1. Power Point Slide Catalogue From PreViser Corporation www.previser.com
Risk-Based Treatment for Caries
This slide series explains caries and the application of risk-based concepts for care.

2. Tooth Decay Defined
An infection caused by bacteria commonly found in the mouth that destroys the tooth
The bacteria are transmissible from parent or caregiver to child, child to child, and adult to adult
The disease has many factors and many stages
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3. Experimental Decay Development of enamel decay Decay arrested
No oral hygiene
Rinse 9x/day with
50% sucrose solution
Regular oral hygiene
Fluoride use
Experimental caries in man. FR von der Fehr, H Loe, E Theilade. Caries Research 1970 volume 4 (2) pages 131 – 148.
Enamel decay occurred in 21 days when patients did not practice oral hygiene and rinsed 9 times per day with a 50% sucrose solution. The decay was arrested in 30 days after regular oral hygiene resumed and fluoride was used. This provides proof that bacteria cause decay, sugar increases risk for decay and oral hygiene can prevent decay.
0 days days days
Timeline
Proof that:
bacteria causes decay
sugar increases risk
oral hygiene can prevent decay
von der Fehr et al 1970
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4. Stages of Decay
The disease process begins with an infection, advances to demineralization, and ends with a cavity
The process does not progress at a uniform rate but is cyclic and intermittent
Demineralization occurs when decay-causing bacteria produce acids from food
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5. Cyclic Process of Decay
Demineralization
Bacteria plus food
makes the saliva
very acidic within
5 minutes
Remineralization
Saliva becomes very acidic within 5 minutes of eating. The acid demineralizes the tooth. After 30 minutes the pH of saliva returns to normal. At this time the tooth remineralizes. The presence of fluoride during the remineralization results in fluor-apetite, which is more resistant to decalcification compared to the original tooth structure.
Saliva is normal
30 minutes
after eating
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6. Tipping the Balance Remineralization Demineralization Cavity
Infrequent or inadequate tooth cleaning
Frequent meals and snacks
Large amount of decay causing bacteria
Deficient fluoride in saliva
Caries results when the scale is tipped in favor of demineralization for a sufficiently long time period. The cavity is the irreversible outcome of the caries process. Once caries exists its repair by a restoration is indicated.
Preventative treatment prevents demineralization or enhances remineralization. Neither process is visible using clinical techniques. The effectiveness of preventative treatment is not readily apparent, as this stage of the disease process is invisible. Prevention is immediately beneficial, as the disease process is always occurring and it is possible that some lesions that have nearly reached the irreversible visible stage would reverse and the tooth heal. The realization of its effectiveness cannot be immediately known since the processes are invisible.
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7. Decay Progression
O Backer Dirks, The clinical testing of agents for the prevention of dental caries. Adv Fluorine Res. 1966; 4: 1-2.
Decay does not progress at a uniform rate. In fact over a period of 7 years only 13% of white spot lesions progressed to decay and 50% re-mineralized with the remaining 37% remaining unchanged.
Progression of 72 white spot lesions followed for 7 years
Backer-Dirks 1966
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8. Diagnosis of Decay Health Decalcification Decay Visual
Normal tooth color
White spot
Black or brown
Feel
Hard
Soft
X-Ray
Normal
Black area
Diagnostic techniques are insufficiently sensitive to accommodate all oral health needs. A condition of health is nearly indistinguishable from decalcification. By the time caries is evident prevention cannot be applied effectively and repair is needed.
None of these methods can detect all lesions early enough to implement treatment to reverse the disease process
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9. Occurrence of Symptoms
0 1 hour ? years years
Time line
Heart Attack
Anaphylactic
Shock
Toothache
Disease processes that are chronic take a very long time to develop. Signs and symptoms for chronic disease processes occur late rather than early in the process. Prevention is preferable to waiting for the occurrence of disease. Common chronic disease processes include cardiovascular disease, cancer, periodontal disease, and caries.
Each symptom occurs at the end of the colored bar
Each disease process is invisible to diagnostic methods
for most or all of the time within the colored bar
Risk predicts chronic disease occurrence
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10. Risk-Based Treatment Risk-based treatment prevents disease progression
Disease State
Cavity
Risk-based treatment prevents disease progression
Risk-based treatment prevents disease occurrence
Decalcification
Risk-based treatment prevents the occurrence of disease during the time it is invisible to diagnostic methods and it prevents disease progression for diagnosed lesions.
Health
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11. Prevention maintains a clinically healthy state
Repair and Prevention
Disease State
Cavity
Repair treats the consequences of disease, which may increase the risk of new disease
Prevention maintains a clinically healthy state
Decalcification
Caries is irreversible and requires surgical removal of the lesion and restoration of the lost tooth structure. Prevention interrupts the disease process before the irreversible stage occurs to maintain a clinically health state. The repair of a tooth has little effect on reducing the risk of new caries lesions and may increase the risk. Restorations have little effect on the causes and risk factors for caries. Restorative margins may trap bacteria, restorations may weaken the tooth making it more susceptible to fracture, and trauma to the pulp may result in devitalization and an abscess.
Health
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12. Fillings
Fillings have no measurable effect on decay-causing bacteria present on tooth surfaces
Fillings have a finite life span and where each replacement filling leaves less tooth structure
Fillings increase the risk of an abscess
Fillings may increase the risk of tooth fracture and gum disease
Fillings are more likely to increase a future adverse event than prevent one as fillings increase risk more than decrease it.
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13. Prevention Preventive treatment can be effective at any time and age
A diagnosis of decay could be indicative that additional lesions not yet visible exist
Apparently healthy teeth might be in the early undetectable stages of decay
Risk assessment can identify when risk is high and preventive treatment is beneficial
Preventative treatment prevents an invisible entity from materializing. Since the disease process takes a variable amount of time during which the earliest stage is invisible and reversible it is logical that preventative treatment would be effective at any time during the invisible period and at any age. This was effectively shown by the work of Axelsson and colleagues. Furthermore, the effects of preventative treatment are immediate, although invisible. The effectiveness is revealed over time as disease incidence is reduced.
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14. Tooth Decay Risk
Tooth decay risk varies between individuals and over time coincident with a change in risk factors
The highest decay-susceptible time is the first 2 years after tooth eruption, but can be high at any time
Risk for caries is based on the risk factors for the individual. The highest decay-susceptible period is the first 2 years after tooth eruption. The decalcification-recalcification cycle especially with fluoride exposure can lessen caries incidence. Tipping the balance towards decalcification will result in caries. Effective preventative treatment requires that treatment is implemented based on the risk factors.
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15. Supplemental and New Diagnostic Methods
Plaque Formation Rate (PFRI)
Salivary level of mutans streptococci (SM)
New Diagnostic Methods
Digital X-rays
Fiber-optic transillumination (FOTI)
Laser fluorescence (LF)
Electrical conductance (EC)
Ultrasound
The plaque formation rate index (PFRI) has been described by Per Axelsson. Axelsson uses the plaque formation rate index with the salivary level of mutans streptococci to determine caries risk. Neither method is popular in the United States. New diagnostic methods are available. While these tools might detect disease in earlier stages none determine risk nor can they predict reversibility with preventative treatment. Earlier identification of lesions especially when this information is used to surgically repair the diseased site will always be inferior to preventing disease and reversing the disease process.
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16. Plaque Formation Rate Score Description 1 1%-10% of surfaces 23
21%-30% of surfaces 4
31%-40% of surfaces 5
>40% of surfaces
Amount of new plaque accumulated in 24 hours following tooth cleaning where patient refrains from oral hygiene
Axelsson 1991
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17. Caries Risk Based on SM and PFRI
SM/ml 1 2 3 4 5
Very Low Risk
<0.5 mill
Low Risk
Moderate Risk
mill
High Risk
>0.9 mill
SM/ml is Mutans streptococci measured in million per milliliter. PFRI is the plaque formation rate index.
Axelsson 1991
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18. New Diagnostic Methods
Very little clinical data are available to validate these technologies
Goal is better accuracy over traditional methods to detect true cavities that should be filled
Goal is detection of currently “invisible” lesions that are in a state of dynamic decalcification and recalcification
Enhances risk assessment and application of preventive treatment
Clarity of the diagnostic methods is required to distinguish which lesion will advance, remain unchanged, or heal. Diagnosis is a determination of the static or current disease state. Risk predicts the future disease state. Risk adds a dynamic dimension to health care. The best treatment practices require information about both diagnosis and risk.
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19. Preventing Tooth Decay
Reduction of decay-causing bacteria
Health promoting dietary practices
Exposure to fluoride
Sealing susceptible tooth defects
Proper frequency of dental visits
This slide lists the common categories of treatment to prevent caries.
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20. Reducing Decay-Causing Bacteria
Personal teeth cleaning
Twice daily tooth brushing and flossing or an equivalent aid for between the teeth
Antibacterial rinses (chlorhexidene)
Rinse with 10 ml for 1 minute at bedtime for 2 weeks repeating the cycle 2 months later
Fluoride toothpaste
Treat all family members
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21. “Teeth Cleaned” Clarified
All tooth surfaces including between teeth
About half of all decay affects the tooth surfaces of adjacent teeth where a tooth brush and oral rinse does not reach
The equivalent of not cleaning between teeth is washing the palm and back of your hands but not between your fingers
Rinsing hands with water is not an effective alternative to scrubbing with soap
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22. Dietary Practices
Foods that are especially harmful contain sugars like sucrose, glucose, and fructose, cooked starch, and other carbohydrates
Eat and drink no more than 3 meals and 3 snacks per day
Sugar-free gum and mints, especially those that contain xylitol can be beneficial
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23. Fluoride
The incorporation of fluoride into developing enamel inhibits tooth decay, however its primary effectiveness occurs by its concentration in plaque and saliva to inhibit demineralization and enhance remineralization
Fluoride inhibits plaque bacteria
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24. Fluoride, cont.
Fluoride is released from dental plaque during the acidic conditions of eating
Released fluoride combines with calcium and phosphate to create a more decay-resistant enamel crystal structure
Fluoride is available in water, toothpaste, over-the-counter rinses, prescription toothpaste and rinses, professional gels, foams, and varnishes
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25. Fluoride, cont. Fluoridated toothpaste should be used twice daily
Professional applications of fluoride is based on risk
High-risk patients should have this done 2 to 3 times per year
More fluoride is not necessarily better, especially for children younger than 6 years as fluorosis can affect cosmetically visible developing teeth
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26. Tooth Sealants
Plastic coating bonded to the biting surfaces of the back teeth
Susceptible tooth defects should be sealed regardless of age
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27. Frequency of Dental Visits
Twice annual professional tooth cleaning as the sole method to prevent cavities is unlikely to be effective especially when risk is high
Frequency of dental visits can be increased for closer monitoring of oral hygiene and dietary practices in addition to applying fluoride and sealants
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28. Dealing with Objections
Prevention doesn’t work
Studies have shown that more than 90% of tooth decay can be prevented
Prevention is only for the young
Studies have shown that prevention works at any age
The benefits of prevention take many years
The benefits are immediate as prevention heals the invisible lesions
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29. Objections, cont. It costs too much; My insurance doesn’t cover it
Filling cavities costs more than preventing them
Cavities can result in a root canal, cap, or extraction
Dentures could ultimately cost more than “saving” your teeth
Insurance doesn’t care if you have dentures
Dentures are OK
Dentures, especially lower ones, are not always successful, which then requires implants
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30. Objections, cont. Flossing is too hard; no time to floss
Tying shoelaces for a child is difficult but they learn the skill
Flossing takes only a minute or two after the skill is learned
Fillings prevent decay
Fillings have no effect on decay-causing bacteria and hence do not reduce the risk of having more cavities
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