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John Kois
Introduction
Over the past 15 years, strategies for managing dental caries increasingly have emphasized the concept of risk assessment. It is estimated that 71% of all restorative treatments are performed on previously restored teeth, with recurrent carious lesions as a predominant cause. (Fontana M et al) . This demonstrates that although the carious lesion was repaired, the dental caries disease was not fully treated, because the actual cause and risk factors were not adequately resolved. Current science has determined that the key to dental caries treatment and disease prevention lies with modifying and correcting the complex dental biofilm and transforming oral factors to favor health. (Young DA et all). This can be accomplished through a best-practices approach that decreases caries risk factors, increases caries protective factors and is the basis for caries management by risk assessment (CAMBRA).
Caries Risk Assessment assists in predicting and diagnosing this type of caseShould you replace these restorations or observe them?
In the simplest of descriptions, dental caries disease is a result of these acid-producing bacteria feeding on fermentable carbohydrates and producing acid by-products that are capable of dissolving the carbonated hydroxyapatite mineral of the tooth surface, forming a carious lesion. The caries process is dependent upon the interaction of protective and pathologic factors in saliva and plaque biofilm as well as the balance between the cariogenic and noncariogenic microbial populations that reside in saliva.
Introduction
Introduction
The caries process involves a combination of factors including Diet Susceptible host Microflora that interplay with a variety of social, cultural and behavioural factors.
With the ability to detect caries in its earliest stages ( i.e. white spot lesions), health care providers can help prevent cavitation. Caries risk assessment (CRA) is a critical component of dental caries management and should be considered a standard of care and included as part of the dental examination
continue
It is essential in decision making to guide the clinician in the diagnosis, prognosis and treatment recommendations for the patient
The Caries Balance/Imbalance model was created to represent the multifactorial nature of dental caries disease and to emphasize the balance between pathological and protective factors in the caries process. (Featherstone JD).
If pathological factors outweigh protective factors, the caries disease process progresses. This is a dynamic and delicate balance, tipping either way several times a day. Progression or reversal of caries disease is determined by the imbalance/balance between disease indicators and risk factors on one side and the competing protective factors on the opposite.
Disease Indicators
Caries disease indicators are described as physical signs of the presence of current dental caries disease or past dental caries disease history and activity. These indicators do not speak to what initially caused the disease or how to treat the disease once it is present, but rather serve as strong predictors of dental caries continuing unless therapeutic intervention is implemented.(Young DA et al)
The Caries Imbalance model uses the acronym WREC to describe the following four disease indicators: White spots visible on smooth surfaces Restorations placed in the last three years as a result of caries activity Enamel approximal lesions (confined to enamel only) visible on dental radiographs Cavitation of carious lesions showing radiographic penetration into the dentin
Etiologic factors true risk factors causing the disease (streptoccocus mutans) Non etiologic factors are those that are not thought to cause the disease but may be related to its occurrence (risk indicators)
The CAMBRA philosophy identifies nine risk factors that are outcome measures of the risk for current or future caries disease, and each of these is supported with research (Anusavice K). These are:
MS and LB medium or high Visible plaque on teeth Frequent snack Deep pits and fissures Recreational drug use Inadequate saliva flow Saliva reducing factors(medication/radiation/systemic) Exposed roots Orthodontic appliances
Etiologic factors
microflora e.g Streptoccocus mutans, Diet Host susceptibility
Risk indicators
Socioeconomic factors e.g. income Educational level Psychosocial factors e.g. health attitudes Clinical variables e.g. number of filled teeth, root fragments Past caries experience is the best caries predictor in primary teeth
Caries or therapeutic measures that can be used to prevent or arrest the pathologic challenges posed by the caries risk factors. The higher the severity of the risk factors, the greater the intensity of protective factors must be in order to reverse the caries process.(Young DA et al). These protective factors include a variety of products and interventions that will enhance remineralization and keep the balance between pathology and protection of the patients oral health
Risk Levels
High-Risk Patient
One or more cavitated lesions. May or may not have rough chalky white spots
Low-Risk Patient
TREATMENT GROUP Low Risk LR Moderate Risk Inactive MRI Moderate Risk Active MRA High Risk Active HRA High Risk Active/Active HRA/A High Risk Inactive HRI Very High Risk VHR
Fill
Temp Cr
Seal
#
1st FLV
Xylitol
MI Paste
CC Interval Months
CC FL V
Home Fluoride
6 + 3 6 + + + 6 6 3 + +
+
+
+
+
+
+
1
3
6
6
+
+
+
+
6
6
6
3
+
+
+
+ + + + 3 12 +
+
+ 12
6
3
+
+
TREATMENT GROUP Low Risk LR Moderate Risk Inactive MRI Moderate Risk Active MRA High Risk Active HRA High Risk Active/Active HRA/A High Risk Inactive HRI Very High Risk VHR
Fill
Temp Cr
Seal
#
1st FLV
Xylitol
MI Paste
CC Interval Months
CC FL V
Home Fluoride
6 + 3 6 + + + 6 6 3 + +
+
+
+
+
+
+
1
3
6
6
+
+
+
+
6
6
6
3
+
+
+
+ + + + 3 12 +
+
+ 12
6
3
+
+
RECOMMENDATIONS
Low Risk Bitewing radiographs every 24-36 months (ADA recommendations) Caries recall exams every 6 months to reevaluate caries risk OTC fluoride-containing toothpaste twice daily. After breakfast and at bedtime. Optional: NaF varnish if excessive root exposure or sensitivity
RECOMMENDATIONS
Moderate Risk Bitewing radiographs every 6-18 months (ADA recommendations) Caries recall exams every 6 months to reevaluate caries risk. Saliva test indicated for salivary hypofunction patient. Xylitol gum or candy. Two tabs of gum or two candies four times daily. OTC fluoride-containing toothpaste twice daily. After breakfast and at bedtime. 0.05% NaF rinse daily Optional: Initial visit 1 application of NaF varnish; 1 application at every 6 month recall.
RECOMMENDATIONS
High Risk
Bitewing radiographs every 6-18 months (ADA recommendations) Caries recall exams every 4-6 months to reevaluate caries risk Saliva flow test and bacterial culture initially and at 6-month recall appt. to assess efficacy and patient cooperation. Chlorhexidine gluconate 0.12% 10 ml rinse once per day for week for one minute (Use separated by 1one hour from high fluoride toothpaste use and fluoride rinse); then 3 weeks of 1.1% NaF toothpaste daily instead of regular fluoride toothpaste. Rinse with OTC fluoride daily. Repeat regimen for three months, then retest biofilm bacteria load and saliva. Repeat until these risk indicators are low risk. Xylitol gum or candies. Two tabs of gum or two candies four times daily 1.1% NaF toothpaste daily instead of regular fluoride toothpaste. Initial visit 1 application of NaF varnish; 1 application at every 3-4 month recall.
New Technologies:
Fluoride-releasing sealants for suspect pits with poor access Fuji Triage can be placed quickly and easily, needing very little cooperation.
Due to the fluoride release, it is less likely than traditional sealants to allow decay below if it leaks.
New Technologies:
Digital Radiography
Allows lower dose exposures. Resistance from patients is reduced. Results are instant. Patient Education is enhanced as they can see radiographs enlarged in front of them. Diagnosis may be enhanced. Essential for online communication with specialists. Complete offsite backup is possible. Sensors are larger and placement takes some practice.
New Technologies:
Diagnodent Pen
New Technologies:
Ozone Treatment of pits A promising new technique involves sterilizing the pits and fissures with ozone. This has been shown to stop decay and even allow remineralization This may make cooperation even easier in early intervention
1. Cleaning
3. Treatment
2. Measurement
New Technologies:
DIFOTI (Digital Imaging Fiber-Optic Trans-Illumination)
This device creates high-resolution digital images of occlusal, interproximal and smooth surfaces. It enables dentists to discover or confirm the presence of decay that cannot be seen radiographically, visually or through use of an explorer
New Technologies:
DIFOTI (Digital Imaging Fiber-Optic TransIllumination)
New Technologies:
Air Abrasion
This technology allows early intervention more conservatively than rotary instruments. Pits with stain, decay in enamel and very early dentin decay (DD 5-30) can be treated, almost always without local anaesthetic.
Any restorative prep can be cleaned out with this unit, allowing better bonding.
Air Abrasion is excellent for cleaning any prosthesis that needs bonding in the mouth, from crowns and posts to fixed ortho. You cannot remove amalgams or treat larger lesions. Auxilliary suction is needed.
New Technologies:
Microburs
Low-tech way to access very small pits. , 1/8 and 1/16 round burs are available for high speed handpieces. Can treat some early pits and grooves almost as well as lasers or air abrasion.
New Technologies:
Laser- Water units
This technology is similar in application to Air Abrasion units, but more versatile. Pits with stain, decay in enamel and early dentin decay (DD 5-30) can be treated, almost always without local anaesthetic. Soft tissue can be trimmed as well. There is less chance of injuring soft tissue with overspray. There is no powder spray mess, so auxilliary suction is not needed.
Like Air Abrasion, you cannot remove amalgams or easily treat larger lesions.
These units cost 20-50X more than air abrasion units, and are much larger.
Medium Risk
Observe stained pits, deep pits, early decay in enamel. (DD<20) Restore old restorations with cracks and broken margins, decay in pits with halo or shadow, any decay in dentin. (DD>25-30) Diet Counselling Intro.
High Risk
Initial Protocol Observe stained pits. Restore early decay in enamel and dentin. (DD>15-20) Restore old restorations with cracks and broken margins. Diet Counselling Intro Fluoride- Supplements for children, Prevident 5000 for adults
3 Month Recare Caries Risk Re-Evaluation s. mutans, lactobacillus test Salivary flow measurement Fluoride, OHI
Low Risk
Recall patient every 9 months, consider increasing if remaining low risk. No Topical Fluoride No Fluoride Supplement Take BW radiographs every 3 years OHI As needed Observe pits and fissures with stain or early decay in enamel, very early decay in dentin. (DD<25-30) Polish or seal old restorations with poor margins, and observe Sealants not required
Medium Risk
Recall patient every 6 months Topical Fluoride for children Fluoride Supplement Take BW radiographs every 2 years OHI As needed Observe stained pits, early decay in enamel (DD<15-20) or optionally seal. Restore pits and fissures with early decay, any very early decay in dentin, old restorations with poor margins. (DD>20) Polish or seal old restorations with fair margins, and observe. Sealants are optional
High Risk
Full diet counselling with diary Recall patient every 3 months: Topical Fluoride Fluoride Varnish on prone areas Home Fluoride Trays, Chlorhexidine Rinses -Adult Fluoride Supplements-Child Xylitol Gum Take BW radiographs yearly OHI Evaluate for xerostomia Restore pits with any very early decay in dentin or enamel, (DD>20) old restorations with fair- poor margins. Sealants/Preventve resins- all deep pits and fissures. (DD>5-20) Fluoride-releasing sealants where possible
WHEN IN DOUBT ABOUT THE RISK LEVEL, IT IS BETTER TO BE MORE AGGRESSIVE IN PREVENTIVE THERAPY THAN TO BE LESS AGGRESSIVE.