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@elmtreedental.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 individual’s 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. Existing Decay No Decay = 0 Some early Pit and Fissure Decay = 0.5 1-2 Existing Lesions =1 >2 Lesions =2 Categories for Simplified CRA

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

9. Existing Decay Previous Decay Root Caries Ratio of exposed root surfaces to decay <25% of root surfaces decayed = 0 25%-50% of surfaces decayed =1 >50% of surfaces decayed =2 Categories for Simplified CRA

10. 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 Categories for Simplified CRA

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 sugarbetween 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 cont’d: • 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. • Link to Acid Erosion Page

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 exposures=0 • 3-4 Sugar exposures =1 • 5-6 Sugar Exposures =2 • >6 exposures =3

18. Existing Decay Previous Decay Root Caries Fluoride Exposure Diet Factors Oral Hygiene 0=Good OH 1=Fair OH PSRs <3 Mod Plaque 2=Poor OH PSRs >3 Heavy Plaque Categories for Simplified CRA

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. Bacterial testing is done only in cases when indicated, if other results are not obvious. >1,000,000 colonies s.mutans or >100,000 lactobacillus = 2 > 4 minutes for 3cc saliva sample =2 Indicates possible Xerostomia Additional Tests S.mutans and Lactobacillus Saliva Flow Categories for Simplified CRA

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 • >6 = 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. Recare Report- Getting the message out Patients remember a percentage of what you tell them while in the chair. They take it far more seriously if they have something they can take home. We use a Recare report to give to patients, or kid’s parents.

26. Recare Report Procedures done today: Medial History Update Blood Pressure Screening Oral Cancer Scan X-rays Tooth Examination Periodontal (gum) Examination- TMJ Check Cavity Risk Assessment PSR Full perio recording Oral Hygiene Evaluation Recommendations: We would like to see you again in: 3 months 6 months 9 months 1 year Oral Hygiene- Brushing Good!Too Hard Missing Areas Not Frequent Enough Other Tools Flossing Sulcabrush Rubber Tip Rotapoints Superfloss Peridex antibacterial mouthwash Power Floss unit Diet Factors- 1.Coffee or tea with sugarbetween meals. 2.Pop, fruit juice, rice milk, sports drinks, Kool-aid or iced tea with sugar between meals. 3. Chewing gum (Not sugarless)? 4.Eating mints, lozenges, candies, dried fruit, chocolate bars. 5.Eating sweetened baked goods (Donuts, cookies, pastries) between meals? Fluoride Program Supplements- ¼ tablet/day ½ tablet/day Prevident 5000 high-fluoride toothpaste Fluoride Rinse Fluoride treatment: 3month/ 6 month/ Home treatment Ongoing issues needing treatment: Decay Gum Disease Failing dental work

27. 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.

28. Dr. Richard Ehrlich www.elmtreedental.com

29. Part 2: Diagnostic, Restorative and Preventive Protocols using Risk Analysis and High Tech instrumentation Richard Ehrlich DDS dre@elmtreedental.com

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

31. 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.

32. 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 (See Literature Review)

33. Other adjuncts- Magnification • Loupes Operating Microscope Intraoral Camera

34. 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.

35. 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) < 25-30 Restore fractured restorations, obvious decay (DD>40).

36. Medium Risk- Initial Protocol Caries Index 3-4 Observe stained pits, deep pits, early decay in enamel. (DD<20). Restore old restorations with cracks and broken margins, decay in pits with halo or shadow, any decay in dentin. (DD>25-30) Diet Counseling Introduction (link to diet page) Fluoride Supplements for children in non fluoridated areas

37. High Risk- Initial ProtocolCaries Index >4 Observestained pits DD<10 Restore early decay in enamel and dentin. (DD>15-20) Restore old restorations with cracks and broken margins Diet Counseling Introduction Fluoride Supplements for children Prevident 5000 for Adults Fluoride varnish on incipient areas

38. 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.

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

40. 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. (DD<25-30) Polish or seal old restorations with poor margins, and observe Sealants not required

41. 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 enamelor optionally seal. (DD<15-20)

42. Medium Risk Suggested Protocol • Restore pits and fissures with early decay, any very early decay in dentin, old restorations with poor margins. (DD>20) Polish or seal old restorations with fair margins, and observe.

43. High Risk Suggested Protocol • Full diet counselling with diary

44. High Risk Suggested Protocol • Full diet counseling 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 • MI Paste • Chlorhexidine Rinses –Adult- 30 seconds before bed • Xylitol-containing gum- 3 pieces daily • Fluoride Supplements-Child • Evaluate for xerostomia

45. Restore pits with early decay, any very early decay in dentin or enamel, (DD>20) old restorations with fair- poor margins. Sealants/Preventve resins- all deep pits and fissures. (DD>5-20)

46. 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.

47. 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.

48. 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.

49. New Technologies: Diagnodent Pen • Smaller and more portable version released in 2006 • Ability to read interproximal lesions Less fragile cable, less chance of damage

50. 31 DIAGNOdent pen – Fissure caries Conventional probe does not detect the size of enamel nor the dentin lesion, but is dangerous to the tooth surfaceKühnisch et al., Quintessenz 10/2003 Sensitivity – teeth withcaries and no cavityLussi et al., Quintessenz 10/2003 Pictures: Dr. Angel Sanchez-Figueras, Jr. DDS