Caries Risk Assessment and its interaction with Preventive and Restorative Protocols Richard Ehrlich...

Caries Risk AssessmentCaries Risk Assessment

and its interaction with and its interaction with Preventive and Restorative Preventive and Restorative

ProtocolsProtocols

Richard Ehrlich DDS

[email protected]

IntroductionIntroduction

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 Applications of Caries Risk AssessmentAssessment

Caries Risk Assessment Caries Risk Assessment assists in predicting assists in predicting and diagnosing this and diagnosing this type of case-type of case-

Should you observe Should you observe this?this?

•Or does it conceal Or does it conceal this?this?

Applications of Caries Risk Applications of Caries Risk AssessmentAssessment

Caries Risk Caries Risk Assessment assists Assessment assists in predicting and in predicting and diagnosing this diagnosing this type of case-type of case-

Should you replace Should you replace these restorations these restorations or observe them?or observe them?

Overview of Caries Risk Overview of Caries Risk Assessment (CRA)Assessment (CRA)• Caries Risk Assessment (CRA) is a simple, quick Caries Risk Assessment (CRA) is a simple, quick

method for assigning a number to an individual’s risk method for assigning a number to an individual’s risk for decay. for decay.

• Using this data, custom preventive and restorative Using this data, custom preventive and restorative programs can be used, with more reliance on evidence-programs can be used, with more reliance on evidence-based dentistry and less on intuition and experience based dentistry and less on intuition and experience alone.alone.

• This simplified version is based on practical application This simplified version is based on practical application of the U of T Caries Risk Assessment in actual clinical of the U of T Caries Risk Assessment in actual clinical practice in a preventive-oriented dental office.practice in a preventive-oriented dental office.

Categories for Simplified Categories for Simplified CRACRAThese are all given numerical scoresThese are all given numerical scores::

• Existing DecayExisting Decay

• Previous DecayPrevious Decay

• Root CariesRoot Caries

• Fluoride ExposureFluoride Exposure

• Diet Factors Diet Factors

• Oral HygieneOral Hygiene

• Additional TestsAdditional Tests• S.mutans and LactobacillusS.mutans and Lactobacillus

• Saliva FlowSaliva Flow

Categories for Simplified Categories for Simplified CRACRA

Existing DecayExisting Decay

• No Decay = 0No Decay = 0

• Some early Pit and Some early Pit and Fissure Decay = 0.5Fissure Decay = 0.5

• 1-2 Existing Lesions 1-2 Existing Lesions =1=1

• >2 Lesions =2>2 Lesions =2


Previous DecayPrevious Decay

• No Decay = 0No Decay = 0

• Some early Pit Some early Pit and Fissure and Fissure Decay = 0.5Decay = 0.5

• Interproximal Interproximal Posterior Decay =1Posterior Decay =1

• Anterior or Smooth Anterior or Smooth Surface Decay =2Surface Decay =2





• Ratio of exposed root Ratio of exposed root surfaces to decaysurfaces to decay

– <25% of root <25% of root surfaces decayed surfaces decayed = 0= 0

– 25%-50% of 25%-50% of surfaces decayed surfaces decayed =1=1

– >50% of surfaces >50% of surfaces decayed =2decayed =2






• Using Fluoride Using Fluoride Toothpaste BID = 0Toothpaste BID = 0

• Using Fluoride Using Fluoride Toothpaste once Toothpaste once daily = 1daily = 1

• Not using Fluoride Not using Fluoride Toothpaste or Rinse Toothpaste or Rinse = 2 = 2

Categories for Simplified Categories for Simplified CRACRA• Existing DecayExisting Decay




• Diet FactorsDiet Factors

Diet Factors:Diet Factors:

• The Diet Questionnaire is presented.The Diet Questionnaire is presented.

• Total sugar exposures are totaled, and Total sugar exposures are totaled, and divided by 3 for the Caries Index Diet divided by 3 for the Caries Index Diet ScoreScore

Diet Questionnaire:Diet Questionnaire:

• Drink Factors:Drink Factors:• How many times a day do you drink:How many times a day do you drink:

– 1. Coffee or tea 1. Coffee or tea with sugarwith sugar between mealsbetween meals? ? – 2. Pop, Kool-aid, lemonade, sports drinks, fruit juice, iced 2. Pop, Kool-aid, lemonade, sports drinks, fruit juice, iced

tea with sugar tea with sugar between meals?between meals?» Total the number of these

• How many glasses of water or How many glasses of water or dilutedilute drinks do you have a drinks do you have a day? This does not include coffee, soft drinks, full strength day? This does not include coffee, soft drinks, full strength juice or sports drinks.juice or sports drinks.

– Chronic Dehydration can increase caries riskChronic Dehydration can increase caries risk» Count 2 if the patient is dehydratedCount 2 if the patient is dehydrated


• Drink Factors cont’d:Drink Factors cont’d:• Important trend: Cariogenic drinks are on a Important trend: Cariogenic drinks are on a

great increase! great increase! Huge marketing efforts have been made, and often soft drink Huge marketing efforts have been made, and often soft drink

companies have a monopoly on vending machines in companies have a monopoly on vending machines in schools. This has paid off with a corresponding increase in schools. This has paid off with a corresponding increase in decay and acid erosion.decay and acid erosion.

• Consumption of soft drinks, sports drinks, fruit juices and Consumption of soft drinks, sports drinks, fruit juices and iced tea have skyrocketed in recent years, especially among iced tea have skyrocketed in recent years, especially among teens and adolescents. Sports drinks are meant for athletes teens and adolescents. Sports drinks are meant for athletes involved in over 60 minutes of aerobic activity. Sedentary involved in over 60 minutes of aerobic activity. Sedentary kids are drinking sports drinks after mild activity, thanks to kids are drinking sports drinks after mild activity, thanks to good marketing.good marketing.

Water and milk consumption is dropping.Water and milk consumption is dropping.

• Link to Link to Acid Erosion Page


Food Factors:Food Factors:

• How many times a day do you: How many times a day do you:

1. Chew regular gum (Not sugarless)?1. Chew regular gum (Not sugarless)?

2.2. Eat mints, lozenges, candies or candy bars, dried Eat mints, lozenges, candies or candy bars, dried fruit, energy bars fruit, energy bars between mealsbetween meals??

3.3. Eat sweetened baked goods (Donuts, cookies, Eat sweetened baked goods (Donuts, cookies, pastries) pastries) between meals?between meals?

Total the number of all of these.


• 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


• 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








• 0=Good OH0=Good OH

• 1=Fair OH1=Fair OH– PSRs <3PSRs <3

– Mod PlaqueMod Plaque

• 2=Poor OH2=Poor OH– PSRs >3 PSRs >3

– Heavy PlaqueHeavy Plaque








• Additional TestsAdditional Tests• S.mutans and LactobacillusS.mutans and Lactobacillus



• Bacterial testing is done only in Bacterial testing is done only in cases when indicated, if other cases when indicated, if other results are not obvious.results are not obvious.

• >1,000,000 colonies >1,000,000 colonies s.mutans or >100,000 s.mutans or >100,000 lactobacillus = 2lactobacillus = 2

• > 4 minutes for 3cc saliva > 4 minutes for 3cc saliva sample =2sample =2

– Indicates possible XerostomiaIndicates possible Xerostomia

•

• Additional TestsAdditional Tests

• S.mutans and S.mutans and LactobacillusLactobacillus


The Simplified Caries The Simplified Caries Index FormIndex Form

CARIES INDEX TOTAL

Existing decay Diet Score

Previous Decay Oral Hygiene

Root caries Bacterial Test

Fluoride Exposure 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 QuestionnaireThe Diet QuestionnaireDiet Questionnaire Number

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?

Yes = 2

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.

<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 CRA Score and Caries Risk: The Total ScoreRisk: The Total Score

• 0-2 = Low Risk0-2 = Low Risk

• 3-4 = Medium Risk3-4 = Medium Risk

• 4-6 = High Risk4-6 = High Risk

• >6 = Severe Risk of Caries>6 = Severe Risk of Caries

CRA Score and Caries CRA Score and Caries Risk: Applying the dataRisk: Applying the data

From this data we can set up custom From this data we can set up custom protocols for the individual patients, protocols for the individual patients, includingincluding

• Fluoride treatmentsFluoride treatments

• Frequency of X-raysFrequency of X-rays

• Frequency of Recall visitsFrequency of Recall visits

• Restorative decisions on borderline lesionsRestorative decisions on borderline lesions– Whether to Observe, Seal or RestoreWhether to Observe, Seal or Restore

Recare Report- Getting Recare Report- Getting the message outthe message out

Patients remember a percentage of Patients remember a percentage of what you tell them while in the what you tell them while in the chair. They take it far more chair. They take it far more seriously if they have something seriously if they have something they can take home. they can take home.

We use a Recare report to give to We use a Recare report to give to patients, or kid’s parents.patients, or kid’s parents.

Recare Report

Procedures done today:

Medial History Update Blood Pressure Screening Oral Cancer Scan X-rays

Tooth Examination Periodontal (gum) Examination- TMJ Check

Cavity Risk Assessment PSR Full perio recording Oral Hygiene Evaluation

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

Oral Hygiene- Brushing Good! Too Hard Missing Areas Not Frequent Enough

Other Tools Flossing Sulcabrush Rubber Tip Rotapoints

Superfloss Peridex antibacterial mouthwash Power Floss unit

Diet Factors-

1. Coffee or tea with sugar between meals.

2. Pop, fruit juice, rice milk, sports drinks, Kool-aid or iced tea with sugar between meals.

3. Chewing gum (Not sugarless)?

4. Eating mints, lozenges, candies, dried fruit, chocolate bars.

5. Eating sweetened baked goods (Donuts, cookies, pastries) between meals?

Fluoride Program

Supplements- ¼ tablet/day ½ tablet/day Prevident 5000 high-fluoride toothpaste

Fluoride Rinse Fluoride treatment: 3month/ 6 month/ Home treatment

Ongoing issues needing treatment: Decay Gum Disease Failing dental work

Application In Practice-Application In Practice- Take-home message: Take-home message:

• Caries Risk Assessment is an essential part of Caries Risk Assessment is an essential part of scientifically based dentistry in real general practicescientifically based dentistry in real general practice

• A practical Caries Risk Assessment takes less than 5 A practical Caries Risk Assessment takes less than 5 minutes to do during a new patient exam, and minutes to do during a new patient exam, and contributes valuable data- please use my version or contributes valuable data- please use my version or your own in your practice, but use it! your own in your practice, but use it! Identify your Identify your high, medium and low risk patients.high, medium and low risk patients.

The next part of the presentation will deal with use of this data The next part of the presentation will deal with use of this data for treatment protocols.for treatment protocols.

Dr. Richard EhrlichDr. Richard Ehrlich

www.elmtreedental.comwww.elmtreedental.com

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

Richard Ehrlich DDSRichard Ehrlich [email protected]@elmtreedental.com

Tools needed:Tools needed:

The Caries Index Form

CARIES INDEX TOTAL

Existing decay Diet Score

Previous Decay Oral Hygiene

Root caries Bacterial Test

Fluoride Exposure Saliva Flow

In addition to the usual instrumentation and radiographs for diagnosis:

Diagnodent- Diagnostic Laser caries detector

Diagnodent LaserDiagnodent Laser

• This device can give a numerical reading of This device can give a numerical reading of early decay in pits.early decay in pits.

• With practice, it can be more accurate than With practice, it can be more accurate than visual, tactile or radiographic examinations.visual, tactile or radiographic examinations.

• Caution is required around hypocalcifications Caution is required around hypocalcifications and existing resins and sealants as the unit and existing resins and sealants as the unit may misread.may misread.

Other adjuncts- Other adjuncts- MagnificationMagnification

• LoupesLoupes

• Operating MicroscopeOperating Microscope

• Intraoral Intraoral CameraCamera

Diagnodent LaserDiagnodent Laser

• Readings under 10 have no Readings under 10 have no decay.decay.

• Readings 10-20 usually have Readings 10-20 usually have stain or enamel cariesstain 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)

•New Technologies:

Protocols using the toolsProtocols using the tools

• At the initial diagnosis, the patient At the initial diagnosis, the patient can usually be assigned to a Risk can usually be assigned to a Risk group.group.

• This is re-evaluated at the next This is re-evaluated at the next recall, as often the status changes recall, as often the status changes after the initial treatment.after the initial treatment.

Low Risk- Initial ProtocolLow Risk- Initial ProtocolCaries Index 0-2Caries Index 0-2

• ObserveObserve pits and fissures pits and fissures with stain or early decay, with stain or early decay, decay in enamel, very early decay in enamel, very early (stable) decay in dentin, old (stable) decay in dentin, old restorations, poor margins.restorations, poor margins.

Diagnodent (DD) < 25-30Diagnodent (DD) < 25-30

Restore fractured restorations, obvious decay (DD>40).

RestoreRestore old restorations with old restorations with cracks and broken margins, cracks and broken margins, decay in pits with halo or decay in pits with halo or shadow, any decay in dentin.shadow, any decay in dentin.(DD>25-30)(DD>25-30)

Medium Risk- Initial Medium Risk- Initial Protocol Protocol Caries Index 3-4Caries Index 3-4

ObserveObserve stained pits, deep stained pits, deep pits, early decay in pits, early decay in enamel. enamel. (DD<20)..

Diet Counseling Introduction Diet Counseling Introduction (link to diet page)Fluoride Supplements for Fluoride Supplements for children in non fluoridated children in non fluoridated areasareas

RestoreRestore early decay in enamel early decay in enamel and dentinand dentin..(DD>15-20)(DD>15-20)

RestoreRestore old restorations with old restorations with cracks and broken marginscracks and broken margins

High Risk- Initial ProtocolHigh Risk- Initial Protocol Caries Index >4Caries Index >4

ObserveObserve stainedstained pits pits DD<10DD<10

Diet Counseling Introduction Diet Counseling Introduction Fluoride Supplements for children Fluoride Supplements for children Prevident 5000 for AdultsPrevident 5000 for AdultsFluoride varnish on incipient areasFluoride varnish on incipient areas

First Re-evaluationFirst Re-evaluation

• All patients are re-assessed after the All patients are re-assessed after the initial treatment.initial treatment.

• Many are at reduced risk once initial Many are at reduced risk once initial decay is removed, and diet/OH decay is removed, and diet/OH improvements are implemented.improvements are implemented.

High Risk- First Evaluation High Risk- First Evaluation 3 month period 3 month period

Caries Risk Re-Evaluation, includingCaries Risk Re-Evaluation, including

s. mutans, lactobacillus test

Salivary flow measurement

• 3-month Topical Fluoride, OHI 3-month Topical Fluoride, OHI

• If risk reduced, proceed to Medium Risk If risk reduced, proceed to Medium Risk Recare protocolRecare protocol

Low Risk Suggested Low Risk Suggested ProtocolProtocol• Recall Recall patient every 9 months, consider increasing if patient every 9 months, consider increasing if

remaining low risk.remaining low risk.

• No Topical FluorideNo Topical Fluoride

• No Fluoride SupplementNo Fluoride Supplement

• Take BW radiographs every 3 yearsTake BW radiographs every 3 years

• OHI As neededOHI As needed

• ObserveObserve pits and fissures with stain or early decay in pits and fissures with stain or early decay in enamel, very early decay in dentin. enamel, very early decay in dentin. (DD<25-30)(DD<25-30)

•Polish or seal Polish or seal old restorations with poor margins, and old restorations with poor margins, and observeobserve•Sealants Sealants not requirednot required

Medium Risk Suggested Medium Risk Suggested ProtocolProtocol

• Recall Recall patient every 6 monthspatient every 6 months

• Topical Fluoride for childrenTopical Fluoride for children

• Fluoride Supplement for areas Fluoride Supplement for areas without water F-without water F-

• Take BW radiographs every 2 Take BW radiographs every 2 yearsyears

• OHI As neededOHI As needed

• ObserveObserve stained pits, early stained pits, early decay in enameldecay in enamel or optionally or optionally sealseal. (DD<15-20). (DD<15-20)

Medium Risk Suggested Medium Risk Suggested ProtocolProtocol

• RestoreRestore pits and fissures pits and fissures with early decay, any with early decay, any very early decay in very early decay in dentin, old restorations dentin, old restorations with poor margins. with poor margins. (DD>20)(DD>20)

•Polish or seal Polish or seal old old restorations with fair restorations with fair margins, and observe.margins, and observe.

High Risk Suggested ProtocolHigh Risk Suggested Protocol• Full diet counsellingFull diet counselling with diary with diary

High Risk Suggested ProtocolHigh Risk Suggested Protocol• Full diet counselingFull diet counseling with diary with diary

• Recall Recall patient every 3 months:patient every 3 months:

– Topical Fluoride Topical Fluoride

– Fluoride Varnish on susceptible areasFluoride Varnish on susceptible areas

– Take BW radiographs yearlyTake BW radiographs yearly

– OHIOHI

• Home Fluoride Trays or Prevident 5000Home Fluoride Trays or Prevident 5000

• Chlorhexidine Rinses –Adult- 30 seconds before bedChlorhexidine Rinses –Adult- 30 seconds before bed

• Xylitol-containing gum- 3 pieces dailyXylitol-containing gum- 3 pieces daily

• Fluoride Supplements-ChildFluoride Supplements-Child

• EvaluateEvaluate for xerostomia for xerostomia

• RestoreRestore pits with early pits with early

decay, any very early decay, any very early decay in dentin or decay in dentin or enamel, enamel, (DD>20)(DD>20) old old restorations with fair- restorations with fair- poor margins.poor margins.

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

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

•New Technologies:New Technologies:

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

• Fluoride-releasing sealantsFluoride-releasing sealants for suspect pits with poor accessfor suspect pits with poor access

• Fuji Triage can be placed quickly Fuji Triage can be placed quickly and easily, needing very little and easily, needing very little cooperation.cooperation.


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

• Digital RadiographyDigital Radiography


•Allows lower dose exposures. Resistance from patients is reduced. Allows lower dose exposures. Resistance from patients is reduced. Results are instant.Results are instant.

•Patient Education is enhanced as they can see radiographs enlarged in Patient Education is enhanced as they can see radiographs enlarged in front of them. Diagnosis front of them. Diagnosis may may be enhanced.be enhanced.

•Essential for online communication with specialists.Essential for online communication with specialists.

•Complete offsite backup is possible.Complete offsite backup is possible.

•Sensors are larger and placement takes some practice.Sensors are larger and placement takes some practice.

• Diagnodent PenDiagnodent Pen


•Smaller and more portable version released in 2006Smaller and more portable version released in 2006

•Ability to read interproximal lesionsAbility to read interproximal lesions

Less fragile cable, less chance of damageLess fragile cable, less chance of damage

• Ozone Treatment of Ozone Treatment of pitspits

• A promising new A promising new technique involves technique involves sterilizing the pits and sterilizing the pits and fissures with ozone. This fissures with ozone. This has been shown to stop has been shown to stop decay and even allow decay and even allow remineralizationremineralization

• This may make This may make cooperation even easier cooperation even easier in early interventionin early intervention

• More research is needed More research is needed here.here.


1. Cleaning

2. Measurement

3. Treatment

4. Reductant FluidPromotes the immediate remineralization of the tooth.

Proposed steps in Healozone Treatment

• DIFOTI (Digital Imaging Fiber-Optic Trans-IlluminationDIFOTI (Digital Imaging Fiber-Optic Trans-Illumination))


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

• DIFOTI (Digital Imaging Fiber-Optic Trans-DIFOTI (Digital Imaging Fiber-Optic Trans-IlluminationIllumination))


• Air AbrasionAir 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.

• MicrobursMicroburs


•Low-tech way to access very small pits. ¼, 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.

• Laser- Water unitsLaser- Water units


•This 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 Practice-Application In Practice- Take-home message: Take-home message:• Identify your high, medium and low risk patients.Identify your high, medium and low risk patients.

• Treat them differently based on their risk levels.Treat them differently based on their risk levels.

• Aim to convert all your patients to low risk, or at least Aim to convert all your patients to low risk, or at least reduce their caries index.reduce their caries index.

• Do not over-treat your low-risk patientsDo not over-treat your low-risk patients. They need their . They need their own preventive and restorative protocols.own preventive and restorative protocols.

• Do not under-treat your high risk patientsDo not under-treat your high risk patients. They need every . They need every preventive and early intervention restorative measure you preventive and early intervention restorative measure you can give them, especially if they cannot convert to lower can give them, especially if they cannot convert to lower risk.risk.

Summary Flow Chart-Summary Flow Chart-

• This flow chart is This flow chart is available from my available from my web page atweb page at

www.elmtreedentalwww.elmtreedental.com.com

Caries Risk- Diagnostic, Restorative and Preventive Protocols

Low Risk Medium Risk High Risk

Low Risk Medium Risk High Risk

Initial Diagnosis Caries Risk Analysis

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.

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.

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

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

Caries Risk Analysis Re-evaluation

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

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

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

SummarySummary

• A system of numerically rating a A system of numerically rating a patient’s caries risk has been presentedpatient’s caries risk has been presented

• Protocols for minimal invasive and Protocols for minimal invasive and preventive treatment for low risk preventive treatment for low risk patients and maximal preventive and patients and maximal preventive and early restorative treatment for high risk early restorative treatment for high risk patients have been demonstrated, to patients have been demonstrated, to allow custom treatment for each allow custom treatment for each ppatient.atient.

Thank youThank you

Dr. Richard EhrlichDr. Richard Ehrlichwww.elmtreedental.comwww.elmtreedental.comdre@[email protected]

905-880-7003905-880-7003

Caries Risk Assessment and its interaction with Preventive and Restorative Protocols Richard Ehrlich...

Documents

Transcript of Caries Risk Assessment and its interaction with Preventive and Restorative Protocols Richard Ehrlich...