Caries Risk Assessment

and its interaction with Preventive and Restorative Protocols

Richard Ehrlich DDS

www.elmtreedental.com dre@elmtreedental.com

Introduction
Caries Risk is used by most general dentists daily, usually on an intuitive level. The first part of this presentation will attempt to help quantify this, and the second part will use this information for more systematic preventive, diagnostic and restorative protocols.

Applications of Caries Risk Assessment

Caries Risk Assessment assists in predicting and diagnosing this type of casecaseShould you observe this?

Or does it conceal this?

Applications of Caries Risk Assessment

Caries Risk Assessment assists in predicting and diagnosing this type of casecaseShould you replace these restorations or observe them?

Overview of Caries Risk Assessment (CRA)

Caries Risk Assessment (CRA) is a simple, quick method for assigning a number to an individual s risk for decay. Using this data, custom preventive and restorative programs can be used, with more reliance on evidenceevidence-based dentistry and less on intuition and experience alone. This simplified version is based on practical application of the U of T Caries Risk Assessment in actual clinical practice in a preventive-oriented preventivedental office.

Categories for Simplified CRA

These are all given numerical scores:
Existing Decay Previous Decay Root Caries Fluoride Exposure Diet Factors Oral Hygiene Additional Tests
S.mutans and Lactobacillus Saliva Flow

Categories for Simplified CRA

Existing Decay No Decay = 0 Some early Pit and Fissure Decay = 0.5 1-2 Existing Lesions =1 >2 Lesions =2

Categories for Simplified CRA

Previous Decay No Decay = 0 Some early Pit and Fissure Decay = 0.5
Interproximal Posterior Decay =1 Anterior or Smooth Surface Decay =2

Categories for Simplified CRA

Existing Decay Previous Decay Root Caries

Ratio of exposed root surfaces to decay <25% of root surfaces decayed =0 25%-50% of 25%surfaces decayed =1 >50% of surfaces decayed =2

Categories for Simplified CRA

Existing Decay Previous Decay Root Caries Fluoride Exposure

Using Fluoride Toothpaste BID = 0 Using Fluoride Toothpaste once daily =1 Not using Fluoride Toothpaste or Rinse =2

Categories for Simplified CRA

Existing Decay Previous Decay Root Caries Fluoride Exposure Diet Factors

Diet Factors:
The Diet Questionnaire is presented. Total sugar exposures are totaled, and divided by 3 for the Caries Index Diet Score

Diet Questionnaire:
Drink Factors:
How many times a day do you drink: 1. Coffee or tea with sugar between meals? meals? 2. Pop, Kool-aid, lemonade, sports drinks, fruit juice, Kooliced tea with sugar between meals? Total the number of these How many glasses of water or dilute drinks do you have a day? This does not include coffee, soft drinks, full strength juice or sports drinks. Chronic Dehydration can increase caries risk
Count 2 if the patient is dehydrated

Diet Questionnaire:
Drink Factors contd:
Important trend: Cariogenic drinks are on a great increase!
Huge marketing efforts have been made, and often soft drink companies have a monopoly on vending machines in schools. This has paid off with a corresponding increase in decay and acid erosion. Consumption of soft drinks, sports drinks, fruit juices and iced tea have skyrocketed in recent years, especially among teens and adolescents. Sports drinks are meant for athletes involved in over 60 minutes of aerobic activity. Sedentary kids are drinking sports drinks after mild activity, thanks to good marketing. Water and milk consumption is dropping. Link to Acid Erosion Page

Diet Questionnaire:
Food Factors: How many times a day do you:
1. Chew regular gum (Not sugarless)? 2. Eat mints, lozenges, candies or candy bars, dried fruit, energy bars between meals? meals? 3. Eat sweetened baked goods (Donuts, cookies, pastries) between meals?
Total the number of all of these.

Diet Questionnaire:
Do you have a habit of sipping a sweetened drink (Coffee, cola, juice) or eating a sweet snack over an extended period of time, 45 minutes or more?
If yes, add 2

Diet Questionnaire:
Total diet scores are added up, divided by 3 and this is the number used for the Caries Risk Assessment score for Diet Factors.
0-2 Sugar exposures=0 3-4 Sugar exposures =1 5-6 Sugar Exposures =2 >6 exposures =3

Categories for Simplified CRA

Existing Decay Previous Decay Root Caries Fluoride Exposure Diet Factors Oral Hygiene

0=Good OH 1=Fair OH
PSRs <3 Mod Plaque

2=Poor OH
PSRs >3 Heavy Plaque

Categories for Simplified CRA

Existing Decay Previous Decay Root Caries Fluoride Exposure Diet Factors Oral Hygiene Additional Tests
S.mutans and Lactobacillus Saliva Flow

Categories for Simplified CRA

Additional Tests Bacterial testing is done only in cases when indicated, if other results are not obvious. S.mutans and Lactobacillus Saliva Flow

>1,000,000 colonies s.mutans or >100,000 lactobacillus = 2 > 4 minutes for 3cc saliva sample =2
Indicates possible Xerostomia

The Simplified Caries Index Form

CARIES INDEX Existing decay Previous Decay Root caries Fluoride Exposure TOTAL Diet Score Oral Hygiene Bacterial Test Saliva Flow

This small form is in a digital template on the computer chart, but can be printed on standard adhesive labels and attached to the daily record portion of a paper chart.

The Diet Questionnaire

Diet Questionnaire
How many times a day do you drink: 1. Coffee or tea with sugar between meals? 2. Pop, Kool-aid, lemonade, fruit juice, sports drinks, iced tea with sugar between meals? How many times a day do you: 1. Chew regular gum (Not sugarless)? 2. Eat mints, lozenges, candiesor candy bars, dried fruit, energy bars? 3. Eat sweetened baked goods (Donuts, cookies, pastries) between meals? Total Do you have a habit of sipping a sweetened drink (Coffee, cola) or eating a sweet snack over an extended period of time, 45 minutes or more? How many glasses of water or dilute drinks do you have a day? This does not include coffee, soft drinks, full strength juice or sports drinks.

Number

Yes = 2 <3 =2

Total divided by 3 = value for caries index

This form is either printed out or displayed on the monitor for the patient to see during review

CRA Score and Caries Risk: The Total Score

0-2 = Low Risk 3-4 = Medium Risk 4-6 = High Risk >6 = Severe Risk of Caries

CRA Score and Caries Risk: Applying the data

From this data we can set up custom protocols for the individual patients, including
Fluoride treatments Frequency of X-rays XFrequency of Recall visits Restorative decisions on borderline lesions
Whether to Observe, Seal or Restore

Recare Report- Getting the Reportmessage out

Patients remember a percentage of what you tell them while in the chair. They take it far more seriously if they have something they can take home. We use a Recare report to give to patients, or kid s parents.

Recare Report
Procedures done today: Medial History Update Tooth Examination Cavity Risk Assessment Blood Pressure Screening Periodontal (gum) ExaminationPSR Full perio recording Oral Cancer Scan TMJ Check Oral Hygiene Evaluation X-rays

Recommendations: We would like to see you again in: 3 months 6 months 9 months 1 year

Oral Hygiene- Brushing Other Tools

Good! Flossing

Too Hard Sulcabrush Superfloss

Missing Areas Not Frequent Enough Rubber Tip Rotapoints

Peridex antibacterial mouthwash Power Floss unit

Diet Factors1. 2. 3. 4. 5. Coffee or tea with sugar between meals. Pop, fruit juice, rice milk, sports drinks, Kool-aid or iced tea with sugar between meals. Chewing gum (Not sugarless)? Eating mints, lozenges, candies, dried fruit, chocolate bars. Eating sweetened baked goods (Donuts, cookies, pastries) between meals?

Fluoride Program Supplements- tablet/day Fluoride Rinse tablet/day Prevident 5000 high-fluoride toothpaste

Fluoride treatment: 3month/ 6 month/ Home treatment

Ongoing issues needing treatment:

Decay

Gum Disease

Failing dental work

Application In PracticePracticeTakeTake-home message:

Caries Risk Assessment is an essential part of scientifically based dentistry in real general practice A practical Caries Risk Assessment takes less than 5 minutes to do during a new patient exam, and contributes valuable datadata- please use my version or your own in your practice, but use it! Identify your high, medium and low risk patients.
The next part of the presentation will deal with use of this data for treatment protocols.

Dr. Richard Ehrlich www.elmtreedental.com

Part 2: Diagnostic, Restorative and Preventive Protocols using Risk Analysis and High Tech instrumentation

Richard Ehrlich DDS

dre@elmtreedental.com

Tools needed:
In addition to the usual instrumentation and radiographs for diagnosis:
The Caries Index Form CARIES INDEX Existing decay Previous Decay Root caries Fluoride Exposure TOTAL Diet Score Oral Hygiene Bacterial Test Saliva Flow

Diagnodent- Diagnostic Laser caries detector

Diagnodent Laser
This device can give a numerical reading of early decay in pits. With practice, it can be more accurate than visual, tactile or radiographic examinations. Caution is required around hypocalcifications and existing resins and sealants as the unit may misread.

Other adjuncts- Magnification adjunctsLoupes Operating Microscope Intraoral Camera

New Technologies:
Diagnodent Laser Readings under 10 have no decay. Readings 10-20 usually have 10stain or enamel caries Readings over 35 generally have decay in dentin. Readings of 99 are decayed well into dentin. Readings 20-35 need individual assessment Diagnodent Readings alone are not sufficient for diagnosis (See Literature Review)

Protocols using the tools

At the initial diagnosis, the patient can usually be assigned to a Risk group. This is re-evaluated at the next recall, as reoften the status changes after the initial treatment.

Caries Index 0-2 0-

Low Risk- Initial Protocol Risk-

Observe pits and fissures with stain or early decay, decay in enamel, very early (stable) decay in dentin, old restorations, poor margins. Diagnodent (DD) < 25-30 25Restore fractured restorations, obvious decay (DD>40).

Caries Index 3-4 3-

Medium Risk- Initial Protocol Risk-

Observe stained pits, deep pits, early decay in enamel. (DD<20). . Restore old restorations with cracks and broken margins, decay in pits with halo or shadow, any decay in dentin. (DD>25(DD>25-30)
Diet Counseling Introduction (link to diet page) Fluoride Supplements for children in non fluoridated areas

High Risk- Initial Protocol RiskCaries Index >4

Observe stained pits DD<10
Restore early decay in enamel and dentin. dentin. (DD>15(DD>15-20) Restore old restorations with cracks and broken margins Diet Counseling Introduction Fluoride Supplements for children Prevident 5000 for Adults Fluoride varnish on incipient areas

First Re-evaluation ReAll patients are re-assessed after the initial retreatment. Many are at reduced risk once initial decay is removed, and diet/OH improvements are implemented.

High Risk- First Evaluation Risk3 month period

Caries Risk Re-Evaluation, including Res. mutans, lactobacillus test Salivary flow measurement

3-month Topical Fluoride, OHI If risk reduced, proceed to Medium Risk Recare protocol

Low Risk Suggested Protocol

Recall patient every 9 months, consider increasing if remaining low risk. No Topical Fluoride No Fluoride Supplement Take BW radiographs every 3 years OHI As needed Observe pits and fissures with stain or early decay in enamel, very early decay in dentin. (DD<25-30) (DD<25Polish or seal old restorations with poor margins, and Sealants not required observe

Medium Risk Suggested Protocol

Recall patient every 6 months Topical Fluoride for children Fluoride Supplement for areas without water FFTake BW radiographs every 2 years OHI As needed Observe stained pits, early decay in enamel or optionally seal. (DD<15seal. (DD<15-20)

Medium Risk Suggested Protocol

Restore pits and fissures with early decay, any very early decay in dentin, old restorations with poor margins. (DD>20)
Polish or seal old restorations with fair margins, and observe.

High Risk Suggested Protocol

Full diet counselling with diary

High Risk Suggested Protocol

Full diet counseling with diary Recall patient every 3 months: Topical Fluoride Fluoride Varnish on susceptible areas Take BW radiographs yearly OHI Home Fluoride Trays or Prevident 5000 Chlorhexidine Rinses Adult- 30 seconds before bed AdultXylitol-containing gum- 3 pieces daily XylitolgumFluoride Supplements-Child SupplementsEvaluate for xerostomia

 Restore pits with early decay, any very early decay in dentin or enamel, (DD>20) old restorations with fairfairpoor margins.

Sealants/Preventve resinsresinsall deep pits and fissures. (DD>5-20) DD>5-

New Technologies:
Often high risk kids present with early decay or deep pits in barely erupted teeth.

These can be very hard to seal due to access or co-operation issues. If there is any moisture contamination, traditional sealants will fail.

New Technologies:
Fluoride-releasing sealants for Fluoridesuspect pits with poor access Fuji Triage can be placed quickly and easily, needing very little cooperation.

Due to the fluoride release, it is less likely than traditional sealants to allow decay below if it leaks.

New Technologies:
Digital Radiography

Allows lower dose exposures. Resistance from patients is reduced. Results are instant. Patient Education is enhanced as they can see radiographs enlarged in front of them. Diagnosis may be enhanced. Essential for online communication with specialists. Complete offsite backup is possible. Sensors are larger and placement takes some practice.

New Technologies:
Diagnodent Pen

Smaller and more portable version released in 2006 Ability to read interproximal lesions Less fragile cable, less chance of damage

New Technologies:
Ozone Treatment of pits A promising new technique involves sterilizing the pits and fissures with ozone. This has been shown to stop decay and even allow remineralization This may make cooperation even easier in early intervention More research is needed here.

Proposed steps in Healozone Treatment

1. Cleaning

3. Treatment

2. Measurement

4. Reductant Fluid Promotes the immediate remineralization of the tooth.

 DIFOTI (Digital Imaging Fiber-Optic Trans-Illumination) FiberTrans-Illumination)

New Technologies:

This device creates high-resolution digital images of highocclusal, interproximal and smooth surfaces. It enables dentists to discover or confirm the presence of decay that cannot be seen radiographically, visually or through use of an explorer

New Technologies:
DIFOTI (Digital Imaging Fiber-Optic TransFiberTransIllumination) Illumination)

New Technologies:
Air Abrasion
This technology allows early intervention more conservatively than rotary instruments. Pits with stain, decay in enamel and very early dentin decay (DD 5-30) can be treated, almost always without local anaesthetic. Any restorative prep can be cleaned out with this unit, allowing better bonding. Air Abrasion is excellent for cleaning any prosthesis that needs bonding in the mouth, from crowns and posts to fixed ortho. You cannot remove amalgams or treat larger lesions. Auxilliary suction is needed.

New Technologies:
Microburs
Low-tech way to access very small pits. , 1/8 and 1/16 round burs are available for high speed handpieces. Can treat some early pits and grooves almost as well as lasers or air abrasion.

New Technologies:
Laser- Water units LaserThis technology is similar in application to Air Abrasion units, but more versatile. Pits with stain, decay in enamel and early dentin decay (DD 5-30) can be treated, almost always without local anaesthetic. Soft tissue can be trimmed as well. There is less chance of injuring soft tissue with overspray. There is no powder spray mess, so auxilliary suction is not needed. Like Air Abrasion, you cannot remove amalgams or easily treat larger lesions. These units cost 20-50X more than air abrasion units, and are much larger.

Application In PracticePracticeTakeTake-home message:

Identify your high, medium and low risk patients. Treat them differently based on their risk levels. Aim to convert all your patients to low risk, or at least reduce their caries index. Do not over-treat your low-risk patients. They need their own overlowpatients. preventive and restorative protocols. Do not under-treat your high risk patients. They need every underpatients. preventive and early intervention restorative measure you can give them, especially if they cannot convert to lower risk.

Summary Flow ChartChartInitial Diagnosis Caries Risk Analysis Low Risk

Observe pits and fissures with stain or early decay, decay in enamel, very early (stable) decay in dentin, old restorations, poor margins. (DD < 25-30) Restore fractured restorations.

Caries Risk- Diagnostic, Restorative and Preventive Protocols

Medium Risk
Observe stained pits, deep pits, early decay in enamel. (DD<20) Restore old restorations with cracks and broken margins, decay in pits with halo or shadow, any decay in dentin. (DD>25-30) Diet Counselling Intro.

High Risk
Initial Protocol Observe stained pits. Restore early decay in enamel and dentin. (DD>15-20) Restore old restorations with cracks and broken margins. Diet Counselling Intro Fluoride- Supplements for children, Prevident 5000 for adults

This flow chart is available from my web page at www.elmtreedental.com

Caries Risk Analysis Re-evaluation

3 Month Recare Caries Risk Re-Evaluation s. mutans, lactobacillus test Salivary flow measurement Fluoride, OHI

Low Risk
Recall patient every 9 months, consider increasing if remaining low risk. No Topical Fluoride No Fluoride Supplement Take BW radiographs every 3 years OHI As needed Observe pits and fissures with stain or early decay in enamel, very early decay in dentin. (DD<25-30) Polish or seal old restorations with poor margins, and observe Sealants not required

Medium Risk
Recall patient every 6 months Topical Fluoride for children Fluoride Supplement Take BW radiographs every 2 years OHI As needed Observe stained pits, early decay in enamel (DD<15-20) or optionally seal. Restore pits and fissures with early decay, any very early decay in dentin, old restorations with poor margins. (DD>20) Polish or seal old restorations with fair margins, and observe. Sealants are optional

High Risk
Full diet counselling with diary Recall patient every 3 months: Topical Fluoride Fluoride Varnish on prone areas Home Fluoride Trays, Chlorhexidine Rinses -Adult Fluoride Supplements-Child Xylitol Gum Take BW radiographs yearly OHI Evaluate for xerostomia Restore pits with any very early decay in dentin or enamel, (DD>20) old restorations with fair- poor margins. Sealants/Preventve resins- all deep pits and fissures. (DD>5-20) Fluoride-releasing sealants where possible

Summary
A system of numerically rating a patient s caries risk has been presented Protocols for minimal invasive and preventive treatment for low risk patients and maximal preventive and early restorative treatment for high risk patients have been demonstrated, to allow custom treatment for each patient.

Thank you

Dr. Richard Ehrlich

www.elmtreedental.com dre@elmtreedental.com 905-880905-880-7003