What is Dental Caries? - Conference Innovators featherstone... · 2010-03-23 · Dental caries is a transmissible bacterial iinnfefecctitioonn Protective Factors “White spot”

Caries Management by Risk Caries Management by Risk AssessmentAssessment ::

The Caries BalanceThe Caries Balance

John D.B. FeatherstoneJohn D.B. Featherstone

Professor and DeanProfessor and Dean

EE--mail [email protected] [email protected]

School of DentistrySchool of Dentistry

University of California San FranciscoUniversity of California San Francisco

DisclosureDisclosure

I have no personal financial interest in any I have no personal financial interest in any company relevant to this presentation. company relevant to this presentation.

I consult for, have consulted for, or have I consult for, have consulted for, or have done research funded or supported by:done research funded or supported by:

Arm and Hammer, Beecham, Cadbury, GSK, Arm and Hammer, Beecham, Cadbury, GSK,

KaVo, Novamin, Omnii Oral Pharmaceuticals, KaVo, Novamin, Omnii Oral Pharmaceuticals, Oral B, Philips Oralcare, Procter and Gamble, Oral B, Philips Oralcare, Procter and Gamble, 3M ESPE Preventive Care, Wrigley, and the 3M ESPE Preventive Care, Wrigley, and the

National Institutes of Health.National Institutes of Health.

Protective Factors

What is Dental Caries?What is Dental Caries?

�� Dental caries is tooth decay Dental caries is tooth decay

�� Specific bacteria (Streptococcus mutans, Specific bacteria (Streptococcus mutans, Streptococcus sobrinus, and lactobacilli) on Streptococcus sobrinus, and lactobacilli) on the tooth surface feed on carbohydrates and the tooth surface feed on carbohydrates and

make acids as waste productsmake acids as waste products

�� Acids travel into the tooth and dissolve Acids travel into the tooth and dissolve mineral mineral -- if mineral loss is not halted or if mineral loss is not halted or reversed a cavity is formedreversed a cavity is formed

�� Dental caries is a transmissible bacterial Dental caries is a transmissible bacterial

infectioninfection

Protective Factors

“White spot” lesion

Protective Factors

Frank occlusal

cavity

Protective Factors

Childhood

Caries

The Caries BalanceThe Caries BalanceProtective Factors

• Saliva flow and components

• Fluoride, Calcium, Phosphate:

remineralization

• Antibacterials:-

chlorhexidine, xylitol, new?

No CariesCaries

Pathological Factors

• Acid-producing bacteria

• Frequent eating/drinking of

fermentable carbohydrates

•Sub-normal saliva flow and

function

Featherstone, Community Dent Oral Epidem, 1999

Protective Factors

Stay in balance to survive

Pathological FactorsPathological Factors

�� Cariogenic bacteria: mutans streptococci Cariogenic bacteria: mutans streptococci ((S. mutans and S. sobrinus) S. mutans and S. sobrinus) and and lactobacillus specieslactobacillus species

�� Frequency of ingestion of fermentable Frequency of ingestion of fermentable carbohydrates: sucrose, glucose, carbohydrates: sucrose, glucose, fructose, cooked starchfructose, cooked starch

�� Reduced salivary function (medication Reduced salivary function (medication induced; radiation therapy; disease; induced; radiation therapy; disease; genetic)genetic)

Protective Factors

Acid producing bacteria are usually

less than 1 percent of the total flora in

the plaque

Scanning

Electron

Micrograph

of bacteria on

a tooth

surface

Streptococcus mutans culture showing active cell

division. S. sobrinus is similar. Sucrose leads to

extracellular polysaccharides that stick the

plaque together

Mutans StreptococciMutans Streptococci

This group of bacteria contains two primary species that appear in humans

�Streptococcus mutans - almost universal

�Streptococcus sobrinus - virulent, high risk

Both species produce acids and can live in

acid

Lactobacillus culture. Lactobacilli species produce

predominantly lactic acid from fermentable carbohydrates

What about

the clinical

relevance?

Does drilling

and filling

really fix

caries?

Clinical Study ResultsClinical Study ResultsNIH/NIDCR GrantNIH/NIDCR Grant

Caries Management By Risk Caries Management By Risk AssessmentAssessment19991999--2004 2004

Principal Investigator: Principal Investigator:

John Featherstone John Featherstone

CoCo--investigators: investigators:

Chuck Hoover, Stuart Gansky, Marcia RapozoChuck Hoover, Stuart Gansky, Marcia Rapozo--Hilo, Kim Tran, Hilo, Kim Tran, Joel White, Jane WeintraubJoel White, Jane Weintraub

Caries Management StudyCaries Management Study

S1

S3 S7S2

Baseline ObservationsSaliva SampleMS, LB and FRadiographs

DMFS1-7 cavities

Co

ntr

ol

Inte

rven

tio

n

Final ObservationsRadiographs

DMFS

Randomization

Restorations +Anti-bacterial

and Fluoride

Treatment

All Restorations

Complete

S2

S4-S6

Conventional Treatment Plan

Restorations

S3 S7

Final ObservationsRadiographs

DMFS

All Restorations

Complete

S4-S6

high low

2 Years

N=116

(CHX + F)

N=115

Decayed Surfaces vs. log MS and log LB

(Revised bacterial classifications 1-07)

High

Bacterial

Challenge

Baseline Bacterial

Levels vs Decay

Existing Cavity = High Risk

M ean (SE) logM S

0 1 2 3 4 5 6 70

1

2

3

4

5

Log MS Control

Log MS Intervention

Visit # - 6 month intervals

Chlorhexidine plus Fluoride

Restorations

Patients With Frank cavitiesPatients With Frank cavities

� One or more frank cavities indicates high risk for future new carious lesions

� Moderate to high levels of mutans streptococci

� Moderate to high levels of lactobacilli

� Patients have a high bacterial challenge that most likely can not be completely overcome by fluoride alone

�� Placing restorations does not reduce the Placing restorations does not reduce the bacterial loading in the rest of the mouthbacterial loading in the rest of the mouth

∆∆∆∆DMFS (SE)24% reduction (p=0.02)

Control Intervention0

1

2

3

4

5

Would you put a new roof on while the house is burning?

Placing a restoration does not significantly reduce the

bacterial loading in the remainder of the mouth.

Caries is a Transmissible Caries is a Transmissible Bacterial InfectionBacterial Infection

� Time for a paradigm shift

� Children infected by mother, caregiver, siblings

� Fluoride is effective only up to a point

� High bacterial challenge can not be completely overcome

� Placing “fillings” has little effect on cariogenic bacterial loading in the mouth

� Need to deal with the infection

First Colonizable Hard Surface. First Colonizable Hard Surface. Soft tissues can also be colonized Soft tissues can also be colonized

beforebefore teeth erupt.teeth erupt.





+

Demineralization:-Step 1

Cariogenic

Bacteria

S. Mutans

S. Sobrinus

Lactobacilli

Fermentable

Carbohydrates

Sucrose

Glucose

Fructose

Cooked starch

Organic Acids

Which penetrate enamel and

dentin

Dissolve tooth mineral

Protective Factors

Cariogenic foods contain fermentable

carbohydrates such as sucrose,

glucose, fructose and cooked starch

NonNon--cariogenic Sweetenerscariogenic Sweeteners

�� SorbitolSorbitol

�� AspartameAspartame

�� SaccharinSaccharin

�� Sodium cyclamateSodium cyclamate

�� XylitolXylitol





Male, 55 years old, before

radiation to the head and neck

for cancer treatment. Causes

saliva flow and function to be

cut by at least 90%

Same male, after radiation

to the head and neck. Six

months later, showing

rampant decay and massive

destruction of the teeth

Protective factorsProtective factors

�� Salivary components and flowSalivary components and flow

�� Fluoride, calcium and phosphate: Fluoride, calcium and phosphate: remineralizationremineralization

�� Antibacterials from extrinsic sourcesAntibacterials from extrinsic sources

Saliva Contains Numerous Saliva Contains Numerous Important ComponentsImportant Components

�� Calcium, phosphate and fluorideCalcium, phosphate and fluoride

�� Proteins and lipids that form the pellicle Proteins and lipids that form the pellicle that protects the tooth surfacethat protects the tooth surface

�� Proteins that keep calcium in solution Proteins that keep calcium in solution --they maintain supersaturationthey maintain supersaturation

�� Buffers: bicarbonate, phosphate, Buffers: bicarbonate, phosphate, peptidespeptides

�� Antibacterial substances & Antibacterial substances & immunoglobulinsimmunoglobulins





+

Demineralization:-Step 2

If fluoride is present in the If fluoride is present in the

solution between the solution between the

crystals it inhibits mineral crystals it inhibits mineral lossloss

Organic

Acids

Dental Mineral =

Carbonated

Hydroxyapatite

Acid soluble

Demineralization

Calcium and phosphate into

solution

Protective Factors

Scanning Electron Microscope image of

Normal Enamel Surface

Protective Factors

SEM of enamel

surface 60,000X,

showing crystal ends

Transmission Electron

Microscope image of enamel

cross-section at 60,000X

showing individual crystals

and the prism (rod) boundary

Protective Factors

Acid-damaged enamel crystals from a carious lesion at

3,000,000x showing rows of calcium atoms. Hexagonal

white patches (arrows) are where acid has dissolved

mineral from calcium deficient/carbonate rich regions.

Dissolved

regions

Water amongst

the crystals

Dr. Fluoride

protects against

mineral loss

Water

amongst

the

crystals

+

Remineralization/Tooth Repair

Fluoride speeds up remineralization ->

less soluble mineral

Calcium

in tooth

water

(from

saliva)

Phosphate

in tooth

water (from

saliva)

Remineralization

Builds on existing crystal remnants

New mineral less soluble

Fluoride helps

Dr. Fluoride speeds

up remineralization

and makes acid

resistant mineral

Demineralized surface blocks need to be replaced

with new calcium, phosphate and fluoride to make

a more acid resistant surface on the crystal

SEM in the body of a carious lesion (~ 30,000x)

showing remaining crystal remnants awaiting

remineralization

Sound enamel crystal (3,000,000x) dissected

from inner enamel showing carbonate rich acid

soluble regions (white patches).

Enamel crystal after remineralization with calcium,

phosphate and fluoride, showing a well-formed, low

solubility, fluorapatite-like veneer overlying the

original defective crystal

Calcium and phosphate are cemented in

place by fluoride providing a new stable wall

Enamel/dentin

crystal =

Carbonated apatite

Partly dissolved

crystal

Crystal

nucleus

ACID

Acid resistantAcid resistant

CaCa10 10 (PO(PO44))6 6 (F)(F)22 = =

fluorapatitefluorapatite--likelikecoating on crystalscoating on crystals

RemineralizationCalcium +

Phosphate

+ Fluoride

Fluoride works primarily via Fluoride works primarily via topical mechanismstopical mechanisms

�� Fluoride inhibits demineralization by Fluoride inhibits demineralization by adsorbing from solution onto tooth adsorbing from solution onto tooth mineral crystal surfacesmineral crystal surfaces

�� Fluoride enhances remineralization Fluoride enhances remineralization

by combining with calcium and by combining with calcium and phosphate to make a “fluorapatitephosphate to make a “fluorapatite--like” remineralized veneer like” remineralized veneer

Protective Factors

H+ + F- HF

HF

H+ + F -

Bacterial Cell

pH 7 H+ + F - H F

pH 4.5 H+ + F - H F

Fluoride can not enter bacteria in its ionic form,

but as the bacteria produce acid HF is formed,

which diffuses readily into the cells

�� Fluoride inhibits demineralizationFluoride inhibits demineralization

�� Fluoride enhances remineralizationFluoride enhances remineralization

�� Fluoride can inhibit plaque bacteriaFluoride can inhibit plaque bacteria

Fluoride works primarily via Fluoride works primarily via topical (surface) mechanismstopical (surface) mechanisms((Fluoride in water, foods, beverages, products)

Protective Factors

Fluoride levels in the mouth are

sufficient to enhance remineralization

Protective Factors

Numerous clinical trials showed ~30% reduction with fluoride dentifrice 1000-2800 ppm F.

Curnow, Pine, et al, 2002 reported 56% reduction with supervised brushing twice daily

Orthodontic brackets attract cariogenic bacteria, leading to

“white patch” decay

Stannous Fluoride Stabilized Formula 2007

Over the counter fluoride rinses (0.05% NaF) are very effective in high caries risk patients when used once or twice daily for one minute, plus a

fluoride-containing dentifrice. O’Reilly and Featherstone, 1987

OfficeOffice--Applied Fluoride ProductsApplied Fluoride ProductsGel (Gel (>> 5,000 ppm F)5,000 ppm F)

and Fluoride Varnishand Fluoride Varnish�� Do not require continuing patient Do not require continuing patient

compliancecompliance

�� Forms slowly soluble calcium fluorideForms slowly soluble calcium fluoride--like like deposits in lesions and the plaquedeposits in lesions and the plaque

�� Gives slow release fluoride for several Gives slow release fluoride for several

weeksweeks

�� Three times a year for high risk patientsThree times a year for high risk patients

Evidence-based Clinical Recommendations:Professionally Applied Topical FluorideThe Council on Scientific Affairs, American

Dental AssociationMay, 2006

� Fluoride gel applied for 4 minutes or more is

effective� Fluoride varnish applied every 6 months is

effective

� Two or more applications of fluoride varnish per year are effective in high caries risk individuals

� Office topical applications no added benefit for low

risk individuals

Protective Factors

Weintraub et al, J Dent Res, 2006. Fluoride

varnish in infants (approx 2 years old at start)

Caries Incidence Infants Over 2 years

0 1 2 30

5

10

15

20

25

30

35

40

45

Fluoride Varnish Applications

Fluoride Varnish for High Risk of All Ages

White “Vanish” Varnish – 3M ESPE Prev Care

High fluoride concentration (5,000 High fluoride concentration (5,000 ppm F) toothpaste more effective ppm F) toothpaste more effective

than 1100 ppm F in high risk than 1100 ppm F in high risk individualsindividuals

Baysan A et al, Caries Res 2001. 5000 ppm F Baysan A et al, Caries Res 2001. 5000 ppm F toothpaste gave statistically significant extra toothpaste gave statistically significant extra reduction in root caries compared to 1100 reduction in root caries compared to 1100

ppm F toothpaste.ppm F toothpaste.

However, caries progression still occurred in However, caries progression still occurred in many subjects even with high concentration many subjects even with high concentration fluoride usefluoride use

High concentration fluoride products for high risk patients. Proven effective for root caries.

Conclusions Conclusions -- FluorideFluoride

�� The antiThe anti--caries effects of fluoride are caries effects of fluoride are primarily topical (surface) in plaqueprimarily topical (surface) in plaque

�� The systemic benefits of fluoride are The systemic benefits of fluoride are minimal minimal

�� Therapeutic levels of F can be achieved Therapeutic levels of F can be achieved

from drinking water and fluoride productsfrom drinking water and fluoride products

�� Fluoride therapy may not overcome a high Fluoride therapy may not overcome a high bacterial challengebacterial challenge

Calcium Phosphopeptide: Calcium Phosphopeptide: CPP/ACPCPP/ACP

Eric Reynolds Eric Reynolds -- Australia Australia

Background and mechanism

Laboratory studies: Three decades

Clinical Studies: clinical evidence

Representation of a proposed Representation of a proposed CPPCPP--ACP complexACP complex

Cross et al. 2007 Curr Pharm Des,

Conclusions Conclusions

�� Limited calcium and phosphate in Limited calcium and phosphate in individuals with reduced salivary function individuals with reduced salivary function is a common problemis a common problem

�� Calcium and phosphate delivery can be Calcium and phosphate delivery can be enhanced to improve remineralizationenhanced to improve remineralization

�� Great need for novel improved Great need for novel improved remineralization methods to better alter remineralization methods to better alter the “caries balance”, especially in the “caries balance”, especially in individuals with high bacterial challengeindividuals with high bacterial challenge

�� MI paste, MI Paste Plus (with fluoride)MI paste, MI Paste Plus (with fluoride)

The Caries BalanceThe Caries Balance

Protective Factors• Saliva flow and components

• Fluoride, calcium, phosphate:-

remineralization

• Antibacterials:- chlorhexidine,

xylitol, new?

No CariesCaries



• Frequent eating/drinking

of fermentable carbohydrates

• Sub-normal saliva flow and

function





Protective Factors

Biofilm Modification is necessary as part of our therapy for high bacterial challenge

individuals. Caries is a transmissible

bacterial infection

Caries is a Transmissible Caries is a Transmissible Bacterial InfectionBacterial Infection

�� Multiple acidMultiple acid--producing species of bacteria are producing species of bacteria are responsibleresponsible

�� Children are infected by mothers, careChildren are infected by mothers, care--givers, givers, siblings, playmates, through saliva transfer siblings, playmates, through saliva transfer

�� Babies and infants are most susceptible from birth Babies and infants are most susceptible from birth to about 4 years of ageto about 4 years of age

�� Children infected early have more cavities later in Children infected early have more cavities later in lifelife

�� Need to break the chain of infection and deal with Need to break the chain of infection and deal with the bacteriathe bacteria

Similarity of bacteriocins of Similarity of bacteriocins of S. S. mutansmutans from mother and infantfrom mother and infant

R.J. Berkowitz and H.V. Jordan

Archs. Oral Biol. 20:725-730, 1975

Demonstrated the likelihood of Demonstrated the likelihood of transmission from mother to childtransmission from mother to child

Oral colonization of S. mutans Oral colonization of S. mutans in Sixin Six--monthmonth--old Predentate old Predentate

InfantsInfants

A.K.L. Wan, W.K. Seow, et al.

J.Dent Res. 80:2060-2065,2001

� Showed that S.mutans colonized even before teeth erupted (50% of infants).

� Related to high S. mutans in mothers, increased frequency of sugar intake, breast feeding and habits with saliva transfer from mother to child

Chlorhexidine Gluconate 0.12%, 10 ml, daily for 1

week reduces MS markedly and LB somewhat after

restorations completed. Repeat every month.

�� Chlorhexidine was effective at reducing Chlorhexidine was effective at reducing the bacterial challenge in high caries risk the bacterial challenge in high caries risk individuals even when compliance was individuals even when compliance was problematicproblematic

�� Preferred regimen is once a day rinse for Preferred regimen is once a day rinse for one week every month for a yearone week every month for a year

�� Monitor success by bacterial testingMonitor success by bacterial testing

�� Ideally we need a better antibacterial Ideally we need a better antibacterial therapy therapy

�� Must combine with remin/fluorideMust combine with remin/fluoride

What about What about toddlers/preschoolers?toddlers/preschoolers?

�� No good antibacterial vehicle available for No good antibacterial vehicle available for

toddlers toddlers -- chlorhexidine has negativeschlorhexidine has negatives

�� Chewing xylitol gum inappropriate & mints Chewing xylitol gum inappropriate & mints

might be aspiratedmight be aspirated

�� Xylitol wipes? Xylitol wipes? -- Spiffies: Unpublished data Spiffies: Unpublished data show caries reduction over one year in infantsshow caries reduction over one year in infants

�� Enlist the mothers and caregiversEnlist the mothers and caregivers

XylitolXylitol

�� Xylitol is a 5 carbon “sugar alcohol”Xylitol is a 5 carbon “sugar alcohol”

�� It looks like sucrose and has about the same It looks like sucrose and has about the same sweetness by weightsweetness by weight

�� It is used in some foods, chewing gum, candies, It is used in some foods, chewing gum, candies, lozenges, and dental products as a sweetenerlozenges, and dental products as a sweetener

�� Cariogenic (caries causing) bacteria can not feed Cariogenic (caries causing) bacteria can not feed on iton it

�� Humans can feed on it and use it as an energy Humans can feed on it and use it as an energy source source

�� It inhibits the transfer of bacteria from person to It inhibits the transfer of bacteria from person to person by altering the way the bacteria stick to person by altering the way the bacteria stick to surfacessurfaces

Influence of maternal xylitol Influence of maternal xylitol consumption on acquisition of consumption on acquisition of

mutans streptococci by infantsmutans streptococci by infants

E. Soderling, P. Pienihakkinen, J. Tenovuo

J. Dent. Res. 79:882-887, 2000

Use of xylitol gum by mothers reduced Use of xylitol gum by mothers reduced colonization in infants.colonization in infants.

Xylitol was better than chlorhexidine varnish, which was better than fluoride varnish

Parallel study showed marked caries reductions Parallel study showed marked caries reductions after 5 years (10 year results still hold up)after 5 years (10 year results still hold up)

Treat the mother or Treat the mother or caregiver to reduce caries in caregiver to reduce caries in

the childthe child�� Mother or caregiver with active Mother or caregiver with active

caries must be taken care ofcaries must be taken care of

�� Chlorhexidine rinses during 3rd Chlorhexidine rinses during 3rd trimester continuing after birthtrimester continuing after birth

�� Fluoride therapy to control the decayFluoride therapy to control the decay

�� 44--5 g/day xylitol chewing gum for 5 5 g/day xylitol chewing gum for 5

minutes each time and/or mints.minutes each time and/or mints.

XylitolXylitol

�� Xylitol chewing gum use enhances Xylitol chewing gum use enhances remineralizationremineralization

�� It inhibits the transfer of bacteria from It inhibits the transfer of bacteria from person to person by altering the way the person to person by altering the way the bacteria stick to surfacesbacteria stick to surfaces

�� It inhibits future recolonizationIt inhibits future recolonization

Xylitol Gum, MintsXylitol Gum, Mints

XylitolXylitol

�� Noncariogenic sweetenerNoncariogenic sweetener

�� Inhibits transfer of bacteria Inhibits transfer of bacteria

from mother to childfrom mother to child

�� Can reduce loading of Can reduce loading of

cariogenic bacteria in the cariogenic bacteria in the mouthmouth

XylitolXylitolPeter Milgrom Peter Milgrom -- University University

of Washington of Washington

Caries response is dose dependent

Gummy bears successful as a delivery vehicle

A Few Xylitol Gum SourcesA Few Xylitol Gum Sources

�� Epic. http://www.epicdental.com/departments.aspEpic. http://www.epicdental.com/departments.asp

You can buy gums and mints from this company, including You can buy gums and mints from this company, including dispensers.dispensers.

�� Omni Preventive Care 3M ESPE. Office and home care Omni Preventive Care 3M ESPE. Office and home care products. products. http://solutions.3m.com/wps/portal/3M/en_US/preventivehttp://solutions.3m.com/wps/portal/3M/en_US/preventive--care/home/care/home/

�� Zellies. Ellie has the full range plus educational materials. Zellies. Ellie has the full range plus educational materials. http://www.zellies.comhttp://www.zellies.com

�� Spry is another company that markets gum and mints to Spry is another company that markets gum and mints to dental officesdental offices

http://www.homesteadmarket.com/xylitol_mints.htmlhttp://www.homesteadmarket.com/xylitol_mints.html

Use The Caries Use The Caries Balance to Balance to Assess the RiskAssess the Risk



• Fluoride, calcium, phosphate:

remineralization



No CariesCaries






function

Sometimes there is a

delicate balance

Caries Risk Assessment Caries Risk Assessment An Actual Case An Actual Case -- 11

21 year old female referred by general dentist

(a)(a) First cavity of her lifeFirst cavity of her life

(b)(b) Numerous interproximal lesions on radiographs, Numerous interproximal lesions on radiographs,

several into dentinseveral into dentin

(c)(c) Apparently good oral hygieneApparently good oral hygiene

(d)(d) College student living in an apartmentCollege student living in an apartment

(e)(e) White patches observed White patches observed -- Orthodontic treatment Orthodontic treatment

completed three years beforecompleted three years before

(f)(f) Did bacteria test Did bacteria test –– Ivoclar/Vivadent CRT Ivoclar/Vivadent CRT

Mixed saliva is added to

the two sided selective

media slide (mutans

streptococci and

lactobacilli)

Incubate for 72

hours and read

versus density

scale

Vivadent Test Strips. An actual case. Used to

measure mutans streptococci and lactobacilli


Pathological factors

(a)(a) Mutans streptococci and lactobacilli very highMutans streptococci and lactobacilli very high

(b)(b) Frequent (greater than 3 times) between meal Frequent (greater than 3 times) between meal snacks of sugars/cooked starch snacks of sugars/cooked starch -- college student college student not eating regular mealsnot eating regular meals

(c)(c) No saliva reducing factors: 1) medications, 2) No saliva reducing factors: 1) medications, 2) radiation to the head and neck, 3) systemic radiation to the head and neck, 3) systemic reasonsreasons

(d)(d) Saliva flow normal (approximately 2.0 ml/min)Saliva flow normal (approximately 2.0 ml/min)

(e)(e) Previously appliances present Previously appliances present -- orthodontic orthodontic bracketsbrackets



(a)(a) Use of fluoride toothpaste not regularUse of fluoride toothpaste not regular

(b)(b) Saliva normal and adequate Saliva normal and adequate

(c)(c) Insufficient to overcome the high and frequent acid Insufficient to overcome the high and frequent acid challengeschallenges

(d)(d) Treatment regimenTreatment regimen

(e)(e) Chlorhexidine rinse daily one week each monthChlorhexidine rinse daily one week each month

(f)(f) High concentration fluoride toothpaste dailyHigh concentration fluoride toothpaste daily

(g)(g) Diet diary and modification of snacking. Add xylitol gum. Diet diary and modification of snacking. Add xylitol gum. Motivated/intelligent individual.Motivated/intelligent individual.

(h)(h) Restore tooth with cavity. Monitor the remainderRestore tooth with cavity. Monitor the remainder

(i)(i) Caries controlled Caries controlled

Protective Factors

Orthodontic brackets attract cariogenic bacteria, leading to

“white patch” decay

Risk Assessment

Assessing the risk for caries in

the future

Putting into practice Putting into practice the results of many the results of many years of research. years of research.

“Caries Management “Caries Management

by Risk Assessment” by Risk Assessment” based upon the based upon the “Caries Balance”“Caries Balance”

CDA Journal CDA Journal

Feb/March 2003Feb/March 2003

http://www.cdafoundation.org/journal

Putting into practice Putting into practice the results of many the results of many years of research. years of research.

“Caries Management “Caries Management

by Risk Assessment”by Risk Assessment”

October, November October, November 2007. On line, free2007. On line, free

California Dental California Dental Association Journal Association Journal

based upon the based upon the “Caries Balance”“Caries Balance”

http://www.cdafoundation.org/journal

The Caries ImbalanceThe Caries Imbalance

Protective

Factors• Saliva

• Fluoride, Ca, P

• Antibacterials

No CariesCaries Progression

Risk Factors

• Acidogenic

bacteria

• Frequent

carbohydrates

•Sub-normal saliva

Disease Indicators

• Cavities/dentin

• Enamel lesions

•Restorations < 3 yr

• White spots

Featherstone, Young, Wolff, 2007

Barriers to CAMBRA ImplementationBarriers to CAMBRA Implementation

�� Up front cost to patientsUp front cost to patients

�� Lack of insurance coverageLack of insurance coverage

�� Practitioners and patients do not have Practitioners and patients do not have therapeutic measures in their mind as part of therapeutic measures in their mind as part of the treatment planthe treatment plan

�� Insufficient trainingInsufficient training

�� Lack of acceptance by traditionally trained Lack of acceptance by traditionally trained

clinicians clinicians -- afraid of the unknownafraid of the unknown

�� Lack of willingness to make the changeLack of willingness to make the change

Caries Risk assessment Caries Risk assessment (Age 6 years and older/adult) (Age 6 years and older/adult) -- 11

1. Disease Indicators = Clinical Observations1. Disease Indicators = Clinical Observations

(a)(a) Visible cavities present Visible cavities present

(b)(b) Caries restored in last 3 yearsCaries restored in last 3 years

(c)(c) Interproximal caries lesions/radiolucenciesInterproximal caries lesions/radiolucencies

(d)(d) White spots on enamel surfacesWhite spots on enamel surfaces

Any one of these signals a bacteria test for MS and Any one of these signals a bacteria test for MS and LBLB

These are all clinical observations that tell us These are all clinical observations that tell us nothing about the cause of the disease nothing about the cause of the disease -- they they indicate presence of diseaseindicate presence of disease


2. Risk Factors (Biological determinants of caries risk)2. Risk Factors (Biological determinants of caries risk)

(a)(a) MS and LB medium or high MS and LB medium or high -- by cultureby culture

(b)(b) Visible heavy plaque on teethVisible heavy plaque on teeth

(c)(c) Frequent (greater than 3 times) between meal snacks of Frequent (greater than 3 times) between meal snacks of sugars/cooked starchsugars/cooked starch

(d)(d) Deep pits and fissuresDeep pits and fissures

(e)(e) Recreational drug useRecreational drug use

(f)(f) Inadequate saliva flow (less than 0.5 ml/min) Inadequate saliva flow (less than 0.5 ml/min)

(g)(g) Saliva reducing factors: 1) medications, 2) radiation to the Saliva reducing factors: 1) medications, 2) radiation to the head and neck, 3) systemic reasons, e.g. Sjogren’s head and neck, 3) systemic reasons, e.g. Sjogren’s syndromesyndrome

(h)(h) Exposed tooth rootsExposed tooth roots

(i)(i) Orthodontic appliances present Orthodontic appliances present


3. Protective Factors3. Protective Factors

(a)(a) Lives/works/school in community with fluoridated waterLives/works/school in community with fluoridated water

(b)(b) Uses fluoride toothpaste once dailyUses fluoride toothpaste once daily

(c)(c) Use fluoride toothpaste at least twice dailyUse fluoride toothpaste at least twice daily

(d)(d) Uses fluoride rinse/gel dailyUses fluoride rinse/gel daily

(e)(e) Uses 5000 ppm F toothpaste dailyUses 5000 ppm F toothpaste daily

(f)(f) Fluoride varnish in last 6 monthsFluoride varnish in last 6 months

(g)(g) Office F topical in last 6 monthsOffice F topical in last 6 months

(h)(h) Chlorhexidine rinse prescribed/used daily for 1 week every Chlorhexidine rinse prescribed/used daily for 1 week every month last 6 monthsmonth last 6 months

(i)(i) Xylitol gum/candies 4 times daily last 6 monthsXylitol gum/candies 4 times daily last 6 months

(j)(j) Calcium/phosphate paste last 6 monthsCalcium/phosphate paste last 6 months

(k)(k) Saliva flow visibly adequate or > 1 ml/min by testSaliva flow visibly adequate or > 1 ml/min by test

Caries Risk AssessmentCaries Risk Assessment (Age 6years (Age 6years -- adult)adult)--5 5

4. Bacterial test for high risk individual as a baseline measure

5. Count the yes’s. Assess caries risk and circle risk as extreme, high, moderate or low

6. Treatment Plan

Includes home care, office preventive treatments and restorative work

7. Home Care Recommendations

8. Recall and Re-assessment of Caries Risk

Extreme Caries Risk IndividualsExtreme Caries Risk Individuals�� High Risk plus severe hyposalivation. Measure High Risk plus severe hyposalivation. Measure

saliva flow rate (less than 0.5 ml/minute)saliva flow rate (less than 0.5 ml/minute)

�� Same as for high risk individuals PLUS:Same as for high risk individuals PLUS:

�� Baking soda rinse 4x daily (2 teaspoons in 8 ounces Baking soda rinse 4x daily (2 teaspoons in 8 ounces water)water)

�� Consider fluoride trays for home use (1.1% neutral Consider fluoride trays for home use (1.1% neutral sodium fluoride gel) dailysodium fluoride gel) daily

�� Consider calcium phosphate home use gelConsider calcium phosphate home use gel

�� Recall 3 months and repeat F varnish etc.Recall 3 months and repeat F varnish etc.

Caries Risk (Age 6 yearsCaries Risk (Age 6 years--Adult):Adult):--Patient RecommendationsPatient Recommendations

�� Daily oral hygiene. Daily oral hygiene. FluorideFluoride--containing toothpastecontaining toothpaste

�� DietDiet. Limit between meal snacks, limit sodas.. Limit between meal snacks, limit sodas.

�� FluorideFluoride. Increase stepwise depending on risk level. . Increase stepwise depending on risk level.

(1) Toothpaste 2x daily, (2) F rinse (0.05% sodium fluoride) daily, (1) Toothpaste 2x daily, (2) F rinse (0.05% sodium fluoride) daily, (3) 5,000 ppm F dentifrice/gel nightly. Consider fluoride (3) 5,000 ppm F dentifrice/gel nightly. Consider fluoride varnish.varnish.

�� Sugar free gum/candy.Sugar free gum/candy. Xylitol containing gum/candy, 4x daily.Xylitol containing gum/candy, 4x daily.

�� Antibacterial rinseAntibacterial rinse. Chlorhexidine gluconate (0.12%) once . Chlorhexidine gluconate (0.12%) once daily for one week every month for 6 months. daily for one week every month for 6 months.

�� For Dry Mouth (EXTREME RISK)For Dry Mouth (EXTREME RISK). Baking soda toothpaste with . Baking soda toothpaste with fluoride, xylitol gum, rinse frequently with baking soda fluoride, xylitol gum, rinse frequently with baking soda suspension in water (2 teaspoons/250 ml water).suspension in water (2 teaspoons/250 ml water).

Caries Risk assessment Caries Risk assessment (Age 6 years and older/adult)(Age 6 years and older/adult)--44

�� TestsTests

(a)(a) Stimulated Stimulated saliva flow ratesaliva flow rate is measured by chewing is measured by chewing and spitting for 3and spitting for 3--5 minutes (timed). Amount (in ml) 5 minutes (timed). Amount (in ml) divided by time = rate (ml/min). Less than 0.7 divided by time = rate (ml/min). Less than 0.7 ml/min is low and , less than 0.5 ml/min is dry.ml/min is low and , less than 0.5 ml/min is dry.

(b)(b) Bacteria testing by the CRT (Caries Risk Test, from Bacteria testing by the CRT (Caries Risk Test, from Vivadent, Amherst, NY) or Dentocult Vivadent, Amherst, NY) or Dentocult (www.edgedental.com). Use selective media sticks (www.edgedental.com). Use selective media sticks for mutans streptococci and lactobacilli. Incubate for mutans streptococci and lactobacilli. Incubate 72 hours and read as low medium or high.72 hours and read as low medium or high.

(c)(c) Follow up with repeat tests at 3Follow up with repeat tests at 3--6 months until 6 months until stablestable

Vivadent Test Strips. Used to measure mutans

streptococci and lactobacilli bacterial challenge level.

HighLow

Mutans

streptococci

Lactobacilli

What is the Caries Risk of What is the Caries Risk of this Individual?this Individual?

15 year old female15 year old female�� No new caries lesions in the last 5 yearsNo new caries lesions in the last 5 years

�� No symptoms of salivary dysfunction No symptoms of salivary dysfunction (dry mouth), no medications with (dry mouth), no medications with salivary side effects salivary side effects

�� Assume low cariogenic bacteria levelsAssume low cariogenic bacteria levels

�� Not a frequent snackerNot a frequent snacker

Low Risk PatientLow Risk Patient

Protective Factors• No new caries in 5 years

• Saliva normal

• Fluoride, calcium, phosphate

- remineralization:-

• 2 x daily F toothpaste

• Antibacterials:- No need

No CariesCaries


• Low Acid-producing bacteria

• Saliva normal

• Carbohydrates o.k.

X

Therapy for Low Caries Risk Therapy for Low Caries Risk IndividualIndividual

15 year old female15 year old female

�� Maintain 2 x daily fluoride toothpaste brushing Maintain 2 x daily fluoride toothpaste brushing

and other habits. and other habits.

�� Recall 12 months.Recall 12 months.



• Remineralization:

•Fluoride, calcium, phosphate



No CariesCaries






function

What is the Caries Risk of this What is the Caries Risk of this Individual?Individual?

19 year old female19 year old female�� Several radiographic lesions into dentinSeveral radiographic lesions into dentin

�� Symptoms of salivary dysfunction (dry Symptoms of salivary dysfunction (dry mouth), taking antimouth), taking anti--anxiety medication, and anxiety medication, and major analgesic daily for three years.major analgesic daily for three years.

�� Risk assessment signals to do a bacteria test Risk assessment signals to do a bacteria test --

medium LB and medium MSmedium LB and medium MS

�� Admits to being a frequent snacker Admits to being a frequent snacker

High/Extreme Risk High/Extreme Risk PatientPatient

Protective Factors•Fluoride - remineralization

F Toothpaste once daily only

Minimal calcium, phosphate

• Antibacterials:- none used

No Caries

Caries

X

High Risk PatientHigh Risk PatientProtective Factors

• Office applied Topical Fluoride

• Chlorhexidine 10 ml daily one

week a month for 6 months

• Brush with high 5000 ppm F

toothpaste daily - enhance

remineralization

• Xylitol gum daily

•Consider MI paste

• Recall 3 or 6 months

No New Caries

CariesOn Hold

Caries risk assessment procedures and treatments for

children aged 0-5 years, can be

accessed in the October 2007 CDA JournalRamos-Gomez et al.,

www.cdafoundation.org/journal

1.1. Modification of the oral flora Modification of the oral flora

2.2. Patient educationPatient education

3.3. Remineralization of nonRemineralization of non--cavitated lesions of enamel cavitated lesions of enamel

and dentin and dentin

4.4. Minimal operative intervention of cavitated lesions Minimal operative intervention of cavitated lesions

5.5. Repair of defective restorationsRepair of defective restorations

FDI statement 2002FDI statement 2002

Minimal Intervention in the Management of Minimal Intervention in the Management of Dental CariesDental Caries

Minimally Invasive DentistryMinimally Invasive Dentistry

� The basic principle is to preserve as much of the natural tooth structure as possible while at the same time encouraging remineralization of early lesions to inhibit further progression.

� Maintaining a balance between caries pathological and protective factors is the key to success and the oral health of the patient

Featherstone, April, 2004

Conservative Caries Conservative Caries Management by the Dental Management by the Dental

TeamTeam�� Detect caries lesions early enough to Detect caries lesions early enough to

reverse or prevent progressionreverse or prevent progression

�� Assess caries risk Assess caries risk

�� Use fluoride and/or antibacterial Use fluoride and/or antibacterial therapy based on observationstherapy based on observations

�� Use minimally invasive restorative Use minimally invasive restorative

procedures to conserve tooth procedures to conserve tooth structurestructure

It is an uphill struggle to get faculty, students and

practitioners to accept the practical application of the

“caries balance” and caries management by risk

assessment, BUT it works and patients are grateful

Documents

What is Dental Caries? - Conference Innovators featherstone... · 2010-03-23 · Dental caries is a transmissible bacterial iinnfefecctitioonn Protective Factors “White spot”