]1[

A warning : the script is about 26 pages. No worries it's a piece of cake! Enjoy it

Part 1:dental caries- early childhood carries(ECC):

We are going to talk about a specific type of dental caries ,which happened in children which is called early childhood carries (ECC) ,it's a clinical entity and we are going to discuss how this happens ; the biological mechanisms ,the risk factors in children make it happen. So the definitions according to AAPD American academy of pediatric dentistry- define it as the presence of one or more decayed teeth (noncavitated or cavitated lesion), missing teeth (due to carries),or filled tooth surface on any primary tooth in children up to 71 months of age ,which mean less than 6 years.

The severity can be rated any child who is less than 3 years has one surface has sever early child carries. Any child between 3-5 years who has DMF(D or M or F smooth surface) one or more has also sever type. Or DMF more than four in child who is 3 years old. Or DMF is more than 5 in child who is 4 years old. Or DMF more than 6 in childs who is 5 years old.

Terms of ECC:
These are the earlier terms have been used in the past , these are called : labial caries, caries of incisors , rampant caries, nursing bottle caries, nursing caries ,baby bottle tooth decay, maxillary anterior caries ,rampant infant and early childhood dental decay. Nowadays we just use ECC.
]2[

Now what are the characteristics of this type of decay? Decay most often:
1-involves maxillary incisors. 2-usually doesnt affect mandibular incisors. 3-may progress to involve other teeth according to their date of eruption the canines of molar of both arches (of course it affect the max. before the man. because they erupt before) so it will affect the ABDCE, so it depends on the age which detected the teeth which will be affected. **This is an example of early child with carries who has all the ant. teeth are affected ,but the lower are not.

**This is another example of child who has the A and B are affected and then the D are affected, the C and E still not affected, because the A,B,D erupt before the C&E.

]3[

** This is another example of rampant caries or ECC.

Epidemiology:
1- in developed countries like Australia ,America, United kingdom There are increased rates of ECC within native& immigrant groups ( this is a study in Australia) , for example in America the red Indians will be more . In immigrant groups which they people who immigrate to those countries, because of war or because other financial or economic reasons. 2- Increased among disadvantage to those from lower socio-economic status (SES). 3-increased in special needs patients (SPNP).

Now the biological mechanesims just like any caries it requires:

1-cariogenic micro-organisims 2-fermentable carbohydrates 3-susceptible tooth and host 4-over time.

]4[

These are the rings of teeth,(do u remember them??:P These are the 3 cycles of keys , the person that give us this model he said that caries occur when these 3 cycles come together. Nowadays we have a 4th cycle which is a time or we can encircle all of these 3 cycles by big one and say they are happened overtime.

Concepts of dental caries:

The fermentation of carbohydrates by the micro-organisims will produce lactic acid which will demineralize the tooth surface and cause the cavitation.

Caries etiology:
View has been around of caries etiology since MILLER first proposed the chemo-parasitic theory for etiology of caries.

biology is modified by factors which are specific in these young children.

What make it so rampant and so sever in these children?

]5[

1- The implantation of the cariogenic bacteria in the infant are being established, so these micro colonies and bacteria are starting to establish them selves in the mouth of the young child. 2- You suppose to have an immune response ,but in young child the immune response is immature so there is no immune response so these micro-organisms will establish themselves strongly. 3- The behavior pattern will be associated with feeding, the feeding patterns and oral hygiene in early childhood, many people think that children dont need to have their teeth cleaned and many people will keep feeding their children by bottle even they are not hungry just to quiet them , so the children will get exposed to high amount of sugar and the teeth will not cleaned , so this is control its behavior of pattern . 4-Tooth surfaces are newly erupted and you know that newly erupted tooth surfaces are always week , they are still not fully mineralized they are hypo-mature , usually the enamel mineralization is still not complete in these teeth and may show hypoplastic defects, so this will also exacerbate the problem.

**Etiological factors: A)CARIOGENIC MICRO-ORGANISMS:

If we come to the micro-organisms the main bacteria are the mutan streptococci (MS), this is a wide group of bacteria which has many variance especially S.mutan and S.sobrinus they are the main ones that start colonizing. Here study shows that only a small infective dose of M.S are required for implantation and then the colonies will get bigger and bigger over time .

]6[

Now where do we get these micro-organisms??

From the primary carrier (father, mother, siblings, or nanny, but most of the time from mother).

Lactobacilli are highly indicated in dentinal caries y3ne when the cavity reaches the dentine. Actinobacilli- indicated in root carries.
previous studies show that M.S usually are not found in the oral cavity prior to eruption of teeth , this is what we always learn that there are no bacteria in the mouth if there are no teeth because the bacteria need the teeth to colonize on, but the recent studies have shown that they dont need the teeth to colonize the bacteria ,and they found the age at which M.S are first acquired in infant is equal to the susceptibility of caries , so the earlier you get these bacteria you have a higher risk of dental caries .

in a study of 78 month = 4 years children ,they found that 89% of those colonized by bacteria at the age of 2 years had DFT= 5, but the ones who dont colonize at that age (2 years ) has small DFT=0.3 the earlier you get these bacteria you get a higher DFT. In another study the found 50% of pre-term and 60% of full term who are at the age of 6 months old had S.M and these children didnt have teeth they were predentate and have the bacteria, which denies the theory that said that you have to have teeth for the bacteria to colonize. Another study showed that 30% of predentate children at the age of 3 months even younger they were infected by the bacteria and at the age of 6 months they became more, over 60% showed presence of S.M in the mouth.

So they showed that SM will increase with age, so that by the age of 24 months, 84% harbored the bacteria.

]7[

The idea is that you can still get the bacteria when you dont have teeth because they can colonize in the oral mucosa which means that we must start prevention very early even before arrival of the child just to make this mother aware, in the developed countries the nurse visits the pregnant mother during pregnancy and even after delivery of the baby for a while until this mother is able to take care of her baby, among the things that get educated about dental caries.

Virulence of MS:
This bacteria in particular so special because it's highly indicated with dental caries in human. 1- It's able to synthesis Alpha-1-3 rich; water-insoluble glucans, they synthesis them from sucrose and these will mediate irreversible adhesion & colonization of MS to teeth, they are very sticky increase thickness of plaque , which result in enhanced rates of sugar diffusion & acid production at deep plaque layers. 2- S.mutans will also synthesize intracellular polysaccharide , this intracellular polysaccharide is like keeping sugar for the day / night when there is no sugar, its like when you stuck on some chocolate and keep them in your jaws, they hide this kind of sugar for the night when you are not having any sugar and they start synthesizing it produce energy. this activity maintains acidogenecity and tooth demineralization during periods of low salivary secretion specially during sleep. so what the problem during sleep? they have their sugar ( ) , and we dont have any protector factor specially with low salivary rate, the teeth are dry even we brush our teeth they will keep synthesizing the acids and demineralizing the teeth thats why brushing teeth before sleep is very important, and the other one which is during the day after breakfast, but before sleep is mandatory!!.

]8[

3- They produce large amount of acid; they are very able to produce lactic acid and cause teeth demineralization. 4- Aciduricity- is the term to indicate acid tolerance in very highly acidic environment (low PH), which allowing colonization & persistence under cariogenic conditions. 5- Production of dextranase ; its a type of enzyme which allows invasion of MS to replace early colonizing, because at the beginning when plaque forms we will have bacteria like :S.mitis & S.sanguris they come and take place by dextranase.

B)FERMENTABLE CARBOHYDRATES: 1- Substrate:

1) Sweetened solid foods: so you give them sucrose main sugar-, fructose & glucose and they are cariogenic as sucrose. Also we give them rise and bread (raw starch), this will causes small drop plaque PH, but all the time the teeth are not cleaned they can still cause caries.

2)Bottle content; it can be human or bovine milk or formula or juice. So milk is not cariogenic because it contain casein its main component involved in reducing demineralization and increasing remineralization , but if u add sugar to the milk it will be cariogenic. If you compare between human milk to bovine milk you will find that human milk contain sugar 7% which is more than bovine milk= 4%. But why did it have this amount of sugar? Because the child need energy at this young age. Milk formulas = cariogenic potential to sucrose because it contain sugar. And the acid drinks in addition to sugar they decrease PH and cause erosion.

]9[

2- Frequency of consumption: this is our main problem, the children are being given the bottle or the breast all the time just to quiet them even if the child is not hungry they given the milk which increases their sugar exposure. 3- Oral clearance of carbohydrates: children are highly give the bottle especially at night because the parents want to sleep and the child will enjoy it :D even they are not hungry , so this will increase sugar exposure.

C)Susceptible tooth and host:

when the tooth is susceptible y3ne immature because it has been demineralized enough,also you have other factors that make the teeth weaker such as :

1)Medical conditions they will cause enamel hypoplasia. So Enamel hypoplasia with sweetened medication, sweet fluids, sweet milk & xerostomic side effect of medication, it will all cause ECC.

2)Malnutrition- will lead to alternations of salivary conditions & volume which will lead to enamel defects enamel hypoplasia. This is a pt. with sickle cell anemia, she has to take antibiotics in a form of syrup( very sweetened), she had to take it every day of her life to avoid sickle cell crisis, because if she get an infection this will lead to crisis. So the sweetened antibiotic along with sweetened food intake and with enamel hypoplasia because of her condition increase risk of dental caries.

]11[

So the risk factors:

1. Medical history 2. Feeding habits 3. SES and ethnicity 4. Family variables such as: single parent , young mom <25 years & 4th or higher children will have higher ECC because of mother careless . 5. Dental health awareness the start of tooth brushing (usually delayed by parents). 6. Behavioral risk factors especially children who have sleep problems will suffer more.

Clinical management of ECC:

One the problems that we face, we have young child with so many dental cavites: pulp therapy, crowns, restorations and we usually have limited tooth structure because all of them are carious and sometimes we end up with extracting the teeth.

1-Behavior management:
As a result of behavior management we usually treat young children under general anesthesia because they are young and cannot cope with dental treatment, sedation is ok but usually doesnt work with these young children, and LA usually not practical due to poor behavior and many dental restoration required.

2- Restorative aspects-how do I choose restoration, it depend on:

-level of caries , amount of tooth destruction , pulp involvement , OH and sugar consumption , behavior of child , parental attitudes toward dental visits and reviews , availability of third party paying for costs , longevity of tooth.
]11[

-So for the posterior teeth we usually prefer SSCs as 1st option , 2nd option is amalgam,composite , GIC, RMGI. -For anterior teeth: composite, GIC &RMGI. -For multiple surface caries we use strip crowns & sometimes we extract. -Atraumatic restorative technique (ART)-removal of carious lesions by hand instruments followed by restoring cavities with F-releasing restorative material.

Here we have an example of a case have ECC , he was 3.5 years when he first attended to the clinic, typical ECC ; caries on anterior teeth then D then C then E. Here is post-operative treatment, Upper: the Dr. extracted the ant. teeth and this is a prosthesis- its like a parietal denture!! and did pulpotomy for the E also artificial teeth for Ds. In the Lower : the Ds pulptherapy and PRR for the Es, so this is a typical case that we do it in one and a half hour under GA.

Prevention of ECC:
We have to think about caries balance , we have to look at protective factors and make them more, the other factors such as bacteria , salivary flow when its abnormal , frequent eating and drinking of sugar. The protective factors is when you increase the salivary flow and its components like by: chewing gum, or by floride remineralize the tooth and make them stronger or by xylitol , or tooth brushing will kill the bacteria all of these in order to reach the no caries status.

]12[

So 3 approaches that have been used to prevent caries:

1) Community based :educating mothers about dietary habits & OH role in ECC, eg; substitute water for cariogenic liquid in bottle and fluoridating the water supply (the most effective way and can reach every one) will decrease caries by (40-60%). 2) Provision of examination & preventive care in dental clinics: regular dental visits and the use of F professional therapy. 3)The development of appropriate dietary and self habits at home : OHI , use of self applied F at home , chlorohixidine gel\varnish and xylitol chewing gum .

Now we finished the 1st part .

]13[

PART 2 :
I'm sorry there won't be slides for this part!! Before the dr. started this part she said that she will not go into details y3ne for the exams we have to study what mentioned in the lecture. Then started viewing pics and reading some topics. also said that every thing has been covered and dont have to explain farther o_o! We can study it from the internet!! But I relied on 2007's script to make it more clear.

DEVELPOMENTAL DENTAL ANOMALIES : so you have to know:

-Abnormalities in teeth number. -Abnormalities in teeth shape. -Abnormalities in teeth size. -Abnormalities in tooth structure (structural defects in enamel, dentine and bone). - Abnormalities in teeth eruption. Hypodontia Hypodontia is considered as developmental anomaly in teeth number and it means a reduction in teeth number. There are many terminologies used in relation to hypodontia so we can say hypodontia if there are less than 6 teeth missing , but if there are 6 teeth or more missing we call this condition oligodontia while if all the teeth are missing we say Anodontia.

]14[

- Hypodontia: less than 6 teeth missing. - Oligodontia: 6 teeth missing or more. - Anodontia: all the teeth are missing. # Incidence of hypodontia - Primary teeth: 0.1 0.7 % - Permanent teeth: 2 9 % Teeth that are commonly involved with hypodontia are 3rd molars, maxillary lateral incisors, 2nd premolars and mandibular central incisors. Of course if you look to different studies, you will find different percentages regarding teeth with hypodontia

- You have to know the syndromes associated with hypodontia like: 1. Ectodermal dysplasia 2. Gardner syndrome 3. Down syndrome 4. cleft lip and palate 5. facial-cranial dysostosis (pt with this syndrome has a hole covering all the face!!!)

Supernumerary teeth. We have classification of supernumerary teeth according to site so they classified as: _ Mesiodense the one that happens in the middle. _ Paramolar the one that happens next to a molar. _ Distomolar the one that happens at the distal side of a molar.
]15[

Supernumerary teeth are also classified according to the shape into: * Conical: happens in the anterior region * Tuberculate (barrel shaped): usually happens in the posterior region but it still can be happened anteriorly, tuberculate means many cusps. *supplemental (look like adjacent tooth). * inverted conical: it is the same as conical but it is inverted upside down and starts erupting at the floor of the nose and it has to be removed surgically. - Incidence of supernumerary teeth - Primary teeth: 0.3 0.8 % - Permanent teeth: 1 3.5 % It happens in 90% of the cases in the maxilla and 75% of them are mesiodense. Supernumerary teeth are associated with a syndrome called clediocranial dysplasia. This is a very common presentation of supernumerary teeth so the pt. comes complaining from one permanent central incisor has erupted and the other central incisor next to it has not erupted and he will find that the one that has erupted is completely or fully erupted or sometimes two thirds of it has been erupted while the one next to it has no sign of eruption ( this scenario is very common) so you should suspect a supernumerary tooth in this case ,because it could be one of the reasons but of course not all the time.

Sometimes you will even have a primary tooth is still present so when you take an x-ray, you will find that there is a tooth impeding the eruption of the permanent central incisor. This is another presentation; here the supernumerary tooth is
]16[

actually erupted. The central incisor had erupted and this supernumerary tooth is called mesiodense according to the location and it is conical according to the shape.

This is clediocranial dysplasia with multiple supernumerary teeth, depressed nasal bridge and the clavicles are either absent or having dysplasia (very small in size). Odontomes 1. Complex odontome 2. Compound odontome
Dentigerous cyst A dentigerous cyst or follicular cyst is an odontogenic cyst - thought to be of developmental origin - associated with the crown of an unerupted (or partially erupted) tooth. The cyst cavity is lined by epithelial cells derived from the reduced enamel epithelium of the tooth forming organ. Regarding its pathogenesis, it has been suggested that the pressure exerted by an erupting tooth on the follicle may obstruct venous flow inducing accumulation of exudate between the reduced enamel epithelium and the tooth crown. In addition to the developmental origin, some authors have suggested that periapical inflammation of non-vital deciduous teeth in proximity to the follicles of unerupted permanent successors may be a factor for triggering this type of cyst formation. (wiki)

Macrodontia: It is rarely affect the whole dentition unless there is something systemic like gigantism which results from increase in the production of the growth hormone before puberty. Usually we get single tooth which is macrodontic and it is usually due to a local cause which can't be identified in most cases, in some cases, they say that there is an increase in arterial
]17[

blood supply to that area or sometimes neural blood supply but actually we are not sure why it happens.

Microdontia: The teeth are smaller than usual. - True microdontia: all the teeth are small and it is usually rare and hormonal condition (hormonal microdontia is the opposite of gigantism) a result from reduction in growth hormone and it is usually relative. (Relative means in relation to the jaws, the jaws are big while the teeth are small leads to relative microdontia) An example of microdontia is peg-shaped lateral incisor.

Fusion and gemination Double tooth or sometimes called con-joined teeth because it is usually hard to differentiate between fusion and gemination and also in some cases it could be a supernumerary tooth so we dont usually attempt to differentiate between them so we say double tooth or con joined teeth. - This is an example of a pt attended to my clinic and he had a gemination or fusion or con-joined teeth on this side and after we did a big study on this case (space analysis, study models, orthodontic consultation and several x-rays), we found that the best is to extract the tooth and place a RPD at this stage and aim for a future implant. - This is the extracted tooth and here we put an appliance to act as space maintainer to keep this space open for the eruption of the impacted canine on this side while on the other side we notice that the canine was erupted because of enough space.

]18[

Dense invaginatus _looks like tooth within a tooth _We should protect them by fissure sealant or composite as soon as possible after eruption.

Dense evaginatus. Talon cusp: - Excessive cusp on the palatal surface that we have to keep on reducing it many times. Taurodontism:
is a condition found in the molar teeth of humans whereby the body of the tooth and pulp chamber is enlarged vertically at the expense of the roots. As a result, the floor of the pulp and the furcation of the tooth is moved apically down the root. The underlying mechanism of taurodontism is the failure or late invagination of Hertwig's epithelial root sheath, which is responsible for root formation and shaping causing an apical shift of the root furcation. The constriction at the amelocemental junction is usually reduced or absent. Taurodontism is most commonly found in permanent dentition although the term is traditionally applied to molar teeth. In some cases taurodontism seems to follow an autosomal dominant type of inheritance. Taurodontism is found in association with amelogenesis imperfecta, ectodermal dysplasia and tricho-dento-osseous syndrome. The term means "bull like" teeth derived from similarity of these teeth to those of ungulate or cud-chewing animals (wiki)

]19[

Enlarged pulp chambers: - There are some conditions where the pulp chamber is very large in size (larger than normal) at the expense of dentine as in: 1. Vitamin D resistant rickets 2. Vitamin D dependant rickets 3. Hypophasphtasia 4. Dentinogenesis imperfecta 5. Regional odontodysplasia In particular, all these conditions are related to dentine (they are dentine defects) - This is an example of enlarged pulp chamber with relation to enamel and dentine, this pt had Vitamin D resistant rickets therefore he had enlarged pulp chamber affecting all the teeth but if it is only in one tooth then you should have something local while in this case it is something systemic.

Developmental defects of enamel: - We talked a lot about them. Extrinsic staining: it is a condition caused by chromogenic bacteria . enamel hypoplasia and opacities.

amelogenesis imperfecta (AI), dentinogenesis imperfecta (DI) - I just want from you to review these conditions because these are the conditions that we usually diagnose at childhood in pediatric dentistry. - This is DI, we can easily diagnose it because it is usually associated with obliterated pulp chamber and bulbous crowns.
]21[

- Most cases of DI are associated with obliterated pulp chamber (The most significant feature).

Pre-eruptive intracoronal resorption of dentine (PEICR) - It's caries that happens pre-eruptively (before the tooth erupts) - This tooth has not erupted yet but we have here radiolucency in the crown because this tooth inside the follicle had a defect in the enamel then became invaded by macrophages, osteoclasts and odontoclasts that invaded enamel and dentine caused cavitation in it. Now this is happening inside the dental follicle but once the tooth erupts, this cavity becomes colonized with bacteria so it looks like dental caries but actually it started pre-eruptively - Some types of occult caries is like PEICR but not all the types because some types of occult caries occur post-eruptively by invasion of M.O to tooth structure through the deep fissures on the occlusal surface. - This is an example of a pt who is 9 years old female, she complained of pain in 36 , which looks normal and healthy but when we took x-ray, we found an abscess appears in the periapical radiograph of that tooth (36) therefore this tooth has Pre-eruptive intracoronal radiolucency which means that this cavitation started pre eruptively while the tooth was forming.

At pre-eruptive stage we never get an abscess because there is no bacteria in the follicle but when the bacteria colonized the tooth post-eruptively we will get this abscess so finally we had to do RCT for this tooth!!

]21[

Eruption hematoma (eruption cyst) Sometimes it will be very big like an abscess and it appears blue in color so the parents will be scared and they came panic to the clinic but it is actually an eruption hematoma or eruption cyst.

Ankylosis - This tooth here is ankylosed and it happens a lot in primary teeth especially lower Es and Ds. Erosion - An example on erosion is the effect of gastroesophegael reflex (GER). Reference: Chapter 7, A Handbook of pediatric dentistry by Cameron & widmer. Or u can Google it ..!

]22[

Part 3:
I'm sorry There won't be slides for this part and its included for the final exam

Chemotheraputic agents
Chlorohexidene : it's actually a salt, it's concentration = 0.2% or 0.12% . Its positively charged molecule, so it means that it can bind to anything negative, like what? Bacterial cell wall. It's also bactericidal, at high concentration it cause coagulation of the cytoplasmic material of the bacteria and then cause cell death. How do we prescribe it? 0.2% CHX 10ml for 1 min. Or 12%CHX 15 ml for 1 min.(most commonly in Jordan). There is a type of CHX, its gel this is what we use for children , it doesn't contain alcohol because it can irritate the mucosa, so they put it in their tooth brush with no irritation and excellent compliance. We can use it also before we put composite filling with children whose high risk carries like ECC. It can be in a form of tube we call it periogard. There's another type used called chloroflour which is a combination of CHX and fluoride gel in one tube .

*Advantages : 1) Bactericidal 2) Reduce discomfort of mouth ulcers 3) Excellent compliance

]23[

4) Low cost But it can cause some staining.

*Characteristics:
The ability to adsorb to anionic substances, ex; hydroxyapatite ,pellicle ,salivary glycoproteins, mucous membranes and polysaccharide coats of bacteria, all these are negatively charged. It's also slow release all the time: which means when it adsorb to these surfaces it cause slow release we call it substantivity . And this give 80% reduction in plaque when used as adjunct in oral hygiene.

*The documented uses of CHX :

1) Plaque control 2) Physically and mentally handicapped pts. 3) High risk caries pts. 4) Pts with removable and fixed ortho appliances 5) In periodontal or gingival cases ,before we use CHX we should do scaling and polishing to be effective.

*Actions:
As we said bactericidal, anti-plaque, but it's not effective against the lacto bacilli, it works against the Strep. Mutans.

*Side effect:
1) Staining 2) Dulling of taste 3) Increase calculus formation 4) Desquamation of the epithelium because it contains alcohol.

Now we will move to xylitol:

Its a non-cariogenic sugar sweetener; it means its a sugar but cannot cause caries, it's produced from xylan-beech wood. Chemically ; its a pentitol which is a 5 carbon ring, it differs from the sucrose which is 6 carbon ring.
]24[

Characteristic of xylitol evidnce based:

1)Not cariogenic
2)Chewing gum is anti cariogenic ; they found that 93% of children who chew Xylitol gum got a caries reduction. Chewing process stimulate salivary flow and washes away the bacteria and the plaque. Also it inhibit mother-child transmission of bacteria, so if a pregnant mother or a mother that has a baby will reduce bacterial count in her mouth which means it will reduce the transmission to the child. 3) The explanation for this is that maternal use of xylitol had effected children's probability of being colonized by S.mutans. 4) Its considered more effective in caries reduction than sorbitol and sucrose. 5) Xylitol maybe used in preventive program to reduce caries.

Xylitol disadvantages :
The biggest dis. of Xylitol is diarrhea if eaten in large amount, which is 20 gr per day.(threshold levels would be lower for children. Another side effects: hypoglycemia if taken in high amount ,osmotic diarrhea, hyperic-acidic levels in blood which can cause kidney stones , allergies to xylitol which is rare cases. The recommended amount is 6-8 gr per day for dental benefit.

]25[

*proposed actions of xylitol:

-Plaque: non-fermentable by MO, reduces plaque quantity, Strep.mutans reduced, and strains with reduced virulence, participate in futile metabolic cycle. reduce adhesion of plaque flora, and also reduce transmission of bacteria from mother to her baby. -On saliva: it changes the quality and the quantity of it. - On enamel: aid in remineralization.

Finally CPP:
CCP ACB = casein phosphopeptide amorphous calcium phosphate , derived from casein part of the protein found in cow's milk, they found that its caries resistance it can be used in caries prevention program ; it increases the level of calcium and phosphate in saliva and concentrate them in ionic form and can adsorb to tooth structure and cause remineralization. The Dr. started showing pic for CPP that present in chewing gum its name is recaldents (43:41) will combine with fluoride so will be synergistic effect, so its good to combine fluoride. And this is tooth mousse and its exactly like yogurt it comes in different flavors (strawberry, vanilla ..) it's used in the teeth like topical cream or you can use it in a tooth brush. There are two types of it, the first type doesnt contain fluoride then they developed a new type which is called MI phase which contain fluoride. So the idea is that it will provide the teeth with calcium and phosphate in its ionic form to get adsorbed to tooth surface, it works: anti caries, remineralization , for erosion , hyper sensitivity , and it has been included to GIC restorative material.
]26[

Its only contraindicated in pts. who have allergy to milk should avoid product contain recaldent, and this allergy comes from casein and protein found in CCP. And can be used for any age. If you want to read about it more there is an article u can Google it or send me an email (me-Dr. for sure not me :P)

Immunization:
The idea of immunization y3ne we make vaccine for dental caries! Its a dream that didnt come true cause it make a problem regarding: safety, effectiveness, specifity, acceptability.

That's all Finally it's done.. And no it wasn't fun. Thank you folks Good luck & I'm sorry for any mistake.

Hadeel Khutaba

]27[