Re: THE CARIES PROCESS: A BRIEF OVERVIEW

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CARIES RISK ASSESSMENT
Our standards for the practice of dental hygiene include risk assessment in order to facilitate patient-centered comprehensive care. Caries risk assessment and caries management by risk assessment exemplify a rapidly changing facet of the dental hygiene process.17,18 The dental hygienist plays an integral role in risk assessment determining not only the development and implementation of preventive interventions but also the evaluation of successful treatment outcomes. Risk assessment is not intended to replace clinical judgment regarding individual patient circumstances but rather to aid in applying a comprehensive approach identifying treatment options to achieve and maintain oral health.

Today’s youth is bombarded with nutritional choices that serve to compromise the oral environment. Soft drinks with low pH and corresponding high sucrose levels as well as the advent of energy drinks provide an ideal environment for demineralization. Demineralization happens in an oral environment that falls below a pH of 5.5. The average soft drink or energy drink has a pH of 2.5 to 3.

There are a number of caries risk indicators as well as protective factors that need to be weighed in order to develop an effective individualized treatment plan (Figure 1). It becomes imperative that daily biofilm management incorporating effective plaque removal and remineralization strategies coupled with education all serve to provide optimal oral health.

The following case report has encompassed risk assessment as part of the assessment phase of the dental hygiene process of care. The product recommendations both for chairside as well as self-care selections are by no means a comprehensive listing of all available therapies. They have been selected to illustrate a patient specific treatment plan.

CASE REPORT
The patient was a 16-year-old female with a noncontributory medical history.

She had a history of routine preventive care and active orthodontic treatment for 3 years (debonded in 2007). Plaque had been noted on several appointments around orthodontic brackets while in active treatment, and she was prescribed home fluoride rinses in past which she was unable to tolerate. Several areas of interproximal incipient caries were noted in 2010; however oral hygiene status had been noted as improving over the last 6 to 12 months. Her care had also included radiographs taken every 6 to 12 months to assess incipient lesions, and in-office fluoride rinse was provided to her at 6 month intervals.

Oral Hygiene Status
Light plaque was visible along gingival margin in posterior areas; both lingual and buccal. Posterior interproximal bleeding on probing was localized to Nos. 2, 3, 14, 15, 18, and 31; all periodontal probing were depths < 3 mm.

Risk Assessment

High risk factors

Caries restored in the past 3 years
Frequent (> 3x/daily) between meal snacks of sugars/cooked starch
Fixed orthodontic retainers on upper/lower arch.

Moderate risk factors

Deep pits and fissures
Interproximal enamel lesions/radiolucencies
Other white spot lesions or occlusal discoloration.

Protective factors

Lives/attends school in fluoridated community
Uses over-the-counter fluoride dentifrice daily
Salivary flow visually adequate (Figure 2).

Clinical Assessment Summary

Permanent dentition; Nos. 1, 16, 17, and 32 unerupted
Occlusal restorations present on teeth Nos. 2, 15, 18, and 31
Pit and fissure sealants on Nos. 3, 14, 19 and 30
Fixed lingual orthodontic retainers from teeth Nos. 7 to 10 and 22 to 27
Demineralization noted on 6 mesiolabial, 7 labial and mesiolabial, 8 distolabial and mesiolabial, 9 distolabial, 22 labial, 23 mesiolabial, 24 distolabial and mesiolabial, 25 mesiolabial and distolabial, 26 mesiolabial, 29 buccal, 30 buccal
Incipient lesions were noted clinically as well as supported by radiographic evidence on 7 mesial, 8 mesial and distal, 9 mesial and distal, 23 mesial, 24 mesial and distal, 25 mesial.
Patient Participation and Comments

Infrequent flossing
Difficulty tolerating fluoride rinses both chairside and with self-care
Brushing twice a day and immediately following ingestion of any soft drinks with a manual toothbrush.

Discussion
Upon completion of risk assessment, the patient was placed in a high-risk category due to having caries restored in the past 3 years. There was also a number of moderate risk factors noted that would automatically place the patient in a high-risk category. The patient stated that she would consume soft drinks during the day and immediately following consumption would brush her teeth. The patient was provided with additional oral hygiene education informing her of the effects of acid erosion and the need to wait a minimum of 30 to 60 minutes before brushing her teeth19 (Figure 3).

A power toothbrush was also recommended to meet the specific needs of the patient. One of the main reasons for the suggestion of a power toothbrush is supported by the numerous studies suggesting that a power toothbrush has been found to remove significantly more plaque than a manual toothbrush when used for one minute of brushing. The Philips Sonicare FlexCare+ with UV sanitizer was recommended for a number of reasons for this particular patient. The Philips Sonicare FlexCare+ has an integrated UV sanitizer that effectively kills up to 99% of selected microorganisms on selected toothbrush heads including S mutans, the predominant microorganism associated with the caries process. The patient reported infrequent and intermittent flossing. Through the patented technology of dynamic fluid force, Sonicare FlexCare+ has been studied resulting in conclusive evidence that it is able to remove interproximal biofilm beyond the reach of the bristles at a distance of 2 to 4 mm. This will aid in delivering the remineralization toothpaste into a number of noted demineralized areas and interproximal incipient lesions (Figure 4).

The patient was placed on a 3-month interval with a recommended application of fluoride varnish (Figures 5 and 6). Extended contact fluoride varnish was placed in site-specific noted areas of demineralization. In the interim, a remineralization toothpaste was recommended to be used twice daily containing calcium and phosphate as well as a therapeutic regiment of xylitol chewing gum taken after each meal and snack. A radiographic prescription was provided to assess radiolucent areas at regular intervals until the caries risk category had been diminished. Further salivary assessment and bacterial culture testing has also been recommended as well as subsequent caries evaluation using caries detection devices.

CONCLUSION
The preceding case report follows the assessment, dental hygiene diagnosis, and resulting implementation of a patient specific treatment plan. Evaluative outcomes will be measured, reassessed, and revised related to progress toward minimizing caries risk. There exists a powerful opportunity to support minimally invasive dentistry by embracing caries management by risk assessment. It’s time to fight back!