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CARIES MANAGEMENT BY RISK ASSESSMENT

(CAMBRA)
Introduction

 The population of individuals susceptible to carious lesion & dental caries continues to expand with increased age
 CAMBRA principle: An evidence based approach to preventing or treating the cause of dental caries at the earliest
stage rather than waiting for irreversible damage to the teeth

Caries risk assessment

 Caries risk assessment (CRA) is essential in decision making to guide clinician in the diagnosis, prognosis and treatment
recommendation – better cost effectiveness & greater successful tx
 CRA forms
o American Dental Association (2 forms; determine low, moderate or high risk)
 For patients 0-6 years old
 For patients >6 years old
o American Academy of Pediatric Dentistry
 For children 0-5 years old
 For children >5 years old
o Journal of California Dental Association
 For patients aged 0-5 years old
 For patient aged >5 years old

Caries Balance Concept

 Balance between pathological & protective factors in the caries process


 Disease indicator (WREC – caries imbalance model)
1) White spots – visible on smooth surface
2) Restoration – in last 3 years due caries activity
3) Enamel approximal lesion – confined to enamel only, visible on dental radiograph
4) Cavitation – caries lesion penetration into dentin
 Patient examination:
1) Visual tactile inspection
 high ability to identify sound tooth surface site
 low ability to correctly identify carious lesion site (esp in early caries)
2) Using sharp dental explorer pushed into pits & fissure
 Controversial – potential to cause an opening (cavitation) in the enamel surface is high
3) Bitewing radiograph
 Not give information about lesion activity, not accurately identify early enamel caries
 Tend to underestimate the actual lesion depth
 Not helpful in detecting early occlusal lesion – because of the superimposition of multiple enamel
surface.
4) Non-invasive, non-radiation, light emitting technologies – higher precision. eg:
 optic transillumination (FOTI & DIFOTI)
 electronic caries monitor
 quantitative light-induced fluorescence
 diode laser fluorescence
 LED light reflectance & refraction

International Caries Detection Assessment System (ICDAS)

Restoration & Sealant Code (Tooth status) Caries lesion code (severity)
0 = Not sealed or restored 0 = Sound tooth surface, no/slight change after prolonged air
drying
1 = Sealant, partial 1 = 1st visual change in enamel seen after prolonged air drying
2 = Sealant, full 2 = Distinct visual changes in enamel
3 = Tooth-colored restoration 3 = Localized enamel breakdown, no dentin involvement
4 = Amalgam restoration 4 = Underlying dark shadow from dentin (not cavitated into dentin)
5 = Stainless steel crown 5 = Distinct cavity with visible dentin
6 = Porcelain, gold, PFM crown or veneer 6 = Extensive distinct cavity with visible dentin
7 = Lost or broken restoration
8 = Temporary restoration
RISK FACTORS
1) Bacteria (MS & LB)

 Cariogenic bacteria reside in plaque biofilm & adhere to the tooth surface, ingested sugars from fermentable
carbohydrates are converted to weak organic acids that will cause demineralization of the hydroxyapatite structure.
 There is a distinct difference between the microflora of healthy (caries free) individual compared to microflora of those
with dental caries.
 Mutans streptococci – has unique ability to produce both intra- and extracellular polysaccharides that help with acid
production and survival during low nutrition periods
 Lactobacilli
o An acidogenic (acid producing) & aciduric (thriving in acid)
o Live in low-pH niche – difficult to clean & near plaque biofilm accumulation
o Live in deep parts of carious lesion
o Resistant to bacteria-reducing substances than are MS
o Fluoride resistant

 Bacterial testing
o If saliva contain high bacterial counts, so does the plaque biofilm
o High risk: >105 colony forming unit (CFU) of MS or LB
o To detect MS = Blue MS agar + bacitracin → small blue colonies with diameter of <1mm
o To evaluate LB = Transparent green MRS agar → appear white colonies

2) Saliva – Inadequate flow & Reducing factors (medication/radiation/systemic)

 Component of saliva:
o Electrolyte – sodium, potassium, calcium, magnesium, bicarbonate & phosphate
o Immunoglobulin
o Protein
o Enzyme
o Mucin
o Urea
o Ammonia
 Function:
o Modulate the bacterial attachment in plaque biofilm, the pH & buffering capacity
o Antibacterial properties
o Tooth surface remineralization & demineralization
 Condition:
o Hyposalivation: less saliva in contact with tooth surface, reducing number of calcium & phosphate ion
o Xerostomia
 Bad effect of hyposalivation:
o High caries risk
o Dental erosion
o Ulceration
o Dysphagia – difficulty in swallowing
o Dysgeusia – taste impairment
o Oral malodour
o Impaired use of removable prosthesis
o Candidiasis
 Salivary flow determined by measuring
o Resting saliva – measure for 4 minutes. [Hypo= <0.1ml/min]
o Stimulated saliva – measure for 5 minutes. More practical way to measure [Hypo= <0.7ml/min]

3) Diet - Frequent snack (>3x)

 Diet effect the pH, quality & quantity of saliva.


o Sugar (sucrose) & other fermentable carbohydrate – lower the salivary & plaque pH
o Sucrose, fructose & glucose are more cariogenic than complex carbohydrate
 Physical properties of food & frequency
o Texture, consistency & temperature of food can affect mastication & oral clearance from mouth
 Patient eat influence by:
o Socioeconomic
o Status
o Culture & ethnicity
o Food cost & availability
o Advertising & marketing
 The higher the severity of the risk factors, the greater the intensity of protective factors must be in order to reverse the
caries process
 Protective factors:
o Fluoridated water
o Regularly using fluoridated tooth paste
o Low fluoride oral rinses
o Xylitol
o Receiving topical application of fluoride, chlorhexidine & calcium phosphate agents
 Antimicrobial
o Destroy or suppress growth of microorganism
o Recommended for patient >6 years old & high or extreme risk of caries
o Example: Chlorhexidine gluconate (effective in reducing the level of MS but not against LB)
 Long term use of chlorhexidine can lead to discoloration of tooth, mucous membrane, tongue &
composite restoration; lead to taste disturbance
 To avoid this side effect, use chlorhexidine varnish
 Xylitol
o Control cariogenic bacteria for patient >6years old & moderate to extreme risk caries
o For children <6 years old, xylitol wipes is recommended
o Xylitol is a naturally occurring sugar alcohol reduces the amount of MS & the quantity of plaque biofilm when
habitually consume
o Dose dependent: 5-6 g/day (5-10 minutes per exposure)
 Fluoride
o Recommended to use >1000 ppm fluoride (but not suitable for very young as it would be developed mild
fluorosis
o Example use: fluoride gels & varnish
 Topical fluoride designed to stay in close contact with the tooth surface for hours
 Effective use in early white spot lesion
 Varnish is more effective than traditional topical gels
 Easy to use & cost effective – viscosity allow it to flow on tooth surface
 Content: 22600 ppm F-, calcium phosphate, tricalcium phosphate, difluorosilane
 Apply 2 – 4x/year for children & adolescence who are at high risk of caries

 Effective lifestyle habits


o Diet:
 reduce fermentable carbohydrates
 eat hard cheese – coat teeth with a lipid layer, protecting surfaces from acid attack
 arginine rich in diet – increase plaque pH (eg nuts, seeds, kidney bean, soybeans, watermelon &
tuna)
o Practice:
 Sodium bicarbonate toothpaste & rinse
 High dose xylitol gum – raise plaque pH & reduce MS
 Calcium phosphate – raise plaque pH, deliver bioavailable calcium & phosphate to the tooth surface.
Recommended for pt with root exposure or sensitivity
 Chewing gum – suitable for pt with salivary hypofunction
o Instrument:
 Sonic power toothbrush – increase salivary flow, decrease numbers of incipient & frank root caries
o Motivational interviewing
 focus on what patient feels, wants & thinks, involving patient speaking and clinicians listening
 for paeds – interview with parentsl

4) Visible heavy plaque on teeth

5) Anatomy - Deep pits & fissure, Exposed root

6) Recreational drug use

 Medication that may reduce salivary flow:


o Anti-allergy medication
o Anti-histamine
o Decongestants
o Central analgesics
o Sedatives
o Cardiovascular medication (ACE inhibitors & calcium channel blockers)
o Muscle relaxant
o Drug for urinary incontinence
o Parkinson’s disease medication
o Antidepressants
o Antacids

7) Orthodontics appliances