DIAGNOSIS, TREATMENT PLANNING, AND CASE CONSULTATION IV “Caries Risk Assessment, Caries Detection and Treatment Planning”

Caries Risk Assessment Caries Risk Assessment is a determination, based on factors that contribute to caries development, that there is probability that the child will develop caries lesions over a specified period of time. Assessing caries risk serves as a basis for determining the number and types of preventive procedures that should be treatment planned for the child. Additionally, it helps to determine the frequency of periodic oral examinations, that is, recall appointments. Caries Risk Assessment is a vital component of ofcaries management and treatment planning.

Factors Contributing to Dental Caries Genetic and Biological Factors Social Environment Physical Environment Health Behaviors Dental and Medical Care

Caries Risk Assessment Fisher-Owens, et al., Influences on Children’s Oral Health: A Conceptual Model. Pediatrics 2007;120(3):e510-e520

Children at Low Risk No carious lesions in the last year Coalesced or sealed pits and fissures Low plaque scores on Oral Hygiene Index (OHI), that is, good oral hygiene. Fluoridated water usage Use of fluoride dentifrice History of periodic oral examinations

Moderate Caries Risk One carious lesion in the last year Deep pits and fissures Oral Hygiene Index (OHI) score of teeth indicates that there is a modest level of plaque accumulation on the teeth Inadequate fluoride usage White spots lesions of initial demineralizations Irregular periodic oral examinations/recall visits Orthodontic appliances in the mouth

High Caries Risk Two or more carious lesions in the last year History of smooth surface lesions Deep pits and fissures No exposure to fluoridated water No history of topical fluoride applications Oral Hygiene Index Scores indicating major accumulation of plaque on teeth Frequent sugar intake Irregular periodic oral examinations Inappropriate bottle feeding habits.

Socio-cultural-behavioral Factors Associated with Higher Risk Low SES status; Children from families receiving Medicaid benefits are at high risk for dental caries Parents poor oral health status Lower level of educational attainment by parents. Children without dental insurance Children who live in areas where access to dental care is challenging Children from ethnic minority populations Children with special health care needs (CSHCN)

Preventive Modalities to Address Caries Risk Education on Causes and Prevention of Dental Caries Oral Physiotherapy Instructions: Brushing and Flossing Dietary Counseling Periodicity (Frequency) of Dental Visits Fluoride Exposure: Systemic and Topical Pit and Fissure Sealants Xylitol Use Antimicrobial Agents: Chlorhexidine Improved Access to Professional Dental Care

International Caries Detection and Assessment System (ICDAS) In an attempt to standardize how dental caries is diagnosed an international committee of experts in dental cariology was convened in 2005 to develop a valid and reliable means of detecting and assessing caries—diagnosing. It was sponsored by the National Institute of Dental and Craniofacial Research of the National Institutes of Health (NIH), the American Dental Association, and the International Association for Dental Research Website: www.icdas.org

ICDAS Coding Code 0: Sound Enamel Code 1: First Visual Change in Enamel Code 2: Distinct Visual Change in Enamel Code 3: Localized Enamel Breakdown Code 4: Underlying Dark Shadow from Dentin Code 5: Distinct Cavity with Visible Dentin Code 6: Extensive Distinct Caries with Visible Dentin

UNDERLYING GREY SHADOW International Caries Detection and Assessment System 1W Detection system: Each of the 7 scICIiiiDASores are illustrated with an example 2W 1B 2B 1W SOUND Score OPACITY with air-drying: WHITE, BROWN Scores 1 OPACITY without air-drying: WHITE, BROWN SURFACE INTEGRITY LOSS UNDERLYING GREY SHADOW DISTINCT CAVITY EXTENSIVE CAVITY Scores 2 Score 3 Score 4 Score 5 Score 6 Sound Ekstrand et al., (1997) modified by ICDAS (Ann Arbor), 2002 and again in 2004 (Baltimore)

Caries Detection is Primarily by Observation Caries detection is by OBSERVATION on first a wet tooth and then a dry tooth. An explorer is not used to detect caries If there is uncertainty as to whether there is a distinct cavitation that would require restoration, a World Health Organization (WHO) Probe is used to examine the potential defect. Also referred to as a CPI probe.

The World Health Organization (WHO) Probe The WHO (CPI) probe has an 0.5 mm ball on the end. This prevents cavitation of demineralized (white spot) enamel which can occur with the use of an explorer.

Explorer Use Using a sharp explorer to diagnose dental caries can result in a number of false positives. One example of this is the wedging of an explorer between the walls of an occlusal fissure, thus detecting a “stick”…but not a carious lesion, as has frequently been assumed. It is now also well-documented through using scanning electron microscopy that a sharp explorer can actually cavitate a white spot lesion that could have otherwise been remineralized. Additionally, using an explorer in moving from tooth to tooth can inoculate a caries free tooth with bacteria from a tooth that was previously examined with the explorer that was carious. Explorers continue to be valuable in dental restorative dentistry, but NOT for diagnosing dental caries.

Iatrogenic Cavitation of White Spot Lesions with a Dental Explorer

Advantages of A Treatment Plan Diagnostic decisions are made at one time; thus avoiding “rediagnosing” each appointment. Valuable chair time is saved as the dentist already knows what is to be done and can begin immediately. Permits the receptionist to arrange a series of appointments of the correct length. Permits the dental assistants to prepare the required instruments and materials ahead of time. Provides a basis for developing a case consultation with the parent…an imperative!

Components of a Treatment Plan Appointments Required Tooth/surface/procedures/appointment Time scheduled/appointment Fee/Appointment ADA Code/procedure

TREATMENT PLANNING FORM

Variables in Treatment Planning Patient Management: It is wise to begin with simple, shorter procedures and move to the more complex and time-consuming ones. Urgency: Some treatment must be performed as soon as possible to prevent further complications from developing.

Variables in Treatment Planning (continued) Convenience: Completing quadrants of work at one time is sound economics and is easier to accomplish when compared to a single tooth approach. Prerequisite Treatment: Occasionally one procedure must be accomplished before another can be performed. This must be provided for in the treatment plan.

Guidelines in Treatment Planning The ability to design rational operational treatment plans is developed through experience. These guidelines (not rules) should prove helpful in gaining wisdom.

Guidelines Provide apprehensive children with one brief, relatively easy restorative experience before challenging them with longer, more difficult, procedures. Plan by quadrant, finishing one quadrant before proceeding to the next. One can exercise better control over the child during anesthesia when treating the left quadrants, if right-handed. Begin on this side, all other things being equal, particularly with the child with questionable levels of cooperation.

Guidelines (continued) Mandibular block injections provide anesthesia for both the labial and lingual soft tissues, thus reducing the potential for unintended pain/discomfort. Anesthetizing maxillary quadrants generally requires more penetrations of the mucosa, and frequently a palatal injection. All other things being equal, start in the mandibular.

Guidelines (continued) Treat the most urgent needs first. Give special attention to sequencing extractions and space management appliances. Usually the bands should be adapted and impressions made the appointment before the extraction(s) in order that the appliance can be placed immediately.

Guidelines (continued) Within the constraints of other guidelines, reserve treating the maxillary anterior area until last. Anesthesia in this area is difficult to administer without some discomfort. Accomplish as much of the treatment required in a quadrant at one time, thus reducing the number of appointments and injections required.

Guidelines (continued) Plan for the worst and hope for the best. It is then reasonable to expect you can remain faithful to the treatment plan. If it is not possible to determine which treatment will be most appropriate until initiating treatment, plan for the more extensive and expensive one. Parents will never object to the deletion of treatment, but may become skeptical with additions in the course of therapy.

Guidelines (continued) Adhere to the treatment plan to the extent possible. Your assistant is also following the treatment plan and preparing instrument trays and the operatory accordingly. Arbitrary deviations create confusion at the beginning of an appointment; wasting time, potentially creating friction, and detracting your attention from the child.

Guidelines (continued) Complete treatment with a favorable experience for the child. A Post Treatment Appointment to polish restorations, reinforce preventive strategies, and to evaluate the treatment provided and its success in achieving the original goals of therapy meet this requirement well.