Treatment Planning and Risk Assessment and Management Dr. Negar Melanie Nasseripour Dr. Frederick Hains Dr George Keleher

Transcription

1 Boston University Goldman School of Dental Medicine 1

2 Treatment Planning and Risk Assessment and Management Dr. Negar Melanie Nasseripour Dr. Frederick Hains Dr George Keleher Department of General Dentistry Boston University Goldman School of Dental Medicine 2

3 Introduction Dental treatment should be customized based on the patient s risk levels for: caries, periodontal disease oral cancer Emphasis being placed on diagnosis and prevention of the disease process Prevention=art and science of managing the risk factors of each individual patient to promote optimum oral health 3

4 Caries Risk 20 % of the population bears at least 60% of the caries burden, with fewer than 5% of adults being caries free 2. The incidence of new carious lesions in adults has been estimated as one new coronal lesion per year. 3 Periodontal Risk More than 75% of American adults have some form of periodontal disease 4

5 We need to change! Paradigm shift in therapeutic approach to caries. Consensus Statement adopted by the World Congress of Minimally Invasive Dentistry (WCMID) on August 16 th 2007 in San Diego, CA introduced CAMBRA 4 : Caries Management by Risk Assessment 5

6 What is CAMBRA? Assessment of risk Management by minimally invasive treatments: 1.remineralization techniques for early lesions, 2.treatment of the cariogenic plaque, 3.minimal intervention of cavitated lesions, Preventing caries and remineralizing early carious lesions = most cost-effective treatment options. 2 6

7 Perio Oral Hygiene. Diet: Sugar and Acid. Female Hormones Genetic Factors.. Smoking and Nicotine Medical Conditions: Diabetes/Osteoporosis and Osteonecrosis /Herpes- Related Gingivitis/ HIV- Associated Gingivitis Contributing factors: Poorly Contoured Restoration Tooth Abnormalities Crowding 3 rd molars Risk Factors Caries Recent history of the disease: caries prevalence/incidence Oral hygiene Diet: fermentable carbohydrates Degree of exposure to fluoride Patient s saliva Patient medical condition 18 Contributing factors Crowded teeth, fissures, Restoration overhangs Developmental disturbances 7

8 Combined Risk Factors The strongest predictor for future caries is a recent history of the disease New patient, a caries prevalence rate should be determined DMFT and DMFS Patient of record, it is the caries incidence or the number of new lesions per unit time (usually over one year). The second important risk factor is oral hygiene Plaque in both quantity and quality It is possible to collect, incubate and analyze patients bacterial composition The third risk factor is fermentable carbohydrates Quantity, quality (consistency) and frequency of carbohydrate intake 8

9 The fourth risk factor is degree of exposure to fluoride A recent meta analysis conducted by Griffin and colleagues (2007) 13 demonstrated that 25% of new carious lesions in adults can be prevented by the use of professionally applied, self-applied (home use) and community water fluoride. The fifth risk factor is the patient s saliva Salivary Flow/Quantity/Quality The sixth factor is patient medical condition 1 Can directly or indirectly influence the caries process 18, 1. changes in saliva 2. certain drugs contribute by their content of fermentable carbohydrates, low ph, or by affecting the saliva 3. radiation towards the head-neck-region leading to a destruction of the salivary glands 4. diseases in early child-hood influencing the formation of the enamel 9

10 Smoking single major preventable risk factor for periodontal disease. can cause bone loss and gingival recession even in the absence of periodontal disease. Genetic factors Up to 30% of the population may have some genetic susceptibility to periodontal disease. Hormones Progesterone dilates blood vessels causing inflammation, and blocks the repair of collagen. 10

11 Risk Assessment 11

12 Each patient = unique combination of risk factors at any point in time. Customized preventive and therapeutic treatment strategy. Each of the risk factors discussed will carry a different weight in the overall assessment of risk. A consensus reached =previous caries experience is the strongest predictor of caries risk 6 and therefore should carry more weight in the patients caries risk evaluation. Patient may have an extensive list of secondary risk factors, when combined, lead to moderate to high risk 12

13 Clinical Exam Full clinical: medical, dietary, dental exam >> dried teeth, using light, mirror,and gentle probing 7 Radiographs Diagnosis of interproximal smooth surface lesions when monitoring the progression of the carious process 11 Adjunctive diagnostic means Electrical conductance examination (Diagnodent) 9 Quantitative Light-induced Fluorescence (QLF) 10 13

14 Bacterial test: 14

15 At Boston University we have found that a visual representation of the patients risk status is highly effective in patient education. 15

16 Caries Experience: number of carious lesions in the past year 0= Caries Free 1=1 active lesion 2=2 active lesions 3=3+ active lesions Use of Fluoride: based on patient interview 0= Receives maximum fluoride program 1=Additional fluoride measures infrequently 2=Fluoride tooth paste only 3=Avoiding fluoride, no fluoride Quantity of Plaque: recorded plaque index 0 =<10% 1= 10-40%/ 2= 50-70% 3=More than 70% Frequency of Carbohydrate: determined from diet inquiry 0=Maximum 3 times a day 1=Maximum 5 times a day 2=Maximum 7 times a day 3=More than 7 times a day Advanced assessment ph: patients salivary ph 0= blue=9 1=green=7-8 2= yellow=6 3=orange=5 Saliva Secretion Rate: 0=Normal >1.1ml stimulated saliva/min 1=Low ml stimulated saliva/min 2=Low ml stimulated saliva/min 3=Very low, Xerostomia, <0.5ml saliva/min Strep MutansTest: 0= negative 3=positive 16

17 Caries Risk Assessment These numbers are plotted onto the Spider chart are representation of the patient s risk. At recall, the same process is repeated Copyright Boston University 17

18 Patient caries risk: high High caries incidence, medication inducing hyposalivation, limited access to fluoride, fair oral hygiene, and high Strep mutans count Preventive Strategy: 4 Months Recall Fluoride prescription 1.1% NaFl toothpaste Hydration, Xylitol chewing gum to help with salivation and strep mutans count Restore carious lesions and faulty restoration Review oral hygiene instructions Review diet Recall: Improved OH, 1 new carious lesion, improved fluoride, improved salivary flow and ph and strep mutans Maintain previous preventive strategy 18

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20 Therapeutic Armada: Impact on Treatment Planning 20

21 Oral hygiene/recall Diet modification Fluoride Antimicrobials: Chlorhexidine/Xylitol Remineralization pastes Smoking cessation Salivary stimulants Minimally invasive dentistry: slot preps/sealants/ comp/ RMGI 21

22 Habit modification The first strategy for prevention = improved or appropriate home care regimen Recall regimen: Low risk : every 6months Mod risk: every 4 months High risk: every 3 months 22

23 Diet modification strategies should also be discussed so that the patient decreases the frequency of ingestion of easily fermentable or sticky carbohydrates. 23

24 Fluoride 24

25 Low Risk Exposure to sufficient amounts of fluoride in fluoridated water and over the counter fluoride toothpastes (~1,100 ppm fluoride) Therefore may not receive additional benefit from professional topical fluoride application 2 Moderate Risk Additional modalities of fluoride delivery are recommended Preparations for at home use include 1.1% NaF toothpaste or gel (5,000 ppm fluoride, available by prescription only) to be used in place of an over the counter toothpaste High Risk Preparations for at home use 1.1% NaF toothpaste or gel (5,000 ppm fluoride, by prescription only) in place of an OTC toothpaste or placed in plastic tray carriers and worn for 5 minutes daily 27,28 Available for at home use, without a prescription, 0.05% NaF mouth rinse (226 ppm fluoride) 10ml of mouth rinse should be swished for one minute, once daily, following tooth brushing. Professionally applied fluoride applications include 5% NaF varnish (22,600 ppm fluoride), 1.23% acidulated phosphate fluoride (12,300 ppm fluoride) and 2% sodium fluoride gel (9,050 ppm fluoride). 26 Frequency of professional application should be at more frequent intervals for high risk patients (3-4 months) 25

26 Xylitol 26

27 Policy on the Use of Xylitol in Caries Prevention AAPD 2006 Sugar not metabolized by S.M and inhibits the attachment to the teeth. 29 Chewing Xylitol gum helps increase salivary flow 30, 31 Long-lasting effects up to 5 years after 2 years of using Xylitol chewing gum 25 The daily suggested dose =6-10 grams per day, 32,33,31 3-5times per day for a minimum of 5 min after meals. 34 Typical piece of chewing gum =1 g of Xylitol, and ensure that Xylitol is listed as the primary ingredient. 27

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29 Chlorhexidine Literature is mixed on effectiveness against dental caries. 35,36 It has been used for high caries risk patients 37,38 primary goal of decreasing S.M levels. Protocols also include concurrent fluoride treatment. Concentrations: 0.1 %, 0.2% or 1% Affects bacteria by: Disturbing the normal membrane functions of the bacteria 1. Interfering with the bacterial adhesion or in the pellicle by affecting a surface enzyme. 2. Interfering with a glycolytic enzyme which leads to a reduced acid production by the bacteria. 29

30 Calcium Phosphate Topical Supplements Mod risk: Optional: Application of calcium/ phosphate paste several times daily High risk: Required: Application of calcium/ phosphate paste twice daily ph Control High risk: Acid-neutralizing pastes as needed if mouth feels dry, after snacking, bedtime and after breakfast. Baking soda gum as needed 30

31 31 41

32 Operative Procedures Treatment modalities based on risk Low risk: monitor: bitewings at regular interval: 6-12 months Mod risk: minimally invasive intervention High risk: aggressive protocol Minimally invasive dentistry: RMGI - fluoride release Preventive Resin Restorations/Sealants Composite more conservative preparation Slot preparations 32

33 Treatment Planning at BUGSDM Step by step of how a patient goes from our Oral Diagnosis and Radiology Department to the Completion of their treatment plan Patient seen in OD/Radiology for 1 st appointment>>>initial triage/fmx/pano Patient is assigned to student who schedule patient for a Data Collection appointment Full clinical (medical, dietary, dental), radiographic, microbial and salivary exam is conducted Preliminary impressions, face bow, Occlusal registration and analysis Patient is scheduled in Diagnostic Clinic where data is presented to Restorative and Perio Faculty 33

34 Tx options are explored with patient Student is asked to write a Written Analysis of their patient Tx options Recommended, Alternative and Accepted Tx plan is sequenced based on the following phases : Phase 1: Diagnosis and Emergent problems Phase 2: Stabilization Phase 3: Definitive restorative treatment Phase 4: Outcomes analysis and maintenance 34

35 Written Analysis Template Date Written Analysis Student name and BU ID # 1). Patient Information: Chief Complaint: Dental History: Medical History: Current Medication: Medication Indications Contra indications Dental Implications 35

36 2). Clinical Exam: General findings: Aesthetic Risk: Extra oral findings: Intra oral findings: Periodontal: Restorative: Endodontic: Oral Surgery: Occlusion: Orthodontics: 36

37 Etiology: Caries Risk Assessment: Patient Caries Risk Evaluation Table/Spider Chart 3). Goals of Treatment 4). Problem List and Diagnosis General terms identifying all the patients dental problems whether or not the patient has accepted therapy to correct these problems 37

38 5). Solution to specific problems Condition / Problem Recommended Therapy Alternative Therapy Therapy accepted by the patient 38

39 6). Sequenced Treatment: (list treatment procedures in the order you plan to do them. Each procedure will have its own line) Phase One (Diagnostic, Emergency and reevaluation if necessary) Caries risk assesment Phase Two (Stabilization and re-evaluation) Phase Three (Definitive therapy and reevaluation) Phase Four (Outcomes Assessment, Recall) Caries Risk Assessment Follow up 39

40 7). Proposed time to complete treatment and cost 8). Signature of Faculty approving the Written Analysis 40

41 Phase1 : Diagnosis and Emergent problems/risk management Diet control and Oral Hygiene Instruction Introduction of fluoride Measure the patients level of motivation Remove the nidus of infection, improve cleans ability, arrest progression of caries If the situation is acute and symptomatic - it must be addressed We want to stabilize the mouth and stop then progression of disease Why is it necessary? Time is not on our side 41

42 Phase Two: Disease Control and Stabilization or Support Therapy Re-establish form, close contacts/ improve the periodontal/gingival response Interim restorations / Caries Control Core build ups / post and cores Crown lengthening procedures Periodontal reasons Prosthetic reasons 42

43 Special preparations and periodontal treatments Grafts Root amputation Endodontics Implants Goal: Elimination/reduction of tooth caries and associated bacterial population in the mouth Opportunity to establish true needs of a particular of tooth and to evaluate the prognosis 43

44 Phase 3: Final restoration This corresponds to the final restorative options/ therapy: Crowns Fixed partial Dentures Implant supported restorations Cast Removable partial dentures Complete dentures Phase 4: Outcomes assessment and Maintenance Restorative assessment Periodontal Risk assessment Caries Risk Assessment Maintenance protocol: scaling prophy/ fluoride/radiographs 44

45 Conclusion 45

46 Patients preventive and therapeutic treatment plan=individualized to meet their needs, This plan will change over time to reflect their changing caries risk assessment. NIH consensus statement (2001) there is reason to believe that preventive strategies may be more effective when they are combined than when they are administered individually 2 important consideration since the development of caries is a multifactorial process and a successful preventive and therapeutic regimen must address all risk factors and indicators. 46

47 Risk Level ### *** Frequency of Radiographs Frequency of Caries Recall Exams Saliva Test (Saliva Flow & Bacterial Culture) Antibacterials Chlorhexidine Xylitol **** Fluoride ph Control Calcium Phosphate Topical Supplements 4 Low risk Bitewing radiographs every 12 months Every 6 months to re-evaluate caries risk May be done as a base line reference for new patients Not required OTC fluoride-containing toothpaste twice daily, after breakfast and at bedtime. Optional: NaF varnish if excessive root exposure or sensitivity Not required Not required Optional: for excessive root exposure or sensitivity Moderate risk Bitewing radiographs every 6-12 months Every 4 months to re-evaluate caries risk Done as a base line reference for new patients and at each recall to assess efficacy and patient cooperation Per saliva test if done Xylitol (6-10 grams/day) gum or candies. Two tabs of gum or two candies four times daily OTC fluoride-containing toothpaste twice daily plus: 0.05% NaF rinse daily. Initially, 1-2 app of NaF varnish; 1 app at 4-6 month recall Not required Optional: Apply calcium/ phosphate paste several times daily High risk* Bitewing radiographs every 6 months or until no cavitated lesions are evident Every 3 months to re-evaluate caries risk and apply fluoride varnish Saliva flow test and bacterial culture initially and at every caries recall appt. to assess efficacy and patient cooperation Chlorhexidine gluconate 0.12% 10 ml rinse for one minute daily for one week each month. Xylitol (6-10 grams/day) gum or candies. Two tabs of gum or two candies four times daily 1.1% NaF toothpaste twice daily instead of regular fluoride toothpaste. Optional: 0.2% NaF rinse daily (1 bottle) then OTC 0.05% NaF rinse 2X daily. Initially, 1-3 app of NaF varnish; 1 app at 3-4 month recall Acid-neutralizing rinses as needed if mouth feels dry, after snacking, bedtime and after breakfast. Baking soda gum as needed Required Apply calcium/ phosphate paste twice daily 47

48 .thank you 48

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