caries risk assessment by dr tega.ppt

Department of Restorative Dentistry

University of Benin Teaching Hospital

CARIES RISK ASSESSMENT IN THE DIAGNOSIS AND MANAGEMENT OF

DENTAL CARIES

Dr. EGEREGOR TEGA, BDS

John Kois

“There is no dentistry better than…no dentistry.”

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 case-

Should you replace these restorations or observe them?

Introduction• 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

• The caries process involves a combination of factors including

• Diet

• Susceptible host

• Microflora

• that interplay with a variety of social, cultural and behavioural factors.

Defining caries risk assessment

• is the determination of the likelihood of the incidence of caries (i.e. the number of new cavitation or incipient lesions) during a certain time period.

• It also involved the likelihood that there will be a change in the size or activity of the lesion already present

continue• 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

• It is essential in decision making to guide the clinician in the diagnosis, prognosis and treatment recommendations for the patient

Caries Balance Concept• 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

Caries Risk Factors

• Caries risk factors are described as biological reasons that cause or promote current or future caries disease. Risk factors traditionally have been associated with the etiology of disease.

• Are variables that either currently are thought to cause the disease directly ( e.g. microflora) or have been shown useful in predicting it.

• These risk factors may vary with:

- Race

- Culture

- ethnicity

• 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)

Risk factors (Biological Predisposing factors)

• Caries Imbalance model uses the acronym “BAD” to describe three risk factors that are supported in the

• literature as causative for dental caries:

• Bad bacteria, meaning acidogenic, aciduric or cariogenic bacteria

• Absence of saliva, meaning hyposalivation or salivary hypofunction

• Destructive lifestyle habits that contribute to caries disease, such as frequent ingestion of fermentable carbohydrates, and poor oral hygiene (self care).

• 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

Protective Factors• Caries protective factors are biologic 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 patient’s oral health

Protective Factors contd

• The Caries Imbalance model uses the acronym “SAFE” to describe the following four protective factors:

• Saliva and sealants• Antimicrobials or antibacterials (including

xylitol)• Fluoride and other products that enhance

remineralization• Effective lifestyle habits

How do we classify risk?

Risk Levels

• High-Risk Patient– One or more cavitated lesions.– May or may not have rough chalky white spots

• Moderate Risk Patient– Rough Chalky White Spots– Moderate risk factors

• Low-Risk Patient

LOW RISK PATIENT

• No cavitated lesions• May have inactive white spots (smooth

shiny).• Cariogenic Bacteria levels are low• Saliva ph is neutral or basic• Diet is normal sugar levels low• Normal Saliva levels• Low DMF (Hx)

MODERATE RISK PATIENT

• No cavitated lesions

• Some active white spot lesions (rough/chalky)

• Cariogenic Bacterial levels elevated

• Saliva ph is acidic

• Moderate sugar use

• Saliva normal or reduced (xerostomia)

• Moderate DMF (Hx)

HIGH RISK PATIENT

• One or more cavitated lesions• May have white spot lesions (active or

inactive)• Cariogenic Bacterial levels are very high• Saliva ph is acidic• Sugar intake very high• Saliva levels low (xerostomia)• High DMF (Hx)

Treatment Groups by Risk/Activity Status.

• 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)

TREATMENTTREATMENT

GROUPGROUP

FillFill TempTemp

CrCr

SealSeal ##11stst

FLVFLV

Mo’s Mo’s CHX CHX UsedUsed

XylitolXylitol MIMI

PastePaste

CRTCRT

TestTest

MonthMonth

CCCC

IntervalInterval

MonthsMonths

CCCC

FLFLVV

HomeHome

FluorideFluoride

Low RiskLow Risk

LRLR 66 1000 ppm Paste1000 ppm Paste

Moderate RiskModerate Risk

InactiveInactive

MRIMRI++ ++ 66 ++

5000 ppm Paste5000 ppm Paste

+ Rinse+ Rinse

Moderate RiskModerate Risk

ActiveActive

MRAMRA33 66 ++ ++ 66 33 ++


+ Rinse+ Rinse

High Risk High Risk

ActiveActive

HRAHRA++ ++ ++ 11 66 ++ ++ 66 66 ++


+ Rinse+ Rinse

High RiskHigh Risk

Active/ActiveActive/Active

HRA/AHRA/A++ ++ ++ 33 66 ++ ++ 66 33 ++


+ Rinse+ Rinse

High RiskHigh Risk

InactiveInactive

HRIHRI++ ++ 66 ++


+ Rinse+ Rinse

Very High RiskVery High Risk

VHRVHR ++ ++++++

33 1212 ++ ++ 1212 33 ++5000 ppm Paste5000 ppm Paste

In a TrayIn a Tray

+ Rinse+ Rinse

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.

RECOMMENDATIONS Extreme Risk (ADA recommendations)

• Bitewing radiographs every 6-18 months• Caries recall exams every 3-4 months to reevaluate caries risk• Saliva flow test and bacterial culture initially and at 6-month recall

appointment to assess efficacy and patient cooperation.• Chlorhexidine gluconate 0.12% 10 ml rinse once per day for week for one

minute; 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. • OTC 0.05% NaF rinse when mouth feels dry, after snacking, breakfast, and

lunch. • Initial visit 1 application of NaF varnish; 1 application at every 3 month

recall.• Acid neutralizing (baking soda) rinses as needed if mouth feels dry, after

snacking, and after meals.• Apply calcium/ phosphate paste twice daily.

• Fluoride-releasing sealants for suspect pits with poor access

• Fuji Triage can be placed quickly and easily, needing very little cooperation.

New Technologies:New Technologies:

Due to the fluoride release, it is Due to the fluoride release, it is less likely than traditional less likely than traditional sealants to allow decay below sealants to allow decay below if it leaks.if it leaks.

Digital RadiographyDigital Radiography


Allows lower dose exposures. Resistance from patients is reduced. Allows lower dose exposures. Resistance from patients is reduced. Results are instant.Results are instant.

Patient Education is enhanced as they can see radiographs enlarged in Patient Education is enhanced as they can see radiographs enlarged in front of them. Diagnosis front of them. Diagnosis may may be enhanced.be enhanced.

Essential for online communication with specialists.Essential for online communication with specialists.

Complete offsite backup is possible.Complete offsite backup is possible.

Sensors are larger and placement takes some practice.Sensors are larger and placement takes some practice.

Diagnodent PenDiagnodent Pen


Smaller and more portable version released in 2006Smaller and more portable version released in 2006

Ability to read interproximal lesionsAbility to read interproximal lesions

Less fragile cable, less chance of damageLess fragile cable, less chance of damage

Ozone Treatment of pitsOzone Treatment of pits

A promising new technique A promising new technique involves sterilizing the pits involves sterilizing the pits and fissures with ozone. This and fissures with ozone. This has been shown to stop has been shown to stop decay and even allow decay and even allow remineralizationremineralization

This may make cooperation This may make cooperation even easier in early even easier in early interventionintervention

More research is needed here.More research is needed here.


1. Cleaning

2. Measurement

3. Treatment

4. Reductant FluidPromotes the immediate remineralization of the tooth.

Proposed steps in Healozone Treatment

DIFOTI (Digital Imaging Fiber-Optic Trans-IlluminationDIFOTI (Digital Imaging Fiber-Optic Trans-Illumination))


This device createsThis device creates high-resolution digital images of high-resolution digital images of occlusal, interproximal and smooth surfaces. It enables occlusal, interproximal and smooth surfaces. It enables dentists to discover or confirm the presence of decay that dentists to discover or confirm the presence of decay that cannot be seen radiographically, visually or through use of cannot be seen radiographically, visually or through use of an exploreran explorer

DIFOTI (Digital Imaging Fiber-Optic Trans-DIFOTI (Digital Imaging Fiber-Optic Trans-IlluminationIllumination))


Air AbrasionAir 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.

MicrobursMicroburs


Low-tech way to access very small pits. ¼, 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.

Laser- Water unitsLaser- 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.

Application In Practice- Take-home message:

• Identify your high, medium and low risk patients.

• Treat them differently based on their risk levels.

• Aim to convert all your patients to low risk, or at least reduce their caries index.

• Do not over-treat your low-risk patients. They need their own preventive and restorative protocols.

• Do not under-treat your high risk patients. They need every preventive and early intervention restorative measure you can give them, especially if they cannot convert to lower risk.

Summary Flow Chart-

• This flow chart is available from my web page at

www.elmtreedental.com

Caries Risk- Diagnostic, Restorative and Preventive Protocols

Low Risk Medium Risk High Risk

Low Risk Medium Risk High Risk

Initial Diagnosis Caries Risk Analysis

Observe pits and fissures with stain or early decay, decay in enamel, very early (stable) decay in dentin, old restorations, poor margins. (DD < 25-30) Restore fractured restorations.

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.

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

Caries Risk Analysis Re-evaluation

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

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

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.

caries risk assessment by dr tega.ppt

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