Caries Risk Assessment Dr. Zahra Saied Moallemi DDS, PhD Oral - - PDF document

6/25/2013 1

Dr . Zahra Saied Moallemi

Caries Risk Assessment

• Dr. Zahra Saied Moallemi

DDS, PhD Oral Public Health Dept., Isfahan Univ. of Medical Sciences Esfand 1391

Dr . Zahra Saied Moallemi Dr . Zahra Saied Moallemi Dr . Zahra Saied Moallemi

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CAMBRA

• physicians should identify and treat patients by

risk rather than treating all patients the same.

• CAMBRA =

Caries Management by Risk Assessment

• CAMBRA does not stop at prevention and

chemical treatments; it includes evidence-based decisions on when and how to restore a tooth to minimize structural loss.

Dr . Zahra Saied Moallemi

• Prevention: “brush and floss” and “don’t eat

sugar.”

• According to the CAMBRA, prevention will be

defined as risk factor management (by maximizing protective factors and minimizing pathological factors).

• Management dental caries

Dr . Zahra Saied Moallemi

Guidelines

• Assessing caries risk is important for all

patients and

• the process has to be repeated at intervals.
• An explicit caries risk assessment should be

made for each person presenting for dental care

Dr . Zahra Saied Moallemi

Risk factors for dental caries

• Previous disease:

– Past caries experience is the most powerful single predictor of future caries increment – in young children (aged six years), caries in deciduous teeth is a better criterion than caries in permanent first molars.

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• Diet:

– consumption of sugary food and drinks both between meals and at meals is associated with a large caries increment (Vipeholm study, 1945-1953). – Children average nearly seven intakes of food per day, many of which are snacks rich in added sugars.

Risk factors for dental caries

Dr . Zahra Saied Moallemi

• Dietary factors are associated with caries

incidence:

– amount of fermentable carbohydrate consumed – sugar concentration of food – physical form of carbohydrate – oral retentiveness (length of time teeth are exposed to decreased plaque pH) – frequency of eating meals and snacks – length of interval between eating – sequence of food consumption.

Dr . Zahra Saied Moallemi

• Dietary factors are associated with caries

incidence:

– amount of fermentable carbohydrate consumed – sugar concentration of food – physical form of carbohydrate – oral retentiveness (length of time teeth are exposed to decreased plaque pH) – frequency of eating meals and snacks – length of interval between eating – sequence of food consumption

Dr . Zahra Saied Moallemi

• Social factors:

– Dental caries is most prevalent in schoolchildren from low socio-economic status families. – Children from these families:

• higher caries prevalence,
• fewer caries-free teeth,
• fewer sealants and
• more untreated lesions

Risk factors for dental caries

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• Use of fluoride:

– Consideration of water fluoridation as a public health measure

Risk factors for dental caries

Dr . Zahra Saied Moallemi

• Plaque control:

– Removal of bacterial plaque is important in minimizing one of the etiological factors in caries. – Health benefits are primarily due to the incorporation of fluoride into most toothpastes.

Risk factors for dental caries

Dr . Zahra Saied Moallemi

• Saliva:

– Saliva fulfils a major protective role against dental caries. – Reduction in salivary flow - usually as a consequence of medical history and related drug therapy

Risk factors for dental caries

Dr . Zahra Saied Moallemi

• Medical history and disability:

– Physical and learning disabilities result in decreased ability to perform oral self-care. Learning disability is often associated with poor

• ral hygiene and frequent consumption of sweet

snacks. – Some disabled patients are resident in institutions where carers are responsible for their oral

• hygiene. Clinicians should therefore be aware of

the need to provide appropriate preventive care to individuals within these groups.

Risk factors for dental caries

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Risk category

Caries risk factors

Clinical evidence Dietary habits Social history Use of fluoride Plaque control Saliva Medical history High risk New lesions Premature extractions Anterior caries or restorations Multiple restorations No fissure sealants Fixed appliance

• rthodontics

Partial dentures Frequent sugar intake Social deprivation High caries in siblings Low knowledge of dental disease Irregular attendance Ready availability of snacks Low dental aspirations Drinking water not fluoridated No fluoride supplements No fluoride toothpaste Infrequent, ineffective cleaning Poor manual control Low flow rate Low buffering capacity High S mutans & lactobacillus counts Medically compromised Physical disability Xerostomia Long term cariogenic medicine

Dr . Zahra Saied Moallemi

Risk category

Caries risk factors

Clinical evidence Dietary habits Social history Use of fluoride Plaque control Saliva Medical history

Low risk No new lesions

Nil extractions for caries Sound anterior teeth No or few restorations Restorations inserted years ago Fissure sealed No appliance Infrequent sugar intake Social advantage Low caries siblings Dentally aware Regular attendance Limited availability of snacks High dental aspirations Drinking water fluoridated Fluoride supplements used Fluoride toothpaste used Frequent, effective cleaning Good manual control Normal flow rate High buffering capacity Low S mutans and lactobacillus counts No medical problems No physical problems Normal salivary flow No long term medication

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• Moderate risk

– Individuals who do not clearly fit into high or low risk categories are considered to be at moderate risk

Adapted from Professor Edwina Kidd

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PREVENTING DENTAL CARIES IN CHILDREN AT HIGH CARIES RISK

1. PRIMARY PREVENTION OF DENTAL CARIES

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6/25/2013 6 Primary prevention Identifying children at high caries risk

• Given the pattern of development of dental

caries and its widespread prevalence in adulthood, most children are "at risk" of dental caries.

Dr . Zahra Saied Moallemi

Primary prevention Behavior modification in high caries risk patients

• 1. Dental health education
• Dental health education advice should be provided to

individual patients at the chairside.

– The dental and allied professions have an ethical responsibility to inform patients about disease and how to prevent it. – Consistent preventive messages should be reinforced. – Dental health education carried out by a professional at the chairside is more often effective than other types of oral health promotion interventions (systematic review)

Dr . Zahra Saied Moallemi

• 2. Oral hygiene
• The value of toothbrushing in caries

prevention lies with the regular topical application of fluoride.

– 1000-2800 ppm in children 6 -16 years

Primary prevention Behavior modification in high caries risk patients

Dr . Zahra Saied Moallemi

Primary prevention

• Adults and children over 7 years should:

– brush teeth twice a day using toothpaste containing at least 1000 ppm fluoride – ensure that all accessible surfaces of teeth are cleaned – spit out the toothpaste and avoid rinsing out with water.

• children up to 7 years of age:

– only a smear or small pea-sized quantity of toothpaste – encourages children to spit out toothpaste after brushing – active rinsing out after brushing

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• 3. Diet and sugar consumption

– lowering sugar intake reduces the incidence of caries in children – incidence of approximal lesions reduce by diet and

• ral hygiene training.

– Limiting the ingestion of refined carbohydrate to meal times is also widely recommended – The need to restrict sugary food and drink consumption to meal times only should be emphasized.

Primary prevention Behavior modification in high caries risk patients

Dr . Zahra Saied Moallemi

• 4. Xylitol

– substitution of xylitol for sugar in the diet results in very much lower caries increments (studies in Finland) – Dietary advice to patients should encourage the use of non-sugar sweeteners, in particular xylitol, in food and drink.

Primary prevention Behavior modification in high caries risk patients

Dr . Zahra Saied Moallemi

• 5. Sugar-free chewing gum

– Chewing gums containing xylitol and sorbitol have anti-caries properties through salivary stimulation. – Xylitol is more effective than sorbitol in caries reduction, as it also has antibacterial properties. – Patients should be encouraged to use sugar-free chewing gum, particularly containing xylitol, when this is acceptable.

Primary prevention Behavior modification in high caries risk patients

Dr . Zahra Saied Moallemi

• Sugar-free medicines

– Medicines for children had highly sweetened – danger to teeth from frequent consumption of sweetened medicines. – iatrogenic damage to children's teeth – widespread availability of sugar-free alternatives for most paediatric medications – Clinicians should prescribe sugar-free medicines whenever possible and should recommend the use

• f sugar-free forms of non-prescription medicines.

Primary prevention Behavior modification in high caries risk patients

Dr . Zahra Saied Moallemi

6/25/2013 8 Primary prevention Tooth protection in patients at high caries risk

• 1. Sealants

– pit and fissure sealants are an effective barrier method of preventing caries – Sealants should be applied and maintained in the tooth pits / fissures of high caries-risk children. – For the majority of "at risk" individuals sealing permanent molars is sufficient. – in high risk patients all pits and fissures should be sealed.

Dr . Zahra Saied Moallemi

Primary prevention

– The condition of sealants should be reviewed at each check-up. – Glass ionomer sealants have poorer retention than composite resin materials – Glass ionomer sealants should only be used when resin sealants are unsuitable: poor patient compliance

Dr . Zahra Saied Moallemi

Primary prevention Tooth protection in children at high caries risk

• 2. Fluoride tablets

– Although caries-inhibiting potential, caries prevention is slight as compliance amongst those most at risk is problematic. – Fluoride supplements are no longer recommended routinely for caries prevention in children living in areas with little fluoride in water; nor should they be prescribed for those residing in areas with optimal levels of fluoride in the water.

Dr . Zahra Saied Moallemi

Primary prevention

– However supplements may still be considered for children with intractable caries risks: fluoride supplements (1mg F, 2.2mg NaF per day) for high caries risk children and can be used where compliance is likely to be favourable. – Fluoride supplements are available as tablets or as a mouthwash, but fluoride tablets are the best

• ption.

– Fluoride tablets (1 mg F daily) for daily sucking should be considered for children at high risk of decay.

Dr . Zahra Saied Moallemi

6/25/2013 9 Primary prevention Tooth protection in children at high caries risk

• 3. Topical varnishes

– For high risk children: fluoride toothpaste and tablets is insufficient, professional application of a fluoride varnish may help to prevent dental caries. – no significant difference in caries increments varnish or gel (study in Finland) – In low risk: more frequently than twice a year does not provide additional caries protection (study in Finland)

Dr . Zahra Saied Moallemi

Primary prevention

• A fluoride varnish (e.g. Duraphat) may be

applied every four to six months to the teeth

• f high caries risk children.
• Correct application according to the

manufacturer's instructions is important.

Dr . Zahra Saied Moallemi

Primary prevention Tooth protection in children at high caries risk

• 4. Chlorhexidine

– chlorhexidine prophylaxis in the form of a rinse, gel or paste can achieve a substantial (average 46%) reduction in caries. – In high-caries patients, professional flossing four times a year with chlorhexidine gel lead to significant reductions in approximal caries. – chlorhexidine varnish (e.g. Cervitec, 1%) is effective in preventing fissure caries (once/3 months)

• Chlorhexidine varnish should be considered as

an option for preventing caries.

Dr . Zahra Saied Moallemi

PREVENTING DENTAL CARIES IN CHILDREN AT HIGH CARIES RISK

2. SECONDARY AND TERTIARY PREVENTION OF DENTAL CARIES

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6/25/2013 10 2nd and 3rd prevention

• Treating any carious lesions operatively will

not prevent further disease and primary preventive measures must be continued.

Dr . Zahra Saied Moallemi

2nd and 3rd prevention SECONDARY AND TERTIARY PREVENTION OF DENTAL CARIES

• 1. Diagnosis of dental caries
• 2. Management of carious lesions
• 3. Re-restoration

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• 1. Diagnosis of dental caries

– Early diagnosis of approximal enamel lesions is important. – the majority of lesions in the outer half of enamel will take at least two years to progress into dentine. – With intervention, lesion progression can be slowed, arrested or even reversed. – monitoring is important as in very caries- active individuals rapid progression can be seen.

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• clinical examination of clean, dried teeth
• This examination may include:

– transillumination – Flossing – temporary separation of the teeth; e.g. with a wooden wedge – clinical examination should be prior to deciding whether to take a radiograph.

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6/25/2013 11 2nd and 3rd prevention

• Benefit of the patient should be considered

for radiographs.

• Radiographic examination detects dentinal

caries 'hidden' under a sound occlusal surface, which may affect 10-15% of teenagers.

• Bitewing radiographs are recommended as

an essential adjunct to a patient's first clinical examination.

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• 2. Management of carious lesions
• The management of carious lesions can be

divided into three caries sites:

– occlusal caries – approximal caries – smooth surface caries.

• The patterns of caries initiation and progression

are different in each site, as are the management

• ptions.

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• 2. Management of carious lesions
• 2.1. Management of occlusal caries in children at high

caries risk

– Once a decision has been taken to initiate operative intervention: sealant restorations are as effective as amalgam restorations in managing small to moderate sized fissure caries and involve less tooth destruction. However, consider that the fissure sealant requires maintenance. If amalgam is used as a filling material, any remaining fissures which are caries free should be fissure sealed in preference to "extension for prevention“.

• If only part of the fissure system is involved in small to

moderate dentine lesions with limited extension, the treatment of choice is a composite sealant restoration.

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• 2. Management of carious lesions
• If fissure caries extends clinically into dentine:

– The treatment choice is to remove the caries and place a restoration, rather than sealing over the caries. – if caries is inadvertently covered by a fissure sealant which is then well maintained, the caries is very unlikely to progress.

• If caries extends clinically into dentine, then

carious dentine should be removed and the tooth restored.

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6/25/2013 12 2nd and 3rd prevention

• 2. Management of carious lesions
• For more extensive lesions: conventional

amalgam fillings

• Dental amalgam is an effective filling material

which remains the treatment of choice in many clinical situations. There is no evidence that amalgam restorations are hazardous to the general health.

– Current advice from the Department of Health is that amalgam fillings should not be used for pregnant women.

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• 2. Management of carious lesions
• 2.2. Management of approximal caries in children

at high caries risk:

• Application of fluoride varnish can slow or arrest

progression of approximal enamel lesions

• therefore operative intervention is not indicated

when lesions are at this stage of development.

• Preventive care (e.g. topical fluoride varnish)

rather than operative care is recommended when approximal caries is confined (radiographically or visually) to enamel.

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• Management strategies for lesions confined to

the enamel should also include:

– twice daily use of a toothpaste containing at least 1000 ppm fluoride – Flossing – dietary advice

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• For approximal lesions requiring restoration:

– Class II approach (1) – tunnel preparation (2) – Composite resin for small to moderate sized restoration (not subjected to direct occlusal loading) Class II cavities in premolar teeth.

• In an approximal lesion requiring restoration, a

conventional Class II restoration should be placed in preference to a tunnel preparation.

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6/25/2013 13 2nd and 3rd prevention

• 2.3. Management of smooth surface

caries in children at high caries risk:

– caries is easier to detect and manage. – The management strategy is the same as that for approximal lesions confined to enamel.

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• Management strategies for smooth surface

(non-cavitated) lesions should include: – twice-daily use of a toothpaste containing at least 1000 ppm fluoride – plaque removal – dietary advice (including the use of sugar free chewing gum, when acceptable)

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• 3. Re-restoration
• It is common to find a range of previous

restorations in high risk patients.

• Reasons for fail: factors associated with the

material or technique used or the operator's skill.

• The margin between restoration and tooth tissue

is a potential site for new decay, known as secondary or recurrent caries.

• More extensive lesions which continue to

progress in spite of preventive care should be restored with an appropriate material

Dr . Zahra Saied Moallemi

2nd and 3rd prevention

• the diagnosis of secondary caries is extremely difficult
• there is a risk that large numbers of false diagnoses of

secondary caries will lead to unwarranted replacement and re-replacementof fillings.

• Unnecessary replacement of fillings is deleterious to
• ral health and wastes scarce financial resources.
• The diagnosis of secondary caries is extremely

difficult and clear evidence of involvement of active disease should be ascertained before replacing a restoration.

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• If only part of a restoration have failed, then

consideration should be given to repairing rather than replacing it.

Dr . Zahra Saied Moallemi Dr . Zahra Saied Moallemi

THE LOW-RISK PATIENT

• Low-risk patients typically present with little

history of carious lesions, extractions, or restorations.

• But, no guarantee of this, due to the change in
• ral hygiene, bacterial levels, diet, salivary

flow, or fluoride use

• dentist should address a caries risk

assessment at each periodic oral exam

Dr . Zahra Saied Moallemi

• The management strategy for the low-risk

patient:

– to maintain the balance of protective factors they currently have and – to make them aware that their risk for caries can change over time.

THE LOW-RISK PATIENT

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• less professional supervision for caries
• bitewing radiograph every 24 to 36 months.

THE LOW-RISK PATIENT

Dr . Zahra Saied Moallemi

THE MODERATE-RISK PATIENT

• They have more risk factors than the low-risk
• patients. However, these patients typically do

not show the signs of continuing dental caries that would put them into the high-risk group.

• one who has some risk factors and could be

moved easily to high risk.

Dr . Zahra Saied Moallemi

• additional fluoride therapy,
• more frequent radiographic evaluation; with

bitewing radiographs approximately every 18 to 24 months

THE MODERATE-RISK PATIENT

Dr . Zahra Saied Moallemi

• diet counseling, oral hygiene instruction, and

use of fluoride rinses: more aggressive implementation and more frequent monitoring.

• Use of sealants as a preventive measure is

more desirable to recommend in this risk category.

THE MODERATE-RISK PATIENT

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THE HIGH-RISK PATIENT

• Patients who currently have dental caries,

determined by cavitated lesions,

• the presence of observable carious lesions,
• Or, two or more high-risk factors

Dr . Zahra Saied Moallemi

THE HIGH-RISK PATIENT

• Having a caries, is a disease indicator,
• And is a very strong indicator that the disease,

dental caries, will progress to produce more cavities, unless we intervene with chemical therapy to lower the bacterial challenge and increase remineralization.

Dr . Zahra Saied Moallemi

THE HIGH-RISK PATIENT

• patients must be managed aggressively to

eliminate or reduce the possibility of a new or recurrent caries lesion:

– Bacterial testing, antimicrobial treatments, 1.1 percent NaF toothpaste, 5 percent NaF fluoride varnish, and xylitol are standard regimens for all high-risk patients.

Dr . Zahra Saied Moallemi

• increased periodic oral exams
• radiographic evaluation with new bitewing

radiographs every six to 12 months.

THE HIGH-RISK PATIENT

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THE EXTREME-RISK PATIENT

• The extreme-risk patient is a high-risk patient

with special needs, or

• who has the additional burden of being

severely hyposalivary: high risk + xreostomia

Dr . Zahra Saied Moallemi

• Patients in this risk group must be even more

aggressively managed and seen more frequently than those in the high-risk group.

• additional therapies including buffering rinses

(e.g., baking soda) to replace the cleansing and buffering functions of normal saliva

• calcium and phosphate pastes to replace the

normal salivary components for remineralization of tooth structure

THE EXTREME-RISK PATIENT

Dr . Zahra Saied Moallemi Dr . Zahra Saied Moallemi

References

• Preventing Dental Caries in Children at High Caries Risk,

Scottish Intercollegiate Guidelines Network, SIGN publication no. 47, Dec 2000.

• Curing the silent epidemic: caries management in the

21st century and beyond. Young DA, Featherstone JD, Roth JR. J Calif Dent Assoc. 2007 Oct;35(10):681-5.

• Clinical protocols for caries management by risk
• assessment. Jenson L, Budenz AW, Featherstone JD,

Ramos-Gomez FJ, Spolsky VW, Young DA. J Calif Dent

• Assoc. 2007 Oct;35(10):714-23.

Dr . Zahra Saied Moallemi