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

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Clinical Trends In The Diagnosis And The Treatment Of Dental Caries

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Clinical trends in the diagnosis and the treatment of dental caries l.jpg

Clinical Trends In The Diagnosis And The Treatment Of Dental Caries

Steven Steinberg DDS

May-June, 2004


Low risk patient l.jpg

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)


Moderate risk patient l.jpg

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)


High risk patient l.jpg

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)


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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.


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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)


1 bacterial control a surgical antimicrobial tx7 l.jpg

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.


1 bacterial control b chemotherapeutic antimicrobial tx l.jpg

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


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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.


3 reverse active sites remineralization tx l.jpg

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.


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4. Long Term Follow UpA. 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.


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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)


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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)


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