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Chapter 19 Dental Caries Management by Risk Assessment (Caries Protective…
Chapter 19 Dental Caries Management by Risk Assessment
Risk Assessment
an estimation of the likelihood that an event will occur in the future
Caries risk assessment
First step in CAMBRA
evidence-based disease indicators, risk factors, and protective factors
a well-trained dental professional who can correctly asses the caries risk and coaches patient to improve their oral health is a first step in successful management of dental caries
CAMBRA
-Low risk
-Moderate risk
-High risk
-Extreme risk
Dental Caries
a multifactorial disease caused by a prolonged acid imbalance in the mouth, primarily facilitated by bacteria biofilm
considered a transmissible bacterial infection
can be prevented, arrested, and in some cases even reversed by remineralization
Dental Caries Process
pH: Measure of Alkalinity or Acidity
pH values range from 0(acidic) to 14(alkaline)
pH of 7 is neutral
pH of water is close to 7
demineralization occurs around pH 5.5 and below
pH of plaque biofilm is typically neutral (7)
Demineralization
a net loss of mineral from the tooth surface that occurs around pH 5.5 and below
The acids diffuse into the tooth and dissolve the calcium and phosphate minerals
White Spot Lesions
demineralization results in the greatest loss of calcium and phosphate minerals in the subsurface zone of the enamel and the formation
enamel surface of white spot typically remain intact but the demineralized areas appear white
partially reversible with appropriate topical fluoride intervention
noncavitated
but is a signal to consider an intervention to avoid the development of a frank carious lesion or cavity
Remineralization
the deposition of minerals into demineralized areas of the tooth surface
minerals in saliva and minerals dissolved out of the tooth are available to redeposit onto existing crystal remnants inside the noncavitated, partially demineralized, carious lesions
ongoing process of destruction (demineralization) and repair (remineralization) occurs with each carbohydrate challenge
Caries Balance or Imbalance
Dental caries is a result of the action of caries risk factors and protective factors in the oral cavity
pathologic factors include acidogenic bacteria
ex: streptococci, lactobacillus species, and several other acid-producing species
frequent eating and/or drinking of fermentable carbohydrates;
subnormal salivary flow and function
Protective factors include calcium, phosphate, proteins, and fluoride in the saliva
Goal of caries management is to restore and maintain a balance, known as caries balance, between protective factors and pathologic factors to remineralize early carious lesions and/or to prevent future caries
Caries Disease Indicators
Teeth with frank cavitations or lesions that radiologically show penetration into dentin
Approximal radiographic lesions confined to enamel only
Visual white spots on smooth surface
Any restorations placed in the last 3 years for a new patient or in the last 12 months for a patient of record
High caries Risk
presence of any one of these four disease indicators automatically places an individual at high caries risk
Extreme Caries Risk
presence of any one of these caries disease indicators in the presence of inadequate salivary flow automatically indicates extreme caries risk
Caries risk Factors
medium or high mutans streptococci and lactobacilli counts
visible heavy plaque biofilm on teeth
frequent snacking between meals
deep pits and fissures
recreational drug use
inadequate salivary flow by observation or measurement
saliva-reducing factors (e.g. medication, head and/or neck radiation, systemic condition)
exposed roots
oral appliances
Caries Protective Factors
lives, works, or attends school in fluoridated community
uses fluoride toothpaste at least once daily
uses fluoride toothpaste at least two times daily
uses fluoride mouthrinse
uses 5000 parts per million fluoride toothpaste daily
has had fluoride varnish applied in the last 6 months
has had an office fluoride topical application in the last 6 months
has used prescribed CHX daily for 1 week in each of the last 6 months
has used xylitol gum or lozenges four to five times daily for the last 6 months
has used calcium and phosphate supplement paste for the last 6 months
had adequate salivary flow
Factors for High Risk Caries for Patients Ages Birth to 5 Years old
parent or primary caregiver has had active dental decay in the last 12 months
recent (less than 2 years) dental restorations have been provided
cavities, white spots, or obvious decalcification is visible
bottle contains fluids other than milk or water
sleeps with bottle or nurses on an ad lib basis
bleeding gums or heavy plaque on teeth is revealed
between-meal snacks of sugars or cooked starch are frequently eaten (more than 3x daily)
appliances are present (space maintainers, obturators)
salivary flow is visually inadequate
one or both of the following saliva-reducing factors are revealed
medications, such as for asthma or hyperactivity
medical reasons (cancer treatment) or genetic predisposition
Protective Factors for Patients ages Birth to 5 Years old
patient is resident in community with fluoridated water
parent or caregiver cleans childs teeth twice a day with fluoridated toothpaste
dental examination is combined with oral hygiene instruction for parent or caregiver
salivary flow is visibly adequate
parent or caregiver uses xylitol gum or mints four to five times daily
parent or caregiver has no caries activity
Criteria for extreme caries Risk for patients ages 6 and up
same as for those with HIGH risk for caries but with saliva-reducing factors that include the following
medications
radiation to the head and neck
systemic reasons (sjorgrens syndrome)
Guiding principles for Caries Management for High Risk Individuals
placing restorations that do not reduce the bacterial challenge
using fluoride at an increased concentration for enhanced remineralization
reducing bacterial challenge through antibacterial therapy
reducing pathologic (caries risk) factors to be at least balanced with protective factors
Topical Fluoride
taken into the oral cavity in three forms
self applied by patients in the form of nonprescription products available over the counter
self applied by patients in the form of prescriptions products
professionally applied prescription products