Clinical Trends In The Diagnosis And The Treatment Of Dental Caries dr shabeel pn

LOW RISK PATIENT No cavitated lesions May have inactive white spots (smooth shiny). Bacteria MS levels are low Diet is normal sugar levels low Normal Saliva levels Low DMF (Hx)

MODERATE RISK PATIENT No cavitated lesions Some active white spot lesions (rough/chalky) Bacterial MS levels elevated Moderate sugar use Saliva normal or reduced (xerostomia) Moderate DMF (Hx)

HIGH RISK PATIENT One or more cavitated lesions May have white spot lesions (active or inactive) Bacterial MS levels are very high Sugar intake very high Saliva levels low (xerostomia) High DMF (Hx)

1. Bacterial Control A. Surgical Antimicrobial Tx Treat cavitated lesions first. Fill with glass ionomer, compomer, composite or IRM. Very large lesions may require temporary crowns (sub-gingival margins),RCT, or EXT. Place sealants as needed: Occlusal surfaces with chalky white spots Deep grooves and Old fillings with poor margins Molars > Premolars Surgical choices based on Site(pit & fissures vs. smooth surface), Activity and Risk.

Treatment Plan Medical Model Bacterial Control Surgical Antimicrobial Tx (Restorations) Wound debridement / I&D = Fill/Temporize cavitated lesions/Place sealants Chemotherapeutic Antimicrobial Tx(meds) Fluoride Varnish, CHX, and Xylitol Gum Reduce Risk Level of At-Risk Patients Reverse Active Sites = Remineralization Long Term Follow Up and Maintenance Home maintenance Office Recall/Continuing Care Heal Vs.Cure (Process/Relationship)

1. Bacterial Control A. Surgical Antimicrobial Tx Treat cavitated lesions first. Fill with glass ionomer, compomer, composite or IRM. Very large lesions may require temporary crowns (sub-gingival margins),RCT, or EXT. Place sealants as needed: Occlusal surfaces with chalky white spots Deep grooves and Old fillings with poor margins Molars > Premolars Surgical choices based on Site(pit & fissures vs. smooth surface), Activity and Risk.

1. Bacterial Control B.Chemotherapeutic Antimicrobial Tx Fluoride Varnish 1-3 initial applications upon completion of Surgical Tx. Use 3 applications in 10 day period for patients who need remineralization or for patients with CHX issues or compliance problems (possible use of Iodine rinse). CHX = Chlorhexidine Rinse 0.12% take ½ oz. before bed for 2 weeks. Repeat in 2-3 months Xylitol Gum. Use 2 pieces for 5 minutes minimum 5 times a day. Mutans Test for Very High Risk patients

2. Reduce Risk Levels of At Risk Patients Reduce Sugar !!!!!!!!!!!!!!!!! (Xylitol/Sucrose substitutes) Reduce Bacteria (antimicrobials, Xylitol gum, and OHI) and MS test PRN. Increase Saliva (Xylitol gum and mints, Rinses, change medications if possible). Increase Home Fluoride use.

3. Reverse Active Sites Remineralization Tx In Office – Fluoride varnish 3 applications in 10 day period (if not done as a part of Step 1B) At Home – Fluoride Moderate or High Risk Patient: Toothpaste (1000 ppm) qd + 5000 ppm dentifrice or gel qd +OTC (over the counter) rinse 250 ppm several times a day especially hs. Very High risk Patient: Toothpaste 5000 ppm dentifrice or gel qd + 5000 ppm dentifrice or gel in a tray qd +OTC (over the counter) rinse 250 ppm several times a day especially hs. Xylitol gum: 2 pieces 5 times a day. Calcium Source: Cheese or new gums with amorphous Calcium Phosphate.

4. Long Term Follow Up A. Home Maintenance At Home – Fluoride Moderate or High Risk Patient: Toothpaste (1000 ppm) qd + 5000 ppm dentifrice or gel qd +OTC (over the counter) rinse 250 ppm several times a day especially hs. Very High risk Patient: Toothpaste 5000 ppm dentifrice or gel qd + 5000 ppm dentifrice or gel in a tray qd +OTC (over the counter) rinse 250 ppm several times a day especially hs. Xylitol gum 2 pieces 5 times a day. Decreased use of sucrose between meals Calcium Source.

4. Long Term Follow Up B. In Office Continuing Care 3 Month Visit Polish (If this is also a 3 mo perio maint patient do perio probing/scaling first) Exam / evaluate white spots for remineralization / return to steps 1-3 PRN (D0140) Fluoride varnish (D1204) 6 Month Visit (3 months later) PSR or Perio Probing / Scaling / Polish Exam / evaluate white spots for remineralization / return to steps 1-3 PRN (D0120) 9 Month Visit (3 months later) 1 Year Visit (3 months later) Bite wing + other x-rays PRN Exam / Evaluate Activity Levels I.e. white spot and interprox x-rays (D0120) Exam / Evaluate Risk Level for next years CC schedule (Low Risk 6mo CC / Moderate or High risk 3mo CC if active: 6mo CC if inactive/ Very High Risk 3mo CC)

Treatment Groups by Risk/Activity Status. Low Risk (LR) Moderate Risk Inactive (MRI) Moderate Risk Active (MRA) High Risk Cavitated (HRC) High Risk Cavitated Active (HRCA) High Risk Inactive (HRI) Very High Risk (VHR)

6 + 3 2 1 ++ 12 TREATMENT GROUP # Home Fluoride Low Risk LR Filling Temp Cr Seal # 1st FLV Per Yr CHX Xylitol CC Interval Months Remin Ca Home Fluoride Low Risk LR 6 1000 ppm Paste Moderate Risk Inactive MRI + 5000 ppm Paste + Rinse Active MRA 3 2 High Risk Cavitated HRA 1 Cavitated Active HRCA HRI Very High Risk VHR ++ 12 In a Tray