Caries Risk + Protocols 06

8/3/2019 Caries Risk + Protocols 06

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Caries Risk Assessment Caries Risk Assessment

and its interaction with Preventiveand its interaction with Preventiveand Restorative Protocolsand Restorative Protocols

Richard Ehrlich DDSwww.elmtreedental.com

[email protected]



Introduction

Introduction

Caries Risk is used by most general

dentists daily, usually on an intuitivelevel.

The first part of this presentation will

attempt to help quantify this, and thesecond part will use this information formore systematic preventive, diagnosticand restorative protocols.



Applications of Caries Risk Applications of Caries Risk

Assessment Assessment

Caries Risk Assessment Caries Risk Assessment assists in predicting andassists in predicting and

diagnosing this type of diagnosing this type of casecase--

Should you observe this?Should you observe this?

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



Applications of Caries Risk Applications of Caries Risk

Assessment Assessment

Caries Risk Assessment Caries Risk Assessment

assists in predictingassists in predictingand diagnosing thisand diagnosing thistype of casetype of case--

Should you replaceShould you replace

these restorations orthese restorations orobserve them?observe them?



Overview of Caries RiskOverview of Caries Risk

Assessment (CRA) Assessment (CRA) Caries Risk Assessment (CRA) is a simple, quickCaries Risk Assessment (CRA) is a simple, quick

method for assigning a number to an individualsmethod for assigning a number to an individuals

risk for decay.risk for decay.

Using this data, custom preventive and restorativeUsing this data, custom preventive and restorativeprograms can be used, with more reliance onprograms can be used, with more reliance onevidenceevidence--based dentistry and less on intuition andbased dentistry and less on intuition and

experience alone.experience alone.

This simplified version is based on practicalThis simplified version is based on practicalapplication of the U of T Caries Risk Assessment inapplication of the U of T Caries Risk Assessment inactual clinical practice in a preventiveactual clinical practice in a preventive--orientedoriented

dental office.dental office.



Categories for Simplified CRACategories for Simplified CRA

These are all given numerical scoresThese are all given numerical scores::

Existing DecayExisting Decay

Previous DecayPrevious Decay

Root CariesRoot Caries

Fluoride ExposureFluoride Exposure

Diet FactorsDiet Factors Oral HygieneOral Hygiene

Additional Tests Additional Tests

S.mutans and LactobacillusS.mutans and Lactobacillus

Saliva FlowSaliva Flow





No Decay = 0No Decay = 0

Some early Pit andSome early Pit andFissure Decay = 0.5Fissure Decay = 0.5

11--2 Existing Lesions =12 Existing Lesions =1

>2 Lesions =2>2 Lesions =2





No Decay = 0No Decay = 0

Some early Pit andSome early Pit andFissure Decay = 0.5Fissure Decay = 0.5

Interproximal PosteriorInterproximal PosteriorDecay =1Decay =1

Anterior or Smooth Anterior or SmoothSurface Decay =2Surface Decay =2







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

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

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

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








Using FluorideUsing FluorideToothpaste BID = 0Toothpaste BID = 0

Using FluorideUsing FluorideToothpaste once dailyToothpaste once daily= 1= 1

Not using FluorideNot using FluorideToothpaste or RinseToothpaste or Rinse= 2= 2








Diet FactorsDiet Factors



Diet Factors:Diet Factors:

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

Total sugar exposures are totaled, andTotal sugar exposures are totaled, and

divided by 3 for the Caries Index Dietdivided 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 tea1. Coffee or tea with sugar with sugar between mealsbetween meals?? ± ± 2. Pop, Kool2. Pop, Kool--aid, lemonade, sports drinks, fruit juice,aid, lemonade, sports drinks, fruit juice,

iced tea with sugar iced 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 adrinks do you have a

day? This does not include coffee, soft drinks, full strengthday? 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



Diet Questionnaire:Diet Questionnaire: Drink Factors cont¶d:Drink Factors cont¶d:

Important trend: Cariogenic drinks are on aImportant trend: Cariogenic drinks are on a

great increase!great increase!Huge marketing efforts have been made, and often soft drinkHuge marketing efforts have been made, and often soft drinkcompanies have a monopoly on vending machines incompanies have a monopoly on vending machines inschools. This has paid off with a corresponding increase inschools. This has paid off with a corresponding increase indecay and acid erosion.decay and acid erosion.

Consumption of soft drinks, sports drinks, fruit juices andConsumption of soft drinks, sports drinks, fruit juices andiced tea have skyrocketed in recent years, especially amongiced tea have skyrocketed in recent years, especially among

teens and adolescents. Sports drinks are meant for athletesteens and adolescents. Sports drinks are meant for athletesinvolved in over 60 minutes of aerobic activity. Sedentaryinvolved in over 60 minutes of aerobic activity. Sedentarykids are drinking sports drinks after mild activity, thanks tokids are drinking sports drinks after mild activity, thanks togood marketing.good marketing.

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

Link toLink to Acid Erosion Page Acid Erosion Page



Diet Questionnaire:Diet Questionnaire: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, driedEat mints, lozenges, candies or candy bars, dried

fruit, energy barsfruit, 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.



Diet Questionnaire:Diet Questionnaire: Do you have a habit of sipping a

sweetened drink (Coffee, cola, juice) or

eating a sweet snack over an extendedperiod of time, 45 minutes or more?

± If yes, add 2



Diet Questionnaire:Diet Questionnaire: Total diet scores are added up, divided

by 3 and this is the number used for the

Caries Risk Assessment score for DietFactors.

0-2 Sugar exposures=0

3-4 Sugar exposures =1

5-6 Sugar Exposures =2

>6 exposures =3









Oral HygieneOral Hygiene

0=Good OH0=Good OH

1=Fair OH1=Fair OH PSRs <3PSRs <3

Mod PlaqueMod Plaque

2=Poor OH2=Poor OH PSRs >3PSRs >3

Heavy PlaqueHeavy Plaque









Oral HygieneOral Hygiene


S.mutans and LactobacillusS.mutans and Lactobacillus





Bacterial testing is doneBacterial testing is done

only in cases whenonly in cases when

indicated, if other resultsindicated, if other resultsare not obvious.are not obvious.

>1,000,000 colonies>1,000,000 colonies

s.mutans or >100,000s.mutans or >100,000

lactobacillus = 2lactobacillus = 2 > 4 minutes for 3cc> 4 minutes for 3cc

saliva sample =2saliva sample =2

± ± Indicates possibleIndicates possible

XerostomiaXerostomia


S.mutans andS.mutans andLactobacillusLactobacillus




The Simplified Caries IndexThe Simplified Caries Index

FormForm

CARIES INDEX TOTAL

Existing decay Diet Score

Previous Decay Oral HygieneRoot caries Bacterial Test

Fluoride Exposure Saliva Flow

This small form is in a digital template on the computer chart, butcan be printed on standard adhesive labels and attached to thedaily 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 betweenmeals?

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 snackover 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 includecoffee, 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 thepatient to see during review



CRA Score and Caries Risk:CRA Score and Caries Risk:

The Total ScoreThe Total Score

00--2 = Low Risk2 = Low Risk

33--4 = Medium Risk4 = Medium Risk

44--6 = High Risk6 = High Risk

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



CRA Score and Caries Risk:CRA Score and Caries Risk:

Applying the data Applying the data

From this data we can set up customFrom this data we can set up custom

protocols for the individual patients,protocols for the individual patients,includingincluding

Fluoride treatmentsFluoride treatments

Frequency of X Frequency of X--raysrays

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 Recare Report-- Getting theGetting the

message out message out

Patients remember a percentage of what Patients remember a percentage of what

you tell them while in the chair. Theyyou tell them while in the chair. Theytake it far more seriously if they havetake it far more seriously if they havesomething they can take home.something they can take home.

We use a Recare report to give to patients,We use a Recare report to give to patients,or kids parents.or kids 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--

TakeTake--home message:home message:

Caries Risk Assessment is an essential part of scientificallyCaries Risk Assessment is an essential part of scientificallybased dentistry in real general practicebased dentistry in real general practice

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

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



Dr. Richard EhrlichDr. Richard Ehrlich

www.elmtreedental.comwww.elmtreedental.com



Part 2:Part 2:Diagnostic, Restorative andDiagnostic, Restorative andPreventive Protocols usingPreventive Protocols usingRisk Analysis and High TechRisk Analysis and High Techinstrumentationinstrumentation

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- DiagnosticLaser caries detector



Diagnodent LaserDiagnodent Laser

This device can give a numerical reading of earlyThis device can give a numerical reading of early

decay in pits.decay in pits.

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

Caution is required around hypocalcifications andCaution is required around hypocalcifications andexisting resins and sealants as the unit mayexisting resins and sealants as the unit maymisread.misread.



Other adjunctsOther adjuncts-- MagnificationMagnification

LoupesLoupes

Operating MicroscopeOperating Microscope Intraoral CameraIntraoral Camera



Diagnodent LaserDiagnodent Laser

Readings under 10 have noReadings under 10 have nodecay.decay.

Readings 10Readings 10--20 usually have20 usually havestain or enamel cariesstain or enamel caries

Readings over 35 generally havedecay in dentin.

Readings of 99 are decayed well into dentin.

Readings 20-35 need individual assessment

Diagnodent Readings alone are not sufficient for diagnosis (SeeLiterature Review)

New Technologies:



Protocols using the toolsProtocols using the tools

At the initial diagnosis, the patient can At the initial diagnosis, the patient can

usually be assigned to a Risk group.usually be assigned to a Risk group. This is reThis is re--evaluated at the next recall, asevaluated at the next recall, as

often the status changes after the initialoften the status changes after the initial

treatment.treatment.



Low RiskLow Risk-- Initial ProtocolInitial ProtocolCaries Index 0Caries Index 0--22

ObserveObserve pits and fissurespits and fissures

with stain or early decay,with stain or early decay,

decay in enamel, very earlydecay in enamel, very early

(stable) decay in dentin, old(stable) decay in dentin, old

restorations, poor margins.restorations, poor margins.

Diagnodent (DD) < 25Diagnodent (DD) < 25--3030

Restore fractured restorations,

obvious decay (DD>40).



RestoreRestore old restorations withold restorations withcracks 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(DD>25--30)30)

Medium RiskMedium Risk-- Initial ProtocolInitial ProtocolCaries Index 3Caries Index 3--44

ObserveObserve stained pits, deepstained pits, deep

pits, early decay inpits, early decay in

enamel.enamel. (DD<20)..

Diet Counseling IntroductionDiet Counseling Introduction(link to diet page)(link to diet page)Fluoride Supplements for childrenFluoride Supplements for childrenin non fluoridated areasin non fluoridated areas



RestoreRestore early decay in enamel andearly decay in enamel anddentindentin..(DD>15(DD>15--20)20)

RestoreRestore old restorations withold restorations withcracks and broken marginscracks and broken margins

High RiskHigh Risk-- Initial ProtocolInitial ProtocolCaries Index >4Caries Index >4

ObserveObserve stainedstained pitspits

DD<10DD<10

Diet Counseling IntroductionDiet Counseling IntroductionFluoride Supplements for childrenFluoride Supplements for childrenPrevident 5000 for AdultsPrevident 5000 for AdultsFluoride varnish on incipient areasFluoride varnish on incipient areas



First ReFirst Re--evaluationevaluation

All patients are re All patients are re--assessed after the initialassessed after the initialtreatment.treatment.

Many are at reduced risk once initial decayMany are at reduced risk once initial decayis removed, and diet/OH improvements areis removed, and diet/OH improvements areimplemented.implemented.



High RiskHigh Risk-- First EvaluationFirst Evaluation3 month period3 month period

Caries Risk ReCaries Risk Re--Evaluation, includingEvaluation, including

s. mutans, lactobacillus test

Salivary flow measurement

33--month Topical Fluoride, OHI month Topical Fluoride, OHI

If risk reduced, proceed to Medium RiskIf risk reduced, proceed to Medium Risk

Recare protocolRecare protocol



Low Risk Suggested ProtocolLow Risk Suggested Protocol

Recall Recall patient every 9 months, consider increasing if remaining lowpatient every 9 months, consider increasing if remaining lowrisk.risk.

No Topical FluorideNo Topical Fluoride

No Fluoride Supplement No 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 enamel, verypits and fissures with stain or early decay in enamel, veryearly decay in dentin.early decay in dentin. (DD<25(DD<25--30)30)

Polish or seal Polish or seal old restorations with poor margins, and observeold restorations with poor margins, and observeSealantsSealants not requirednot required



Medium Risk Suggested ProtocolMedium Risk Suggested Protocol Recall Recall patient every 6 monthspatient every 6 months

Topical Fluoride for childrenTopical Fluoride for children

Fluoride Supplement for areasFluoride Supplement for areas

without water Fwithout water F-- Take BW radiographs every 2Take BW radiographs every 2

yearsyears

OHI As neededOHI As needed

ObserveObserve stained pits, earlystained pits, earlydecay in enameldecay in enamel or optionallyor optionallysealseal. (DD<15. (DD<15--20)20)



Medium Risk Suggested ProtocolMedium Risk Suggested Protocol

RestoreRestore pits and fissurespits and fissures

with early decay, anywith early decay, any

very early decay invery early decay in

dentin, old restorationsdentin, old restorations

with poor margins.with poor margins.

(DD>20)(DD>20)

Polish or sealPolish or seal oldold

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 diarywith diary



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

RecallRecall patient every 3 months:patient every 3 months:

± ± Topical FluorideTopical 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 RinsesChlorhexidine Rinses ± ±Adult Adult-- 30 seconds before bed30 seconds before bed

XylitolXylitol--containing gumcontaining gum-- 3 pieces daily3 pieces daily

Fluoride SupplementsFluoride Supplements--ChildChild

EvaluateEvaluate for xerostomiafor xerostomia



RestoreRestore pits with earlypits with early

decay, any very earlydecay, any very early

decay in dentin or decay in dentin or

enamel,enamel, (DD>20)(DD>20) oldoldrestorations with fair restorations with fair--

poor margins.poor margins.

Sealants/Preventve resinsSealants/Preventve resins--

all deep pits and fissures.all deep pits and fissures.

((DD>5DD>5--20)20)



Often high risk kids present withOften high risk kids present with

early decay or deep pits inearly decay or deep pits inbarely erupted teeth.barely erupted teeth.

New Technologies:New Technologies:

These can be very hard to sealdue to access or co-operationissues. If there is any moisturecontamination, traditional

sealants will fail.



FluorideFluoride--releasing sealantsreleasing sealants forfor

suspect pits with poor accesssuspect pits with poor access

Fuji Triage can be placed quickly andFuji Triage can be placed quickly andeasily, needing very little cooperation.easily, needing very little cooperation.


Due to the fluoride release, it Due to the fluoride release, it is less likely than traditionalis less likely than traditionalsealants to allow decay belowsealants to allow decay belowif it leaks.if it 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 inPatient Education is enhanced as they can see radiographs enlarged in

front of them. Diagnosisfront 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 pitsOzone Treatment of pits A promising new technique A promising new technique

involves sterilizing the pitsinvolves sterilizing the pitsand fissures with ozone. Thisand fissures with ozone. Thishas been shown to stophas been shown to stopdecay and even allowdecay and even allowremineralizationremineralization

This may make cooperationThis may make cooperationeven easier in earlyeven easier in early

interventionintervention More research is neededMore research is needed

here.here.




1. Cleaning

2. Measurement

3. Treatment

4. Reductant Fluid

Promotes the immediate

remineralization of the tooth.

Proposed steps in Healozone Treatment



DIFOTI (Digital Imaging Fiber DIFOTI (Digital Imaging Fiber--Optic TransOptic Trans--IlluminationIllumination))New Technologies:New Technologies:

This device createsThis device creates highhigh--resolution digital images of resolution digital images of

occlusal, interproximal and smooth surfaces. It enablesocclusal, interproximal and smooth surfaces. It enablesdentists to discover or confirm the presence of decay thatdentists 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 explorer an explorer



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




Air AbrasionAir Abrasion


This technology allows earlyintervention more conservatively thanrotary instruments.

Pits with stain, decay in enamel andvery early dentin decay (DD 5-30) can

be treated, almost always without localanaesthetic.

Any restorative prep can be cleaned out with this unit, allowing better bonding.

Air Abrasion is excellent for cleaningany prosthesis that needs bonding in the

mouth, from crowns and posts to fixedortho.

You cannot remove amalgams or treat larger lesions.

Auxilliary suction is needed.



MicrobursMicroburs


Low-tech way to access verysmall pits. ¼, 1/8 and 1/16round burs are available for highspeed handpieces.

Can treat some early pits andgrooves almost as well as lasersor air abrasion.



Laser Laser-- Water unitsWater units


This technology is similar in applicationto Air Abrasion units, but moreversatile.

Pits with stain, decay in enamel andearly dentin decay (DD 5-30) can be

treated, almost always without localanaesthetic.

Soft tissue can be trimmed as well.

There is less chance of injuring soft tissue with overspray.

There is no powder spray mess, soauxilliary suction is not needed.

Like Air Abrasion, you cannot removeamalgams or easily treat larger lesions.

These units cost 20-50X more than airabrasion units, and are much larger.



Application In Practice Application In Practice--

TakeTake--home message: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 reduce their Aim to convert all your patients to low risk, or at least reduce their

caries index.caries index.

Do not overDo not over--treat your lowtreat your low--risk patientsrisk patients. They need their own. They need their ownpreventive and restorative protocols.preventive and restorative protocols.

Do not underDo not under--treat your high risk patientstreat your high risk patients. They need every. They need everypreventive and early intervention restorative measure you can givepreventive and early intervention restorative measure you can give

them, especially if they cannot convert to lower risk.them, especially if they cannot convert to lower risk.



Summary Flow Chart Summary Flow Chart--

This flow chart isThis flow chart isavailable from my webavailable from my webpage at page at

www.elmtreedental.comwww.elmtreedental.com

Caries Risk- Diagnostic, Restorative and Preventive Protocols

Low Risk Medium Risk High Risk

Low Risk Medium Risk High Risk

Initial DiagnosisCaries Risk Analysis

Observe pits and fissureswith stain or early decay,decay in enamel, very early(stable) decay in dentin, oldrestorations, poor margins.

(DD < 25-30)Restore fractured

restorations.

Observe stained pits, deeppits, early decay in enamel.(DD<20)Restore old restorations withcracks and broken margins,decay in pits with halo or shadow, any decay in dentin.(DD>25-30)

Diet Counselling Intro.

Initial ProtocolObservestained pits.Restore early decay inenamel and dentin.(DD>15-20) Restore old restorations withcracks and broken margins.Diet Counselling IntroFluoride- Supplements for children, Prevident 5000 for adults

3 Month RecareCaries Risk Re-Evaluations. mutans, lactobacillus testSalivary flow measurementFluoride, OHI

Caries Risk AnalysisRe-evaluation

Recall patient every 9months, consider increasing if remaininglow risk.No Topical FluorideNo Fluoride SupplementTake BW radiographsevery 3 yearsOHI As neededObservepits andfissures with stain or early decay in enamel,very early decay indentin. (DD<25-30) Polish or seal oldrestorations with poor

margins, and observeSealants not required

Recall patient every 6 monthsTopical Fluoride for childrenFluoride SupplementTake BW radiographs every 2yearsOHI As neededObservestained pits, earlydecay in enamel (DD<15-20) or optionally seal.Restore pits and fissures withearly decay, any very earlydecay in dentin, oldrestorations with poor margins. (DD>20) Polish or seal old restorations

with fair margins, and observe.Sealants are optional

Full diet counselling with diaryRecall patient every 3 months:Topical FluorideFluoride Varnish on prone areasHome Fluoride Trays,Chlorhexidine Rinses -AdultFluoride Supplements-ChildXylitol GumTake BW radiographs yearlyOHIEvaluate for xerostomiaRestore pits with any very earlydecay in dentin or enamel, (DD>20) old restorations with fair- poor margins.Sealants/Preventve resins- alldeep pits and fissures. (DD>5-20) Fluoride-releasing sealants wherepossible



SummarySummary

A system of numerically rating a patients A system of numerically rating a patientscaries risk has been presentedcaries risk has been presented

Protocols for minimal invasive andProtocols for minimal invasive andpreventive treatment for low risk patientspreventive treatment for low risk patientsand maximal preventive and earlyand maximal preventive and early

restorative treatment for high riskrestorative treatment for high riskpatients have been demonstrated, topatients have been demonstrated, toallow custom treatment for eachallow custom treatment for each ppatient.atient.



Thank youThank you

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

905905--880880--70037003

Caries Risk + Protocols 06

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