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

2. 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.

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

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

5. 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

6. 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

7. 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.

8. 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)

9. 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

10. 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:

11. 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

12. 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)

13. 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.

14. 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.

15. 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.

16. Iatrogenic Cavitation of White Spot Lesions with a Dental Explorer

18. 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!

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

20. TREATMENT PLANNING FORM

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.