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Department of Restorative Dentistry University of Benin Teaching Hospital

CARIES RISK ASSESSMENT IN THE DIAGNOSIS AND MANAGEMENT OF DENTAL CARIES

Dr. EGEREGOR TEGA

Outline
Introduction Definition Caries Balance Concept Detection and Diagnosis Treatment plan and Caries classification

John Kois

There is no dentistry better thanno 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 bestpractices 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 byproducts 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

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

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.

The Caries Balance


Pathological Factors Acid-producing bacteria Sub-normal saliva flow and/or function Frequent eating/drinking of fermentable carbohydrate Protective Factors Saliva flow and components Fluoride: remineralization Antibacterials: - chlorhexidine, iodine?, xylitol, new? Ph controling rinses

Caries
Featherstone JD 2000

No Caries

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
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 patients 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

Caries Risk Assessment Detection and Diagnosis


The CAMBRA philosophy advocates the detection of the carious lesion at the earliest possible stage so the process can be reversed or arrested before cavitation and subsequent restoration is needed. Diagnosis identifies the disease (bacterial infection, biofilm disease) Detection identifies signs (cavitations) and symptoms

Thus, the accurate detection and diagnosis of noncavitated carious lesions are high priorities. The most commonly used method for detecting carious lesions is visual-tactile inspection and traditional bitewing radiographs for interproximal lesions.

. CAMBRA oral health interview/Examination: They are various caries assessment forms. All available CRA forms weigh the disease indicators, risk factors and protective factors to some degree, evaluating the balance or imbalance that exists on a case-by-case basis for each patient Ivoclar CRT bacterial test: Ivoclar vivadents caries risk test - use for quantifying the levels of bacteria as well as the buffer and demineralization strength. Cariostat plaque acid test : Cariostat plaque acid tests - cariostat - cariostat saliva buffer test

Digital radiography has a slight but not statistically significant advantage in lesion detection compared with traditional film radiography. (Chong MJ et al) Noninvasive, non-radiation, light-emitting technologies have been developed that are designed to serve as adjuncts to the traditional visual-tactile methods of detection. Some of these technologies include fiberoptic transillumination (FOTI and DIFOTI), electronic caries monitor, quantitative light-induced fluorescence, diode laser fluorescence, and LED light reflectance and refraction radiography

CARIOSTAT
Is a semi- synthetic liquid containing 2o% sucrose and a mixture of PH indicator. As a colorimeter test, it determines the ability of the acid producing bacteria in dental plaque to change the colour of the supplied medium, from dark blue to varying shade of blue, green and yellow. ( please refer to the handout)

CARIOSTAT
Colour Score Blue 0 Green 1.0 Light green 2.0 Yellow 3.0 PH 6.1 5.4 4.7 4.0 Risk level low

moderate high

Note PH value +0.3 or 0.3

Newer Technologies
Diagnodent Laser This device can give a numerical reading of early decay in pits. With practice, it can be more accurate than visual, tactile or radiographic examinations. Caution is required around hypocalcifications and existing resins and sealants as the unit may misread.

Other adjuncts- Magnification


Loupes
Operating Microscope

Intraoral Camera

New Technologies:
Diagnodent Laser Readings under 10 have no decay. Readings 10-20 usually have stain or enamel caries

Readings over 35 generally have decay in dentin.


Readings of 99 are decayed well into dentin. Readings 20-35 need individual assessment Diagnodent Readings alone are not sufficient for diagnosis

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

Smaller and more portable version released in 2006


Ability to read interproximal lesions Less fragile cable, less chance of damage

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

More research is needed here.

Proposed steps in Healozone Treatment

1. Cleaning

3. Treatment

2. Measurement

4. Reductant Fluid Promotes the immediate remineralization of the tooth.

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.

Treatment Plan Surgical Model


1. Drill 2. Fill 3. Bill 4. To cut is to cure

Treatment Plan Medical Model


1. Bacterial Control
A. Surgical Antimicrobial Tx (Restorations) Wound debridement / I&D = Fill/Temporize cavitated lesions/Place sealants B. Chemotherapeutic Antimicrobial Tx(meds) Fluoride Varnish, and Xylitol Gum

2. Reduce Risk Level of At-Risk Patients 3. Reverse Active Sites/Remineralization 4. Long Term Follow Up and Maintenance
A. B. C. Home maintenance Office Recall/Continuing Care Heal Vs.Cure (Process/Relationship)

Two treatment plans for caries:


Restorative treatment
Fixing holes Surgical treatment

Managing the disease


Preventing the disease process Chemotherapeutics Risk reduction Remineralization therapy Long term management

Can the caries process be controlled?


Formation of the biofilm on a tooth surface cannot be prevented in surface irregularities. Metabolic fluctuations in the biofilm can occur. Regular, random demineralizations and remineralizations cannot be prevented because they are a ubiquitous and natural process. Their effects on tooth surfaces over time can be influenced and the metabolic processes can be modified. Carious lesion development and progression can thus be controlled.

Prevention Vs. Therapeutics


In the past, we were preventing cavitations. We were also treating existing cavitations surgically (restorations). Now, we are preventing demineralization. (Fluoride Varnish, Xylitol Gum, MI paste) We are also treating existing demineralization chemotherapeutically, i.e. remineralization. (Fluoride Varnish, Xylitol Gum, MI paste) After remineralization, we once again attempt to prevent further demineralization. (Fluoride Varnish, Xylitol Gum, MI paste)

Caries Classification

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)

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

Mos CHX Used

Xylitol

MI Paste

CRT Test Month

CC Interval Months

CC FL V

Home Fluoride

6 + 3 6 + + + 6 6 3 + +

1000 ppm Paste

5000 ppm Paste + Rinse 5000 ppm Paste + Rinse

+
+

+
+

+
+

1
3

6
6

+
+

+
+

6
6

6
3

+
+

5000 ppm Paste + Rinse

5000 ppm Paste + Rinse

+
+ + + + 3 12 +

+
+ 12

6
3

+
+

5000 ppm Paste + Rinse

5000 ppm Paste In a Tray + Rinse

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

Mos CHX Used

Xylitol

MI Paste

CRT Test Month

CC Interval Months

CC FL V

Home Fluoride

6 + 3 6 + + + 6 6 3 + +

1000 ppm Paste

5000 ppm Paste + Rinse 5000 ppm Paste + Rinse

+
+

+
+

+
+

1
3

6
6

+
+

+
+

6
6

6
3

+
+

5000 ppm Paste + Rinse

5000 ppm Paste + Rinse

+
+ + + + 3 12 +

+
+ 12

6
3

+
+

5000 ppm Paste + Rinse

5000 ppm Paste In a Tray + 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. 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 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 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. 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.

Conclusion
Assessment of the caries risk of the individual patient is a critical component in determining an appropriate and successful management strategy

References
World Congress of Minimally Invasive Dentistry: www.wcmidentistry.com/index.php accessed 2/22/11 Ramos-Gomez, F.J., Crystal, Y.O., Ng, M.W., Crall, J.J. & Featherstone, J.D.B. (2010). Pediatric Dental Care: Prevention and Management Protocols Based on Caries Risk Assessment. Journal of the California Dental Association, 38 (10), 748-761. cda.org/library/cda_member/pubs/journal/journal_1010.pdf accessed 2/22/11 Chong MJ, Seow WK, Purdie DM, Cheng E, Wan V. Visual-tactile examination compared with conventional radiography, digital radiography, and diagnodent in the diagnosis of occlusal occult caries in extracted premolars. J Clin Dent. 2004;15(3):76-82. Fontana M, Gonzlez-Cabezas C. Secondary caries and restoration replacement: an unresolved problem. Compend Contin Educ Dent. 2000;21(1):15-30. Young DA, Featherstone JD, Roth JR. Curing the silent epidemic: caries management in the 21st century and beyond. J Calif Dent Assoc. 2007;35(10):681-685. Marsh PD. Microbiology of dental plaque biofilms and their role in oral health and caries. Dent Clin N Am. 2010;54:441-454.

Hara AT, Zero DT. The caries environment: saliva, pellicle, diet and hard tissue ultrastructure. Dent Clin N Am. 2010;54:455-467 Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent. 2004;2(Suppl 1):259-264. Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703-713 Young DA, Featherstone JBD. Implementing caries risk assessment and clinical interventions. Dent Clin N Am. 2010;54:495-505. Anusavice K. Clinical decision-making for coronal caries management in the permanent dentition. J Dent Educ. 2001;65(10):1143-1146