Beyond Straight Teeth! The Periodontic/Orthodontic Connection · · 2013-07-01Beyond Straight Teeth! The Periodontic/Orthodontic Connection ... therefore need orthodontic treatment;

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Beyond Straight Teeth! The Periodontic/Orthodontic Connection Kristy Menage Bernie, RDH, BS, RYT • [email protected]

On

‐ Orthodontic therapies are no longer confined to the adolescent population and as such the role of the dental hygienist in patient education has grown significantly in recent years. This course will review the exciting science of bio‐adaptive therapy; a process of working with nature and the body to move teeth while maximizing periodontal health and minimizing invasive procedures such as tooth extraction or palatal expansion, as well as the periodontic/orthodontic connection. A review of current tooth movement sciences will be included as well as methods to maximize oral health pre, during and post‐orthodontic therapy. Our Opportunities:

• Understand and apply the principles of the periodontic/orthodontic connection, including review of the 2011 AAP treatment guidelines.

• Integrate occlusal assessment and identify patients who would benefit from tooth movement therapy. • Maximize orthodontic success through collaborate practice and integration of the latest technologies

designed for optimal oral health. Orthodontic Therapy: Current & Future Need Estimated % of patients who would benefit from orthodontic therapy = The Periodontal Orthodontic Connection: Biological & Synergistic Tooth Movement Identifying the Orthodontic Patient Orthodontic Six‐Point Quick Check System: Begin by examining each arch separetly and evaluating the following categoris:

1. Arch width (molar‐to‐molar transpalatal width of 36 mm is average). 2. Excessive spacing or crowding present. 3. Missing or ankylosed teeth.

Then note the relationship between the upper and lower teeth in occlusion. Evaluate the following: 4. Angle’s classification. 5. The amount of overbite and overjet present. 6. Any openbite or crossbite present.

Seven Signs & Symptoms of Occlusal Disease:

1. Pathological occlusal wear and fractures of teeth/restorations. 2. Cervical dentin hypersensitivity. 3. Tooth hypermobility. 4. Fremitus. 5. Abfractions. 6. Vertical bone loss or localized bone destruction (secondary to periodontal disease). 7. Pain and tired facial and masticatory muscles or TMJ pain.


Facial Type: Mesocephalic – Jaw bones are in harmony with the rest of the face & with each other; teeth may be malposed & therefore need orthodontic treatment; most common facial type. Brachycephalic – Jaw bones, usually the mandible, are too large in proportion to the face; the face appears short & wide; mandible is usually strong, angular, and possibly prognathic; tendency to brux & grind teeth leading to excessive wear to incisal & occlusal surfaces; when smiling very little tooth structure shows; strong muscles of mastication; from profile perspective the mouth area appears concave; extractions are rarely performed; older in appearance than age suggests. Dolichocephalic – Jaw bones, usually the mandible, are too small in proportion to the face; the face appears long; mandible is usually retrognathic depicting a deficient horizontal growth; teeth can be long or appear large with a ‘gummy’ smile; weak muscles of mastication; from the profile perspective the mouth area appears convex; extractions are common in this facial type; appear younger than age would suggest; hereditary, thumb sucking, & mouth breathing are associated with this facial type; extractions are more commonly recommended with this facial type along with orthognathic surgery; considered more difficult to treat than other facial types.

Caries Risk Management by Assessment (CAMBRA) – Active orthodontic patients are automatically considered moderate risk for caries. Periodontal Assessment – Visit www.perio.org for a patient self‐assessment. Orthodontic Therapy Options:

Traditional orthodontic fixed appliances, with ligation Two‐Phase therapy includes early intervention and fixed traditional appliances Bio‐Adaptive therapy considers tissue and bone while accelerating the tooth movement process, gaining arch width and generating oxygenation during tooth movement (self‐ligated systems)

Aligner technologies include a series of custom aligners worn sequentially over time Accelerated osteogenic orthodontics includes a combination of periodontal surgery and fixed appliances to accelerate the tooth movement process by removing alveolar bone and using bone regenerative materials

Active Orthodontic Considerations: Hard Tissue

Fluoride: Mechanism of Action

1. Inhibits demineralization at the time of acid challenge. 2. Enhances remineralization when present by accelerating the formation of new mineral, combining

calcium, phosphate, and fluoride forming a low soluble veneer. The resulting mineral is much less soluble then the original tooth mineral.

3. Generates antibacterial action through the formation of hydrogen fluoride (HF), which is a result of acid produced by bacteria combining with fluoride. HF diffuses through cell walls and interferes with enzyme pathways slowing down and even killing bacteria.


Fluoride Options • Neutral Sodium Fluoride (NaF) • Acidulated Phosphate Fluoride (APF) – ‘Minute’ products • Stannous Fluoride (SnF)

Professionally Applied Fluoride Options

• Professionally applied o Tray systems – 2% NaF and 1.23% APF o Varnish – 5% NaF o Rinses – 2% NaF and APF/SnF combination

• In‐Office Candidates (Wilkins) o Primary teeth o Posteruptive period o Active caries o Secondary/ recurrent caries o Wearing orthodontic appliance, bands, bonded brackets o Compromised salivary flow o Teeth supporting an overdenture o Exposed root surfaces following periodontal recession o Lack of compliance and conscientious efforts for daily dental biofilm removal o Low or no fluoride in drinking water o Early carious lesions

ADA Resolution 37B ‐ Fluoride Varnish Resolved, that the ADA supports the use of fluoride varnishes as safe & efficacious within a caries prevention program that includes caries diagnosis, risk assessment, and regular dental care, and be it further Resolved, that the ADA encourage the FDA to consider approving professional applied fluoride varnish for reducing dental caries, based on substantial amount of available data supporting the safety and effectiveness of this indication.

ADA Topical Fluoride Recommendations – 2006 – Summary

Fluoride gel is effective in preventing caries in school‐age children Patients whose caries risk is low may not receive additional benefit from professional topical fluoride application

There are considerable data on caries reduction for professionally applied topical fluoride gel treatments of 4 minutes or more

Fluoride varnish applied every 6 months is effective in preventing caries in primary and permanent dentition of children and adolescents

2 or more applications of fluoride varnish per year are effective in preventing caries in high risk populations

Fluoride varnish applications take less time, create less patient discomfort and achieve greater patient acceptability than fluoride gel especially in preschool children

4‐minute fluoride foam applications, every 6 months are effective in caries prevention in the primary dentition & newly erupted permanent first molars

There is insufficient evidence to address whether or not there is a difference in the efficacy of NaF versus APF gels

Full guideline document online at: http://www.ada.org/prof/resources/topics/evidencebased.asp


Take Home Fluoride Options • NaF, APF, SnF toothpastes, gels & rinses • Rx • 5,000 ppm or Over‐the‐counter • 250 (rinses) – 1,500 ppm (toothpastes)

Calcium & Phosphate (CP) – How do they work?

• Building blocks for HAP • Desensitization • Remineralization

• Improved surface appearance/ luster • Enhance fluoride ‘uptake’

Effective CP Systems must:

• Be soluble to release Ca and phosphate ions

• Not remove fluoride from the oral cavity

• Not produce calculus • Not prevent remineralization

Remineralization Requirements & Calcium Phosphate Systems

• A source of calcium • A source of phosphate • The proper pH to react

• A substrate on which to precipitate • Time


CAMBRA – Remineralization/Antimicrobial Considerations: REMINERALIZATION: 5% Sodium Fluoride Varnish – Consider products containing xylitol and/or calcium phosphate; can replace fluoride tray treatments (see ADA Professional Fluoride Utilization). Calcium Phosphate Systems

• Tri‐Calcium Phosphate (TCP): During the manufacturing process, a protective barrier is created around the calcium allowing it to coexist with the fluoride ions. As the toothpaste comes in contact with saliva during brushing, the barrier breaks down and makes the calcium, phosphate and fluoride readily available.

o Clinical Application: Vanish XT Varnish • 3M ESPE & Vanish Varnish (5% NaF & TCP) o Daily Care Products: Clinpro 5000 (5,000 ppm NaF & TCP) Toothpaste • 3M ESPE &

Prevident Booster Plus (5,000 ppm NaF & TCP) • Colgate

• Casein Phosphopeptide Amorphous Calcium Phosphate (CPP‐ACP): Recaldent™ ‐ casein (milk protein) enclosed system that binds to oral tissues, plaque, etc. and then releases ACP at an acidic pH.

o Clinical Application: MI 5% NaF Varnish • GC America o Daily Care Products: MI Paste & MI Paste Plus (950 ppm NaF) • GC America

• Calcium Sodium Phosphosilicate (CSP): Novamin® ‐ bioactive glass assists in sustained release of

calcium & phosphate while neutralizing the pH. o Clinical Application: Nupro Sensodyne Prophy Paste • Dentsply & Sylc Airpolishing

Powder • OSSPRAY o Daily Care Products: Renew (5,000 ppm NaF & CSP) Toothpaste • Sultan Products

• Amorphous Calcium Phosphate (ACP): ADA Foundation Technology ‐ Immediate release of CP

upon contact with oral cavity, without dependency on pH or other oral factors. o Clinical Application: Enamel Pro Varnish (5% NaF & ACP); Enamel Pro Prophy Paste &

Enamel Pro APF (1.23% non‐acidulated fluoride & ACP) • Premier Dental o Daily Application: Relief Oral Care Gel (1,000 ppm NaF, KNO3 & ACP) • Philips

• Other:

o MaxMin – Calcium Phosphate prophy paste • Preventech o Arginine Bicarbonate & Calcium Carbonate• Clinical Application: ProRelief • Colgate o Sodium Phosphate, Disodium Phosphate & Calcium Disodium (ACT Restoring MR) o Nano Hydroxyapitite • CariFree pHluorigel (5,000 NaF) by CariFree o Xylitol‐coated calcium phosphate • Embrace Varnish by Pulpdent

ANTIMICROBIAL: Chlorhexidine

• 0.12% CHX rinses • CHX varnish (10% once solvent dissipates) – Cervitec Plus by Ivoclar

Xylitol • Various products, including mints, chewing gum, lollipops, etc.


Active Orthodontic Considerations Soft Tissue:

Full Mouth vs. Quadrant (Partial Mouth) Periodontal Therapy Full-mouth disinfection (FMD) was introduced in 1995 and was designed to target intraoral niches and periodontal pockets and reduce the likelihood of reinfection of previously treated areas. Partial Mouth Protocol:

Traditional quadrant scaling and root planing over a 6 week period of time at 2 week intervals

4 – 6 consecutive sessions Quadrant or sextant therapy Reinfection potential? Patient/ Client centered approach?

Research Protocol - FMD:

Scaling and root planing 4 quads in 24 hours with hand instruments Application of chlorhexidine to all intra-oral niches Tongue disinfection 2x a day rinse and/or spray of buccal mucosa and tonsil area combined with daily

tongue disinfection

Research on the efficacy of FMD has proven that this protocol: • Improves probing depth and increases clinical attachment for up to 8 months. • Reduces oral malodor • Decreases spirochetes and motile organisms in subgingival flora • Eliminates P. gingivalis

FMD provides the following additional benefits:

• Fast-tracking of aesthetic treatment • Rapid healing and/or assessment for surgical intervention • Facilitates client-centered approach • Minimizes time spent in Phase I therapy by facilitating control of treatment

planning and patient compliance Contemporary research on adjunctive therapies always begins with full-mouth therapy that is completed in one to two weeks using both hand and powered

instrumentation. This substantial body of research utilizing this process of care provides the full rationale to accelerate periodontal instrumentation in daily practice.

Optimal Oral Health - A standard of health of the oral and related tissues which enable an individual to eat, speak, or socialize without active disease, discomfort or embarrassment and which contributes to general well-being and overall health – ADHA, 1999.


PROPOSED ACCELERATED INSTRUMENTATION PROTOCOL: 2 appointments of appropriate length scheduled within 24 hours – to 2 weeks • ½ mouth per appointment

1. Pre-procedural antimicrobial rinse for 30 seconds

2. Anesthesia administration/ pain control procedures

3. Instrumentation

a. Powered instrumentation with self-contained water / medicament reservoir and antimicrobial irrigant

b. Hand instrumentation

4. Laser Therapy

a. Bacterial decontamination of pocket sites (prior and post instrumentation)

b. Removal of diseased epitheal lining (post instrumentation in sites greater than 5mm)

5. Placement of locally delivery/ control release medicaments

6. Tongue deplaquing/ scraping with antimicrobial/VSC neutralizing agent

7. Post-procedural rinse for 30 seconds with antimicrobial/VSC neutralizing agent

8. Professional fluoride treatment and/or CHX varnish application (Ivoclar/Vivadent)

9. 2 to 3 month evaluation

a. Utilization of diagnostic devices to assess clinical outcome

b. Placement of local delivery / controlled release agent for nonresponsive sites / or prescription for subgingival dosage doxycycline:

i. 2.5 mg chlorhexidine chip ii. 10% doxycycline gel iii. 1 mg minocycline microsphere power iv. 20 mg systemic/ subgingival dosage doxycycline bid

c. Appropriate recare schedule

10. Re-evaluation at appropriate time with referral for non-responsive cases.

• Daily oral hygiene should include toothbrushing; interdental cleansing and tongue deplaquing along with appropriate adjunctive chemotherapy for caries prevention, sensitivity control and antimicrobial benefits.

IMPLEMENTING & INTEGRATION:

• Full-mouth disinfection, or accelerated instrumentation, accounts for a client- and clinician centered approach to periodontal therapy that maximizes clinical outcomes while providing immediate benefits.

• Utilization of ultrasonics in FMD protocols will greater increase the likelihood of success and provide patients with the high-tech therapy they appreciate and deserve.

• Completing periodontal instrumentation within 1 to 2 weeks is an easy factor to control that will lend to fast-tracking aesthetic treatment plans, healing, and referral.


Post Orthodontic Therapy Considerations:

Additional Considerations: • Collaborate with referring orthodontics practices to determine systems, recommendations and

patient needs • Promote orthodontic options for adults as well as children/teens • Utilize education resources provided through orthodontic manufacturers • Consider participating in motivation program • Offer to monitor periodontal response & health with adult patients

Additional Action Plans for Orthodontic Treatment Considerations: Products ‐ Need to purchase: Orthodontist(s) to contact: Updates to Assessment Phase: Updates to Clinical Phase: Updates to Post‐treatment Phase: Seminar Resources/ Additional Reading: Home Study Course: Clinical Considerations for the Dental Hygienist in Orthodontic Therapy Hosted by the California Dental Hygienists’ Association • 2 hours CE credit • Download at: http://cdha.org/education/homestudy.htm Damon Orthodontists: www.damonbraces.com The Braces Cookbook: www.bracescookbook.com Floss Fish: www.flossfish.com Platypus Flosser: http://www.pdtdental.com/platypus.php ShowerFloss; www.showerfloss.com Lil’ Palates Sweepers: www.lilpalates.com

Comprehensive Periodontal Therapy: A Statement by theAmerican Academy of Periodontology*

The American Academy of Periodontology (AAP)periodically publishes reports, statements, and guide-lines on a variety of topics relevant to periodontics.These papers are developed by an appointed commit-tee of experts, and the documents are reviewed andapproved by the AAP Board of Trustees.

The American Academy of Periodontology offersthe following statement that sets forth thescope, objective, and procedures that consti-

tute periodontal therapy. This statement is providedto assist all members of the dental team who provideperiodontal care and should be considered in itsentirety. This statement may also be useful to thosewho supervise, teach, or regulate the provision ofperiodontal therapy.

SCOPE OF PERIODONTALTHERAPY

As a result of advances in knowledge and therapy, themajority of patients can retain their dentition over theirlifetime with proper treatment, reasonable plaque/bi-ofilm control, and continuing care. Periodontics is thespecialty of dentistry that encompasses prevention,diagnosis, and treatment of diseases of the supportingand surrounding tissues of teeth and dental implants.

Thescopeofthespecialtyofperiodonticsalsoencom-passesmaintenanceofthehealth, function,comfort,andesthetics of all supporting structures and tissues in themouth.Thegoalsof periodontal therapyare topreserve,improve, and maintain the natural dentition, dental im-plants, periodontium, and peri-implant tissues in orderto achieve health, comfort, esthetics, and function. Ahealthy periodontium is characterized by the absenceof inflammation,whichmayappearclinicallyasredness,swelling, suppuration, and bleeding on probing.

PERIODONTAL EVALUATION

A comprehensive assessment of a patient’s currenthealth status, history of disease, and risk characteris-

tics is essential to determine the periodontal diagnosisand prognosis of the dentition and/or the suitability ofdental implants.Patientsshould receiveacomprehen-sive periodontal evaluation and their risk factorsshould be identified at least on an annual basis. Suchan evaluation includes discussion with the patient re-garding his/her chief complaint, medical and dentalhistory review, clinical examination, and radiographicanalysis. Microbiologic, genetic, biochemical, or otherdiagnostic tests may also be useful, on an individ-ual basis, for assessing the periodontal status of se-lected individuals or sites. The following proceduresshould be included in a comprehensive periodontalevaluation:

1. Extra- and intraoral examination to detect non-periodontal oral diseases or conditions.

2. Examination of teeth and dental implants toevaluate the topography of the gingiva and relatedstructures; to measure probing depths, the width ofkeratinized tissue, gingival recession, and attachmentlevel; to evaluate the health of the subgingival areawith measures such as bleeding on probing andsuppuration; to assess clinical furcation status; andto detect endodontic–periodontal lesions.

3. Assessment of the presence, degree, and/or dis-tribution of plaque/biofilm, calculus, and gingival in-flammation.

4. Dental examination including caries assessment,proximal contact relationships, the status of dentalrestorations and prosthetic appliances, and othertooth- or implant-related problems.

5. An occlusal examination that includes, but maynot be limited to, determining the degree ofmobility ofteeth and dental implants, occlusal patterns and dis-crepancy, and determination of fremitus.

6. Interpretation of current and comprehensive di-agnostic-quality radiographs to visualize each toothand/or implant in its entirety and assess the quality/quantity of bone and establish bone loss patterns.

7. Evaluation of potential periodontal–systemicinterrelationships.

8. Assessment of the need for and suitability ofdental implants.

9. Determination and assessment of patient riskfactors such as age, diabetes, smoking, cardiovascu-lar disease, and other systemic conditions associated

*This statement was developed under the direction of the Task Force toUpdate the Guidelines for Periodontal Therapy and approved by the Boardof Trustees of the American Academy of Periodontology in November 2010.

DISCLAIMER: This statement represents the views of the Academyregarding periodontal therapy and related procedures. It must be recog-nized, however, that decisions with respect to the treatment of patients mustbe made by the individual practitioner in light of the condition and needs ofeach specific patient. Such decisions should be made in the best judgmentof the practitioner, taking into account all relevant circumstances.

NOTE: The Academy updates guidelines and statements on a periodicbasis. All previous publications should be considered in light of theirhistorical context with regard to current knowledge and practices. doi: 10.1902/jop.2011.117001

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with development and/or progression of periodontaldisease.

ESTABLISHING A DIAGNOSIS, PROGNOSIS,AND TREATMENT PLAN

Clinical findings together with a diagnosis and prog-nosis should be used to develop a logical plan of treat-ment to eliminate or alleviate the signs and symptomsof periodontal diseases, thereby arresting or slowingfurther disease progression. The treatment plan shouldbe used to establish the methods and sequence of de-livering appropriate periodontal treatment, which mayinclude non-surgical, surgical, regenerative, and cos-metic periodontal therapy or dental implant place-ment. When indicated, the plan should include:

1. Medical and dental consultation or referral fortreatment, when appropriate.

2. Surgical and non-surgical periodontal and im-plant procedures to be performed.

3. Consideration of adjunctive restorative, pros-thetic, orthodontic, and/or endodontic consultation ortreatment.

4. Provision for ongoing reevaluation during peri-odontal or dental implant therapy and throughout themaintenance phase of treatment.

5. Consideration of diagnostic testing that may in-clude microbiologic, genetic, or biochemical assess-ment or monitoring during the course of periodontaltherapy.

6. Consideration of risk factors including, but notlimited to, diabetes and smoking, which play a rolein development, progression, and management ofperiodontal diseases.

7. Periodontal maintenance program including on-going evaluation and reevaluation for treatment.

INFORMED CONSENTAND PATIENT RECORDS

Informed consent should be obtained prior to thecommencement of therapy. Complete records ofthe periodontal examination (including full charting),diagnosis, treatment, and recommended follow-upare essential and should be maintained according tostate law. Information given to the patient should in-clude the following:

1. The diagnosis, etiology, proposed therapy, pos-sible alternative treatment(s), and the prognosis withand without the proposed therapy or possible alterna-tives.

2. Recommendations for treatment to be per-formed by other dentists or physicians.

3. The reasonably foreseeable inherent risks andpotential complications associated with the proposedtherapy, including failure with the ultimate loss ofteeth or dental implants.

4. The need for periodontalmaintenance treatmentafter active therapy due to the potential for disease re-currence.

TREATMENT PROCEDURES

When indicated, treatment should include:

1. Patient education, training in oral hygiene, andcounseling on control of risk factors (e.g., stress,medical status, smoking, etc.) with appropriate refer-ral if needed.

2. Management of periodontal–systemic interrela-tionships, when appropriate.

3. Removal of supra- and subgingival bacterialplaque/biofilm and calculus by comprehensive, me-ticulous periodontal scaling and root planing. In someinstances, these proceduresmay be incorporated intothe surgical treatment.

4. Chemotherapeutic agents may be used as ap-propriate to reduce, eliminate, or change the qualityof microbial pathogens, or to alter the host responsethrough local or systemic delivery.

5. Resective procedures to reduce or eliminateperiodontal pockets and create an acceptable gingi-val form that facilitates oral hygiene and periodontalmaintenance. Soft tissue procedures include gingi-vectomy, gingivoplasty, and various mucogingivalflap procedures. Osseous procedures include ostec-tomy and osteoplasty. Dental tissue proceduresinclude root resection, tooth hemisection, and odon-toplasty. Combined dental tissue and osseous proce-dures may be required.

6. Periodontal regenerative procedures includingbone replacement grafts, use of biologics, root biomo-dification, guided tissue regeneration, and combina-tions of these procedures for osseous, furcation, andgingival recession defects. Periodontal/oral recon-structive procedures include guided bone regenera-tion, ridge augmentation, ridge preservation, implantsite development, and sinus grafting.

7. Periodontal plastic surgery for gingival augmen-tation, correction of recession or soft tissue defor-mities, or enhancement of oral esthetics.

8. Occlusal therapy that may include tooth move-ment, occlusal adjustment, splinting, periodontally ac-celeratedosteogenicorthodontics, or biteguard therapyas a means to establish and maintain occlusal health.

9. Preprosthetic periodontal procedures includingexploratory flap surgery, resective procedures, regen-erativeprocedures,mucogingival procedures, or crownlengthening.

10. Selective extraction of teeth, roots, or implants.11. Surgical placement of dental implants andman-

agement of peri-implant disease.12. Procedures to facilitate orthodontic treatment

including tooth exposure, frenulectomy, fiberotomy,

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temporary anchorage devices, and gingival augmen-tation.

13. Finishing procedures, which include post-treatment evaluation with review and reinforcementof daily oral hygiene when appropriate.

EVALUATION OF THERAPY

Upon completion of planned periodontal therapy, therecord should document that:

1. The patient has been counseled on why and howto perform an effective daily personal oral hygieneprogram including managing their own personal riskfactors associated with development and/or progres-sion of periodontal diseases.

2. All indicated therapeutic procedures have beenperformed.

3. The patient’s response to therapy has been eval-uated, and treatment objectives have been met.

4. A recommendation has been made for the cor-rection of any tooth form, tooth position, restoration,or prosthesis considered to be contributing to the peri-odontal disease process.

5. An appropriate professional periodontalmainte-nance program, specific to individual circumstances,has been recommended to the patient for long-termcontrol of his/her condition, as well as for the mainte-nance of dental implants, if present. This should in-clude professional management of those risk factorsassociated with development and/or progression ofperiodontal diseases including, but not limited to,smoking and diabetes.

FACTORS MODIFYING RESULTS

The results of periodontal therapy may be adverselyaffected by factors that include systemic diseases; in-adequate plaque/biofilm control; unknown or unde-terminable etiologies; pulpal–periodontal problems;inability or failure of thepatient to follow the suggestedtreatment or maintenance program; adverse envi-ronmental influences such as smoking and stress;occlusal dysfunction; and uncorrectable anatomic,structural, or iatrogenic causalities.

Patients with medical compromises, those who re-fuse or delay treatment, or those who present withother limitations may be unable to undergo recom-mended procedures required to establish a completelyhealthy periodontium. In those situations, appropriatetherapy to establish the best possible periodontalhealth is indicated.

PERIODONTAL MAINTENANCE THERAPY

Upon completion of active periodontal therapy, peri-odontal maintenance visits should include:

1. Update of medical and dental histories.

2. Evaluation of current extra- and intraoral peri-odontal and peri-implant soft tissues as well as dentalhard tissues and referral when indicated (e.g., fortreatment of carious lesions, pulpal pathoses, or otherconditions) and diagnostic-quality radiographs whenappropriate.

3. Assessment of the oral hygiene status with rein-struction when indicated.

4. Mechanical tooth cleaning to disrupt/removedental plaque, biofilms, stain, and calculus. Local de-livery or systemic chemotherapeutic agents may beused as adjunctive treatment for recurrent or refrac-tory disease.

5. Ongoing assessment of risk factors to identify anindividual who may be more highly susceptible to on-going breakdown of the periodontal or peri-implanttissues, with elimination ormitigation of newor persis-tent risk and etiologic factors with appropriate treat-ment.

6. Identification and treatment of new, recurrent, orrefractory areas of periodontal and peri-implant pa-thoses.

7. Establishment of an appropriate interval for peri-odontal maintenance.

The patient should be kept informed of:

1. Areasofpersistent, recurrent, refractory, ornewlyoccurring periodontal or peri-implant disease.

2. Changes in the periodontal prognosis and riskfactors associated with periodontal diseases.

3. Advisability of further periodontal treatment orretreatment of indicated sites.

4. Status of dental implants.5. Other oral health problems thatmay include car-

ies, defective restorations, and non-periodontal mu-cosal diseases or conditions.

6. Changes that would warrant referral to, or con-sultation with, other dental or medical specialists.

BIBLIOGRAPHYAas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE.

Defining the normal bacterial flora of the oral cavity. JClin Microbiol 2005;43:5721-5732.

Abdellatif HM, Burt BA. An epidemiological investigationinto the relative importance of age and oral hygienestatus as determinants of periodontitis. J Dent Res1987;66:13-18.

Albandar JM, Brunelle JA, Kingman A. Destructive peri-odontal disease in adults 30 years of age and older inthe United States, 1988-1994 [published correction ap-pears in J Periodontol 1999;70:351]. J Periodontol 1999;70:13-29.

Albandar JM, Kingman A. Gingival recession, gingivalbleeding, and dental calculus in adults 30 years of ageand older in the United States, 1988-1994. J Periodontol1999;70:30-43.

Albandar JM, Rams TE. Global epidemiology of periodon-tal diseases: An overview. Periodontol 2000 2002;29:7-10.

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c d a j o u r n a l , v o l 3 9 , n º 1 0

o c t o b e r 2 0 1 1 711

table 1

caries risk Assessment form — children Age 6 and over/Adults

Patient Name: ___________________________________________________________________________________Chart #:________________________________Date:________________________________________________________

Assessment date: is this (please circle) baseline or recall

disease indicators (Any one “yes” signifies likely “high risk” and to do a bacteria test**)

yes = circle yes = circle yes = circle

Visible cavities or radiographic penetration of the dentin yes

Radiographic approximal enamel lesions (not in dentin) yes

White spots on smooth surfaces yes

Restorations last 3 years yes

risk factors (Biological predisposing factors) yes

MS and LB both medium or high (by culture**) yes

Visible heavy plaque on teeth yes

Frequent snack (> 3x daily between meals) yes

Deep pits and fissures yes

Recreational drug use yes

Inadequate saliva flow by observation or measurement (**If measured, note the flow rate below)

yes

Saliva reducing factors (medications/radiation/systemic) yes

Exposed roots yes

Orthodontic appliances yes

Protective factors

Lives/work/school fluoridated community yes

Fluoride toothpaste at least once daily yes

Fluoride toothpaste at least 2x daily yes

Fluoride mouthrinse (0.05% NaF) daily yes

5,000 ppm F fluoride toothpaste daily yes

Fluoride varnish in last 6 months yes

Office F topical in last 6 months yes

Chlorhexidine prescribed/used one week each of last 6 months yes

Xylitol gum/lozenges 4x daily last 6 months yes

Calcium and phosphate paste during last 6 months yes

Adequate saliva flow (> 1 ml/min stimulated) yes

**Bacteria/saliva test results: Ms: lB: flow rate: ml/min. date:

VISUALIZE CARIES BALANCE(Use circled indicators/factors above)(EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION)CARIES RISK ASSESSMENT (CIRCLE): EXTREME HIGH MODERATE LOW

Doctor signature/#: _______________________________________________________________________________________________________________________ Date:_________________________________________________________

Caries Risk Assessment Form (Age >6)

Patient Name:

Birth Date: Date:

Age: Initials:

Low Risk Moderate Risk High Risk

Contributing Conditions Check or Circle the conditions that apply

I.Fluoride Exposure (through drinking water, supplements,

professional applications, toothpaste) Yes No

II.Sugary Foods or Drinks (including juice, carbonated or

non-carbonated soft drinks, energy drinks, medicinal syrups)

Primarily at mealtimes

Frequent or prolonged between meal exposures/day

III.Caries Experience of Mother, Caregiver and/or other Siblings (for patients ages 6-14)

No carious lesions in last 24 months

Carious lesions in last 7-23 months

Carious lesions in last 6 months

IV. Dental Home: established patient of record, receiving

regular dental care in a dental office Yes No

General Health Conditions Check or Circle the conditions that apply

I.

Special Health Care Needs (developmental, physical, medi-

cal or mental disabilities that prevent or limit performance of

adequate oral health care by themselves or caregivers)

NoYes (over age 14) Yes (ages 6-14)

II. Chemo/Radiation Therapy No Yes

III. Eating Disorders No Yes

IV. Medications that Reduce Salivary Flow No Yes

V. Drug/Alcohol Abuse No Yes

Clinical Conditions Check or Circle the conditions that apply

I.

Cavitated or Non-Cavitated (incipient)

Carious Lesions or Restorations (visually or

radiographically evident)

No new carious lesions or restorations in

last 36 months

1 or 2 new carious lesions or restorations

in last 36 months

3 or more carious lesions or restorations

in last 36 months

II. Teeth Missing Due to Caries in past 36 months No Yes

III. Visible Plaque No Yes

IV.Unusual Tooth Morphology that compromises

oral hygiene No Yes

V. Interproximal Restorations - 1 or more No Yes

VI. Exposed Root Surfaces Present No Yes

VII.Restorations with Overhangs and/or Open Margins; Open

Contacts with Food Impaction No Yes

VIII. Dental/Orthodontic Appliances (fixed or removable) No Yes

IX. Severe Dry Mouth (Xerostomia) No Yes

Overall assessment of dental caries risk: Low Moderate High

Patient Instructions:

© American Dental Association, 2009, 2011. All rights reserved.

Circle or check the boxes of the conditions that apply. Low Risk = only conditions in “Low Risk” column present;

Moderate Risk = only conditions in “Low” and/or “Moderate Risk” columns present; High Risk = one or more

conditions in the “High Risk” column present.

The clinical judgment of the dentist may justify a change of the patient’s risk level (increased or decreased) based

on review of this form and other pertinent information. For example, missing teeth may not be regarded as high

risk for a follow up patient; or other risk factors not listed may be present.

The assessment cannot address every aspect of a patient’s health, and should not be used as a replacement for

the dentist’s inquiry and judgment. Additional or more focused assessment may be appropriate for patients with

specific health concerns. As with other forms, this assessment may be only a starting point for evaluating the

patient’s health status.

This is a tool provided for the use of ADA members. It is based on the opinion of experts who utilized the most

up-to-date scientific information available. The ADA plans to periodically update this tool based on: 1) member

feedback regarding its usefulness, and; 2) advances in science. ADA member-users are encouraged to share their

opinions regarding this tool with the Council on Dental Practice.

Caries Risk Assessment Form (Age >6)

716 O C T O B E R 2 0 0 7

C D A J O U R N A L , V O L 3 5 , N º 1 0TA

BLE

1

Risk

Lev

el##

#**

*

Freq

uenc

y of

Ra

diog

raph

sFr

eque

ncy

ofCa

ries

Reca

ll Ex

ams

Saliv

a Te

st(S

aliv

a Fl

ow &

Bact

eria

l Cul

ture

)

Antib

acte

rials

Chlo

rhex

idin

e X

ylito

l**

**

Fluo

ride

pH C

ontr

olCa

lciu

m

Phos

phat

eTo

pica

l Su

pple

men

ts

Seal

ants

(Res

in-b

ased

or

Glas

s Io

nom

er)

Low

risk

Bite

win

g ra

dio-

grap

hs e

very

24-

36 m

onth

s

Ever

y 6-

12

mon

ths

to re

-ev

alua

te c

arie

s ris

k

May

be

done

as

a ba

se li

ne re

fer-

ence

for n

ew

patie

nts

Per s

aliv

a te

st if

don

eO

TC fl

uorid

e-co

ntai

ning

to

othp

aste

twic

e da

ily,

afte

r bre

akfa

st a

nd a

t be

dtim

e. O

ptio

nal: N

aF

varn

ish

if ex

cess

ive

root

ex

posu

re o

r sen

sitiv

ity

Not

requ

ired

Not

requ

ired

Opt

iona

l: for

ex

cess

ive

root

ex

posu

re o

r sen

-si

tivity

Opt

iona

l or a

s pe

r ICD

AS s

eal-

ant p

roto

col

(TAB

LE 2

)

Mod

erat

e ris

kBi

tew

ing

radi

o-gr

aphs

eve

ry 18

-24

mon

ths

Ever

y 4-

6 m

onth

s to

re-

eval

uate

car

ies

risk

May

be

done

as

a ba

se li

ne re

fer-

ence

for n

ew

patie

nts

or if

th

ere

is s

uspi

cion

of

hig

h ba

cter

ial

chal

leng

e an

d to

as

sess

eff

icac

y an

d pa

tient

coo

p-er

atio

n

Per s

aliv

a te

st if

don

e Xy

litol

(6-1

0 gr

ams/

day)

gu

m o

r can

dies

. Tw

o ta

bs

of g

um o

r tw

o ca

ndie

s fo

ur ti

mes

dai

ly

OTC

fluo

ride-

cont

aini

ng

toot

hpas

te tw

ice

daily

pl

us: 0

.05%

NaF

rins

e da

ily. I

nitia

lly, 1

-2 a

pp o

f N

aF v

arni

sh; 1

app

at 4

-6

mon

th re

call

Not

requ

ired

Not

requ

ired

Opt

iona

l: for

ex

cess

ive

root

ex

posu

re o

r sen

-si

tivity

As p

er IC

DAS

seal

ant p

roto

col

( TAB

LE 2

)

Hig

h ris

k*Bi

tew

ing

radi

o-gr

aphs

eve

ry 6

-18

mon

ths

or u

ntil

no

cavi

tate

d le

sion

s ar

e ev

iden

t

Ever

y 3-

4 m

onth

s to

re-

eval

uate

car

ies

risk

and

appl

y flu

orid

e va

rnis

h

Saliv

a flo

w te

st

and

bact

eria

l cu

lture

initi

ally

an

d at

eve

ry c

ar-

ies

reca

ll ap

pt. t

o as

sess

eff

icac

y an

d pa

tient

coo

p-er

atio

n

Chlo

rhex

idin

e gl

ucon

ate

0.12

%

10 m

l rin

se fo

r one

min

-ut

e da

ily fo

r one

wee

k ea

ch m

onth

. Xyl

itol (

6-10

gr

ams/

day)

gum

or c

an-

dies

. Tw

o ta

bs o

f gum

or

two

cand

ies

four

tim

es

daily

1.1%

NaF

toot

hpas

te

twic

e da

ily in

stea

d of

re

gula

r flu

orid

e to

oth-

past

e. O

ptio

nal: 0

.2%

N

aF ri

nse

daily

(1 b

ottle

) th

en O

TC 0

.05%

NaF

rin

se 2

X da

ily. I

nitia

lly, 1

-3

app

of N

aF v

arni

sh; 1

app

at

3-4

mon

th re

call

Not

requ

ired

Opt

iona

l:Ap

ply

calc

ium

/ ph

osph

ate

past

ese

vera

l tim

es

daily

As p

er IC

DAS

seal

ant p

roto

col

( TAB

LE 2

)

Extr

eme

risk*

*(H

igh

risk

plus

dr

y m

outh

or

spec

ial n

eeds

)

Bite

win

g ra

dio-

grap

hs e

very

6

mon

ths

or u

ntil

no

cavi

tate

d le

sion

s ar

e ev

iden

t

Ever

y 3

mon

ths

to re

-eva

luat

e ca

ries

risk

and

appl

y flu

orid

e va

rnis

h.

Saliv

a flo

w te

st

and

bact

eria

l cu

lture

initi

ally

an

d at

eve

ry c

ar-

ies

reca

ll ap

pt. t

o as

sess

eff

icac

y an

d pa

tient

coo

p-er

atio

n

Chlo

rhex

idin

e 0.

12%

(p

refe

rabl

y CH

X in

wat

er

base

rins

e) 10

ml r

inse

fo

r one

min

ute

daily

for

one

wee

k ea

ch m

onth

. Xy

litol

(6-1

0 gr

ams/

day)

gu

m o

r can

dies

. Tw

o ta

bs

of g

um o

r tw

o ca

ndie

s fo

ur ti

mes

dai

ly

1.1%

NaF

toot

hpas

te

twic

e da

ily in

stea

d of

re

gula

r flu

orid

e to

oth-

past

e. O

TC 0

.05%

NaF

rin

se w

hen

mou

th fe

els

dry,

afte

r sna

ckin

g,

brea

kfas

t, an

d lu

nch.

In

itial

ly, 1

-3 a

pp. N

aF

varn

ish;

1 ap

p at

3 m

onth

re

call.

Acid

-neu

tral

izin

g rin

ses

as n

eede

d if

mou

th fe

els

dry,

afte

r sna

ckin

g,

bedt

ime

and

afte

r br

eakf

ast.

Baki

ng

soda

gum

as

need

ed

Requ

ired

Appl

y ca

lciu

m/ p

hos-

phat

e pa

ste

twic

e da

ily

As p

er IC

DAS

seal

ant p

roto

col

( TAB

LE 2

)

* Pat

ient

s w

ith o

ne (o

r mor

e) c

avita

ted

lesi

on(s

) are

hig

h-ris

k pa

tient

s. **

Pat

ient

s w

ith o

ne (o

r mor

e) c

avita

ted

lesi

on(s

) and

sev

ere

hypo

saliv

atio

n ar

e ex

trem

e-ris

k pa

tient

s. **

* All

rest

orat

ive

wor

k to

be

done

with

th

e m

inim

ally

inva

sive

phi

loso

phy

in m

ind.

Exi

stin

g sm

ooth

sur

face

lesi

ons

that

do

not p

enet

rate

the

DEJ

and

are

not

cav

itate

d sh

ould

be

trea

ted

chem

ical

ly, n

ot s

urgi

cally

. For

ext

rem

e-ris

k pa

tient

s, u

se h

oldi

ng c

are

with

gla

ss io

nom

er m

ater

ials

unt

il ca

ries

prog

ress

ion

is c

ontr

olle

d. P

atie

nts

with

app

lianc

es (R

PDs,

pro

stho

dont

ics)

requ

ire e

xcel

lent

ora

l hyg

iene

toge

ther

with

inte

nsiv

e flu

orid

e th

erap

y e.

g., h

igh

fluor

ide

toot

h-pa

ste

and

fluor

ide

varn

ish

ever

y th

ree

mon

ths.

Whe

re in

dica

ted,

ant

ibac

teria

l the

rapy

to b

e do

ne in

con

junc

tion

with

rest

orat

ive

wor

k. #

## F

or a

ll ris

k le

vels

: Pat

ient

s m

ust m

aint

ain

good

ora

l hyg

iene

and

a d

iet l

ow in

fr

eque

ncy

of fe

rmen

tabl

e ca

rboh

ydra

tes.

****

Xyl

itol i

s no

t goo

d fo

r pet

s (e

spec

ially

dog

s).

Carie

s M

anag

emen

t by

Risk

Ass

essm

ent

Clin

ical

Gui

delin

es fo

r Pat

ient

s Ag

e 6

and

Old

er

Professionally Applied Topical Fluoride: Evidence-based Clinical Recommendations1

Levels of evidence and strength of recommendations:Each recommendation is based on the best available evidence. The level of evidence available to support each recommendation may

differ. Lower levels of evidence do not mean the recommendation should not be applied for patient treatment.

Assess Advise DecideCaries Risk(see back for risk factors)

• Low

• Moderate

• High

& Patient Age

Risk Group/Age < 6 years 6–18 years 18+ years • whether to apply

fl uoride

• type of fl uoride

• frequency of application

• how often to

re-evaluate

LowPatient may not receive any additional benefi t*

Patient may not receive any additional benefi t*

Patient may not receive any additional benefi t*

ModerateVarnish every 6

monthsVarnish or Fluoride gel

every 6 monthsVarnish or Fluoride gel

every 6 months

HighVarnish every 6 or 3

months

Varnish every 6 or 3 months

orFluoride gel every 6 or

3 months

Varnish or Fluoride gel every 6 or 3 months

* Fluoridated water and fl uoride toothpastes may provide adequate caries prevention in this risk category.

• Application time for fl uoride gel and foam should be 4 minutes. • Due to limited evidence these recommendations have not been extrapolated to foams.

• There is limited evidence differentiating NaFand APF gels.

A B C DRecommendation based on higher

levels of evidence

Recommendation based on lower

levels of evidence

Determination of Caries Risk

There are many systems to determine caries risk.

One such system is offered below that can be used for caries risk assessment.

* Medication, radiation or disease induced xerostomia.

1 ADA Council on Scientifi c Affairs. Professionally applied topical fl uoride: Evidence-based clinical recommendations. JADA 2006;137(8):1151-59. Copyright ©2006 American Dental Association. All rights reserved. Adapted 2008 with permission. To see the full text of this article, please go to http://jada.ada.org/cgi/reprint/137/8/1151.

This page may be used, copied, and distributed for non-commercial purposes without obtaining prior approval from the ADA. Any other use, copying, or distribution, whether in printed or electronic format, is strictly

prohibited without the prior written consent of the ADA

Professionally Applied Topical Fluoride: Evidence-based Clinical Recommendations1

Individual risk factors increasing risk for developing caries may also include, but are not limited to:• High titers of cariogenic bacteria

• Poor oral hygiene

• Prolonged nursing (bottle or breast)

• Poor family dental health

• Developmental or acquired enamel defects

• Genetic abnormality of teeth

• Many multisurface restorations

• Chemo/radiation therapy

• Eating disorders

• Drug/alcohol abuse

• Irregular dental care

• Cariogenic diet

• Active orthodontic treatment

• Presence of exposed root surfaces

• Restoration overhangs and open margins

• Physical or mental disability with inability or unavailability of performing proper oral health care

Risk group Age Primary or Secondary Carious lesions in the past three years Risk factors listed above

Low All age groups None and None

Moderate< 6 years None and At least one risk factor

> 6 years One or two or At least one risk factor

High

< 6 years Any orMultiple risk factors or Low Socioeconomic status or

Xerostomia* or suboptimal fl uoride exposure

> 6 years Three or more orMultiple risk factors or Xerostomia* or

suboptimal fl uoride exposure

Beyond Straight Teeth! The Periodontic/Orthodontic Connection · · 2013-07-01Beyond Straight Teeth! The Periodontic/Orthodontic Connection ... therefore need orthodontic treatment;

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