caries risk assessment and its interaction with preventive and restorative protocols

1. Caries Risk Assessmentand its interaction with Preventive and Restorative Protocols

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?

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

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

9. Categories for Simplified CRA 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

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

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. Categories for Simplified CRA 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

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 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

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.

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.

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

30. Tools needed:

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. Other adjuncts- Magnification Loupes

33. Diagnodent Laser Readings under 10 have no decay. Readings 10-20 usually have stain or enamel caries

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

36. Medium Risk- Initial Protocol Caries Index 3-4 Observe stained pits, deep pits, early decay in enamel. (DD<20).

37. High Risk- Initial Protocol Caries Index >4 Observe stained pits DD<10

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 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)

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 enamel or 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)

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 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.

46. Often high risk kids present with early decay or deep pits in barely erupted teeth.

47. Fluoride-releasing sealants for suspect pits with poor access Fuji Triage can be placed quickly and easily, needing very little cooperation.

51.

57. 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.

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

59. Summary A system of numerically rating a patient�s 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.

60. Thank you Dr. Richard Ehrlich www.elmtreedental.com dre@elmtreedental.com 905-880-7003