Preventive management of root caries

Question 1

Where are root caries found?

Answer 1

• Root caries is located on the root surface
• Due to the root having less mineralised materials, root caries spread very easily
• Gingival recession is frequently associated with root caries, though some lesions are found subgingivally
• Usually found more commonly where salivary glands are absent: maxillary anterior, mandibular molars

Question 2

Discuss aetiological factors surrounding root caries, mentioning the critical pH of dentine

Answer 2

• Cariogenic biofilm that is regularly supplied with fermentable carbohydrates
• Root caries is faster progressing than enamel caries due to the less mineral content
• Critical pH for enamel demineralisation is 5.5 but for dentine it is 6.2
• The collagen in dentine is readily broken by the enzymes produced by bacteria

Question 3

List some risk factors associated with root caries

Answer 3

• Age: people are living longer with more tooth retention. Nursing home residents
• Periodontal disease because this results in gingival recession
• Decreased saliva function, mainly due to medications
• Wearing partial dentures
• Huge alcoholic intake or smoking tobacco (through modifying oral bacteria)
• Unemployed/ retired people
• Patients with cognitive issues
• Altered diets with high carbohydrates
• Low functional ability like arthritis = low ability to partake in OH
• Irregular dental attendance due to either mobility or decreased income

Question 4

Differentiate the microbes found in culturing methods vs the microbes found through molecular technology.

Answer 4

Cultures
• Staphylococcus
• Streptococcus
• Pepto streptococcus
• Candida ssp

Molecular techniques
• Actinomyces
• Lactobacillus
• Pseudoramibacter 
• S mutans

Question 5

State how root caries are diagnosed

Answer 5

• Colour, texture, surface smoothness, depth, distinctive border
• Bitewings
• Use the side of the probe/ explorer to feel defects
• Inactive lesions: smooth, shiny, hard and dark
• Active lesions: Plaque covered, soft, pale colour

Question 6

List the four steps involved in preventive management

Answer 6

Identify and control risk factors

Remineralise

Restore if required

Prevention and recall

Question 7

Explain the step of “identifying and controlling risk factors”

Answer 7

Risk factor: biofilm
• OH: electric toothbrush, ID cleaning, air floss or waterpik
• Leave dentures out at night

Risk factor: Sugar substrates
• Improve diet and eating patterns

Risk factor: saliva
• Check if meds can be changed with GP to improve saliva
• Limit intake of diuretics
• Drink water
• Encourage them to eat chewy foods
• Eat xylitol containing sweets
• Use a bicarbonate with water as a mouth rinse to increase pH

Question 8

Explain the step of remineralisation

Answer 8

Once roots are exposed, plaque control is essential to enable remineralisation. Applying 5000PPM Fl- has reversed root caries

Remineralising agents:
• Silver Diamine Fluoride
• Arginine containing toothpastes 
• Duraphat
• Chlorhexidine 
• Fuji VII

Question 9

Describe the mechanism of silver diamine fluoride

Answer 9

• Alkaline solution with contain silver nitrate and sodium fluoride
• Silver is antimicrobial. It reduces growth of cariogenic bacteria
• Remineralise dentine
• Prevents collagen degradation by inhibiting the action of collagenases and cathepsins

Question 10

Describe the mechanism of arginine containing toothpastes

Answer 10

• Contains arginine an amino acid
• This is metabolised by plaque bacteria and ammonia is released
• Ammonia helps neutralises plaque acids and pH
• Not as great as SDF, CH or Fl

Question 11

List considerations associated with the remineralisation step

Answer 11

Considerations
• Sodium laurel sulphate inactivates chlorhexidine
• Chlorhexidine works better on a plaque free surface
• Chlorhexidine works great with Fluoride
• Stannous Fluoride stains demineralised lesions
• Acidulated phosphate fluoride (APF) can dissolve CR, CIG and porcelain restorations

Question 12

Explain the step of restoring and its challenges

Answer 12

• Shallow: Smoothen out lesion, polishing and slight recontouring with home care can arrest lesions
• Lesions progress rapidly because of low mineral content. The margins of the lesion finish in areas that are difficult to access
• It is impossible to adequately isolate and it is difficult to determine whether adequate caries removal is achieved
• Restoration placement and retention is challenging

Question 13

Explain the step of prevention and recall

Answer 13

• Reinforce OHI/ denture hygiene
• Reinforce diet
• Check saliva flow
• Regular recalls with professional cleaning and fluoride/ CHx varnish
• Check integrity of restorations