Dental Caries Management by Risk

AssessmentDr. Hakan Çolak

DDS, PhD

Ishik University School of Dentistry

Department of Restorative Dentistry

Introduction

• Risk assessment is an estimation of the likelihood that an event will occur in the future.

• For more than two decades, medical science has recommended that physicians identify and treat patients based on their risk status, rather than treating all patients as if they were the same.

CAMBRA

• Caries risk assessment is the first step in Caries Management by Risk Assessment

• an evidence-based disease management protocol.

CAMBRA

caries disease indicators

risk factors

protective factors

The level of caries risk

LowModer

ateHigh

Extreme

The clinician first assesses

CAMBRAthe level of caries risk

an evidence-based care plan is developed

Behavioral procedures

Chemical procedures

minimally invasive preventive procedures

therapeutic procedures

manage the individual’s

dental caries disease

Dental Caries: a Continuing Health issue

• Dental caries is a transmissible bacterial infection that is pre-ventable and in some cases even reversible.

• Dental decay, however, remains the single most common disease of child-hood that is not self-limiting or amenable to a course of antibiotics.

Review of Dental Caries Process

• Demineralization

• Dental caries is caused by mutans streptococci (a group that includes the Streptococcus mutans and Streptococcus sobrinus species) and lactobacilli that live in the plaque biofilm that attach to teeth

Review of Dental Caries Process

CariogenicBacteria• S. mutans• S. sobrinus• Lactobacilli

FermentableCarbohydrates• Sucrose• Glucose• Fructose• Cooked

starch

Organic AcidsWhich

penetrateenamel

anddentin

Dissolve tooth

mineral

Demineralization:step1.

Review of Dental Caries Process

Dental Mineral

Acid soluble

Carbonated

hydroxyapatite

Organic Acid

s

Demineralization*Calcium

and phosphatedissolve

out of thetooth into solution

Demineralization:step2.

Remineralization

• After the ingestion of fermentable carbohydrates stops, the pH gradually returns to neutral in 30 to 60 minutes provided there is adequate saliva.

• Saliva plays a key role in that it neutralizes acids and provides minerals and proteins that protect the teeth

Remineralization

Saliva’s Beneficial Actions

Providescalciumandphosphateforremineralization • Carriestopicalfluoridearoundthemouthforremineralization • Neutralizesorganicacidsproducedinplaquebiofilm • Discouragesthegrowthofbacteria,inhibitinginfection • Recyclesingestedfluorideintothemouth • Protectshardandsofttissuesfromdrying • Facilitateschewingandswallowing • Speedsoralclearanceoffood

FromEakleSW,FeatherstoneJDB:Caries risk instruction[course handout],SanFrancisco, 2002,UniversityofCaliforniaSchoolofDentistry

Remineralization

Calcium intooth water

(from saliva)

Phosphate in

tooth water(from saliva)

Remineralization

Builds on existing

crystal remnantsNew mineral is

lesssoluble

Fluoride speeds up

remineralization

The white spot lesion

• Demineralization results in the greatest loss of calcium and phosphate minerals in the subsurface zone of the enamel and the formation of a white spot lesion.

• The enamel surface of the white spot typically remains intact• The demineralized area appears white owing to the loss of

mineral in the subsurface zone of the enamel (see Figure 16-4).

• By comparison, the enamel surrounding the white spot appears sound and translucent.

The white spot lesion

• The white spot lesion is a signal to intervene to avoid the development of a frank carious lesion.

• It is not a signal to do surgery

The Caries Balance

Pathologic Factors Protective Factors

Antibacterials: chlorhexidine, xylitol, new?

Fluoride: remineralization

Protective Factors

Subnormal salivary flow and function

Frequent eating/drinking of fermentable carbohydrates

Acid-producing bacteria

The Caries Balance. (Redrawn from Feather-stoneJDB:Thecariesbalance:contributingfactorsandearlydetection,J Calif Dent Assoc31:129,2003)

Dental Caries risk assessment for Clients age 6 through adult

• A group of experts from across the United States convened at a consensus conference in 2002 produced a caries risk assessment procedure and form for 6-year-olds through adults that was subsequently validated in a large cohort study.

Disease Indicators

Protective Factors

White spots

Restorations <2 yr

Enamel lesions

Cavities/dentin

Antibacterials

Fluoride

Saliva

• Acidogenic bacteria

• Frequent carbohydrates

• Subnormal saliva

Cariesimbalance.(RedrawnfromFeatherstoneJDB,Domejean-OrliaquetS,JensonL,etal:Cariesassessmentinpracticeforage6throughadult,J Calif Dent Assoc35:705,2007.)

Dental Caries risk assessment for Clients age 6 through adult

• The goal of caries risk assessment for clients 6 years old or older is to assign a client to a caries risk level for development of future caries as the first step in managing the disease pro-cess.

Caries Disease indicators

Four Caries Disease Indicators for Caries Risk Assessment

• Teethwithfrankcavitationsorlesionsthatradio-graphicallyshowpenetrationintodentin• Approximalradiographiclesionsconfinedtotheenamelonly• Visualwhitespotsonsmoothsurfaces• Anyrestorationsplacedinthelast3years

Presence of any one of these four indicators automatically places the client at high caries risk unless therapeutic interventions are already in place and disease progress has been arrested.

The presence of any one of these caries disease indicators in the presence of inadequate salivary flow automatically indicates extreme cares risk

Caries risk factors

• Caries risk factors are biologic factors that contribute to the level of risk for developing new carious lesions in the future or having the existing lesions progress.

• Risk factors are things clinicians can do something about.

Caries risk factors

• These nine pathologic risk factors are as follows:• Medium or high mutans streptococci and lactobacilli counts• Visible heavy plaque biofilm on teeth• Frequent (>3 times daily) snacking between meals• Deep pits and fissures• Recreational drug use• Inadequate salivary flow by observation or measurement• Saliva-reducing factors (medication, radiation, systemic condition)• Exposed roots• Orthodontic appliances

Caries risk factors

• These risk factors also help us to understand why the person may have an ongoing caries problem.

• f there are no If there are no clinical signs of caries disease indicators, the caries risk status (low, moderate, high, or extreme) is determined by the balance between the pathologic factors and protective factors described in the following section

Caries Protective factors

• Caries protective factors are biologic or therapeutic factors that can collectively offset the challenge presented by the caries risk factors.

Caries Protective factors

• Lives, works, attends school in a fluoridated community

• Uses fluoride toothpaste at least once daily

• Uses fluoride toothpaste at least two times daily (implies an additional benefit over and above once a day or less).

• Uses fluoride mouth rinse (0.05% NaF) daily

• Uses 5000 ppm fluoride toothpaste daily

• Had fluoride varnish applied in the last 6 months

• Had an office fluoride topical application in the last 6 months

Caries Protective factors

• Used prescribed chlorhexidine daily for 1 week in each of the last 6 month

• Used xylitol gum or lozenges four to five times daily in the last 6 months

• Used calcium and phosphate supplement paste during the last 6 months

• Has adequate salivary flow (>1 mL/min stimulated)

Use of the Caries risk assessment form

Use of the caries risk assessment form

STEP 1 Basedondataobtainedfromthehealthhistoriesandclinicalexamination,circletheYescategoriesinthethreecolumnsontheform

STEP 2 Makenotationsregardingthenumberofcariouslesionspresent,theoralhygienestatus,thebrandoffluoridesused,thetypeofsnackseaten,andthenamesofmedicationsordrugscausingdrymouth.

STEP 3 IftheanswerisYestoanyoneofthefourdiseaseindicatorsinthefirstcolumn,thentakeabacterialcultureusingtheCariesRiskTest(seeProcedure16-2)(Vivadent,Amherst,NewYork)oranequivalenttest.

STEP 4 Makeanoveralljudgmentastowhethertheclientisatlow,moderate,high,orextremeriskdependingonthebalancebetweenthediseaseindicatorsorriskfactorsandtheprotectivefactorsusingthecariesbalanceconcept.

(Clientswhohaveacurrentcarieslesionorhadoneintherecentpastareathighriskforfuturecaries.Clientswhoareathighriskandhaveseveresalivaryglandhypofunctionorspecialneedsareatextremeriskandrequireveryintensivetherapy.Iftheclientisnotathighorlowrisk,thenheorshebydefaultisatmoderaterisk.)

Criteria for High Caries Risk: Ages 6 Years and Older to Adult

Oneormorediseaseindicators: • Cavities • Radiographiclesionstodentin • Recentrestorations • Whitespotsand/or • Multipleriskfactors: • Heavyplaqueonteeth • Frequent(greaterthanthreetimesperday)between-mealsnacksofsugarsorcookedstarch • Appliancespresent(e.g.,orthodonticbrackets)coupled with • Littleornoprotectivefactors

Criteria for Extreme Caries Risk: Ages 6 Years and Older to Adult

Sameashighcariesriskbutwithsaliva-reducing factors,includingthefollowing: • Medications • Radiationtotheheadandneck • Systemicreasons(e.g.Sjögren’ssyndrome)

Moderate Caries Risk: Ages 6 Years and Older to Adult

Ifyoucannotdecidewhetheraclientisathighcariesriskorlowcariesrisk,thentheclientshouldbeconsideredtobeatmoderatecariesrisk.

Salivary flow rate test

• If visually inadequate salivary flow is noticed, or if the client reports having a dry mouth, then a salivary flow rate test should be conducted

• Saliva neutralizes acids and provides minerals and proteins that protect the teeth from dental caries. Therefore it is essential for controlling dental caries.

Caries Bacteria testing

• If any one of the four disease indicators in the first column of the caries risk assessment form is present, then a bacterial culture should be taken.

Caries Bacteria testing

• This test allows a bacterial culture to be made from collected saliva and is sensitive enough to provide a level of low, medium, or high cariogenic bacterial challenge.

• The level of bacterial challenge is recorded in the client’s record as low, medium, or high.

• The client is informed of the results and their implications for car-ies risk and caries management.

Caries Bacteria testing

Dental Caries risk assessment for CHilDren 0 to 5 Years of age

• Early childhood caries (ECC) is an infectious disease that af-fects children from birth to 2 years of age and rapidly destroys newly erupted teeth. Initially ECC appears as bands of demin-eralized areas usually first seen on the primary maxillary incisors.

Dental Caries risk assessment for CHilDren 0 to 5 Years of age

• Etiology of ECC• cariogenic bacteria • diet high in fermentable carbohydrates. • Mothers, caregivers, siblings, and other children transmit mutans

streptococci • frequent or prolonged feedings with bottled milk, formula, human

breast milk, fruit juice, or sugared drinks are highly cariogenic.

Factors for High Caries Risk for Ages 0 to 5 Years

• Motherorprimarycaregiverwithactivedentaldecayinthelast12months

• Sleepswithbottleornursesonad libbasis

• Bottlecontainsfluidsotherthanmilkorwater

• Visiblecavities,whitespots,orobviousdecalcification

• Recentdentalrestorations(<2years)

• Bleedinggumsorheavyplaqueonteeth

• Frequent(morethanthreetimes)between-mealsnacksofsugarsorcookedstarch

• Appliancespresent(e.g.,spacemaintainers,obturators)

• Visuallyinadequatesalivaryflow

• Presenceofsaliva-reducingfactors,asfollows:Medications,suchasforasthmaorhyperactivity Medicalreasons(cancertreatment)orgeneticpredisposition

Protective Factors for Ages 0 to 5 Years

• Residenceinacommunitywithfluoridatedwater

• Motherorcaregiverwhocleanschild’steethtwiceadaywithfluoridetoothpaste(smallamount)

• Dentalexaminationforchildcombinedwithoralhygieneinstructionforparentorcaregiver

• Visiblyadequatesalivaryflow

• Motherorcaregiverwhousesxylitolgumormintsfourtofivetimesdaily

• Motherorcaregiverwhohasnocariesactivity

The protocol for a comprehensive CAMBRA 0-to-5-years

• Completion of the caries risk assessment form

• Parent interview

• Examination of the child

• Assignment of caries risk level

• Individualized treatment based on risk level

• If indicated, bacterial culture on parent or caregiver and child

• Sharing of bacterial results with parent or caregiver as the basis for treatment recommendations and to enhance motivation

The protocol for a comprehensive CAMBRA 0-to-5-years (con’t)

• Individualized homecare recommendations

• Motivational interview of parent or caregiver for caries control

• Setting of self-management goals with parent and child

• Anticipatory guidance according to a specific age category

• Determination of the interval for periodic oral examination

• Collaboration with other healthcare professionals

Parent /Caregiver Recommendations for Caries Prevention: Ages 0 to 5 Years

• Daily Oral Hygiene• Smallamountoffluoride-

containingtoothpastebyclothorbrushtwicedaily• Selectivedailyflossing

• Diet• Eliminationofbottleswithsugaredfluidsorjuices• Limitedbetween-mealsnacks,limitedsodas;substitutionofnon–caries-

causingsnacks

Parent /Caregiver Recommendations for Caries Prevention: Ages 0 to 5 Years

• Sugar-Free Gum• Forparentorcaregiverofhigh-riskinfant,useofxylitol-

containinggumfourtofivetimesdaily

• Antibacterial Rinse•

Forparentorcaregiver,useofchlorhexidinegluconate(0.12%)oncedailyfor2weeksevery2to3monthsanduseoffluoriderinse(0.05%NaF)dailyininterveningweeks

Caries management

• Caries management is aimed at restoring and maintaining a balance between protective factors and pathologic factors

Caries management

• Caries management involves the following:• Suppressing bacteria that cause the infection• Remineralizing early noncavitated carious lesions by enhancing

salivary flow, using fluorides, and possibly using calcium and phosphate paste products, especially if the client is at extreme caries risk (e.g., low salivary flow

• Protecting tooth surfaces by using sealants and fluorides• Decreasing the frequency of sugar intake• Surgically removing carious lesions that are beyond hope of

remineralization and restoring the teeth with minimally invasive techniques and materials

Caries management

• Decreasing pathologic factors involves strategies such as • client education, • oral hygiene instruction, • reduction of the intake of fermentable carbohydrates,• addition of the use of chlorhexidine rinse and/or xylitol gum.

Caries management

• Guiding Principles for Caries Management for High-Risk Individuals

• Placing restorations does not reduce the bacterial challenge.• Fluoride use should be increased for remineralization.• Bacterial challenge can be reduced through antibacterial therapy.• Pathologic factors should be balanced with protective factors.

Caries management

• Evidence-Based Therapy for High–Caries-Risk Individuals• Fluoridetoothpasteatleasttwotimesdaily• Increaseoffluorideto5000ppmtoothpasteforage6yearsthroughadult• Fluoridevarnishtwoorthreetimesann• Xylitolformothersandcaregiversof0-to5-year-olds• Chlorhexidine(oncedaily1weekeachmonth)andxylitolforage6yearsthr

oughadultually

CamBra Clinical guidelines for Patients age 6 Years and older

Risk Level*

Frequency of Radiographs

Frequency of Caries Recall Examinations

Saliva Test (Saliva Flow and Bacterial Culture)

Antibacterials, Chlorhexidine, Xylitol

Fluoride pH Control

Calcium Phosphate Topical Supplements

Sealants (Resin-Based or Glass Ionomer

Lowrisk Bitewingradio-graphsevery24-36months

Every6-12monthstoreevaluatecariesrisk

Maybedoneasabaselinereferencefornewpatients

Persalivatestifdone

OTCfluoride-containingtoothpastetwicedaily,afterbreakfastandatbedtime

OptionalNaFvarnishifexcessiverootexposureorsensitivity

Notrequired

Notrequired Optionalforexcesiverootexposureorsensitivity

OptionalorasperICDASsealantpro-tocol

Moderaterisk

Bitewingradiographsevery18-24months

Every4-6monthstoreevaluatecariesrisk

Maybedoneasabaselinereferencefornewpatientsorifthereissuspicionofhighbacterial challengeandtoassessefficacyandpatientcooperation

PersalivatestifdoneXylitol(6-10g/day)gumorcandies;twotabsofgumortwocandiesfourtofivetimesdaily

OTCfluoride-containingtoothpastetwicedailyplus0.05%NaFrinsedailyInitially,oneortwoapplicationsofNaFvarnish;oneapplicationat4-to6-monthrecal

Notrequired

Notrequired Optionalforexcessiverootexposureorsensitivity

Asper ICDAS sealant protocol

Risk Level* Frequency of Radiographs

Frequency of Caries Recall Examinations

Saliva Test (Saliva Flow and Bacterial Culture)

Antibacterials, Chlorhexidine, Xylitol

Fluoride pH Contro Calcium Phosphate Topical Supplements

Sealants (Resin-Based or Glass Ionomer

Highrisk Bitewingradiographsevery6-18monthsoruntilnocavitatedlesionsareevident

Every3-4monthstoreevaluatecariesriskandapplyfluoridevarnish

Salivaflowtestandbacterialcultureinitiallyandateverycariesrecallappointmenttoassessefficacyandpatientcooperation

Chlorhexidinegluconate0.12%10-mLrinsefor1minutedailyfor1weekeachMonth Xylitol(6-10g/day)gumorcandies;twotabsofgumortwocandiesfourtofivetimesdaily

1.1%NaFtoothpastetwicedailyinsteadofregularfluoridetooth-pasteOptional0.2%NaFrinsedaily(onebottle)thenOTC0.05%NaFrinsetwotimesdailyInitially,onetothree applicationsat3-to4-monthrecal

Notrequired Optional:Applycalcium/phosphatepasteseveraltimesdaily

Asper ICDAS sealant protoco

Extremerisk§(highriskplusdrymouthorspecialneeds)

Bitewingradio-graphsevery6monthsoruntilnocavi-tatedlesionsareevident

Every3monthstoreevaluatecariesriskandapplyfluoridevarnish

Salivaflowtestandbacterialculture initiallyandateverycariesrecallappoint-menttoassessefficacyandpatientcooperation

Chlorhexidine0.12%(preferablychlorhexidineinwaterbaserinse)10-mLrinsefor1minutedailyfor1weekeachmonthXylitol(6-10g/day)gumorcandies;twotabsofgumortwocandiesfourtofivetimesdaily

1.1%NaFtoothpastetwicedailyinsteadofregularfluoridetooth-pasteOTC0.05%NaFrinsewhenmouthfeelsdryandaftersnacking,breakfast,andlunchInitially1-3 applicationsofNaFvarnish;oneapplicationat3-monthrecall

Acid-neutral-izingrinsesasneededifmouthfeelsdry;aftersnacking,atbedtime,andafterbreakfastBakingsodagumasneeded

Required:Applycalcium/phosphatepastetwicedaily

AsperIC-DASsealant protocol

Further Reading

• Dental Hygiene: Theory and Practice, • Saunders; 4 edition Hardcover – April 4, 2014 • by Michele Leonardi Darby BSDH MS (Author), 

Margaret Walsh RDH MS MA EdD (Author)