholic extracts of *E. uniflora* showed antibacterial activity against *L. casei*.

#### **3.13.** *Myrciaria cauliflora* **(Mart.) O. Berg.**

*Myrciaria cauliflora* (Mart.) O. Berg. (Myrtaceae) is a native plant from Brazil and can be found throughout the country [135]. Tests performed *in vitro* using the alcoholic extract of this plant's leaves against *S. mutans* demonstrated that this extract acts on biofilm formation and could be an alternative for use in toothpastes [136, 137].

#### **3.14.** *Syzygium aromaticum*

*Syzygium aromaticum* (Myrtaceae), an aromatic flower bud of a tree that is native to the Maluku Islands in Indonesia, is commonly used as a spice. Cloves are commercially harvested primarily in Indonesia, India, Madagascar, Zanzibar, Pakistan, and Sri Lanka. The essential oil of *S. aromaticum* is used for flavoring and as a natural food preservative, as it presents antifungal and antibacterial activities [138, 139]. Its essential oil is rich in the compound eugenol, which is the most abundant substance in the tree's bark and is widely used in dentistry as an anesthetic in dental hygiene and to relieve toothaches [140]. This tree's branches contain a predominance of α and β-pinene, α-phellandrene, *p*-cymene, limonene, linalool, α-sequiter‐ penes copaene, β-caryophyllene, caryophyllene oxide, alilbenzenos ε-cinnamaldehyde, and aceto of ε-cinnamyl monoterpenes [141]. Tests performed *in vitro* demonstrated that the essential oil of *S. aromaticum*, when pure and incorporated into a toothpaste, presented antibacterial activity against *S. mutans* [142].

#### **3.15.** *Cinnamomum zeylanicum*

*Cinnamomum zeylanicum* (Lauraceae), native to Sri Lanka in South Asia, is a small or medium sized tree, commonly reaching 20 to 40 ft. in height. *C. zeylanicum* was widely used in ancient times as a spice. It is currently used as a flavoring in cooking food as well as in medicine as an antimicrobial agent. The essential oil extracted from its leaves contain a greater quantity of an aldehyde called cinnamaldehyde. Oliveira *et al.* [142] evaluated the essential oil of this plant against *S. mutans* and *L. casei*. These authors observed that the essential oil of *C. zeylanicum* showed inhibition zones of close to or above those of standard chlorhexidine, which was the same result observed for toothpastes formulated with the oil. Other studies have demonstrated the action of this essential oil on yeasts, such as *C. albicans* and *C. tropicalis*, which produce oral candidiasis in denture users [143].

#### **3.16.** *Cymbopogon citratus*

adherent activities against cariogenic bacteria *S. mutans, S. sanguinis* and *L. casei* [129]. Ac‐ cording to studies performed by Lins *et al.* [130], a simple application of a mouthwash based on the hydroalcoholic extract of *M. recutita* proved effective in controlling biofilm formations caused by microorganisms, such as *S. mutans* and *S. sanguinis*, found in the oral cavity. In addition, this plant has been used in commercial toothpastes formulations for adults and

*Eugenia uniflora* L. (Myrtaceae), popularly known as "pitangueira", is a fruitful plant that is native to Brazil but can also be found in northern Argentina and Uruguay. [131]. Its leaves have been related to the treatment of various ailments, including fever, stomach ailments, hypertension, and obesity [132]. Antimicrobial activity was observed in this plant's leaves and cherries against *S. mutans*, *S. sanguinis*, *S. salivarius*, *S. mitis*, and *S. oralis* bacteria*.* Toothpastes containing the alcoholic extract of the ripe fruit of *E. uniflora* showed a similar efficacy to the Colgate Total 12 toothpaste, used as controlling agents in tests performed *in vivo* by Jovito *et al.* [133]. Castro *et al.* [134] demonstrated that hydroalcoholic extracts of *E. uniflora* showed

*Myrciaria cauliflora* (Mart.) O. Berg. (Myrtaceae) is a native plant from Brazil and can be found throughout the country [135]. Tests performed *in vitro* using the alcoholic extract of this plant's leaves against *S. mutans* demonstrated that this extract acts on biofilm formation and could be

*Syzygium aromaticum* (Myrtaceae), an aromatic flower bud of a tree that is native to the Maluku Islands in Indonesia, is commonly used as a spice. Cloves are commercially harvested primarily in Indonesia, India, Madagascar, Zanzibar, Pakistan, and Sri Lanka. The essential oil of *S. aromaticum* is used for flavoring and as a natural food preservative, as it presents antifungal and antibacterial activities [138, 139]. Its essential oil is rich in the compound eugenol, which is the most abundant substance in the tree's bark and is widely used in dentistry as an anesthetic in dental hygiene and to relieve toothaches [140]. This tree's branches contain a predominance of α and β-pinene, α-phellandrene, *p*-cymene, limonene, linalool, α-sequiter‐ penes copaene, β-caryophyllene, caryophyllene oxide, alilbenzenos ε-cinnamaldehyde, and aceto of ε-cinnamyl monoterpenes [141]. Tests performed *in vitro* demonstrated that the essential oil of *S. aromaticum*, when pure and incorporated into a toothpaste, presented

*Cinnamomum zeylanicum* (Lauraceae), native to Sri Lanka in South Asia, is a small or medium sized tree, commonly reaching 20 to 40 ft. in height. *C. zeylanicum* was widely used in ancient

children.

**3.12.** *Eugenia uniflora* **L.**

134 Emerging Trends in Oral Health Sciences and Dentistry

antibacterial activity against *L. casei*.

**3.14.** *Syzygium aromaticum*

**3.13.** *Myrciaria cauliflora* **(Mart.) O. Berg.**

an alternative for use in toothpastes [136, 137].

antibacterial activity against *S. mutans* [142].

**3.15.** *Cinnamomum zeylanicum*

*Cymbopogon citratus* (Poaceae) is a herbaceous plant that is, native to the tropical regions of Asia, especially India. Also known as *Cymbopogon (nardus*) or by synonyms, such as *Andropogon citratus ceriferus, Andropogon citratus, Andropogon citriodorum, Andropogon nardus ceriferus, Andropogon roxburghiie,* and *Andropogon schoenanthus*. The essential oil extracted from this plant's leaves contains the main components of citral, geraniol, methyleugenol, myrcene, and citronellal [144]. Oliveira *et al.* [142] evaluated this plant's essential oil against *S. mutans* and *L. casei* and noted that it presented inhibition zones of close to those of standard chlorhexidine against the microorganism *S. mutans*. However, when analyzing the formulation of toothpastes containing the essential oil, it was found that this oil proved ineffective in the concentration tested to inhibit the growth of microorganisms. Perazzo *et al.* [145] also evaluated the essential oil of *C. citratus* on bacterial biofilm formation, especially in strains of *S. mutans* (ATCC 25175), *S. salivarius* (ATCC7073), and *S. oralis* (ATCC1055) and observed that this essential oil was more effective against *S. mutans*.

#### **3.17.** *Malva sylvestris*

*Malva sylvestris* (Malvaceae) is a biennial or perennial erect herbaceous species that is native to Europe and is widely known for its anti-inflammatory and antimicrobial properties [146]. Its phytochemical composition includes tannins, glycolipids, and flavonoids, which were tested as regards their capacity to control the growth of bacteria and biofilm formation [147, 18]. *M. sylvestris* has proven to be so effective that it already exists on the commercial market, called Malvatricin®, which is widely used as an antimicrobial agent against cariogenic bacteria. This effect is most likely due to the action of quinosol, a substance present in its composition [148].

#### **3.18.** *Nasturtium officinale*

*Nasturtium officinale* (Cruciferaceae) is a native plant of Europe and Asia that has many uses in medicine and pharmacology [149]. It is rich in vitamins and active substances, and is most commonly used in the treatment of urinary tract infections in children [150]. Tests performed *in vitro* with a mouthwash containing 10% hydroalcoholic extract of *N. offici‐ nale* was effective in controlling the growth of the microorganisms present in the oral cavity and dental plaque [151].

#### **3.19.** *Aloe vera*

*Aloe vera* (L.) Burm and *Aloe barbadensis* Miller (Asphodelaceae), popularly known as "aloe", are native from Africa and are widely used in traditional medicine. The gel of this plant contains healing, antibacterial, and antifungal activities due to the presence of anthraquinones, such as aloenin, barbaloin, and isobarbaloin in its chemical composition [152-155]. Studies have demonstrated the antimicrobial activity of toothpastes containing *A. vera* on oral microorgan‐ isms, such as *S. mutans*, *S. sanguis, A. viscosus,* and *C. albicans* [27].

#### **3.20.** *Magnolia officinalis*

*Magnolia officinalis* (Magnoliaceae) is a native plant of the mountains and valleys of China at altitudes of 300-1500 meters. The highly aromatic bark is stripped from the stems, branches, and roots, and is used in traditional Chinese medicine, where it is known as "hou po" [156]. The traditional use indications are to eliminate the dampness and phlegm, and relieve the distension. Huang *et al.* [157] have shown that the magnolol isolated from this plant was able to inhibit the growth of cariogenic bacteria.


**Table 1.** Medicinal plants use in the treatment of oral diseases clinical studies.

#### **3.21.** *Salvia officinallis*

*Salvia officinallis* (Labiatae) is plant that is native to the Mediterranean region, though it has been naturalized in many places throughout the world. It is a perennial, evergreen subshrub that has a long history of medicinal and culinary uses. Its essential oil contains cineole, borneol, and thujone. Sage leaf contains tannic acid, oleic acid, ursonic acid, ursolic acid, carnosol, carnosic acid, fumaric acid, chlorogenic acid, caffeic acid, niacin, nicotinamide, flavones, flavonoid glycosides, and estrogenic substances [158]. Tests performed *in vivo* by Celeste *et* *al*. [159] have shown that a mouthwash containing a 10% alcoholic extract of *S. officinalis* reduced the visible plaque index (VPI) of the volunteers in 15.3% and the gingival index (GI) in 9.3% when compared to the chlorhexidine control.

### **3.22.** *Azadirachta indica*

**3.19.** *Aloe vera*

**3.20.** *Magnolia officinalis*

136 Emerging Trends in Oral Health Sciences and Dentistry

*Punica granatum Linn.* and *Centella asiatica*

*M. recutita L./Enchinacea angustifólia*/

**3.21.** *Salvia officinallis*

to inhibit the growth of cariogenic bacteria.

*Aloe vera* (L.) Burm and *Aloe barbadensis* Miller (Asphodelaceae), popularly known as "aloe", are native from Africa and are widely used in traditional medicine. The gel of this plant contains healing, antibacterial, and antifungal activities due to the presence of anthraquinones, such as aloenin, barbaloin, and isobarbaloin in its chemical composition [152-155]. Studies have demonstrated the antimicrobial activity of toothpastes containing *A. vera* on oral microorgan‐

*Magnolia officinalis* (Magnoliaceae) is a native plant of the mountains and valleys of China at altitudes of 300-1500 meters. The highly aromatic bark is stripped from the stems, branches, and roots, and is used in traditional Chinese medicine, where it is known as "hou po" [156]. The traditional use indications are to eliminate the dampness and phlegm, and relieve the distension. Huang *et al.* [157] have shown that the magnolol isolated from this plant was able

**Plants Pharmaceutical form Use**

*Plantago psyllium L* mouthwash periodontitis

*Aloe ferox Mill* mouthwash gingivitis *Calendula officinalis L* mouthwash Gengivite and periodontitis *Lippia sidoides Cham* mouthwash plaque and bleeding on probing

*Punica granatum Linn.* toothpaste gingivitis

*Calendula officinalis L* toothpaste gingivitis

*Punica granatum Linn.* Gel candidiasis, plaque and gingivitis

*Salvia officinallis* (Labiatae) is plant that is native to the Mediterranean region, though it has been naturalized in many places throughout the world. It is a perennial, evergreen subshrub that has a long history of medicinal and culinary uses. Its essential oil contains cineole, borneol, and thujone. Sage leaf contains tannic acid, oleic acid, ursonic acid, ursolic acid, carnosol, carnosic acid, fumaric acid, chlorogenic acid, caffeic acid, niacin, nicotinamide, flavones, flavonoid glycosides, and estrogenic substances [158]. Tests performed *in vivo* by Celeste *et*

*Krameria triandria Ruíze Pavon* toothpaste gingivitis

**Table 1.** Medicinal plants use in the treatment of oral diseases clinical studies.

*Salvia officinalis* mouthwash plaque and bleeding on probing

mouthwash periodontitis

isms, such as *S. mutans*, *S. sanguis, A. viscosus,* and *C. albicans* [27].

*Azadirachta indica* (Meliaceae) is native plant of India and the Indian subcontinent including Nepal, Pakistan, Bangladesh, and Sri Lanka. The tree can reach a height of 15 to 20 m (49 to 66 ft.). It has been used in India for decades in the treatment of several diseases in medicine and dentistry. Chatterjee *et al*. [160] evaluated a 0.19% *A. indica* mouthwash in tests performed *in vivo* and observed that the *A. indica* mouthwash is as effective in reducing periodontal indices as is chlorhexidine, which was used as the control, showing a significant reduction in gingival bleeding, and plaque indices.

## **4. Conclusion**

The decrease in the amount of fluoride associated with the presence of plant extracts with proven antimicrobial activity is a positive factor for the reduction of fluorosis. For babies, we recommend the use of toothpastes containing only plant extracts, with no fluoride, since there is no risk of caries at this age. In such cases, these toothpastes can be used to adapt the babies to a proper hygiene of their oral cavity as well as maintain their beneficial microbiota.

## **Acknowledgements**

The authors are grateful to CNPq, CAPES and FAPEMIG for their financial support.

## **Author details**

Marisa Alves Nogueira Diaz1\*, Isabela de Oliveira Carvalho1 and Gaspar Diaz2

\*Address all correspondence to: marisanogueira@ufv.br

1 Departament of Biochemistry and Molecular Biology, Federal University of Viçosa, Viçosa, Minas Gerais, Brazil

2 Departament of Chemistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

### **References**


[16] Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral disease and risks to oral health. Bulletin of the World Health Organization 2005;83(9) 661-669.

**References**

138 Emerging Trends in Oral Health Sciences and Dentistry

[1] Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the normal bacterial flora of the oral cavity. Journal of Clinical Microbiology 2005;43(5) 721−732.

[2] Zaura E, Keijser BJ, Huse SM, Crielaard W. Defining the healthy "core microbiome"

[3] Groppo FC, Bergamaschi CC, Cogo K, Franz-Montan M, Motta RHL, Andrade ED. Use of Phytotherapy in Dentistry. Phytotherapy Research 2008; 22 993–998.

[4] Marsh PD, Moter A, Devine DA. Dental plaque biofilms: communities, conflict and

[5] Meyer DH, Fives-Taylor PM. Oral pathogens: from dental plaque to cardiac disease.

[6] Barrau K, Boulamery A, Imbert G, Casalta JP, Habib G, Messana T, Bonnet JL, Rubin‐ stein E, Raoult D. Causative organisms of infective endocarditis according to host

[7] Okuda K, Kato T, Ishihara K. Involvement of periodontopathic biofilm in vascular

[8] Kolenbrander PE. Intergeneric coaggregation among human oral bacteria and ecolo‐

[9] Bowenand WH, Koo H. Biology of *Streptococcus mutans* derived glucosyltransferases: role in extracellular matrix formation of cariogenic biofilms. Caries Research,

[10] Bradshaw DJ, Marsh PD, Watson GK, Allison C. Role of *Fusobacterium nucleatumand* coaggregation in anaerobe survival in planktonic and biofilm oral communities dur‐

[11] Marsh PD. Dental plaque as a biofilm and a microbial community-implications for

[12] Socransky SS, Haffajee AD. Periodontal microbial ecology. Periodontol 2000.

[13] Thibodeau EA, O'Sullivan DM. Salivary *mutans* streptococci and caries development in the primary and mixed dentitions of children. Community Dentistry and Oral Epi‐

[14] Loesche W. Dental caries and periodontitis: contrasting two infections that have medical implications. Infectious Disease Clinics of North America 2007;21(2) 471-502.

[15] Featherstone JDB. Dental caries: a dynamic disease process. Australian Dental Jour‐

gy of dental plaque. Annual Review of Microbiology 1988;42(1) 627-656.

of oral microbial communities. BMC Microbiology 2009;9(1) 259-271.

control. Periodontology 2011;53(1) 16-35.

diseases. Oral Diseases 2004;10(1) 5-12.

2011;45(1) 69-86.

2005;38(1) 135-187.

demiology 1999;27(6) 406-412.

nal 2008;53(3) 286-291.

Current Opinion in Microbiology 1998;1(1) 88-95.

status. Clinical Microbiology and Infection 2004;10(4) 302-308.

ing aeration. Infection and Immunity 1998;66(10) 4729-4732.

health and disease. BMC Oral Health 2006;6(suppl 1) S14.


[44] Sonavane GS, Sarveiya VP, Kasture VS, Kasture SB. Anxiogenic activity of *Myristica fragrans* seeds. Pharmacology Biochemistry and Behavior 2002;71(1-2) 239-244.

[30] DenBesten P, Berkowitz RJ. Early childhood caries: an overvview with reference to our experience in California. Journal of California Dental Association 2003;31(1)

[31] Agarwala M, Yadav RNS. Phytochemical analysis of some medicinal plants. Journal

[32] Okpalugo J, Ibrahim K, Inyang US. Toothpaste formulation efficacy in reducing oral

[33] Pistorius A, Willershausen B, Steinmeier EM, Kreislert M. Efficacy of subgingival irri‐ gation using herbal extracts on gingival inflammation. Journal of Periodontology

[34] Pannuti CM, Mattos JP, Ranoya PN, Jesus AM, Lotufo RF, Romito GA. Clinical effect of a herbal dentifrice on the control of plaque and gingivitis: a double-blind study.

[35] Zhou L, Ding Y, Chen W, Zhang P, Chen Y, Lv X. Thein vitro study of ursolic acid and oleanolic acid inhibiting cariogenic microorganisms as well as biofilm. Oral Dis‐

[36] Knoll-Kohler E, Stiebel J. Amine fluoride gel affects the viability and the generation of superoxide anions in human polymorphonuclear leukocytes: an in vitro study. Eu‐

[37] Neumegen RA, Fernández-Alba AR, Chisti Y. Toxicities of triclosan, phenol, and copper sulfate in activated sludge. Environmental Toxicology 2005;20(2) 160-164. [38] Vieira MD, Hirata Júnior R, Barbosa ARS. Avaliação antimicrobiana de três dentifrí‐ cios para uso infantil: estudo in vitro. Revista Brasileira de Odontologia 2008;65(1)

[39] Jose M, Deepa KC, Prabhu V. Ethnomedicinal Practices for Oral health and hygiene of Tribal population of Wayanad Kerala. In International Journal of Research in

[40] Jaiswal P, Kumar P, Singh VK., Singh D.K. Biological effects of *Myristica fragrans.* An‐

[41] Qiu Q, Zhang G, Sun X, Liu X. Study on chemical constituents of the essential oil from *Myristica fragrans* Houtt. by supercritical fluid extraction and steam distillation.

[42] Chung JY, Choo JH, Lee MH, Hwang JK. Anticariogenic activity of macelignan iso‐ lated from *Myristica fragrans* (nutmeg) against *Streptococcus mutans*. Phytomedicine

[43] Yang XW, Huang X, Ahmat M. "New neolignan from seed of *Myristica fragrans*,"

flora. Tropical Journal of Pharmaceutical Research 2009;8(1) 71-77.

Pesquisa Odontológica Brasileira 2003;17(4) 314-318.

ropean Journal of Oral Sciences 2002;110(4) 296-301.

Ayurveda & pharmacy (IJRAP) 2011;2(4) 1246-1250.

nual Review of Biomedical Sciences 2009;11(1) 21-29.

Zhongguo Zhongyao Zazhi 2008;33(4) 397-402.

Journal of Chinese Medicinal Materials 2004; 27(11) 823-826.

139-143.

2003;7 4616–622.

eases 2013;19(5) 494-500.

52-56.

2006;13(4) 261-266.

of Phytology 2011;3(12) 10-14.

140 Emerging Trends in Oral Health Sciences and Dentistry


streptococci biofilms and caries development in rats. Archives of Oral Biology 2006;51(1) 15-22.


[69] Tarsi R, Muzzarelli R, Guzmàn C, Pruzzo C. Inhibition of *Streptococcus mutans* ad‐ sorption to hydroxyapatite by low-molecular-weigth chitosans. Journal of Dental Re‐ search 1997;76(2) 665-672.

streptococci biofilms and caries development in rats. Archives of Oral Biology

[57] Bankova V. Chemical diversity of propolis and the problem of standardization. Jour‐

[58] Piccinelli AL, Fernández MC, Cuesta-Rubio O, Hernández IM, De Simone F, Rastrelli L. Isoflavonoids isolated from Cuban propolis. Journal of Agricultural and Food

[59] Ikeno K, Ikeno T, Miyazawa C. Effects of propolis on dental caries in rats. Caries Re‐

[60] Park YK, Koo MH, Abreu JA, Ikegaki M, Cury JA, Rosalen PL. Antimicrobial activity of propolis on oral microorganisms. Current Microbiology 1998;36(1) 24-28.

[61] Duailibe SA, Gonçalves AG, Ahid FJ. Effect of a propolis extract on *Streptococcus mu‐*

[62] Arslan S, Silici S, Perçin D, Ko AN, Er Ö. Antimicrobial activity of poplar propolis on mutans streptococci and caries development in rats. Turkish Journal of Biology

[63] Barrientos L, Herrera CL, Montenegro G, Ortega X, Veloz J, Alvear M, Cuevas A, Saavedra N, Salazar LA. Chemical and botanical characterization of Chilean propolis and biological activity on cariogenic bacteria *Streptococcus mutans* and *Streptococcus*

[64] Kubota N, Tastumoto N, Sano T, Toya K. A simple preparation of half N-acetylated chitosan highly soluble in water and aqueous organic solvents. Carbohydrate Re‐

[65] Kittur FS, Kumar ABV, Varadaraj MC, Tharanathan RN. Chitooligosaccharides-prep‐ aration with the aid of pectinase isozyme from *Aspergillus nigerand* their antibacterial

[66] Verkaik MJ, Busscher HJ, Jager D, Slomp AM, Abbas F, van der Mei HC. Efficacy of natural antimicrobials in toothpaste formulations against oral biofilms *in vitro*. Jour‐

[67] Choi BK, Kim KY, Yoo YJ, Oh SJ, Choi JH, Kim CY.i*n vitro* antimicrobial activity of a chitooligosaccharide mixture against *Actinobacillus actinomycete comitans* and *Strepto‐ coccus mutans*. International Journal of Antimicrobial Agents 2001;18(6) 553-557. [68] Íkinci G, Şenel S, Akıncıbay H, Kaş S, Erciş S, Wilson CG, Hıncal AA. Effect of chito‐ san on a periodontal pathogen *Porphyromonas gingivalis*. International Journal of Pha‐

*tans* counts *in vivo*. Journal of Applied Oral Science 2000;15(5) 420-423.

*sobrinus*. Brazilian Journal of Microbiology 2013;44(2) 577-585.

activity. Carbohydrate Research 2005;340(6) 1239-1245.

nal of Ethnopharmacology 2005;100(1-2) 114-117.

Chemistry 2005;53(23) 9010-9016.

search 1991;25(5) 347-351.

2012;36(1) 65-73.

search 2000;324(4) 268-274.

nal of dentistry 2011;39(3) 218-224.

maceutics 2002; 235(1/2) 121-127.

2006;51(1) 15-22.

142 Emerging Trends in Oral Health Sciences and Dentistry


[93] Cascon V, Gilbert B. Characterization of the chemical composition of oleoresins of *Copaifera guianensis* Desf.,*Copaifera duckei* Dwyer and *Copaifera multijuga* Hayne. Phy‐ tochemistry 2000;55(7) 773-778.

[81] Chang ST, Kwan HS, Kang YN. Collection, characterization and utilization of germ

[82] Eira AF, Kaneno R, Rodrigues Filho E, Barbisan LF, Pascholati SF, Di Piero RM, Sal‐ vadori DMF, Lima PLA, Ribeiro LR. Farming technology, biochemistry characteriza‐ tion, and protective effects of culinary-medicinal mushrooms *Agaricus brasiliensis* and *Lentinus edodes*: five years of research in Brazil. International Journal of Medicinal

[84] Van Lo J, Coussement P, Leenheer L, Hoebregs H, Smits G. On the presence of inulin and oligofructose as natural ingredients in the western diet. Critical Reviews in Food

[85] Signoretto C, Canepari P, Pruzzo C, Gazzani G. Anticaries and antiadhesive proper‐ ties of food constituents and plant extracts and implications for oral health. In: Wil‐ son M. (ed) Food constituents and oral health: current status and future prospects.

[86] Daglia, M, Papetti A,Mascherpa D,Grisoli P, Giusto G, Lingström P, Pratten J, Signo‐ retto C, Spratt DA, Wilson M, Zaura E, Gazzan G. Plant and fungal food components with potential activity on the development of microbial oral diseases. Journal of Bio‐

[87] Spratt DA, Daglia M, Papetti A, Stauder M, Donnell DO, Ciric L, Tymon A, Repetto B, Signoretto C, Houri-Haddad Y, Feldman M, Steinberg D, Lawton S, Lingström P, PrattenJ, Zaura E,Gazzani G,Pruzzo C,Wilson M. Evaluation of plant and fungal ex‐ tracts for their potential antigingivitis and anticaries activity. Journal of Biomedicine

[88] Signoretto AM, Bertoncelli A, Burlacchini G, Tessarolo F, Caola L, Pezzati E, Zaura E, Papetti A, Lingstrom P, Pratten J, Spratt DA, Wilson M, Canepari P. Effects of mush‐ room and chicory extracts on the physiology and shape of *Prevotella intermedia*, a pe‐ riodonto pathogenic bacterium. Journal of Biomedicine and Biotechnology 2011;1-8.

[89] Veiga Junior VF, Pinto AC, Calixto JB, Zunino L, Patitucci ML. Phytochemical and antiedematogenic studies of commercial copaíba oils available in Brazil. Phytothera‐

[90] Lima SRM, Veiga Junior VF, Christo HB, Pinto AC, Fernandes PD. *In vivo* and *in vitro* studies on the anticancer activity of *Copaifera multijuga* Hayne and its fractions. Phy‐

[91] Francisco SG. Uso do óleo de copaíba (*Copaifera officinalis*) em inflamação ginecológi‐

[92] Pontes AB, Correia DZ, Coutinho MS, Mothé CG. Emulsão dermatológica a base de

plasm of *Lentinula edodes*. Canadian Journal of Botany 1995;73(1) 955-961.

Mushrooms 2005;7(1/2) 281-300.

144 Emerging Trends in Oral Health Sciences and Dentistry

[83] Galvão G. Almeirão. Natureza 1995;8(7) 53-55.

Science and Nutrition 1995;35(6) 525-552.

medicine and Biotechnology 2011;1-9.

and Biotechnology 2012;1-12.

py Research 2001;15(6) 476-480.

ca. Femina 2005;33(2) 89-93.

totherapy Research 2003;17(9) 1048-1053.

copaíba. Revista Analytica 2003; 7(7) 36-42

Cambridge: Woodhead Publishing Limited; 2009.


[117] Santin DA, Leitão HF. Restabelecimento e revisão taxonômica do gênero *Myracro‐ druon* Freire Allemão (Anacardiacea). Revista Brasileira de Botânica 1991;14(2) 133-145.

[105] Lemos TL, Craveiro AA, Alencar JW, Matos FJ, Clarck AM, Macchesney JD. Antimi‐ crobial activity of essential oil of Brazilian plants. Phytotherapy Research 1990;4(2)

[106] Nunes RS. Desenvolvimento galënico de produtos de uso odontologico (creme den‐ tal e enxaguatorio bucal) a base de *Lippia sidoides* Cham (verbenaceae) Master thesis.

[107] Girão VCC, Nunes-Pinheiro DCS, Morais SM, Sequeira JL, Gioso MA. A clinical trial of the effect of a mouthrinse prepared with *Lippia sidoides* Cham essential oil in dogs with mild gingival disease. Preventive Veterinary Medicine 2003;59(1/2) 95-102. [108] Cavalcanti ESB, Morais SM, Lima MA, Santana EWP. Larvicidal activity of essential oils from Brazilian plants against *Aedes aegypti* L. Memórias do Instituto Oswaldo

[109] Sobreira FFE, Morais SM, Fonseca SGC, Mota OML. Preparation and clinical evalua‐ tion of an antiseptic mouthrinse using *Lippia sidoides* Cham (Alecrim pimenta) essen‐

[110] Nunes RS, Lira AAM, Lacerda CM, Silva, DOB, Silva JA, Santana DP. Obtenção e avaliação clínica de dentifrícios à base do extrato hidroalcoólico da *Lippia sidoides* Cham (Verbenaceae) sobre o biofilme dentário Revista de Odontologia 2006;35(4)

[111] Ramos A, Edreira A, Vizoso A, Betancourt J, López M, Décalo M. Genotoxicity of ex‐ tract of *Calendula officinalis* L. Journal of Ethnopharmacology 1998;61(1) 49-55. [112] Lorenzo MRO, Madrigal RG, Pineda PJ. Efectos de la tintura de calendula al 10 por ciento en adolescentes afectados por gingivitis crónica. Mediciego 1997;3(2) 33-36.

[113] Amoian B, Moghadamnia AA, Mazandarani M. The effect of calendula extract tooth‐ paste on the plaque index and bleeding in gingivitis. Research Journal of Medicinal

[114] Vinagre NPL, Farias CG, Araújo RJG, Vieira JMS, Silva Júnior JOC, Corrêa AM. Clin‐ ical efficacy of a phytotherapic mouthrinse with standardized tincture of *Calendula of‐ ficinalis* in the maintenance of periodontal health. Revista de Odontologia da UNESP

[115] Arantes AB, Luz MMS, Santos CAM, Sato MEO. Desenvolvimento de dentifrícios com extratos fluídos de *Calendula officinalis* L. (Asteraceae) e *Casearia sylvestris* Sw. (Flacourtiaceae) destinado ao combate à placa bacteriana. Revista Brasileira de Farm‐

[116] Kato ETM, Akisue G. Estudo farmacognóstico de cascas *Myracrodruon urundeuva* Fr.

Universidade Federal de Pernambuco; 1999.

cial oil. Revista ABO Nacional 1998;6(5) 323-325.

Cruz 2004;99(5) 541-544.

146 Emerging Trends in Oral Health Sciences and Dentistry

Plant 2010;4(3) 132-140.

acognosia 2005;86(2) 61-64.

All. Revista Lecta 2002;20(1) 69-76.

2011;40(1) 30-35.

82-84.

275-283.


*ria recutita* Linn. sobre microrganismos do biofilme dental. Revista de Biologia e Farmácia 2010;4(1) 19-25.


[140] Chong BS, Ford TRP, Kariyawasam SP. Short-term tissue response to potential rootend filling materials in infected root canals. International Endodontic Journal 1997;30(4) 240-249.

*ria recutita* Linn. sobre microrganismos do biofilme dental. Revista de Biologia e

[129] Albuquerque ACL, Pereira MSV, Pereira JV, Pereira LF, Silva DF, Macedo-Costa MR, Higino JS. Efeito antiaderente do extrato da *Matricaria recutita* Linn. sobre microrga‐ nismos do biofilme dental. Revista de Odontologia da UNESP 2010; 39(1) 21-25. [130] Lins R, Vasconcelos FHP, Leite RB, Coelho-Soares RS, Barbosa DN. Avaliação clínica de bochechos com extratos de Aroeira (*Schinus terebinthifolius*) e Camomila (*Matrica‐ ria recutita* L.) sobre a placa bacteriana e a gengivite. Revista Brasileira de Plantas Me‐

[131] Bezerra JEF, Lederman IE, Silva Júnior JF, Alves MA. Comportamento da pitangueira (*Eugenia uniflora*) sob Irrigação na Região do Vale do Rio Moxotó, Pernambuco. Re‐

[132] Schmeda-Hirschmann G, Theoduloz C, Franco L, Ferro E, Arias AR. Preliminary pharmacological studies on *Eugenia uniflora* leaves: xanthine oxidase inhibitory activ‐

[133] Jovito VC, Almeida LFD, Ferreira DAH, Moura D, Paulo MQ, Padilha WWN. Avalia‐ ção *in vivo* de dentifrício contendo extrato da *Eugenia uniflora* L. (Pitanga) sobre Indi‐ cadores de saúde bucal. Pesquisa Brasileira em Odontopediatria e Clínica Integrada

[134] Castro RD, Freires IA, Ferreira DAH, Jovito VC, Paulo, MQ. Atividade antibacteriana *in vitro* de produtos naturais sobre *Lactobacillus casei.* International Journal of Dentist‐

[135] Agra MF, França PF, Barbosa-Filho JM. Synopsis of the plants known as medicinal and poisonous in Northeast of Brazil. Revista Brasileira de Farmacognosia 2007;17(1)

[136] Carvalho CM, Macedo-Costa MR, Pereira MSV, Higino JS, Carvalho LFPC, Costa, LJ. Efeito antimicrobiano in vitro do extrato de jabuticaba (*Myrciaria cauliflora* (Mart.) O. Berg.) sobre *Streptococcus* da cavidade oral. Revista Brasileira de Plantas Medicinais

[137] Costa, MR, Diniz, DN, Carvalho, CM, Pereira MSV, Pereira JV, Higino JS. Eficácia do extrato de *Myrciaria cauliflora* (Mart.) O. Berg. (jabuticabeira) sobre bactérias orais. Re‐

[138] Lima IO, Oliveira RAG, Lima EO, Farias NMP, Souza EL. Antifungal activity from essential oils on Candida species. Revista Brasileira de Farmacognosia 2006;16(2)

[139] Matan N, Rimkeeree H, Mawson AJ, Chompreeda P, Haruthaithanasan V, Parker M. Antimicrobial activity of cinnamon and clove oils under modified atmosphere condi‐

tions. International Journal of Food Microbiology 2006;107(2) 180-185.

Farmácia 2010;4(1) 19-25.

148 Emerging Trends in Oral Health Sciences and Dentistry

dicinais 2013;15(1) 112-120.

2009;9(1) 81-86.

ry 2010;9(2) 74-77.

2009;11(1) 79-83.

114-140.

197-201.

vista Brasileira de Fruticultura 2004;26(1) 177-179.

ity. Journal of Ethnopharmacology 1987;21(2) 183-186.

vista Brasileira de Farmacognosia 2009;19(2B) 565-571.


**Chapter 7**

## **Infant Oral Health**

[153] Okamura N, Asai M, Hine N, Yagi A. High-performance liquid chromatographic de‐ termination of phenolic compounds in Aloe species. Journal of Chromatography

[154] Kuzuya H, Tamai I, Beppu H, Shimpo K, Chihara T. Determination of aloenin, barba‐ loin and isobarbaloin in Aloe species by micellar electrokinetic chromatography.

[155] Steinert J, Khalaj S, Rimpler M. High-performance liquid chromatographic separa‐ tion of some naturally occurring naphthoquinones and anthraquinones. Journal of

[156] Ho KY, Tsai CC, Chen CP, Huang JS, Lin CC. Antimicrobial activity of honokiol and magnolol isolated from *Magnolia officinalis*. Phytotherapy Research 2001;15(2)

[157] Huang BB, Fan MW, Wang SL, Huang YB, Zhou J, Wang Q. Inhibitory effect of *Mag‐ nolia officinalis* extract on growth of *Streptococcus mutans*. The Chinese Journal of Den‐

[158] Oliveira FQ, Gobira B, Guimarães C, Batista J, Barreto M, Souza M. Espécies vegetais indicadas na odontologia. Revista Brasileira de Farmacognosia 2007;17(3) 466-476.

[159] Celeste RK, Slavutzky SMB, Van PGL. Ação preventiva do bochecho de sálvia: efei‐ tos sobre placa dental e gengivite. Revista Gaúcha de Odontologia 1998;46(2) 97-99.

[160] Chatterjee A, Saluja M, Singh N, Kandwal A. To evaluate the antigingivitis and anti‐ palque effect of an Azadirachta indica (neem) mouthrinse on plaque induced gingivi‐ tis: A double-blind, randomized, controlled trial. Journal of Indian Society of

1996;746(2) 225-231.

150 Emerging Trends in Oral Health Sciences and Dentistry

139-141.

Journal of Chromatography 2001;752(1) 91-97.

Chromatograhy A 1996;723(1/2) 206-209.

tal Research 2004;7(2) 15-9.

Periodontology 2011;15(4) 398–401.

Preetika Chandna and Vivek K. Adlakha

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59245

## **1. Introduction**

Infancy is the first year of life after birth and a newborn child is called an infant from birth till the completion of the first year of life. In the initial half of infancy, the oral cavity has gum pads alone and towards the later half there is the eruption of primary teeth in the oral cavity. Preventive oral care in infancy is the basis of future oral health. The primary aim of a dentist or pediatric dentist at this stage is to educate and motivate the new parents to maintain good oral hygiene of the infant. An infant is completely dependent on the parents/caregivers to fulfil his basic needs. Thus, the entire responsibility of preventive care for optimal oral health lies in the hands of the infant's parents/ caregivers.

#### **1.1. Importance of infant oral health care**

Infant oral health is the foundation upon which education and motivation regarding dental hygiene and other preventive dental care must be built on, to augment the prospect of a lifetime free of preventable dental diseases. Infant oral health is an integral part of general well being of an infant, as he or she increases in age. It encompasses the care of the oral cavity and monitoring of the development of the teeth. Unfortunately, pregnant women, parents and caregivers of infants often do not receive timely and accurate education about preventive oral and dental health care [1].

### **1.2. Role of infant oral health care in preventive dentistry**

Prevention is the primary focus of infant oral health care and prevention of dental diseases should be initiated in infancy itself. For diseases that occur early in life such as early childhood caries (ECC) prevention of diseases and the promotion of healthy behavior among parents/ caregivers must be given importance [2]. Preventive oral healthcare must be initiated in infancy because of the following reasons:

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#### **1.3. Causes and risk factors leading to poor infant oral health**

Evidence suggests that early-in-life risk factors play a significant role as predictors of future dental caries in children [3-6]. These risk factors include the extent of parental knowledge, attitude and practices (KAP) and an infant's oral hygiene status, medical history, oral medi‐ cations and feeding habits. Thus it is important to understand the causes and risk factors of poor infant oral health to avoid the risk of early childhood caries later in life. A major factor contributing to poor infant oral health is insufficient or improper knowledge, attitudes and practices (KAP) related to infant feeding practices and oral care. Evidence gathered from both global and Indian studies shows that both pregnant mothers and parents/caregivers of infants have inadequate KAP regarding infant feeding, weaning, and bottle feeding practices and cleaning of the mouth [7-10]. Lower socio economic status has also been correlated to a low dental KAP [11, 12]. The age group of parents does not show a consistent correlation with lack of dental KAP, with different studies reporting varying results [7, 13]. In addition to the lack of KAP regarding infant oral health, pregnant women seldom attain regular dental care and have dental care needs that are not satisfactorily dealt with [14].

Infants with medically compromised health such as congenital heart disease (CHD) may also be prone to poor oral health. Despite good dental care and intensive prevention, poorer dental health has been seen in children with CHD than in healthy children [15]. Medically compro‐ mised children may also have poor oral hygiene since in the presence of life threatening conditions, oral hygiene takes on low priority.

Medical illness and long term medication for it, is another risk factor for poor infant oral health [16-7]. Medically compromised infants are often on long term medication that may have side effects of xerostomia or alteration of salivary properties such as flow, buffering capacity or rate. For example, diuretics are used in congenital heart disease since they increase the excretion of water from the circulatory system. Reduced saliva and altered salivary flow are known side effects of diuretics [18]. Disturbed mineralization in teeth has also been reported [19]. Additionally, medications in syrup form for infants are often sweetened and this may result in a caries promoting oral environment. Sucrose is still used as a sweetener in some drugs, to enhance flavor [20-1].

Inappropriate infant feeding practices related to bottle feeding, breastfeeding and sweetened pacifiers/ liquids may be another cause of early childhood caries (ECC) as the teeth in the infant [22]. Nighttime bottle feeding with sweetened or sweet liquids is a risk factor for ECC due to salivary reduction and prolonged exposure of the teeth to fermentable carbohydrates [22]. The American Academy of Pediatrics (AAP) recommends breastfeeding as the ideal method of feeding and nurturing infants and recognizes the role of breastfeeding as primary in achieving optimal infant growth and development [23]. Further, the AAP recommends exclusive breastfeeding for the first 6 months followed by the addition of iron-enriched solid foods between 6 to 12 months of age [23]. Though breastfeeding serves several health and immuno‐ logic advantages to the infant, certain breastfeeding practices may result in ECC. The factors associated with breastfeeding that may result in ECC are ad libitum or at-will feeding, prolonged breastfeeding and frequent breastfeeding during the night, resulting in accumula‐ tion of milk in the teeth, which, combined with reduced salivary flow and lack of oral hygiene, may produce tooth decay [24-5].

#### **1.4. Consequences of poor infant oral health**

Dental caries remains the most widespread chronic disease of childhood and can have damaging effects on growth and development when it progresses to severe forms [26]. Early childhood caries is a public health problem with its etiologic factors playing a role from infancy itself. Low-income and minority children experience disproportionately more dental caries than other groups because of their added barriers, such as limited access to dental services [27].

Poor infant oral health may lead to early childhood caries which is an infectious disease, and *S. mutans* is the most likely causative agent. Early acquisition, i.e., in infancy, of *S. mutans* is a crucial event in the natural history of ECC [28].

## **2. The infant's mouth**

**1.** Poor oral hygiene and improper infant feeding practices create an environment that promotes the colonization of cariogenic bacteria such as *Streptococcus mutans*in the infant's mouth. Thus, when a tooth erupts in an infant's mouth, it is in an undesirable oral

**2.** Risk factors such as improper feeding practices and poor oral hygiene that may lead to early childhood caries (ECC) may be identified at an early age and appropriate interven‐

**3.** Parents/caregivers may be educated regarding good oral health care practices to maintain

**4.** Undesirable consequences of poor dental health such as ECC may be avoided and the

**5.** Psychologic health of the child can be maintained as unesthetic appearance of teeth

Evidence suggests that early-in-life risk factors play a significant role as predictors of future dental caries in children [3-6]. These risk factors include the extent of parental knowledge, attitude and practices (KAP) and an infant's oral hygiene status, medical history, oral medi‐ cations and feeding habits. Thus it is important to understand the causes and risk factors of poor infant oral health to avoid the risk of early childhood caries later in life. A major factor contributing to poor infant oral health is insufficient or improper knowledge, attitudes and practices (KAP) related to infant feeding practices and oral care. Evidence gathered from both global and Indian studies shows that both pregnant mothers and parents/caregivers of infants have inadequate KAP regarding infant feeding, weaning, and bottle feeding practices and cleaning of the mouth [7-10]. Lower socio economic status has also been correlated to a low dental KAP [11, 12]. The age group of parents does not show a consistent correlation with lack of dental KAP, with different studies reporting varying results [7, 13]. In addition to the lack of KAP regarding infant oral health, pregnant women seldom attain regular dental care and

Infants with medically compromised health such as congenital heart disease (CHD) may also be prone to poor oral health. Despite good dental care and intensive prevention, poorer dental health has been seen in children with CHD than in healthy children [15]. Medically compro‐ mised children may also have poor oral hygiene since in the presence of life threatening

Medical illness and long term medication for it, is another risk factor for poor infant oral health [16-7]. Medically compromised infants are often on long term medication that may have side effects of xerostomia or alteration of salivary properties such as flow, buffering capacity or rate. For example, diuretics are used in congenital heart disease since they increase the excretion of water from the circulatory system. Reduced saliva and altered salivary flow are known side effects of diuretics [18]. Disturbed mineralization in teeth has also been reported

infant may escape its complications such as dental pain and poor nutrition.

environment that promotes demineralization.

the infant's mouth in a state of good dental health.

negatively impacts the psychology of a child.

**1.3. Causes and risk factors leading to poor infant oral health**

have dental care needs that are not satisfactorily dealt with [14].

conditions, oral hygiene takes on low priority.

tion may be planned.

152 Emerging Trends in Oral Health Sciences and Dentistry

Oral microbial colonization of an infant's mouth begins shortly after birth [29]. The infants mouth consists only of gum pads in the pre-dentate stage, i.e., till about 6-7 months of age. As the teeth begin to erupt into the oral cavity (as the infant enters dentate stage), the colonization changes as the teeth present additional hard tissue surfaces for colonization. Influences from the mother/caregiver and siblings also play a role in the type of colonization of an infant's mouth.

#### **2.1. Infant Oral Microbiology**

The initial microbial microorganisms that colonize an infant's mouth are *Streptococcus salivar‐ ius*, *Streptococcus mitis* and *Streptococcus oralis* which belong to the group Mutans streptococcus

[30-3]. Of interest to the dentist is the acquisition of another species of the group Mutans streptococcus – *Streptococcus mutans* (*S. mutans*), which is strongly implicated in the etiology of dental caries [34]. Early-in-life or infant colonization by *S. mutans* is a chief risk factor for early childhood caries and future dental caries [28]. *Streptococcus mutans* was believed to show feeble adhesion to epithelial surfaces found in the pre-dentate infant's mouth [35-6]. The infants' mouth in the pre-dentate stage was thus considered unlikely to harbor *S. mutans* colonization. However, more recent evidence has shown that *S. mutans* colonization does occur in pre-dentate infants and the tongue may serve as an ecological niche in such cases [37-9]. Recently, a new microorganism *Scardovia wiggasiae* has been isolated from the plaque of ECC affected children using polymerase chain reaction (PCR) technology and research in this area is in progress [40].

#### **2.2. Clinical aspects: Acquisition and transmission of** *Streptococcus mutans*

Early-in-life acquisition of *Streptococcus mutans* has an impact on the future oral health of infants [28]. Infants may develop oral colonization with *S. mutans* colonization from their colonized parents [41]. The mother is the main source of transmission of S. mutans to a child as seen from clinical and microbiologic studies [42]. Mother-to-child or maternal transmission of *S. mutans* is one of the primary sources of transmission of *S. mutans* to an infant's mouth. This type of transmission of *S. mutans* is also known as *vertical transmission* [43]. In support of this route of transmission, several studies have reported identical bacteriocin profiles [44-5] and plasmid or chromosomal DNA patterns [46-7] of *S. mutans* strains in mother-child pairs. One study reported that when maternal salivary reservoirs exceed 105 colony forming units (CFU) the frequency of transmission of *S. mutans* to the infant was 9 times greater than when the maternal salivary levels of *S. mutans* were less than or equal to 103 CFU [48].

*Horizontal transmission* is the other major mode of transmission of *S. mutans* which occurs thorough sharing of spoons, glasses and interpersonal contact between the infant and other members of his/her environment such as siblings, daycare supervisors etc. Evidence for this mode of microbial transmission comes from several studies which have shown that infants and children in the same environment shared *S. mutans* isolates [49, 50]. Accordingly, vertical and horizontal transmission of *S. mutans* needs to be evaluated when taking into account risk factors for dental caries in an infant.

## **3. Dental home: Concept and advantages**

The first step towards promotion of good infant oral health is the creation and maintenance of a dental home. This concept is derived from the concept of medical home that was proposed by the American Academy of Pediatrics in 1992 [51]. The premise behind the medical home was that the best care may be offered to a child when the child in focus and his/her family has a good relationship with the doctor.

The American Academy Pediatric Dentistry (AAPD) recommends that a dental home may be designed for the infant on the same lines as the medical home concept. The characteristics of an ideal dental home are the following [52]:


There are several advantages of developing a dental home for an infant. Most importantly, the timing of the first dental visit of an infant may be planned within 1 year of age of an infant. This is in accordance with AAPD recommendations for the first dental visit of the child. Earlyin-life risk factors can thus be identified at an early stage and appropriate intervention through increase in KAP related to infant feeding and oral hygiene suggested to the parents/caregivers [52]. Moreover, a dental home personalized or tailored preventive program may be designed to suit the specific oral health needs of a child at every stage.

## **4. Anticipatory guidance**

[30-3]. Of interest to the dentist is the acquisition of another species of the group Mutans streptococcus – *Streptococcus mutans* (*S. mutans*), which is strongly implicated in the etiology of dental caries [34]. Early-in-life or infant colonization by *S. mutans* is a chief risk factor for early childhood caries and future dental caries [28]. *Streptococcus mutans* was believed to show feeble adhesion to epithelial surfaces found in the pre-dentate infant's mouth [35-6]. The infants' mouth in the pre-dentate stage was thus considered unlikely to harbor *S. mutans* colonization. However, more recent evidence has shown that *S. mutans* colonization does occur in pre-dentate infants and the tongue may serve as an ecological niche in such cases [37-9]. Recently, a new microorganism *Scardovia wiggasiae* has been isolated from the plaque of ECC affected children using polymerase chain reaction (PCR) technology and research in this area

Early-in-life acquisition of *Streptococcus mutans* has an impact on the future oral health of infants [28]. Infants may develop oral colonization with *S. mutans* colonization from their colonized parents [41]. The mother is the main source of transmission of S. mutans to a child as seen from clinical and microbiologic studies [42]. Mother-to-child or maternal transmission of *S. mutans* is one of the primary sources of transmission of *S. mutans* to an infant's mouth. This type of transmission of *S. mutans* is also known as *vertical transmission* [43]. In support of this route of transmission, several studies have reported identical bacteriocin profiles [44-5] and plasmid or chromosomal DNA patterns [46-7] of *S. mutans* strains in mother-child pairs. One study reported that when maternal salivary reservoirs exceed 105 colony forming units (CFU) the frequency of transmission of *S. mutans* to the infant was 9 times greater than when

*Horizontal transmission* is the other major mode of transmission of *S. mutans* which occurs thorough sharing of spoons, glasses and interpersonal contact between the infant and other members of his/her environment such as siblings, daycare supervisors etc. Evidence for this mode of microbial transmission comes from several studies which have shown that infants and children in the same environment shared *S. mutans* isolates [49, 50]. Accordingly, vertical and horizontal transmission of *S. mutans* needs to be evaluated when taking into account risk

The first step towards promotion of good infant oral health is the creation and maintenance of a dental home. This concept is derived from the concept of medical home that was proposed by the American Academy of Pediatrics in 1992 [51]. The premise behind the medical home was that the best care may be offered to a child when the child in focus and his/her family has

CFU [48].

**2.2. Clinical aspects: Acquisition and transmission of** *Streptococcus mutans*

the maternal salivary levels of *S. mutans* were less than or equal to 103

factors for dental caries in an infant.

a good relationship with the doctor.

**3. Dental home: Concept and advantages**

is in progress [40].

154 Emerging Trends in Oral Health Sciences and Dentistry

The dental home provides scope for anticipatory guidance at every stage of a child's devel‐ opment. Anticipatory guidance is the process of providing practical, developmentally appropriate information about children's health to prepare parents for the significant physical, emotional and psychological milestones [43, 53]. Anticipatory guidance encompasses 3 types of responsibilities: (1) gathering information, (2) establishing a therapeutic alliance, and (3) providing education and guidance [43, 54].

## **5. Prenatal oral health counseling**

Prenatal oral health counseling for parents is the first step to infant oral healthcare. The rationale of prenatal oral health counseling is to generate awareness among expectant mothers about dental disease, its prevention and the means to promote good oral health in the infant [54]. A mother's DMFS scores, education, and feeding habits are strong risk indicators for the colonization of caries-related micro-organisms and ECC [55].

#### **5.1. Importance of prenatal oral health care (during pregnancy)**

Ideally, optimization of infant oral health begins prenatally and continues with the monitoring and counseling of the mother and child, beginning when the infant is approximately 6 months of age, with the eruption of the first tooth [56]. Infants with low birth weight and malnourished infants are at risk for development of enamel hypoplasia [22, 57-8]. Enamel hypoplasia may result in a rough enamel surface which can result in areas more prone to plaque accumulation and resultant caries [57, 59]. Thus, expecting mothers should be advised to optimize nutrition during the third trimester and the infant's first year, when the enamel is undergoing matura‐ tion [54]. Recent literature also reports an association between periodontitis in the mother and preterm birth [60] and between *S. mutans* levels in mothers and caries experience in their children [42].

Evaluation of the oral status of expectant mothers followed by pre-and perinatal counseling regarding the expectant mothers' nutrition, oral hygiene, caries experience and KAP regarding infant feeding practices can have a significant impact on the child's caries rate in the future [54]. A dental home can address these needs, if developed at the prenatal stage itself. Pediatric dentists, pediatricians and nutritionists have a combined role in relation to prenatal counseling with a goal to providing the best oral and overall health for the newborn and infant. Future parents should be monitored on a regular basis to ensure effective oral hygiene and dietary habits have been established through regular pre-and perinatal parent counseling.

### **5.2. Anticipatory guidance for the pregnant mother**

Anticipatory guidance has been recommended for the pregnant mother to avoid caries and gingival problems and promote later oral health for the child. These include the following [43, 61-2]:


**5. Prenatal oral health counseling**

156 Emerging Trends in Oral Health Sciences and Dentistry

children [42].

61-2]:

colonization of caries-related micro-organisms and ECC [55].

**5.1. Importance of prenatal oral health care (during pregnancy)**

Prenatal oral health counseling for parents is the first step to infant oral healthcare. The rationale of prenatal oral health counseling is to generate awareness among expectant mothers about dental disease, its prevention and the means to promote good oral health in the infant [54]. A mother's DMFS scores, education, and feeding habits are strong risk indicators for the

Ideally, optimization of infant oral health begins prenatally and continues with the monitoring and counseling of the mother and child, beginning when the infant is approximately 6 months of age, with the eruption of the first tooth [56]. Infants with low birth weight and malnourished infants are at risk for development of enamel hypoplasia [22, 57-8]. Enamel hypoplasia may result in a rough enamel surface which can result in areas more prone to plaque accumulation and resultant caries [57, 59]. Thus, expecting mothers should be advised to optimize nutrition during the third trimester and the infant's first year, when the enamel is undergoing matura‐ tion [54]. Recent literature also reports an association between periodontitis in the mother and preterm birth [60] and between *S. mutans* levels in mothers and caries experience in their

Evaluation of the oral status of expectant mothers followed by pre-and perinatal counseling regarding the expectant mothers' nutrition, oral hygiene, caries experience and KAP regarding infant feeding practices can have a significant impact on the child's caries rate in the future [54]. A dental home can address these needs, if developed at the prenatal stage itself. Pediatric dentists, pediatricians and nutritionists have a combined role in relation to prenatal counseling with a goal to providing the best oral and overall health for the newborn and infant. Future parents should be monitored on a regular basis to ensure effective oral hygiene and dietary

Anticipatory guidance has been recommended for the pregnant mother to avoid caries and gingival problems and promote later oral health for the child. These include the following [43,

**a.** Education concerning development and prevention of dental disease and also demon‐

**d.** Visiting a dentist for an examination and restoration of all active decay as soon as feasible

**e.** Eating healthy foods such as fruits, vegetables, grain products (especially whole grain), and dairy products (milk, cheese) during meals and snacks. Limit eating between meals.

habits have been established through regular pre-and perinatal parent counseling.

**b.** Counseling to instill preventive attitudes and motivation among mothers. **c.** Providing information to pregnant women about pregnancy gingivitis.

and to decrease chances of developing pregnancy gingivitis.

**5.2. Anticipatory guidance for the pregnant mother**

stration of oral hygiene procedures.

## **6. Infant oral health care: Strategies and methods**

An effective approach toward primary prevention of early childhood caries is to develop an approach that targets its infectious element, for example by preventing or delaying primary acquisition of *S. mutans* at an early age or infancy, through suppression of maternal reservoirs of *S. mutans* [63]. Mothers with dense salivary or plaque reservoirs of *S. mutans* are at high risk for transmitting the microorganism to their infants early-in-life [54].

#### **6.1. Parent oral health counseling and education**

Parent education and increase in knowledge, attitude and practices (KAP) regarding infant oral health care may provide long lasting benefits on an infant's oral health. Maternal/ Caregiver KAP [7-9] is an area where several lacunae exist regarding infant nutrition, feeding practices and first dental visit. Emphasis must be placed on behavioral approaches to condi‐ tions such as ECC that begin early in life the prevention of diseases and the promotion of healthy behavior among mothers and their children [2]. Low-cost health education combined with external motivation proved to be a valuable tool for promoting health behavior in mothers and their children [64].

#### **6.2. Infant feeding related behavior**

Infant feeding practices related to breastfeeding, bottle feeding and their timing of cessation must be given importance. Infant formulas are acidogenic and possess cariogenic potential [65-6]. Prenatal and postnatal counseling is essential to generate awareness about the unfav‐ orable consequences of inappropriate infant feeding practices on infant oral health. Recom‐ mendations for appropriate infant feeding practices behaviors include [54, 67-8]:


**•** Between-meal snacks and prolonged exposures to foods and juice or other beverages containing fermentable carbohydrates should be avoided.

#### **6.3. Oral hygiene for the infant**

Oral hygiene measures must be implemented no later than the time of eruption of the first primary tooth. These measures include the following [25, 68]:


#### **6.4. Fluoride supplementation**

Fluoride is a well documented agent in caries control and it may be used for infants also. As per the AAPD, daily fluoride exposure for all children is recommended as a primary preventive procedure [69]. An infant's exposure to drinking water fluoride should be determined based on access to fluoridated water in community water supplies or through water analysis for those drinking well water [69]. A comprehensive knowledge of high fluoride belts and regions with endemic fluorosis is also important especially in countries like India with several geographic high fluoride belts. For infants older than 6 months of age who are exposed to water with less than 0.3 ppm fluoride, dietary fluoride supplements of 0.25 mg fluoride per day should be prescribed [69]. Irrespective of fluoride exposure in water, dietary supplements should not be prescribed for infants under the age of 6 months [69].

## **7. First dental visit: timing and its relevance**

To promote early detection of dental caries and the establishment of a dental home, both the American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry recommend the first dental visit by 1 year old. The AAPD recommends that the first oral evaluation visit should occur within 6 months of the eruption of the first primary tooth and no later than 12 months of age [70]. Since *S. mutans* begins to colonize an infant's mouth even prior to tooth eruption, a good dental care regime complemented by a dental home that is established at an initial stage of infancy may lead to long term oral health benefits for the infant.

## **8. Conclusion**

Infant oral health forms the basis of a lifetime of good oral health. The primary focus of infant oral health is prevention and every effort must be made to prevent and promote oral health at this crucial stage of infancy. A dental home must be developed for each child, which provides anticipatory guidance from infancy through adolescence. Maternal education and emphasis on good maternal oral health should also be encouraged at pre-and perinatal stages to further prevent early colonization of cariogenic microorganisms.

## **Author details**

**•** Between-meal snacks and prolonged exposures to foods and juice or other beverages

Oral hygiene measures must be implemented no later than the time of eruption of the first

**•** If an infant falls asleep while feeding, the teeth should be cleaned before placing the child

**•** Tooth brushing of all dentate children should be performed twice daily with a fluoridated

**•** Parents should use a 'smear' of toothpaste to brush the teeth of a child less than 2 years of

Fluoride is a well documented agent in caries control and it may be used for infants also. As per the AAPD, daily fluoride exposure for all children is recommended as a primary preventive procedure [69]. An infant's exposure to drinking water fluoride should be determined based on access to fluoridated water in community water supplies or through water analysis for those drinking well water [69]. A comprehensive knowledge of high fluoride belts and regions with endemic fluorosis is also important especially in countries like India with several geographic high fluoride belts. For infants older than 6 months of age who are exposed to water with less than 0.3 ppm fluoride, dietary fluoride supplements of 0.25 mg fluoride per day should be prescribed [69]. Irrespective of fluoride exposure in water, dietary supplements should not be

To promote early detection of dental caries and the establishment of a dental home, both the American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry recommend the first dental visit by 1 year old. The AAPD recommends that the first oral evaluation visit should occur within 6 months of the eruption of the first primary tooth and no later than 12 months of age [70]. Since *S. mutans* begins to colonize an infant's mouth even prior to tooth eruption, a good dental care regime complemented by a dental home that is established at an initial stage of infancy may lead to long term oral health benefits for the infant.

Infant oral health forms the basis of a lifetime of good oral health. The primary focus of infant oral health is prevention and every effort must be made to prevent and promote oral health at

containing fermentable carbohydrates should be avoided.

primary tooth. These measures include the following [25, 68]:

toothpaste and a soft, age-appropriate sized toothbrush.

age and perform or assist with their child's tooth brushing.

prescribed for infants under the age of 6 months [69].

**7. First dental visit: timing and its relevance**

**6.3. Oral hygiene for the infant**

158 Emerging Trends in Oral Health Sciences and Dentistry

**6.4. Fluoride supplementation**

**8. Conclusion**

in bed.

Preetika Chandna\* and Vivek K. Adlakha

\*Address all correspondence to: drpreetikachandna@gmail.com

Department of Paedodontics and Preventive Dentistry, Subharti Dental College, Meerut, Uttar Pradesh, India

## **References**


[23] Breastfeeding and the use of human milk. Pediatrics. 2012 Mar;129(3):e827-41.

[9] Shivaprakash PK, Elango I, Baweja DK, Noorani HH. The state of infant oral health‐ care knowledge and awareness: Disparity among parents and healthcare professio‐

[10] Hoeft KS, Masterson EE, Barker JC. Mexican American mothers' initiation and un‐ derstanding of home oral hygiene for young children. Pediatr Dent. 2009 Sep-Oct;

[11] Suresh BS, Ravishankar TL, Chaitra TR, Mohapatra AK, Gupta V. Mother's knowl‐ edge about pre-school child's oral health. J Indian Soc Pedod Prev Dent.

[12] Williams NJ, Whittle JG, Gatrell AC. The relationship between socio-demographic characteristics and dental health knowledge and attitudes of parents with young

[13] Rwakatema DS, Ng'ang'a PM. Oral health knowledge, attitudes and practices of pa‐ rents/guardians of pre-school children in Moshi, Tanzania. East Afr Med J

[14] Villa A, Abati S, Pileri P, Calabrese S, Capobianco G, Strohmenger L, Ottolenghi L, Cetin I, Campus GG. Oral health and oral diseases in pregnancy: a multicentre sur‐

[15] Stecksen-Blicks C, Rydberg A, Nyman L, Asplund S, Svanberg C. Dental car-ies ex‐ perience in children with congenital heart disease: a case-control study. Int J Paediatr

[16] Moore PA, Guggenheimer J. Medication-induced hyposalivation: etiology, diagnosis,

[17] Maupome G, Shulman JD, Medina-Solis CE, Ladeinde O. Is there a relation-ship be‐ tween asthma and dental caries?: a critical review of the literature. J Am Dent Assoc.

[18] Scully C, Felix DH. Oral medicine-update for the dental practitioner lumps and swel‐

[19] Hakala PE, Haavikko K. Permanent tooth formation of children with congenital cya‐

[20] Bigeard L. The role of medication and sugars in Paediatric dental patients. Dent Clin

[21] Moursi AM, Fernandez JB, Daronch M, Zee L, Jones CL. Nutrition and oral health considerations in children with special health care needs: implications for oral health

[22] Seow WK. Biological mechanisms of early childhood caries. Community Dent Oral

vey of Italian postpartum women. Aust Dent J. 2013 Jun;58(2):224-9.

and treatment. Compend Contin Educ Dent. 2008;29:50-5.

notic heart disease. Proc Finn Dent Soc 1974;70:63-6.

care providers. Pediatr Dent. 2010; 32:333-42.

Epidemiol. 1998; 26 (1 Suppl):8-27.

nals. J Indian Soc Pedod Prev Dent. 2009;27:39-43.

31(5):395-404.

160 Emerging Trends in Oral Health Sciences and Dentistry

2010;28:282-7.

2009;86:520-5.

Dent 2004;14:94-100.

2010;141:1061-74.

lings. Br Dent J. 2005;199:763-70.

North Am. 2000; 44:443-56.

children. Br Dent J 2002;193:651-4.


[55] Ersin NK, Eronat N, Cogulu D, Uzel A, Aksit S. Association of maternal-child charac‐ teristics as a factor in early childhood caries and salivary bacterial counts. J Dent Child (Chic). 2006 May-Aug;73(2):105-11.

[40] Tanner AC, Mathney JM, Kent RL, Chalmers NI, Hughes CV, Loo CY, Pradhan N, Kanasi E, Hwang J, Dahlan MA, Papadopolou E, Dewhirst FE Cultivable anaerobic microbiota of severe early childhood caries. J Clin Microbiol. 2011 Apr;49(4):1464-74.

[41] Douglass JM, Li Y, Tinanoff N. Association of mutans streptococci between caregiv‐

[42] Berkowitz R. Mutans streptococci: Acquisition and transmission. Pediatr Dent.

[43] Pinkham J, Casamassimo P, Fields H, McTigue D, Nowak A. Pediatric Dentistry: In‐

[44] Berkowitz RJ, Jordan H. Similarity of bacteriocins and Streptotoccus mutans from

[45] Davey AL, Rogers AH. Multiple types of the bacterium *Streptococcus mutans* in the human mouth and their intra-family transmission. Arch Oral Biol. 1984; 29(6):453–60.

[46] Caufield PW, Wannemuehler Y, Hensen J. Familiar clustering of the *Streptococcus mu‐ tans* cryptic plasmid strain in a dental clinic population. Infect Immun. 1982; 38(2):

[47] Kulkarni GV, Chan KH, Sandham HJ. An investigation into the use of restriction en‐ donuclease analysis in the study of transmission of mutans streptococci. J Dent Res.

[48] Berkowitz RJ, Turner J, Green P. Maternal salivary levels of *Streptococcus mutans* and

[49] Mattos-Graner RO, Smith DJ, King WF, Mayer MP. Water insoluble glucan synthesis by mutans streptococcal strains correlates with caries incidence in 12-to 30-month-

[50] van Loveren C, Buijs JF, ten Cate JM. Similarity of bacteriocin activity profiles of mu‐ tans streptococci within the family when the children acquire the strains after the age

[51] The American Academy of Pediatrics Ad Hoc Task Force on Definition of the Medi‐

[52] Nowak AJ, Casamassimo PS. The dental home: a primary care oral health concept. J

[53] Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the pediatrician in the

[54] Chandna P, Adlakha VK. Oral health in children guidelines for pediatricians. Indian

oral health of children: A National survey. Pediatr. 2000;106:E84.

primary oral infection in infants. Arch Oral Biol 1981; 26(2):147–9.

fancy through Adolescence. 4th Ed. Philadelphia: Saunders; 2005.

ers and their children. Pediatr Dent 2008; 30:375-87.

mother and infant. Arch Oral Biol. 1975; 20(11):725–30.

2006;28:106-9.

162 Emerging Trends in Oral Health Sciences and Dentistry

785–7.

1989; 68(7):1155–61

old children. J Dent Res. 2000;79:1371-7.

cal Home. The medical home. Pediatr. 1992;90:774.

of 5. Caries Res 2000; 34(6):481–5.

Am Dent Assoc. 2002 Jan;133(1):93-8.

Pediatr. 2010 Apr;47(4):323-7.


## **Comparative School Dental Sealant Program to Alleviate Dental Caries Problem — Thai versus International Perspective**

Sukanya Tianviwat

[69] American Academy on Pediatric Dentistry Liaison with Other Groups Committee; American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on

[70] American Academy of Pediatric Dentistry. Clinical Affairs Committee-Infant Oral Health Subcommittee. Guideline on infant oral health care. Pediatr Dent. 2012 Sep-

fluoride therapy. Pediatr Dent. 2008-2009;30(7 Suppl):121-4.

Oct;34(5):148-52

164 Emerging Trends in Oral Health Sciences and Dentistry

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59516

## **1. Introduction**

The application of dental sealant has been recommended for caries prevention in pit and fissure surfaces. For school dental sealant programes, the Community Preventive Services Task Force recommends the implementation of school dental sealant delivery programs based on strong evidence of their effectiveness in preventing dental caries among children [1]. In the United States, school-based dental sealant programs have been implemented successfully around the country, and the American Association for Community Dental Programs and the National Maternal and Child Oral Health Resource Center have published the guideline of "Seal America" to promote the implementation of this program [2]. School dental sealant program offer several advantages over other approaches [2, 3]: increasing access to dental service among deprived children, strengthening the relationship between schools and health care institutions, and establishing the follow-up and maintenance system of the dental sealant program.

The implementation of school dental sealant programs differs from country to country. Most of the evidence of effectiveness of these programs are found in well-equipped studies con‐ ducted in developed countries. This chapter will present more than fifteen years of scientific experience of the program operating among rural primary school children in Thailand and make comparisons with scientific data published in international journals. The scope of this chapter will include several topics related to school dental sealant programs: their effective‐ ness, factors related to effectiveness, critical findings and most common failures, and the impact of the program on oral health status.

© 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

## **2. Background**

In Thailand, the dental sealant program was initiated in 1996 and has been delivered to children on either a "school-based" or a "school-linked" pattern [3, 4]. In the school-based pattern, dental equipment is carried out by the dental health section of the community hospital, which visits all schools in the area under its responsibility at least once a year. Each school visit lasts 1-2 days. The mobile dental clinic, with portable field equipment, is transported from the hospital to schools by van. The equipment includes a patient chair, a portable artificial light, an operator stool, a master unit with slow-speed and high-speed handpieces with a triple syringe, a portable suction and a light polymerization unit. A temporary clinic is usually set up in an available area at each school (Figures 1 and 2). In the school-linked or hospital-based pattern, by contrast, the children receive dental sealant at the district or sub-district hospital (Figure 3). Children are screened by dentists or dental nurses at school and the parents requested to bring their children to the hospital to receive sealant. Some hospitals, however, request school teachers to bring the group of children whose parents have given permission for the child to receive dental sealant to the hospital. Some hospitals combine the two patterns of dental sealant delivery program – a school-based pattern for children in areas remote from a hospital and a school-linked pattern for children who live nearby.

**Figure 1.** Mobile dental equipment delivered to school by van.

**Figure 2.** Mobile dental equipment set up in an available area at a school where dental services are delivered.

**Figure 3.** Dental equipment at a district or a sub-district hospital

**2. Background**

166 Emerging Trends in Oral Health Sciences and Dentistry

In Thailand, the dental sealant program was initiated in 1996 and has been delivered to children on either a "school-based" or a "school-linked" pattern [3, 4]. In the school-based pattern, dental equipment is carried out by the dental health section of the community hospital, which visits all schools in the area under its responsibility at least once a year. Each school visit lasts 1-2 days. The mobile dental clinic, with portable field equipment, is transported from the hospital to schools by van. The equipment includes a patient chair, a portable artificial light, an operator stool, a master unit with slow-speed and high-speed handpieces with a triple syringe, a portable suction and a light polymerization unit. A temporary clinic is usually set up in an available area at each school (Figures 1 and 2). In the school-linked or hospital-based pattern, by contrast, the children receive dental sealant at the district or sub-district hospital (Figure 3). Children are screened by dentists or dental nurses at school and the parents requested to bring their children to the hospital to receive sealant. Some hospitals, however, request school teachers to bring the group of children whose parents have given permission for the child to receive dental sealant to the hospital. Some hospitals combine the two patterns of dental sealant delivery program – a school-based pattern for children in areas remote from

a hospital and a school-linked pattern for children who live nearby.

**Figure 1.** Mobile dental equipment delivered to school by van.

In 2005, the Dental Health Division, Ministry of Public Health, Thailand, initiated the Oral Health Promotion and Prevention in School Children Project under the National Health Security with the slogan "Yim Sodsai Dek Thai Fun Dee" project, which can be translated as "Bright Smile and Healthy Teeth in Thai Children" [5]. One of the objectives of this project is to achieve 50% of the first grade children with an average 2.5 teeth that have received dental sealant, especially the first permanent molars. Due to this universal coverage project the number of 12-year-old children whose teeth were sealed increased from 12.7% in the year 2007 [6] to 35.2% in the year 2012 [7].

In the following text, the phrase "school dental sealant program" is used to refer to both "school-based and school-linked dental sealant programs". The content of this chapter is based mainly on reports of the sealant program implementation published since 1996, which was the year of that marked the beginning of the school dental sealant program. Experimental studies, such as those concerned with sealant materials or properties, are not included. The main content is based on resin sealant, which is in widespread use in the school programs.

## **3. Effectiveness of the school dental sealant program**

Evaluation of the effectiveness of school dental sealant programs has been evaluated mostly on the basis of the percentage of full retention sealant and/or percentage of caries on sealed surfaces. Tables 1 and 2 compare such rates between Thailand [8-17, 25] and other countries [18-24]. Because of differences in the pattern of dental sealant delivery, in the summary of the setting, the terms "hospital" or "clinical setting" are used to represent the use of stationery dental equipment and "mobile clinic" to represent the use of mobile van or mobile dental equipment.

Major differences in sealant effectiveness between Thailand and other countries are evident. International publications report high percentages of full sealant retention within 1 to 5 years; 52.7-91.0 % [18-20, 22, 24], 74.7-85.0 % [20, 22, 24], 61.7-81.0 % [22, 24], 76 % [22] and 69% [22]. Very high long-term sealant retention at 15 and 20 years of 65% has also been reported [21]. In that study, the children had continuous access to comprehensive dental services. Moreover, the caries rate on sealed surfaces was generally low: 0.8-10.7% of the sealed teeth at one year [18-20]. Within 2 years, 0.9% of sealed surfaces had caries [20] and at 5 years 8% [22]. Very low long-term caries rate has also been reported 5.0 and 13.0% at 15 and 20 years respectively [21]. Results from Australia [23] are difficult to compare because of variation in follow-up time for evaluation of sealant retention in the study.

In Thailand, school dental sealant programs present a major difference from international results. Full sealant retention at one year in Thailand has varied between 19.6 and 67.7% [8, 9, 12, 13, 16] and that at 2 and 3 years from 8.9 to 41.8% [11, 14 - 17] and from 0 to 52.1% [9, 10, 12, 17], respectively. Moreover, higher rates of caries on sealed teeth in Thailand have been reported. At one year, the caries rate on sealed surfaces was 24% [16] and at two years 14.5-32.6% [11, 13-17]. In 2014, the 5-year caries on sealed surface rate was reported to be 13.4% [25].

In a follow-up study of sealant effectiveness in Thailand based on the Markov model [12], in which sealant was evaluated every 6 months for 30 months, the rate of sealant loss decreased with time. The first six months after application was the most vulnerable period of sealant retention, with a loss of 32.8% of teeth while caries incidence surged in the first year and also in the subsequent six months, the caries rates on sealed teeth were 10.2 % and 16.9 % in 1 and 1.5 years.

These data from the Markov model are in concordance with data presented in Tables 1 and 2, which show that school dental sealant in Thailand had relatively short-term retention and most of the caries on sealed teeth develops within 1-1.5 years after application.

## **4. Factors related to the school dental sealant effectiveness**

In 2005, the Dental Health Division, Ministry of Public Health, Thailand, initiated the Oral Health Promotion and Prevention in School Children Project under the National Health Security with the slogan "Yim Sodsai Dek Thai Fun Dee" project, which can be translated as "Bright Smile and Healthy Teeth in Thai Children" [5]. One of the objectives of this project is to achieve 50% of the first grade children with an average 2.5 teeth that have received dental sealant, especially the first permanent molars. Due to this universal coverage project the number of 12-year-old children whose teeth were sealed increased from 12.7% in the year 2007

In the following text, the phrase "school dental sealant program" is used to refer to both "school-based and school-linked dental sealant programs". The content of this chapter is based mainly on reports of the sealant program implementation published since 1996, which was the year of that marked the beginning of the school dental sealant program. Experimental studies, such as those concerned with sealant materials or properties, are not included. The main

Evaluation of the effectiveness of school dental sealant programs has been evaluated mostly on the basis of the percentage of full retention sealant and/or percentage of caries on sealed surfaces. Tables 1 and 2 compare such rates between Thailand [8-17, 25] and other countries [18-24]. Because of differences in the pattern of dental sealant delivery, in the summary of the setting, the terms "hospital" or "clinical setting" are used to represent the use of stationery dental equipment and "mobile clinic" to represent the use of mobile van or mobile dental

Major differences in sealant effectiveness between Thailand and other countries are evident. International publications report high percentages of full sealant retention within 1 to 5 years; 52.7-91.0 % [18-20, 22, 24], 74.7-85.0 % [20, 22, 24], 61.7-81.0 % [22, 24], 76 % [22] and 69% [22]. Very high long-term sealant retention at 15 and 20 years of 65% has also been reported [21]. In that study, the children had continuous access to comprehensive dental services. Moreover, the caries rate on sealed surfaces was generally low: 0.8-10.7% of the sealed teeth at one year [18-20]. Within 2 years, 0.9% of sealed surfaces had caries [20] and at 5 years 8% [22]. Very low long-term caries rate has also been reported 5.0 and 13.0% at 15 and 20 years respectively [21]. Results from Australia [23] are difficult to compare because of variation in follow-up time for

In Thailand, school dental sealant programs present a major difference from international results. Full sealant retention at one year in Thailand has varied between 19.6 and 67.7% [8, 9, 12, 13, 16] and that at 2 and 3 years from 8.9 to 41.8% [11, 14 - 17] and from 0 to 52.1% [9, 10, 12, 17], respectively. Moreover, higher rates of caries on sealed teeth in Thailand have been reported. At one year, the caries rate on sealed surfaces was 24% [16] and at two years 14.5-32.6% [11, 13-17]. In 2014, the 5-year caries on sealed surface rate was

content is based on resin sealant, which is in widespread use in the school programs.

**3. Effectiveness of the school dental sealant program**

[6] to 35.2% in the year 2012 [7].

168 Emerging Trends in Oral Health Sciences and Dentistry

equipment.

evaluation of sealant retention in the study.

reported to be 13.4% [25].

Sealant retention depends on the time since application. For short-term retention, loss of sealant is related to application technique and saliva contamination. Long-term retention, on the other hand, is related to masticatory function and wear. However, a recent report of the strategy adopted to improve sealant effectiveness indicated that sealant policy also had an effect on sealant effectiveness [26]. Since, in Thailand, most of the studies have examined sealant effectiveness over the short term and have shown rather poor effectiveness, the related factors have included those dealing with basic techniques, sealant delivery conditions and strategies to improve dental sealant performance comprising attitude of the provider and sealant policy [8, 9, 26]. By contrast, international studies have dealt with more advance techniques and policy to increase coverage or access to sealant [27-32].

As mentioned above, loss of sealant in Thailand occurs within 6-12 months; such loss is related with techniques and factors of moisture control. In a study of factors related to short-term sealant retention in Thailand [8], the researcher controlled for sealant type, oral hygiene, child's cooperation and position of the teeth. After reviewing sealant procedure according to manu‐ facturer's instruction, sealant was performed within the routine program, and after sealing for 6 months the sealant retention was examined. It was found that the checking procedure and the presence of an assistant were significant factors influencing full sealant retention. The odds of full sealant retention increased significantly, 2.8 times, when the providers checked for both occlusion and sealant retention compared with checking for sealant retention alone. The presence of an assistant increased the odds of full retention 2.3 times when compared to not having an assistant present. The shortage of dental assistants was also found to be a limitation in optimizing the mix of basic dental services (sealing, filling and extraction) for southern Thai schoolchildren [33]. This study identified the limited number of dental assistants as the crucial constraint for school dental service delivery.

The setting of the Thai school sealant program, i.e., school-based or mobile dental clinic and school-link or hospital-based dental clinic, has also been investigated as a potential factor in sealant effectiveness [9, 26], but with conflicting results. One study reported that the applica‐ tion of sealant in a school-based or mobile setting significantly increased the rate of sealant loss compared to that done in a hospital-based setting [26]. The other study reported a higher percentage of full sealant retention in school or mobile dental clinics than in hospital-based dental clinics [9]. However, the mobile dental conditions of two studies were different. The latter study employed a split mouth design with high power suction and the presence of a dental assistant. In each child, a dentist provided sealant on the two lower first permanent molars and restricted the number of children to be sealed in order to reduce the providers' stress from working. In this study, the percentage of full sealant retention was the highest among the studies of sealant effectiveness in Thailand (please see Table 1). On the other hand, the former study conducted in an actual situation, employing a mobile dental clinic with saliva ejector, and with no restriction on number of children or number of teeth to be sealed. Therefore, either hospital-based or school-based dental clinic could provide good results if optimal conditions for sealant – good moisture control and no tension of provider – are fulfilled. Moreover, the researcher [9] discussed that children felt more comfortable in school setting than hospital-based setting.

A recent study on strategies to improve sealant performance yielded an interesting result regarding providers' attitude and sealant policy [26]. The study examined whether audit and feedback could improve the quality of application of dental sealant in rural Thai school children. The design was a single-blind, cluster-randomized controlled trial. Sealant qualities (retention and caries), were examined prior to and after the intervention. The intervention consisted of confidential feedback of data and tailor-made problem-solving workshops. After the audit and feedback, focus group discussions (FGD) were conducted in 6 intervention clusters, including 22 dental nurses. The participating dental nurses were asked how they felt about the results from the audit and feedback and what they did when they received feedback indicating poor sealant quality. It became apparent that the participants had two distinct reactions to such feedback. The impression emerging from their direct statements was of a conflict between the quantity of children treated and the quality of service they received. On the other hand, their indirect statements indicated their wish to identify problems and to find ways of solving the problems identified by the data in the feedback. The dental nurses in all the clusters complained that the policy, which aims to maximize the number of cases in whom sealant is applied, has resulted in poor service quality because the goal of the policy does not take account of the actual situation in terms of the available manpower, overall workload, number of children needing to be treated and the condition of their teeth.

In the international perspective, more studies than in Thailand have been conducted on techniques to improve sealant effectiveness. Such studies have examined surface preparation before sealing [28, 29], four-handed sealant condition [30] and type of operator [22].

Gray et al. (2009) [28] conducted a study to review manufacturers' instructions for surface preparation in sealant use. Ten sealant products from five manufacturers which were com‐ monly used in school sealant programs were included. The use of pumice, prophylaxis paste or prophylaxis brush was included in five products, implying handpiece use. The other five products were nonspecific. Seven products indicated that the use of fluoride-containing or oilcontaining pastes should be avoided. None of the products mentioned that the operator should perform enameloplasty, fissureotomy, air abrasion or air polishing to clean the tooth surface before placing the sealant. However, one product directed the operator to remove minimal caries with a small round bur in a slow-speed handpiece after surface cleaning. In the same study, the authors conducted a review of studies comparing sealant effectiveness between mechanical preparation with pumice and using an air-water spray with sharp probe and found two studies of clinical design. Both studies reported retention rates greater than 96% at one year after sealing. Various modes of fissure preparation in combination with two filling levels were studied by Geiger (2000) [29]. In this *in vitro* study, fissure preparation was divided into three groups; no mechanical preparation, mechanical preparation with a round carbide bur, and mechanical preparation with a tapered fissure diamond bur. Then, sealant filling level in each preparation group was subdivided into minimal filling (just to the border of pit and fissure) or overfilled. The result showed that sealant penetration and retention were signifi‐ cantly improved in mechanically prepared compared to non-prepared fissures and prepara‐ tion with a tapered fissure diamond bur was superior to that with a round carbide bur. Overfilled fissures caused significantly higher levels of micro leakage. However, nowadays, the sealant placement recommendation developed by an expert working group supported by the Centers for Disease Control and Prevention (CDC) does not recommended additional surface preparation methods, such as air abrasion or enameloplasty [27].

percentage of full sealant retention in school or mobile dental clinics than in hospital-based dental clinics [9]. However, the mobile dental conditions of two studies were different. The latter study employed a split mouth design with high power suction and the presence of a dental assistant. In each child, a dentist provided sealant on the two lower first permanent molars and restricted the number of children to be sealed in order to reduce the providers' stress from working. In this study, the percentage of full sealant retention was the highest among the studies of sealant effectiveness in Thailand (please see Table 1). On the other hand, the former study conducted in an actual situation, employing a mobile dental clinic with saliva ejector, and with no restriction on number of children or number of teeth to be sealed. Therefore, either hospital-based or school-based dental clinic could provide good results if optimal conditions for sealant – good moisture control and no tension of provider – are fulfilled. Moreover, the researcher [9] discussed that children felt more comfortable in school

A recent study on strategies to improve sealant performance yielded an interesting result regarding providers' attitude and sealant policy [26]. The study examined whether audit and feedback could improve the quality of application of dental sealant in rural Thai school children. The design was a single-blind, cluster-randomized controlled trial. Sealant qualities (retention and caries), were examined prior to and after the intervention. The intervention consisted of confidential feedback of data and tailor-made problem-solving workshops. After the audit and feedback, focus group discussions (FGD) were conducted in 6 intervention clusters, including 22 dental nurses. The participating dental nurses were asked how they felt about the results from the audit and feedback and what they did when they received feedback indicating poor sealant quality. It became apparent that the participants had two distinct reactions to such feedback. The impression emerging from their direct statements was of a conflict between the quantity of children treated and the quality of service they received. On the other hand, their indirect statements indicated their wish to identify problems and to find ways of solving the problems identified by the data in the feedback. The dental nurses in all the clusters complained that the policy, which aims to maximize the number of cases in whom sealant is applied, has resulted in poor service quality because the goal of the policy does not take account of the actual situation in terms of the available manpower, overall workload,

number of children needing to be treated and the condition of their teeth.

In the international perspective, more studies than in Thailand have been conducted on techniques to improve sealant effectiveness. Such studies have examined surface preparation

Gray et al. (2009) [28] conducted a study to review manufacturers' instructions for surface preparation in sealant use. Ten sealant products from five manufacturers which were com‐ monly used in school sealant programs were included. The use of pumice, prophylaxis paste or prophylaxis brush was included in five products, implying handpiece use. The other five products were nonspecific. Seven products indicated that the use of fluoride-containing or oilcontaining pastes should be avoided. None of the products mentioned that the operator should perform enameloplasty, fissureotomy, air abrasion or air polishing to clean the tooth surface before placing the sealant. However, one product directed the operator to remove minimal caries with a small round bur in a slow-speed handpiece after surface cleaning. In the same

before sealing [28, 29], four-handed sealant condition [30] and type of operator [22].

setting than hospital-based setting.

170 Emerging Trends in Oral Health Sciences and Dentistry

The effect of having a dental assistant or four-handed delivery for sealant application was reviewed after controlling for various factors, namely years since placement, toothsurface cleaning method, isolation technique, and type of primary operator [30]. The review included 11 studies; eight studies using four-handed delivery and the other three using two-handed delivery. Summary retention rates in studies using fourhanded delivery were higher than those in studies using two-handed delivery at 1, 2 and 3 years; 89.8% vs 84.8%, 83.0 % vs 72.4% and 83.0% vs 67.9%, respectively. Multivariate analysis indicated that four-handed delivery increased sealant retention by about 9 percentage points compared with two-handed delivery.

Most school dental sealant application in Thailand is implemented by dental nurses. From Tables 1 and 2, the sealant effectiveness does not obviously differ between dentists and dental nurses. In other countries sealant application in school programs is mostly done by dentists (Table 1 and 2). There was the review to identify the effect of operator and sealant effectiveness [30]. This review showed unexpected finding of the association between having a dentist as the primary operator and lower sealant retention rates. The authors suggested two possible reasons for unexpected results. First, many dentists likely had limited experience with sealant materials and/or placement techniques. And the studies in which dentists were the primary operators may have been less likely to provide training in sealant placement than the studies in which the primary operators were non dentists.

There has been an effort to distribute the simple task of sealant application to other dental personnel, i.e., dental assistants [22] or dental therapists [23]. Very high sealant was achieved when sealing was performed by a dental assistant [22]. In another study, conducted in Australia [23], it was difficult to evaluate the performance of dental therapists owing to variation of follow-up time of the sealant. It seems, therefore, that type of operator is not a critical factor influencing sealant effectiveness.


**Table 1.** Full sealant retention rates in Thailand and other countries by period of follow-up


**Table 2.** Caries rates on sealed surfaces in Thailand and other countries by period of follow-up

**First author, year Age, tooth Number of children, teeth at baseline Setting, Provider Material** 

Tianviwat, 2011 [8] Grade 1\$, M1 206, 347 M, DN with or without DA Light-cured resin 67.7\*

Choomphupan, 2011 [9] 6-9, M1 212, 848 M, D H, D Light-cured Helioseal F 62.7 42.5 35.9 24.6

[10] Grade 1\$, M1 175, 355 M, NA NA 52.1

Thamtadawiwat, 2008 [11] 6-8, M1 183, 349 H, DN Light-cured Prevocare 41.8

Tianviwat, 2008 [12] Grade 1\$, M1 184, 332 M and H, DN Light-cured resin 54.8 30.7#

**Table 1.** Full sealant retention rates in Thailand and other countries by period of follow-up

Obsuwan, 2008 [13] 6-8, M1 500, 2000 H, NA NA 45.6\*

Kongtawelert, 2008 [14] 6-8, M1 865, 2193 H, DN without DA Light-cured resin 36.0

Kantamaturapoj, 2008 [15] 6-8, M1 320, 1280 H, NA Resin (not specific) 33.2\*\*

[16] 6-7, M1 107, 107 M, NA Light-cured resin 19.6 8.9

102, 260

20-21 months: 86 teeth

M, DN NA 18.6\*\* 0\*\*\*

32-33 months: 174 teeth

Taiwan [18] 6-9, M1 122, 229 M, 1D:1DA Light-cured 3M ESPE 86.0

[19] 6-7, M1 253, 421 H, 1D:1DA Light-cured Delton 52.7

Kuwait [20] 6-8, M1 452, 1372 H, D Light-cured Delton plus 79.8 75.0

Thipsoonthornchai, 2003

Tianviwat, 2001 [17] 6-7, M1

**Other countries**

Hsieh, 2014

Muller-Bolla, 2013 France

Francis, 2008

Wendt, 2001

NA, M1

45, 153

H, D

Self-cured

Delton 65.0 65.0

H, D

M2 976, 3218 H, DA Light-cured Delton 91.0 85.0 81.0 76.0 69.0

NA

56.0

(1-48

months)

Conceal

45, 161

NA, M2

6-10, M1 11-14,

Sweden [21]

Holst, 1998

Sweden [22]

Messer, 1997

Bravo, 1996

\$ average 6-8 years old; \* follow-up at 6 months; #

M1 = first permanent molar; M2 = second permanent molar; All = permanent premolar and molar; NA = not available

M = mobile dental equipment or van; H = hospital or clinical dental equipment; DN = dental nurses; D = dentist; DT= dental therapist; DA= dental assistant

Australia [23] 6-12, All 774, 2875 H, 2DT: 1DA

Spain [24] 6-8, M1 104, 416 M, 1D:1DA Light-cured Delton 87.3 74.7 61.7

follow-up at 30 months; \*\* follow-up at 20-21 months; \*\*\* follow-up at 32-33 months

**Thailand**

Charnvanishporn, 2009

**Full sealant retention rate (% of teeth)** 

**Period of follow-up (years)** 

172 Emerging Trends in Oral Health Sciences and Dentistry

## **5. Critical findings and most common failures**

Most studies of sealant effectiveness have reported sealant retention as full, partial or total loss, and reported caries or no caries on sealed surfaces. However, among these sealant failures, there were a few common or typical types of sealant loss, and these reflect the cause of failures and could suggest how to improve school dental sealant effectiveness [26]. The most common failure scenarios in the Thai context are presented below with illustrations. In each picture, a combination of failures might be seen; however, for explanation purposes the major failure is demonstrated. The causes of failure which were summarized from a problem-solving work‐ shop in the audit and feedback study [26] are also discussed.

#### **5.1. Partial retention with ledge and caries present**

The common characteristics of this type of loss are loss of some sealant and a pit/fissure with ledge exposed when exploring with a sharp probe. Caries is present with loss of tissue beyond the boundaries of the pits and fissures on occlusal surfaces and lesions contain demineralized dentine, usually light brown, and have a soft texture when explored with a blunt probe using gentle pressure (Figure 4). This common failure was present in 67.6% of the total caries on sealed surfaces at 6 months follow-up after a single sealant application [26] (data available from author). The same result was found in a long-term follow-up study in the context of high caries risk children in an inefficient school dental sealant program [12]. The effect of partial sealant retention with ledge present is to increase the risk of caries 3.1 times compared with total sealant loss [12]. A study in Scotland [34] confirmed the result: teeth with partially retained sealant at baseline were found to have a significantly higher percentage of caries (22.9%) than teeth with complete sealing (14.4%).

**Figure 4.** Partial retention with ledge and caries present

One review has addressed the controversy over the caries risk in formerly sealed teeth [35]. The authors examined the risk of caries development in teeth with partially or fully lost sealant relative to the risk in teeth that had never received sealants and concluded that teeth with fully or partially lost sealant were not at a higher risk of developing caries than teeth that had never been sealed. The studies included in the review were conducted in developed countries, where the risk of caries is quite low, the services are provided in well-equipped clinics and the sealant effectiveness is high.

It is obviously important that follow-up and repair of sealant loss should be promoted to increase the effectiveness of any school dental sealant program.

#### **5.2. Loss of sealant at poor oral hygiene surfaces**

**5. Critical findings and most common failures**

174 Emerging Trends in Oral Health Sciences and Dentistry

shop in the audit and feedback study [26] are also discussed.

**5.1. Partial retention with ledge and caries present**

(22.9%) than teeth with complete sealing (14.4%).

**Figure 4.** Partial retention with ledge and caries present

Most studies of sealant effectiveness have reported sealant retention as full, partial or total loss, and reported caries or no caries on sealed surfaces. However, among these sealant failures, there were a few common or typical types of sealant loss, and these reflect the cause of failures and could suggest how to improve school dental sealant effectiveness [26]. The most common failure scenarios in the Thai context are presented below with illustrations. In each picture, a combination of failures might be seen; however, for explanation purposes the major failure is demonstrated. The causes of failure which were summarized from a problem-solving work‐

The common characteristics of this type of loss are loss of some sealant and a pit/fissure with ledge exposed when exploring with a sharp probe. Caries is present with loss of tissue beyond the boundaries of the pits and fissures on occlusal surfaces and lesions contain demineralized dentine, usually light brown, and have a soft texture when explored with a blunt probe using gentle pressure (Figure 4). This common failure was present in 67.6% of the total caries on sealed surfaces at 6 months follow-up after a single sealant application [26] (data available from author). The same result was found in a long-term follow-up study in the context of high caries risk children in an inefficient school dental sealant program [12]. The effect of partial sealant retention with ledge present is to increase the risk of caries 3.1 times compared with total sealant loss [12]. A study in Scotland [34] confirmed the result: teeth with partially retained sealant at baseline were found to have a significantly higher percentage of caries

From observational study, this type of loss accounts for approximately 60.7% of all failures of dental sealant [26]. Poor oral hygiene gauged by the presentation of soft debris covering more than 2/3 of the exposed tooth surface (Figure 5) based on the Debris index of Simplified Oral Hygiene Index [36]. The characteristics are partial or total loss of sealant and the presence of poor oral hygiene. This recent finding indicates a significant effect of poor oral hygiene on failure of sealant retention.

**Figure 5.** Loss of sealant at poor oral hygiene surfaces

#### **5.3. Loss of sealant at cervical part of buccal pit and groove among lower first permanent molars.**

In Thailand, lower first permanent molar is the first priority for the school dental sealant program among grade 1 schoolchildren as the first permanent molars present the highest percentage of caries: 51.4% in 12-year-old children [37]. Among all children, the lower first permanent molars comprised 36.4% and the upper first permanent molars 17.5% of all carious teeth [5]. The ratio of sealant service between lower teeth and upper teeth varied between 1.4:1 and 2.2:1 [8, 26]. This failure is characterized by a lack of sealant remaining at the lower end of the the buccal pit and groove (Figure 6) and was found in approximately 31.9% of sealed lower permanent molars. The significant concern of the scenario is the frequent presentation of caries development. The causes are related to tooth eruption and policy. Findings from focus group discussion in the sealant study [26] revealed that the policy of achieving 50% of first grade children being sealed placed a considerable burden on providers and had a negative impact on the quality of the program. A study of the eruption pattern in American children [38] found that only 57 % of first graders had all first permanent molars sufficiently erupted for sealing. In Taiwan [18], children aged 6-9 years presented only 46.9% (229 teeth among 488 teeth) of first permanent molars had erupted without decay, and eruption with decay or filling was present in 23.8% (116 teeth among 488 teeth). The loss of buccal surface was higher than that of occlusal surface among lower first permanent molars [23].

A study of eruption pattern of first permanent molar among Thai kindergarten level 2 and grade 1 and grade 2 schoolchildren [39] found that the percentages of at least one first permanent molar eruption were 6.0%, 75.1% and 98.5%, respectively. Among grade-1 children, who are the target group of the school dental sealant program in Thailand, the right lower first permanent molar had erupted 65.3% and caries was found 12.1%, whereas on the left side 64.3% had erupted and caries was present 9.1%. In the context of high caries prevalence, it is likely that the provider might seal teeth that are not in a suitable condition for sealing, such as being insufficiently erupted which more than half of the buccal surface covered by gingival tissue.

**Figure 6.** Loss of sealant at cervical part of buccal pit and groove among lower first permanent molars.

### **5.4. Loss of sealant at distal pit and groove of the occlusal surface of lower molars**

teeth [5]. The ratio of sealant service between lower teeth and upper teeth varied between 1.4:1 and 2.2:1 [8, 26]. This failure is characterized by a lack of sealant remaining at the lower end of the the buccal pit and groove (Figure 6) and was found in approximately 31.9% of sealed lower permanent molars. The significant concern of the scenario is the frequent presentation of caries development. The causes are related to tooth eruption and policy. Findings from focus group discussion in the sealant study [26] revealed that the policy of achieving 50% of first grade children being sealed placed a considerable burden on providers and had a negative impact on the quality of the program. A study of the eruption pattern in American children [38] found that only 57 % of first graders had all first permanent molars sufficiently erupted for sealing. In Taiwan [18], children aged 6-9 years presented only 46.9% (229 teeth among 488 teeth) of first permanent molars had erupted without decay, and eruption with decay or filling was present in 23.8% (116 teeth among 488 teeth). The loss of buccal surface was higher than

A study of eruption pattern of first permanent molar among Thai kindergarten level 2 and grade 1 and grade 2 schoolchildren [39] found that the percentages of at least one first permanent molar eruption were 6.0%, 75.1% and 98.5%, respectively. Among grade-1 children, who are the target group of the school dental sealant program in Thailand, the right lower first permanent molar had erupted 65.3% and caries was found 12.1%, whereas on the left side 64.3% had erupted and caries was present 9.1%. In the context of high caries prevalence, it is likely that the provider might seal teeth that are not in a suitable condition for sealing, such as being insufficiently erupted which more than half of the buccal surface covered by gingival

**Figure 6.** Loss of sealant at cervical part of buccal pit and groove among lower first permanent molars.

that of occlusal surface among lower first permanent molars [23].

176 Emerging Trends in Oral Health Sciences and Dentistry

tissue.

The characteristics of this failure were no sealant remaining at the distal pit and groove of the occlusal surfaces of the lower molars and the presence of a ledge (Figure 7). The sealant was often was bulked or thick. This type of failure was seen in 16.3% of sealed lower permanent molars [26] (data available from author). The cause of failure, summarized from the problemsolving workshop, concerned the application technique. The provider used a brush to deliver sealant onto the tooth surface and the excess sealant flowed under gravity collecting in bulk and forming a thick layer at the distal end of the groove. When the children chewed, this area was at risk of fracture.

**Figure 7.** Loss of sealant at distal pit and groove of the occlusal surface of lower molars

There were other failures related with case selection and sealant technique; for instance, operculum covered on sealed surfaces (Figure 8), and void in sealant with or without caries (Figure 9). Most of the failures could be prevented by following the correct sealant procedure and instructions. The study of audit and feedback showed that these common failure scenarios and their own performance data as reflected in retention and caries rates could change the provider's attitude toward dental service quality [26]. The result from focus group discussion showed that they realized the poor quality of the dental service and felt they had to achieve a balance between quantity and quality of school dental sealant. They identified the means of solving their problems of service quality in terms of reallocating manpower, increasing their awareness, and improved equipment maintenance and sealant technique.

**Figure 8.** Operculum cover on sealed surface

**Figure 9.** A void in sealant with caries

#### **6. Impact of school dental sealant on oral health status**

Evidence showing the effectiveness of dental sealant for caries prevention is drawn from several scientific papers [27, 40, 41]. Data from the evaluation of the school dental sealant program under the universal coverage of health care service in Thailand are presented. The macro scale data from Ministry of Public Health and data from each area and published in Thai journals are included. The impact of the program on the dental status of children as reflected in reports of the National Oral Health Survey before and after implementation of the school dental sealant program is also discussed.

As mentioned at the beginning of the chapter, the school As mentioned at the beginning of the chapter, the school sealant sealant program was first implemented in Thailand in 1996 on a small scale [17]. By 2001, the coverage of dental sealant was still very low; only 4.5% of 12-yearold children received dental sealant [42]. In 2005, the Oral Health Promotion and Prevention in School Children Project under National Health Security "Yim (smile) Sodsai (Bright), Dek Thai (Thai Children) Fun Dee (Health Teeth)", which was a joint project of the Dental health division, Department of health, and the National Health Security Organization was launched [5]. This project was managed as a vertical program by signing a contract between chief executive officers of the Provincial Health Office and the Department of Health. The project included prevention and promotion activities; full mouth examination of first grade and third grade students, sealant for the first grade students, and after-lunch tooth brushing for primary school children. Sealant activities of the project during 2005-2007 were evaluated based on monthly reports via a web-based system. After-lunch tooth brushing activity is an on-going activity which has been conducted since 1988 in the Oral Health Surveillance and Dental Health Promotion Program for primary school children [43].

**Figure 8.** Operculum cover on sealed surface

178 Emerging Trends in Oral Health Sciences and Dentistry

**Figure 9.** A void in sealant with caries

**6. Impact of school dental sealant on oral health status**

Evidence showing the effectiveness of dental sealant for caries prevention is drawn from several scientific papers [27, 40, 41]. Data from the evaluation of the school dental sealant program under the universal coverage of health care service in Thailand are presented. The macro scale data from Ministry of Public Health and data from each area and published in Thai journals are included. The impact of the program on the dental status of children as The percentages of dental examination and sealant activities are presented in Table 3. The data were retrieved from 75 provinces in Thailand. Among first grade primary school children 35.9 – 48.8% had access to dental sealant in the period 2005-2007. In 2007, the number of sealed children was lower than in 2005-2006, partly explained by the diminished incentive for sealant service providers. However, the proportion of sealed children was still lower than that in other countries, for example, Slovenia with 62-100% (1988) [44], Ireland with 50-80% (1997) [45], and theUnitedStateswith51.1-88.0%andanextremelylowcoverage inoneareaof41.0%(2002)[46].

The impact of the program was evaluated after two years of implementation based on the number of carious teeth among third grade children who had received sealant when they were in grade 1. Table 4 compares data between grade 3 sealed and unsealed children. Number of caries in first permanent molars among sealed children was 33.1% - much lower than that in unsealed children (66.9%). Nevertheless the number of caries in sealed group was quite high compared to other studies at the same follow-up period in Thai context (please see table 2). Evidence to support dental sealant effectiveness has been reported in several international publications. However, reports of the impact of the school dental sealant program at the macro level are few. In Slovenia, the most recent caries decline during 1987-1998; i.e. from 5.1 to 1.8 for 12-year-olds, and from 10.2 to 4.3 for 15-year-olds, was most likely due to supervised brushing with concentrated fluoride gel taking place several times a year in primary schools attended by children aged 7–15 years, improved oral hygiene, and a comprehensive program of applying fissure sealants, particularly on first molars. The Cochran database published a review of pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents [40]. The review showed that the probability of sealed teeth remaining noncarious in patients who had received resin sealant at 24 months was 4.5 times less than that in the corresponding teeth of unsealed children (relative risk= 0.22; 95% confidence interval 0.34 to 0.22).


NA = not available; \$ data from 75 provinces; # data from 70 provinces

Source: Modified from Jirapongsa W, Prasertsom P. [5]

**Table 3.** Percentage coverage of dental examination and dental sealant in the Oral Health Promotion and Prevention in School Children Project under National Health Security


**Table 4.** Number of children and percentage of carious first permanent molars classified by sealed and unsealed grade 3 primary school children

An area-based study in Thailand found a marginally significant impact of the program regarding the proportion of children in whom caries was prevented [13]. This was a cohort study comparing sealed and unsealed groups of children. Both groups were enrolled in afterlunch tooth brushing with fluoride toothpaste. Table 5 presents the frequency of caries on first permanent molars in the two groups. A high percentage of early sealant loss was found in this study; at 6 months only 45.6% had full sealant retention – a value that is quite low compared to the data for the same period in Thailand, 54.8-67.7 % (Table 1). Therefore, in the high and early sealant loss area, the caries preventive effect was difficult to reach.


**Table 5.** Caries on first permanent molars at 24 months between sealed and unsealed group

The percentages of sealed and unsealed surfaces having caries have been compared in several cross-sectional studies using baseline data from the web-based system and examined caries at the end of the study. Table 6 summarizes the caries data from three studies comparing children who received dental sealant with others who did not. The differences were only marginally significant (rows 1 and 3) or non-significant (row 2). The sealant retention rates in these studies were quite low (please see Table 1). In two of the studies; 42% at 2 years [11] and 33.2% at 20 months [15], although somewhat higher in the third study, 52.1% at three years [10]. Thus, under low effectiveness conditions, caries preventive effect was low.


\*only carious data at teeth level are available: 57 from 349 teeth (16.3%) among sealed group and 56 from 422 teeth (13.3%) among unsealed group

**Table 6.** Percentage of caries in sealed and unsealed children

**Activities Educational year 2005 Educational year 2006 Educational year 2007**

and 3 (children) 1,299,959 81.3 1,257,486 78.6 941,968 58.9

(children) 414,827 48.6 430,044 48.8 316,404 35.9

(teeth) 1,051,542 NA 1,212,398 NA 901,704 NA Brushing (school) 28,647\$ 91.8 27,771# 94.1 27,432# 95.4 (children) 4,604,179\$ 87.5 4,190,561# 88.6 4,194,000# 92.5

data from 70 provinces

**Table 3.** Percentage coverage of dental examination and dental sealant in the Oral Health Promotion and Prevention in

**Table 4.** Number of children and percentage of carious first permanent molars classified by sealed and unsealed grade

An area-based study in Thailand found a marginally significant impact of the program regarding the proportion of children in whom caries was prevented [13]. This was a cohort study comparing sealed and unsealed groups of children. Both groups were enrolled in afterlunch tooth brushing with fluoride toothpaste. Table 5 presents the frequency of caries on first permanent molars in the two groups. A high percentage of early sealant loss was found in this study; at 6 months only 45.6% had full sealant retention – a value that is quite low compared to the data for the same period in Thailand, 54.8-67.7 % (Table 1). Therefore, in the high and

**Number of children with**

0.052

**caries (%)**

**Percent of children who had carious**

**in first permanent molars**

**Carious teeth Mean (sd)**

Examination grade 1

NA = not available; \$

data from 75 provinces; #

**Group Number of examined children**

Children who receive sealant 149,837 33.1 Children who did not received sealant 303,023 66.9

early sealant loss area, the caries preventive effect was difficult to reach.

Children who did not received p-value < .001

500 159 (31.8)

**Table 5.** Caries on first permanent molars at 24 months between sealed and unsealed group

Children who receive sealant <sup>500</sup> 163 (32.6) p-value

Source: Modified from Jirapongsa W, Prasertsom P. [5]

180 Emerging Trends in Oral Health Sciences and Dentistry

School Children Project under National Health Security

**Group Number of children**

Source: Jirapongsa W, Prasertsom P. [5]

3 primary school children

sealant

Source: Obsuwan K. [13]

Sealant grade 1

**Number Percent Number Percent Number Percent**

In Thailand, the Dental Health Division, Department of Health, has conducted a National Oral Health Survey every 5 years, the most recent one was the 7th survey conducted in 2012. The data from 4 surveys were used to reveal the impact of dental sealant on the oral health status of children (Figure 10). As the target group of the school dental sealant project was grade 1 primary-school children, aged 6-8 years, the data of 12-year-olds were used. The number of examined children and caries experience in permanent teeth of each survey are shown in Table 7. The survey data did not report caries experience in first permanent molars (only the 4th survey reported caries by tooth), therefore the total caries experience in permanent teeth is present as proxy for caries experience of first permanent molars since 51.4% of caries teeth in 12 years old children were in first permanent molars [37].

The 4th, 6th and 7th surveys were conducted in 17 provinces, 4 provinces from each region (north, south, north-east and central) and Bangkok, the capital province. The sample size of the 5th survey was very large because the Dental Health Division expanded the survey from 17 to 48 provinces and increased the size of the sample for improved representative‐ ness at the provincial level (Table 7). The 4th survey was conducted before the small scale implementation of school dental sealant activity, therefore the data from this survey together with other dental health programs could be used as baseline data. Data from the 5th survey were used to assess the impact of the small scale school dental sealant pro‐ gram. The 6th and 7th survey data were used to assess the impact of the large scale program. Caries experience of 12-year-old children from the four surveys is presented in Table 7. Coverage of dental sealant is shown in Table 8. Other dental health care programs implemented during 1994 to date are summarized in Table 9. surveys is presented in Table 7. Coverage of dental sealant is shown in Table 8. Other dental health care programmes implemented during 1994 to date are summarized in Table 9.

Figure 10: Summary of implementation timeline of National Oral Health Surveys and the dental sealant programme During the period 1994 to 2000/2001 [42, 47], the percentage of children affected by caries increased but the average caries **Figure 10.** Summary of implementation timeline of National Oral Health Surveys and the dental sealant program

experience in permanent teeth was quite stable (Table 7). The oral health programme at that time comprised school dental sealant on a small scale, ongoing after-lunch tooth brushing and oral health education (Table 8). However, from the 5th survey, the proportion of children who enrolled every day in the after-lunch tooth brushing programme was low, only 26.3%. The proportion of children who brushed their teeth every day was 86.2% in the morning and 34.6% in the evening. Between 2000/2001 and 2006/2007 [42, 6], caries experience in terms of percentage of children affected by caries and average caries teeth per child among 12-year-olds was slightly decreased (Table 7). Sealant service was increased 2.8 times from the 5th to the 6th survey. This period included the first phase of the large-scale implementation of school dental sealant and the campaign to control of sugar consumption, which emphasized the creation of networks and activities in childcare centers. However, the number of sealed children was still low (Table 8). Other dental heath activities, such as after-lunch tooth brushing and oral health education, were ongoing. The proportion of children who brushed their teeth every day at During the period 1994 to 2000/2001 [42, 47], the percentage of children affected by caries increased but the average caries experience in permanent teeth was quite stable (Table 7). The oral health program at that time comprised school dental sealant on a small scale, ongoing after-lunch tooth brushing and oral health education (Tables 8 and 9). However, from the 5th survey, the proportion of children who enrolled every day in the after-lunch tooth brushing program was low, only 26.3%. The proportion of children who brushed their teeth every day was 86.2% in the morning and 34.6% in the evening.

school decreased to 21.7% and that of children who did not brush increased to 57.9%. Brushing at home seemed to increase slightly (Table 8). During the 6th and 7th surveys [6, 7], the proportion of children having caries decreased approximately five percentage points and the average number of caries teeth decreased from 1.55 to 1.3 teeth per child. The percentage of children with sealant at 12 years of age increased from 12.7% to 35.2% (Table 8). The large-scale dental sealant was implemented for nearly 7 years. The percentage of tooth brushing continued on the rise. However, snack consumption also increased during the same period (Table 8). Table 7: Number of children, percentage and mean caries experience of 12-year-olds from in four surveys The 4th survey [47] (1994) The 5th survey [42] (2000-2001) The 6th Survey [6] (2006-2007) The 7th Survey [7] (2012) Between 2000/2001 and 2006/2007 [42, 6], caries experience in terms of percentage of children affected by caries and average carious teeth per child among 12-year-olds was slightly decreased (Table 7). Sealant service was increased 2.8 times from the 5th to the 6th survey. This period included the first phase of the large scale implementation of school dental sealant and the campaign to control of sugar consumption, which emphasized the creation of networks and activities in childcare centers. However, the number of sealed children was still low (Table 8). Other dental heath activities, such as after-lunch tooth brushing and oral health education, were ongoing. The proportion of children who brushed their teeth every day at school decreased to 21.7% and that of children who did not brush increased to 57.9%. Brushing at home seemed to increase slightly (Table 8).

Number of children 2,801 35,623 2,208 2,618 Percent caries 53.9 % 57.3 % 56.9 % 52.3 % Mean and SE of caries 1.6േ0.04 1.64\* 1.55\* 1.30\* NA = not applicable \*SE data are not applicable During the 6th and 7th surveys [6, 7], the proportion of children having caries decreased approximately five percentage points and the average number of carious teeth decreased from 1.55 to 1.3 teeth per child. The percentage of children with sealant at 12 years of age increased from 12.7% to 35.2% (Table 8). The large scale dental sealant was implemented for nearly 7 years. The percentage of tooth brushing occasion continued on the rise. However, snack consumption also increased during the same period (Table 8).

survey [42] The 6th

Survey [6] The 7th

Survey [7]

Table 8: Percentage of 12-year-old children enrolled in the oral health prevention and promotion activities

survey [47] The 5th

Activities The 4th

Comparative School Dental Sealant Program to Alleviate Dental Caries Problem — Thai versus International… http://dx.doi.org/10.5772/59516 183


\*SE data are not available

gram. The 6th and 7th survey data were used to assess the impact of the large scale program. Caries experience of 12-year-old children from the four surveys is presented in Table 7. Coverage of dental sealant is shown in Table 8. Other dental health care programs implemented during 1994 to date are summarized in Table 9. surveys is presented in Table 7. Coverage of dental sealant is shown in Table 8. Other dental health care programmes

Figure 10: Summary of implementation timeline of National Oral Health Surveys and the dental sealant programme

**Figure 10.** Summary of implementation timeline of National Oral Health Surveys and the dental sealant program

During the period 1994 to 2000/2001 [42, 47], the percentage of children affected by caries increased but the average caries experience in permanent teeth was quite stable (Table 7). The oral health programme at that time comprised school dental sealant on a small scale, ongoing after-lunch tooth brushing and oral health education (Table 8). However, from the 5th survey, the proportion of children who enrolled every day in the after-lunch tooth brushing programme was low, only 26.3%. The proportion of children who brushed their teeth every day was 86.2% in the morning and 34.6% in the evening.

During the period 1994 to 2000/2001 [42, 47], the percentage of children affected by caries increased but the average caries experience in permanent teeth was quite stable (Table 7). The oral health program at that time comprised school dental sealant on a small scale, ongoing after-lunch tooth brushing and oral health education (Tables 8 and 9). However, from the 5th survey, the proportion of children who enrolled every day in the after-lunch tooth brushing program was low, only 26.3%. The proportion of children who brushed their teeth every day

The 6th

2006-2007

Survey

2005 Large scale school sealant

The 7th

2012

Survey

Between 2000/2001 and 2006/2007 [42, 6], caries experience in terms of percentage of children affected by caries and average caries teeth per child among 12-year-olds was slightly decreased (Table 7). Sealant service was increased 2.8 times from the 5th to the 6th survey. This period included the first phase of the large-scale implementation of school dental sealant and the campaign to control of sugar consumption, which emphasized the creation of networks and activities in childcare centers. However, the number of sealed children was still low (Table 8). Other dental heath activities, such as after-lunch tooth brushing and oral health education, were ongoing. The proportion of children who brushed their teeth every day at school decreased to 21.7% and that of children who did not brush increased to 57.9%. Brushing at home seemed to increase

 During the 6th and 7th surveys [6, 7], the proportion of children having caries decreased approximately five percentage points and the average number of caries teeth decreased from 1.55 to 1.3 teeth per child. The percentage of children with sealant at 12 years of age increased from 12.7% to 35.2% (Table 8). The large-scale dental sealant was implemented for nearly 7 years. The percentage of tooth brushing continued on the rise. However, snack consumption also increased during

Between 2000/2001 and 2006/2007 [42, 6], caries experience in terms of percentage of children affected by caries and average carious teeth per child among 12-year-olds was slightly decreased (Table 7). Sealant service was increased 2.8 times from the 5th to the 6th survey. This period included the first phase of the large scale implementation of school dental sealant and the campaign to control of sugar consumption, which emphasized the creation of networks and activities in childcare centers. However, the number of sealed children was still low (Table 8). Other dental heath activities, such as after-lunch tooth brushing and oral health education, were ongoing. The proportion of children who brushed their teeth every day at school decreased to 21.7% and that of children who did not brush increased to 57.9%. Brushing at

The 6th

2,801 35,623 2,208 2,618

During the 6th and 7th surveys [6, 7], the proportion of children having caries decreased approximately five percentage points and the average number of carious teeth decreased from 1.55 to 1.3 teeth per child. The percentage of children with sealant at 12 years of age increased from 12.7% to 35.2% (Table 8). The large scale dental sealant was implemented for nearly 7 years. The percentage of tooth brushing occasion continued on the rise. However, snack

1.6േ0.04 1.64\* 1.55\* 1.30\*

survey [42] The 6th

Survey [6]

Survey [6] The 7th

The 7th

Survey [7]

Survey [7]

(2012)

(2006-2007)

Table 7: Number of children, percentage and mean caries experience of 12-year-olds from in four surveys

(2000-2001)

Percent caries 53.9 % 57.3 % 56.9 % 52.3 %

Table 8: Percentage of 12-year-old children enrolled in the oral health prevention and promotion activities

survey [47] The 5th

consumption also increased during the same period (Table 8).

survey [42]

The 5th

implemented during 1994 to date are summarized in Table 9.

182 Emerging Trends in Oral Health Sciences and Dentistry

Dental Sealant

Years

National Oral Health Survey

Survey

The 5th

1996 Small scale school sealant

2000-2001

Survey

The 4th

1994

slightly (Table 8).

Number of children

Mean and SE of caries

Activities The 4th

the same period (Table 8).

The 4th

NA = not applicable \*SE data are not applicable

survey [47]

was 86.2% in the morning and 34.6% in the evening.

(1994)

home seemed to increase slightly (Table 8).

**Table 7.** Number of children, percentage and mean caries experience of 12-year-olds from four surveys


NA = not available

\* received dental sealant and dental sealant presence at 12 years old
