Clinical Trends In The Diagnosis And The Treatment Of Dental Caries

1. Clinical Trends In The Diagnosis And The Treatment Of Dental Caries Steven Steinberg DDS May-June, 2004

2. LOW RISK PATIENT • No cavitated lesions • May have inactive white spots (smooth shiny). • Bacteria MS levels are low • Diet is normal sugar levels low • Normal Saliva levels • Low DMF (Hx)

3. MODERATE RISK PATIENT • No cavitated lesions • Some active white spot lesions (rough/chalky) • Bacterial MS levels elevated • Moderate sugar use • Saliva normal or reduced (xerostomia) • Moderate DMF (Hx)

4. HIGH RISK PATIENT • One or more cavitated lesions • May have white spot lesions (active or inactive) • Bacterial MS levels are very high • Sugar intake very high • Saliva levels low (xerostomia) • High DMF (Hx)

5. 1. Bacterial Control A. Surgical Antimicrobial Tx • Treat cavitated lesions first. • Fill with glass ionomer, compomer, composite or IRM. • Very large lesions may require temporary crowns (sub-gingival margins),RCT, or EXT. • Place sealants as needed: • Occlusal surfaces with chalky white spots • Deep grooves and Old fillings with poor margins • Molars > Premolars • Surgical choices based on Site(pit & fissures vs. smooth surface), Activity and Risk.

6. Treatment Plan Medical Model • Bacterial Control • Surgical Antimicrobial Tx (Restorations) Wound debridement / I&D = Fill/Temporize cavitated lesions/Place sealants • Chemotherapeutic Antimicrobial Tx(meds) Fluoride Varnish, CHX, and Xylitol Gum • Reduce Risk Level of At-Risk Patients • Reverse Active Sites = Remineralization • Long Term Follow Up and Maintenance • Home maintenance • Office Recall/Continuing Care • Heal Vs.Cure (Process/Relationship)

7. 1. Bacterial Control A. Surgical Antimicrobial Tx • Treat cavitated lesions first. • Fill with glass ionomer, compomer, composite or IRM. • Very large lesions may require temporary crowns (sub-gingival margins),RCT, or EXT. • Place sealants as needed: • Occlusal surfaces with chalky white spots • Deep grooves and Old fillings with poor margins • Molars > Premolars • Surgical choices based on Site(pit & fissures vs. smooth surface), Activity and Risk.

8. 1. Bacterial Control B.Chemotherapeutic Antimicrobial Tx • Fluoride Varnish 1-3 initial applications upon completion of Surgical Tx. Use 3 applications in 10 day period for patients who need remineralization or for patients with CHX issues or compliance problems (possible use of Iodine rinse). • CHX = Chlorhexidine Rinse 0.12% take ½ oz. before bed for 2 weeks. Repeat in 2-3 months • Xylitol Gum. Use 2 pieces for 5 minutes minimum 5 times a day. • Mutans Test for Very High Risk patients

9. 2. Reduce Risk Levels of At Risk Patients • Reduce Sugar !!!!!!!!!!!!!!!!! (Xylitol/Sucrose substitutes) • Reduce Bacteria (antimicrobials, Xylitol gum, and OHI) and MS test PRN. • Increase Saliva (Xylitol gum and mints, Rinses, change medications if possible). • Increase Home Fluoride use.

10. 3. Reverse Active SitesRemineralization Tx • In Office – Fluoride varnish 3 applications in 10 day period (if not done as a part of Step 1B) • At Home – Fluoride • Moderate or High Risk Patient: Toothpaste (1000 ppm) qd + 5000 ppm dentifrice or gel qd +OTC (over the counter) rinse 250 ppm several times a day especially hs. • Very High risk Patient: Toothpaste 5000 ppm dentifrice or gel qd + 5000 ppm dentifrice or gel in a tray qd +OTC (over the counter) rinse 250 ppm several times a day especially hs. • Xylitol gum: 2 pieces 5 times a day. • Calcium Source: Cheese or new gums with amorphous Calcium Phosphate.

11. 4. Long Term Follow Up A. Home Maintenance • At Home – Fluoride • Moderate or High Risk Patient: Toothpaste (1000 ppm) qd + 5000 ppm dentifrice or gel qd +OTC (over the counter) rinse 250 ppm several times a day especially hs. • Very High risk Patient: Toothpaste 5000 ppm dentifrice or gel qd + 5000 ppm dentifrice or gel in a tray qd +OTC (over the counter) rinse 250 ppm several times a day especially hs. • Xylitol gum 2 pieces 5 times a day. • Decreased use of sucrose between meals • Calcium Source.

12. 4. Long Term Follow Up B. In Office Continuing Care • 3 Month Visit • Polish (If this is also a 3 mo perio maint patient do perio probing/scaling first) • Exam / evaluate white spots for remineralization / return to steps 1-3 PRN (D0140) • Fluoride varnish (D1204) • 6 Month Visit (3 months later) • PSR or Perio Probing / Scaling / Polish • Exam / evaluate white spots for remineralization / return to steps 1-3 PRN (D0120) • Fluoride varnish (D1204) • 9 Month Visit (3 months later) • Polish (If this is also a 3 mo perio maint patient do perio probing/scaling first) • Exam / evaluate white spots for remineralization / return to steps 1-3 PRN (D0140) • Fluoride varnish (D1204) • 1 Year Visit (3 months later) • Bite wing + other x-rays PRN • PSR or Perio Probing / Scaling / Polish • Fluoride varnish (D1204) • Exam / Evaluate Activity Levels I.e. white spot and interprox x-rays (D0120) • Exam / Evaluate Risk Level for next years CC schedule (Low Risk 6mo CC / Moderate or High risk 3mo CC if active: 6mo CC if inactive/ Very High Risk 3mo CC)

13. Treatment Groups by Risk/Activity Status. • Low Risk (LR) • Moderate Risk Inactive (MRI) • Moderate Risk Active (MRA) • High Risk Cavitated (HRC) • High Risk Cavitated Active (HRCA) • High Risk Inactive (HRI) • Very High Risk (VHR)