Caries Risk Assessment

Question 1

How is risk assessed in caries?

Answer 1

Caries are managed by a risk assessment which takes an evidence based approach to prevent or treat the cause of dental caries at any early stages rather than waiting for irreversible damage.

Question 2

What are indicators of dental caries?

Answer 2

White spot lesions

Restorations placed in the last 3 years

Proximal caries confined to enamel

Cavitation of caries into dentine

Question 3

What are the risk factors for dental caries?

Answer 3

Cariogenic bacteria

Absence of saliva

Lifestyle habits that contribute to the disease

Question 4

What does the caries risk management form used at UWA dental school ask about?

Answer 4

Modifying risk factors

Diet analysis

Fluoride history

Caries experience

Plaque score

Salivary and bacterial clinical tests

Question 5

What kinds of medications cause xerostomia?

Answer 5

Prescribed meds

Over the counter meds

Recreational drugs

Question 6

What kinds of systemic disease cause dry mouth?

Answer 6

Primarily from diseases such as autoimmune disorders

Secondary by means of the disease management

Question 7

What are some caries modifying factors?

Answer 7

Lifestyle factors including sugar intake, oral hygiene, smoking, and fluoride.

Prostheses increase plaque accumulation and make cleaning more difficult.

Fluoride history (Water supply as well as toothpaste)

PAST EXPERIENCE WITH CARIES IS THE BIGGEST INDICATOR

Question 8

What increases caries prevalence?

Answer 8

Sugary food

Snacking

Milk bottle feeding at night

Carbonated drinks

Question 9

Where can carious lesions arise?

Answer 9

Pit and fissure lesions

Smooth surface lesions

Carious lesion site can be hidden or exposed. Hidden caries are harder to detect and require additional diagnostic imaging.

Question 10

What is dental plaque?

Answer 10

Dental plaque has been defined as the nonmineralized microbial accumulation that adheres tenaciously to tooth surface, restorations and prosthetic appliances, shows structural organization with predominance of filamentous forms, is composed of an organic matrix derived
from salivary glycoproteins and extracellular microbial products, and cannot be removed by rinsing or water
spray

Question 11

What oral hygiene indices are used?

Answer 11

Oral hygieve index (greene and vermiliion)

Simplified Oral Hygiene Index, OHI-S

Silness-Loe Index

Quigely Hein index

Plaque control record (Plaque score)

Question 12

What are the 5 key roles of saliva?

Answer 12

Lubrication and protection

Buffering action and clearance

Maintenance of tooth integrity

Antibacterial activity

Taste and digestion

Question 13

What are the 5 steps of saliva testing?

Answer 13

Step 1: Resting saliva hydration

Step 2: Resting saliva viscosity (watery vs bubbly)

Step 3: Resting saliva pH (Red = acidic, yellow = moderate, and healthy saliva = green)

Step 4: Stimulated saliva quantity (<3.5ml = red, 3.5 - 5.0ml = yellow, and >5.0ml = green)

Step 5: Stimulated saliva buffering capacity

Question 14

How is the strep mutans test done?

Answer 14

Chew the wax, collect saliva

Add 1 drop of reagent

Add 4 drops of reagent 2, shake until saliva sample becomes green

Dispense 3 scales of saliva in the sample window of the test device and wait 15 minutes

After 15 minutes observe the control line C and result in Test window T (positive result - either a faint or clear red line appearing means there are over 500000, negative result - no red line appearing means there are less than 500000 of 5 minutes)

Question 15

What is the caries balance between?

Answer 15

Pathological factors and protective factors.

Pathological factors include acid producing bacteria, frequent eating/drinking of fermentable carbohydrates, sub-normal saliva flow and function.

Protective factors: Saliva flow and components, fluoride (remineralization with calcium and phosphate), and antibacterials

Question 16

What is the evidence for effectiveness of caries management by risk assessment?

Answer 16

Randomised controlled trial conducted from 1999 to 2005.

Examined the concept of the caries balance and whether altering that balance could reduce new dental caries.

Adults aged 18 to 65 y who had 1 to 7 cavities.

Control group was patients who continues with conventional treatment.

Test group had an intervention that consistsed of a combination of fluoride mouth rinse, fluoride toothpaste, and 0.12% chlorhexidine gluconate mouth rinse.

RESULTS:

A statistically significant reduction in 2 year caries increment in initially high-caries-risk patients provided with the combined therapeutic intervention.

Placing restorations did not significantly affect mean bacteria levels in the mouth, either initially or over a 2 year follow-up period after restorative work was complete.

In the control group ~70% of the subjects returned with new cavities.

Question 17

Which bacteria in the mouth were related to a high number of decayed surfaces? What does this tell us about treating caries?

Answer 17

High numbers of decayed surfaces at baseline were correlated to high levels of mutans streptococci and lactobacilli.

Caries reduction was mediated by combined action of changes in salivary bacterial levels and fluoride concentration, as well as additional unmeasured factors.

Question 18

How should low caries risk patients be managed?

Answer 18

Low risk: Recall exams every 6 months, radiograph examinations as necessary, saliva tests at baseline, twice daily toothbrushing using fluoride toothpaste.

Question 19

How should caries moderate risk patients be managed?

Answer 19

Recall exams every 6 months, radiograph examinations as necessary, saliva tests at baseline and recall exam, twice daily toothbrushing using fluoride toothpaste and fluoride varnish application, dental sealant for children under 6 years old.

Question 20

How should caries high risk patients be managed?

Answer 20

Recall every 3 months, radiograph examinations as necessary, saliva tests at baseline and recall exam, twice daily toothbrushing using fluoride toothpaste and fluoride varnish application, antimicrobial mouthwash for one week every month, dental sealant is recommended.

Question 21

How should caries extreme risk patients be managed?

Answer 21

Recall exams every 3 months

Radiograph examinations as necessary

Saliva tests at baseline and recall exam

Twice daily toothbrushing using fluoride toothpaste and fluoride varnish application

Antimicrobial mouthwash for one week every month

Acid neutralising mouthwash

Dental sealant is recommended

Question 22

How should a patient with the following characteristics be treated: 18 year old, loves energy drinks, snacks more than 2 times a day, brushes once a day, and has a dental cavity?

Answer 22

1. Take dental and medical history.
2. Conduct clinical examination.
3. Detect caries lesions early enough to reverse or prevent progression.
4. Assess the caries risk as low, high, moderate, or extreme using data from 1, 2, and 3 and a short questionnaire.
5. Produce a treatment plan that includes chemical therapy appropriate to the caries risk level.
6. Use chemical therapy that includes fluoride and/or antibacterial agents based on risk level.
7. Use minimally invasive restorative procedures to conserve tooth structure and function.
8. Recall and review at intervals appropriate to the caries risk status.
9. Reassess caries risk level at recall and modify the treatment plan as necessary