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Caries Risk Assessment and its interaction with Preventive and Restorative Protocols

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Caries Risk Assessment and its interaction with Preventive and Restorative Protocols Richard Ehrlich DDS www.elmtreedental.com dre_at_elmtreedental.com – PowerPoint PPT presentation

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Title: Caries Risk Assessment and its interaction with Preventive and Restorative Protocols


1
Caries Risk Assessmentand its interaction with
Preventive and Restorative Protocols
Richard Ehrlich DDS www.elmtreedental.com dre_at_elmt
reedental.com
2
Introduction
  • Caries Risk is used by most general dentists
    daily, usually on an intuitive level.
  • The first part of this presentation will attempt
    to help quantify this, and the second part will
    use this information for more systematic
    preventive, diagnostic and restorative protocols.

3
Applications of Caries Risk Assessment
  • Caries Risk Assessment assists in predicting and
    diagnosing this type of case-
  • Should you observe this?
  • Or does it conceal this?

4
Applications of Caries Risk Assessment
  • Caries Risk Assessment assists in predicting and
    diagnosing this type of case-
  • Should you replace these restorations or observe
    them?

5
Overview of Caries Risk Assessment (CRA)
  • Caries Risk Assessment (CRA) is a simple, quick
    method for assigning a number to an individuals
    risk for decay.
  • Using this data, custom preventive and
    restorative programs can be used, with more
    reliance on evidence-based dentistry and less on
    intuition and experience alone.
  • This simplified version is based on practical
    application of the U of T Caries Risk Assessment
    in actual clinical practice in a
    preventive-oriented dental office.

6
Categories for Simplified CRA
  • These are all given numerical scores
  • Existing Decay
  • Previous Decay
  • Root Caries
  • Fluoride Exposure
  • Diet Factors
  • Oral Hygiene
  • Additional Tests
  • S.mutans and Lactobacillus
  • Saliva Flow

7
Categories for Simplified CRA
  • Existing Decay
  • No Decay 0
  • Some early Pit and Fissure Decay 0.5
  • 1-2 Existing Lesions 1
  • gt2 Lesions 2

8
Categories for Simplified CRA
  • Anterior or Smooth Surface Decay 2
  • Previous Decay
  • No Decay 0
  • Some early Pit and Fissure Decay 0.5
  • Interproximal Posterior Decay 1

9
Categories for Simplified CRA
  • Existing Decay
  • Previous Decay
  • Root Caries
  • Ratio of exposed root surfaces to decay
  • lt25 of root surfaces decayed 0
  • 25-50 of surfaces decayed 1
  • gt50 of surfaces decayed 2

10
Categories for Simplified CRA
  • Existing Decay
  • Previous Decay
  • Root Caries
  • Fluoride Exposure
  • Using Fluoride Toothpaste BID 0
  • Using Fluoride Toothpaste once daily 1
  • Not using Fluoride Toothpaste or Rinse 2

11
Categories for Simplified CRA
  • Existing Decay
  • Previous Decay
  • Root Caries
  • Fluoride Exposure
  • Diet Factors

12
Diet Factors
  • The Diet Questionnaire is presented.
  • Total sugar exposures are totaled, and divided by
    3 for the Caries Index Diet Score

13
Diet Questionnaire
  • Drink Factors
  • How many times a day do you drink
  • 1. Coffee or tea with sugar between meals?
  • 2. Pop, Kool-aid, lemonade, sports drinks, fruit
    juice, iced tea with sugar between meals?
  • Total the number of these
  • How many glasses of water or dilute drinks do you
    have a day? This does not include coffee, soft
    drinks, full strength juice or sports drinks.
  • Chronic Dehydration can increase caries risk
  • Count 2 if the patient is dehydrated

14
Diet Questionnaire
  • Drink Factors contd
  • Important trend Cariogenic drinks are on a great
    increase!
  • Huge marketing efforts have been made, and often
    soft drink companies have a monopoly on vending
    machines in schools. This has paid off with a
    corresponding increase in decay and acid
    erosion.
  • Consumption of soft drinks, sports drinks, fruit
    juices and iced tea have skyrocketed in recent
    years, especially among teens and adolescents.
    Sports drinks are meant for athletes involved in
    over 60 minutes of aerobic activity. Sedentary
    kids are drinking sports drinks after mild
    activity, thanks to good marketing.
  • Water and milk consumption is dropping.

15
Diet Questionnaire
  • Food Factors
  • How many times a day do you
  • 1. Chew regular gum (Not sugarless)?
  • Eat mints, lozenges, candies or candy bars, dried
    fruit, energy bars between meals?
  • Eat sweetened baked goods (Donuts, cookies,
    pastries) between meals?
  • Total the number of all of these.

16
Diet Questionnaire
  • Do you have a habit of sipping a sweetened drink
    (Coffee, cola, juice) or eating a sweet snack
    over an extended period of time, 45 minutes or
    more?
  • If yes, add 2

17
Diet Questionnaire
  • Total diet scores are added up, divided by 3 and
    this is the number used for the Caries Risk
    Assessment score for Diet Factors.
  • 0-2 Sugar exposures0
  • 3-4 Sugar exposures 1
  • 5-6 Sugar Exposures 2
  • gt6 exposures 3

18
Categories for Simplified CRA
  • Existing Decay
  • Previous Decay
  • Root Caries
  • Fluoride Exposure
  • Diet Factors
  • Oral Hygiene
  • 0Good OH
  • 1Fair OH
  • PSRs lt3
  • Mod Plaque
  • 2Poor OH
  • PSRs gt3
  • Heavy Plaque

19
Categories for Simplified CRA
  • Existing Decay
  • Previous Decay
  • Root Caries
  • Fluoride Exposure
  • Diet Factors
  • Oral Hygiene
  • Additional Tests
  • S.mutans and Lactobacillus
  • Saliva Flow

20
Categories for Simplified CRA
  • Additional Tests
  • S.mutans and Lactobacillus
  • Saliva Flow
  • Bacterial testing is done only in cases when
    indicated, if other results are not obvious.
  • gt1,000,000 colonies s.mutans or gt100,000
    lactobacillus 2
  • gt 4 minutes for 3cc saliva sample 2
  • Indicates possible Xerostomia

21
The Simplified Caries Index Form
22
The Diet Questionnaire
23
CRA Score and Caries Risk The Total Score
  • 0-2 Low Risk
  • 3-4 Medium Risk
  • 4-6 High Risk
  • gt6 Severe Risk of Caries

24
CRA Score and Caries Risk Applying the data
  • From this data we can set up custom protocols for
    the individual patients, including
  • Fluoride treatments
  • Frequency of X-rays
  • Frequency of Recall visits
  • Restorative decisions on borderline lesions
  • Whether to Observe, Seal or Restore

25
Application In Practice- Take-home message
  • Caries Risk Assessment is an essential part of
    scientifically based dentistry in real general
    practice
  • A practical Caries Risk Assessment takes less
    than 5 minutes to do during a new patient exam,
    and contributes valuable data- please use my
    version or your own in your practice, but use it!
    Identify your high, medium and low risk patients.
  • The next part of the presentation will deal with
    use of this data for treatment protocols.

26
  • Dr. Richard Ehrlich
  • www.elmtreedental.com

27
Part 2 Diagnostic, Restorative and Preventive
Protocols using Risk Analysis and High Tech
instrumentation
  • Richard Ehrlich DDS
  • dre_at_elmtreedental.com

28
Tools needed
In addition to the usual instrumentation and
radiographs for diagnosis
Diagnodent- Diagnostic Laser caries detector
29
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.

30
Other adjuncts- Magnification
  • Loupes
  • Operating Microscope
  • Intraoral Camera

31
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

32
Protocols using the tools
  • At the initial diagnosis, the patient can usually
    be assigned to a Risk group.
  • This is re-evaluated at the next recall, as often
    the status changes after the initial treatment.

33
Low Risk- Initial ProtocolCaries Index 0-2
  • Observe pits and fissures with stain or early
    decay, decay in enamel, very early (stable) decay
    in dentin, old restorations, poor margins.
  • Diagnodent (DD) lt 25-30
  • Restore fractured restorations, obvious decay
    (DDgt40).

34
Medium Risk- Initial Protocol Caries Index 3-4
  • Observe stained pits, deep pits, early decay in
    enamel. (DDlt20).
  • Restore old restorations with cracks and broken
    margins, decay in pits with halo or shadow, any
    decay in dentin.
  • (DDgt25-30)

Diet Counseling Introduction Fluoride
Supplements for children in non fluoridated areas
35
High Risk- Initial Protocol Caries Index gt4
  • Observe stained pits DDlt10

Restore early decay in enamel and
dentin. (DDgt15-20) Restore old restorations with
cracks and broken margins
Diet Counseling Introduction Fluoride
Supplements for children Prevident 5000 for
Adults Fluoride varnish on incipient areas
36
First Re-evaluation
  • All patients are re-assessed after the initial
    treatment.
  • Many are at reduced risk once initial decay is
    removed, and diet/OH improvements are implemented.

37
High Risk- First Evaluation 3 month period
  • Caries Risk Re-Evaluation, including
  • s. mutans, lactobacillus test
  • Salivary flow measurement
  • 3-month Topical Fluoride, OHI
  • If risk reduced, proceed to Medium Risk Recare
    protocol

38
Low Risk Suggested Protocol
  • 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.
    (DDlt25-30)
  • Polish or seal old restorations with poor
    margins, and observe
  • Sealants not required

39
Medium Risk Suggested Protocol
  • Recall patient every 6 months
  • Topical Fluoride for children
  • Fluoride Supplement for areas without water F-
  • Take BW radiographs every 2 years
  • OHI As needed
  • Observe stained pits, early decay in enamel or
    optionally seal. (DDlt15-20)

40
Medium Risk Suggested Protocol
  • Restore pits and fissures with early decay, any
    very early decay in dentin, old restorations with
    poor margins. (DDgt20)
  • Polish or seal old restorations with fair
    margins, and observe.

41
High Risk Suggested Protocol
  • Full diet counselling with diary

42
High Risk Suggested Protocol
  • Full diet counselling with diary
  • Recall patient every 3 months
  • Topical Fluoride
  • Fluoride Varnish on susceptible areas
  • Take BW radiographs yearly
  • OHI
  • Home Fluoride Trays or Prevident 5000
  • Chlorhexidine Rinses -Adult
  • Fluoride Supplements-Child
  • Evaluate for xerostomia

43
  • Restore pits with early decay, any very early
    decay in dentin or enamel, (DDgt20) old
    restorations with fair- poor margins.
  • Sealants/Preventve resins- all deep pits and
    fissures. (DDgt5-20)

44
  • New Technologies
  • Often high risk kids present with early decay or
    deep pits in barely erupted teeth.
  • These can be very hard to seal due to access or
    co-operation issues. If there is any moisture
    contamination, traditional sealants will fail.

45
  • 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.
46
  • 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.

47

Proposed steps in Healozone Treatment
1. Cleaning
3. Treatment
4. Reductant Fluid Promotes the immediate
remineralization of the tooth.
2. Measurement
48
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.

49
Summary Flow Chart-
  • This flow chart is available from my web page at
  • www.elmtreedental.com

50
Summary
  • A system of numerically rating a patients caries
    risk has been presented
  • Protocols for minimal invasive and preventive
    treatment for low risk patients and maximal
    preventive and early restorative treatment for
    high risk patients have been demonstrated, to
    allow custom treatment for each patient.

51
Thank you
  • Dr. Richard Ehrlich
  • www.elmtreedental.com
  • dre_at_elmtreedental.com
  • 905-880-7003
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