Patient-Centered Explanation of Risk-Based Treatment

1. Patient-Centered Explanation of Risk-Based Treatment Tooth Decay

2. Tooth Decay Defined • An infection caused by bacteria commonly found in the mouth that destroys the tooth • The bacteria are transmissible from parent or caregiver to child, child to child, and adult to adult • The disease has many factors and many stages

3. Development of enamel decay Decay arrested Experimental Decay • No oral hygiene • Rinse 9x/day with • 50% sucrose solution • Regular oral hygiene • Fluoride use 0 days 21 days 51 days Timeline • Proof that: • bacteria causes decay • sugar increases risk • oral hygiene can prevent decay von der Fehr et al 1970

4. Stages of Decay • The disease process begins with an infection, advances to demineralization, and ends with a cavity • The process does not progress at a uniform rate but is cyclic and intermittent • Demineralization occurs when decay-causing bacteria produce acids from food

5. Demineralization Remineralization Cyclic Process of Decay Bacteria plus food makes the saliva very acidic within 5 minutes Saliva is normal 30 minutes after eating

6. Tipping the Balance Remineralization Demineralization Cavity • Infrequent or inadequate tooth cleaning • Frequent meals and snacks • Large amount of decay causing bacteria • Deficient fluoride in saliva

7. Decay Progression Progression of 72 white spot lesions followed for 7 years Backer-Dirks 1966

8. Diagnosis of Decay None of these methods can detect all lesions early enough to implement treatment to reverse the disease process

9. 0 1 hour ? years 30 years Time line Occurrence of Symptoms Heart Attack Anaphylactic Shock Toothache • Each symptom occurs at the end of the colored bar • Each disease process is invisible to diagnostic methods • for most or all of the time within the colored bar • Risk predicts chronic disease occurrence

10. The Early Stages of Decay are Indistinguishable from Health Disease State Cavity Decalcification Health

11. Risk Defined • Risk is a prediction that disease will occur or progress • Risk is distinct from disease and cannot be accurately predicted from the disease state • Risk is determined by risk factors

12. Risk-Based Treatment Disease State Cavity Decalcification Health

13. Repair and Prevention Disease State Cavity Decalcification Health

14. Fillings • Fillings have no measurable effect on decay-causing bacteria present on tooth surfaces • Fillings have a finite life span and where each replacement filling leaves less tooth structure • Fillings increase the risk of an abscess • Fillings may increase the risk of tooth fracture and gum disease

15. Prevention • Preventive treatment can be effective at any time and age • A diagnosis of decay could be indicative that additional lesions not yet visible exist • Apparently healthy teeth might be in the early undetectable stages of decay • Risk assessment can identify when risk is high and preventive treatment is beneficial

16. Tooth Decay Risk • Tooth decay risk varies between individuals and over time coincident with a change in risk factors • The highest decay-susceptible time is the first 2 years after tooth eruption, but can be high at any time

17. Determining Risk and Treatment

19. Supplemental andNew Diagnostic Methods • Plaque Formation Rate (PFRI) • Salivary level of mutans streptococci (SM) • New Diagnostic Methods • Digital X-rays • Fiber-optic transillumination (FOTI) • Laser fluorescence (LF) • Electrical conductance (EC) • Ultrasound

20. Plaque Formation Rate Amount of new plaque accumulated in 24 hours following tooth cleaning where patient refrains from oral hygiene Axelsson 1991

21. Caries Risk Based on SM and PFRI Axelsson 1991

22. New Diagnostic Methods • Very little clinical data are available to validate these technologies • Goal is better accuracy over traditional methods to detect true cavities that should be filled • Goal is detection of currently “invisible” lesions that are in a state of dynamic decalcification and recalcification • Enhances risk assessment and application of preventive treatment

23. Preventing Tooth Decay • Reduction of decay-causing bacteria • Health promoting dietary practices • Exposure to fluoride • Sealing susceptible tooth defects • Proper frequency of dental visits

24. Reducing Decay-Causing Bacteria • Personal teeth cleaning • Twice daily tooth brushing and flossing or an equivalent aid for between the teeth • Antibacterial rinses (chlorhexidene) • Rinse with 10 ml for 1 minute at bedtime for 2 weeks repeating the cycle 2 months later • Fluoride toothpaste • Treat all family members

25. “Teeth Cleaned” Clarified • All tooth surfaces including between teeth • About half of all decay affects the tooth surfaces of adjacent teeth where a tooth brush and oral rinse does not reach • The equivalent of not cleaning between teeth is washing the palm and back of your hands but not between your fingers • Rinsing hands with water is not an effective alternative to scrubbing with soap

26. Dietary Practices • Foods that are especially harmful contain sugars like sucrose, glucose, and fructose, cooked starch, and other carbohydrates • Eat and drink no more than 3 meals and 3 snacks per day • Sugar-free gum and mints, especially those that contain xylitol can be beneficial

27. Fluoride • The incorporation of fluoride into developing enamel inhibits tooth decay, however its primary effectiveness occurs by its concentration in plaque and saliva to inhibit demineralization and enhance remineralization • Fluoride inhibits plaque bacteria

28. Fluoride, cont. • Fluoride is released from dental plaque during the acidic conditions of eating • Released fluoride combines with calcium and phosphate to create a more decay-resistant enamel crystal structure • Fluoride is available in water, toothpaste, over-the-counter rinses, prescription toothpaste and rinses, professional gels, foams, and varnishes

29. Fluoride, cont. • Fluoridated toothpaste should be used twice daily • Professional applications of fluoride is based on risk • High-risk patients should have this done 2 to 3 times per year • More fluoride is not necessarily better, especially for children younger than 6 years as fluorosis can affect cosmetically visible developing teeth

30. Tooth Sealants • Plastic coating bonded to the biting surfaces of the back teeth • Susceptible tooth defects should be sealed regardless of age

31. Frequency of Dental Visits • Twice annual professional tooth cleaning as the sole method to prevent cavities is unlikely to be effective especially when risk is high • Frequency of dental visits can be increased for closer monitoring of oral hygiene and dietary practices in addition to applying fluoride and sealants

32. Dealing with Objections • Prevention doesn’t work • Studies have shown that more than 90% of tooth decay can be prevented • Prevention is only for the young • Studies have shown that prevention works at any age • The benefits of prevention take many years • The benefits are immediate as prevention heals the invisible lesions

33. Objections, cont. • It costs too much; My insurance doesn’t cover it • Filling cavities costs more than preventing them • Cavities can result in a root canal, cap, or extraction • Dentures could ultimately cost more than “saving” your teeth • Insurance doesn’t care if you have dentures • Dentures are OK • Dentures, especially lower ones, are not always successful, which then requires implants

34. Objections, cont. • Flossing is too hard; no time to floss • Tying shoelaces for a child is difficult but they learn the skill • Flossing takes only a minute or two after the skill is learned • Fillings prevent decay • Fillings have no effect on decay-causing bacteria and hence do not reduce the risk of having more cavities