Examination and Treatment Protocols for Dental Caries and Inflammatory Periodontal Disease Dental Caries The current understanding of the caries process supports the shift in caries management from a restorative-only treatment philosophy for a caries diagnosis to a philosophy that restores only as a last resort and prevention is optimized. Present-day caries diagnosis categorizes a caries lesion by the full spectrum of mineral loss severity (FIGURE) and lesion activity plus determination of patient-level risk including patient-specific causative and contributory factors. Optimization of prevention is important because initial and moderate mineral loss can be prevented, reversed or arrested when appropriate preventive interventions are applied. Accordingly, the current best-practice prevents caries before it begins (i.e., primary prevention), reverses or arrests caries that may not be visible (i.e., secondary prevention), and restores caries only when necessary and in a way that preserves as much sound tooth structure as possible (i.e., minimal intervention and minimally invasive). Thus it is no longer appropriate to restore every tooth with a radiolucency. The current best-practice to prevent caries applies a preventive service that is specific to a causative or contributory factor of the patient s risk for caries. (TABLE) Additionally, each preventive service is typically applied at a frequency guided by risk level. It is in this way that recall frequency is influenced by risk level. As a general guide, recall frequency has been suggested to be: Once a year for low risk patients Twice a year for moderate risk patients Three or more times a year for high risk patients. Restorative and preventive treatment of caries today requires an accurate diagnosis and assessment of risk. In contrast to caries diagnosis, which describes the current condition, risk assessment provides information unique to the patient about the likelihood and causes that the current caries lesion will progress or a new caries lesion will develop at a future time. Diagnosis of caries relies on an examination conducted on a dry clean tooth with adequate light and use of a rounded explorer or ball-end probe. A rounded explorer and ball-end probe provides tactile distinction of a normal smooth from a tooth surface made rough by mineral loss. In contrast, use of a sharp explorer has been discouraged because it can permanently damage a tooth surface at a stage of mineral loss that is reversible. In addition to visual and tactile observations, radiographs and transillumination are valuable diagnostic aids for many particular situations. Treatment cannot be justified solely from a diagnosis because the caries process, which varies among patients, is influenced by risk level. A patient s risk level is determined from the presence, strength, and interaction of causative and contributory factors for caries. These factors manifest different and variable weights and the interaction of factors may be non-linear and synergistic or antagonistic. Hence the determination of risk level is a complex task. Because of this fact, scientific evidence has clearly shown that risk is best assessed using a standardized objective tool such as the Oral Health Information Suite by PreViser. Furthermore, the assessment of risk should be done at each recall visit because: 1) early stages of caries have no visible clinical or radiographic signs and 2) risk can change from one visit to the next. More information about caries diagnosis and caries treatment protocols have been published by the American Dental Association 1 and the World Dental Federation. 2 Furthermore, it is important to understand that caries treatment may adversely affect another oral or non-oral disease, disorder, or condition and vice versa. 1 P a g e
FIGURE Initial Caries Initial caries is the earliest visually or radiographically detectable lesion. An accurate diagnosis of initial caries requires drying the tooth surface. The enamel of an established and active initial caries lesion no longer has a normal gloss and the tooth surface may be white or brown. An established and active initial caries lesion of a pit or fissure that is brown does not have an underlying dark gray shadow. Initial caries is not visually cavitated. And radiolucency may include the outer one-third of dentin. Appropriate treatment of initial caries is remineralization. A PreViser assessment considers initial caries to be early decalcification and not primary caries. Moderate Caries Cavitation distinguishes initial from moderate caries. Enamel loss is visible on smooth surfaces. Pits and fissures, which may appear intact, are brown possibly including a dark gray shadow or translucency visible through the enamel. A radiograph is usually needed to diagnose caries on an approximal surface. The radiographic aphic sign of moderate caries is a radiolucency that extends into the middle one-third of dentin. Appropriate treatment choices include remineralization and restoration as depicted by both the blue and red sections in the diagram. Furthermore, a restoration, if needed, should be done in a way that preserves as much sound tooth structure as possible. A PreViser assessment considers moderate caries to be caries and months the patient has been caries-free is to be interpreted as the months the patient has been without moderate or severe caries. Advanced Caries Advanced caries is characterized by cavitation through the enamel and exposure of dentin. The radiographic sign of advanced caries is a radiolucency that extends into the inner one-third of dentin. Appropriate treatment choices include restoration, endodontic treatment, and extraction. Furthermore, a restoration should be done in a way that preserves as much sound tooth structure as possible. A PreViser assessment considers severe caries to be caries and months the patient has been caries-free is to be interpreted as the months the patient has been without moderate or severe caries. 2 P a g e
TABLE 1 Primary prevention Secondary prevention Prevents caries by interventions that target risk or protective factors Poor oral hygiene (Bacteria) Oral hygiene instruction (D1330) Chlorhexidine/thymol varnish (D9630) Frequent dietary sugars (Diet) Nutritional counseling (D1310) Inadequate salivary flow rate (Saliva) Sugar-free gum after meals Pits, fissures, or other defects Sealants (D1351) Suboptimal fluoride exposure Fluoride varnish (D1206) Fluoride, topical (D1208) OTC fluoride mouth rinse & toothpaste Reverses or arrests a subclinical (i.e., not visible), initial or moderate carious lesion Boosts remineralization Fluoride varnish (D1206) Fluoride topical gel (D1208) Silver diamine fluoride (D1354) OTC fluoride mouth rinse & toothpaste Inhibits or Retards demineralization Nutritional counseling (D1310) Oral hygiene instruction (D1330) Fluoride varnish (D1206) Fluoride topical gel (D1208) Silver diamine fluoride (D1354) OTC fluoride mouth rinse & toothpaste Sugar-free gum after meals Seals pits, fissures, or other defects Sealants (D1351, D2940) Resin infiltration (D2990) Caries References 1. Young DA, Novy BB, Zeller GG, Hale R, Hart TC, Truelove EL. The American Dental Association Caries Classification System for clinical practice: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015: 146(2): 79 86. Available at: http://jada.ada.org/article/s0002-8177(14)00029-4/abstract 2. Caries Prevention Partnership: White paper on dental caries prevention and management. Nigel Pitts and Domenick Zero. FDI World Dental Federation 2016. Available at: www.fdiworldental.org/media/93783/2016-fdi_cpp-white_paper.pdf 3 P a g e
Inflammatory Periodontal Disease There are two distinctly different categories of inflammatory periodontal disease, gingivitis and periodontitis. Both include inflammation but only periodontitis has loss of connective tissue attachment. Simplistically, the diagnosis of gingivitis and periodontitis includes observing bleeding on probing as an indicator of inflammation and clinical attachment loss for the loss of connective tissue attachment. But measuring clinical attachment loss is a multi-step process that is difficult to do accurately, is not a good indicator of treatment need or which treatment might improve periodontal status, and is not a factor to determine periodontal disease risk. Alternatively, a periodontitis diagnosis can be defined by bleeding on probing, pocket depth, and radiographic bone loss. Not only are these three clinical characteristics easily and accurately measured, but they inform about treatment need, appropriate treatment, and periodontitis risk. Because of these issues, bleeding on probing, pocket depth, and radiographic bone loss are used to calculate the periodontal disease severity score in the Oral Health Information Suite by PreViser. A benefit of this method is changes in pocket depth or bone height cause the score to change establishing a way to determine improvement, deterioration, or stability of periodontal status over time. In contrast to a periodontal diagnosis, which describes the current condition, risk assessment provides information unique to the patient about the likelihood and causes that the current periodontal condition will worsen or periodontitis will develop at a future time. A patient s risk level is determined from the presence, strength, and interaction of causative and contributory factors for periodontal disease. These factors manifest different and variable weights and the interaction of factors may be non-linear and synergistic or antagonistic. Furthermore, while severe periodontitis logically implies high risk, simply using the current periodontal condition to determine risk will not yield an accurate conclusion. This error is eventually observed for the high-risk patient with mild or moderate periodontitis who experiences loose teeth, tooth sensitivity, unattractive appearance, or tooth loss as periodontitis slowly and quietly progresses. Because the determination of risk level is a complex task it is best assessed using a standardized objective tool such as the Oral Health Information Suite by PreViser. Furthermore, the assessment of risk should be done at each recall visit because risk can change from one visit to the next and a patient s periodontal status can be tracked. It is important to effectively manage periodontitis because it can result in loose teeth, tooth sensitivity, unattractive appearance, and tooth loss. The best-practice for treatment of periodontal disease is illustrated in the flow chart for a new or recall patient. Not included is the general recommendation for more intense active treatment (e.g., periodontal surgery compared to scaling and root planing) for a high compared to low risk patient. Also not included is the element of time needed to elapse, which may be months or years, to accurately interpret the results of treatment. Risk is one factor to determine the frequency for periodontal maintenance, which has been suggested to be: Once a year for low risk patients Twice a year for moderate risk patients Three or more times a year for high risk patients. Additionally, it is important to understand that periodontal disease and its treatment may adversely affect another oral or non-oral disease, disorder, or condition and vice versa. More information about diagnosis of inflammatory periodontal disease has been published by the American Academy of Periodontology. 1,2 4 P a g e
FLOW CHART 5 P a g e
Periodontal disease severity score Inflammatory Periodontal Disease References 1. American Academy of Periodontology. Task force report on the update to the 1999 Classification of periodontal diseases and conditions. J Periodontol 2015; 86: 835 835-838. Available at: http://www.joponline.org/doi/abs/10.1902/jop.2015.157001 ttp://www.joponline.org/doi/abs/10.1902/jop.2015.157001 2. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999; 4: 1-6. Available at: http://www.joponline.org/doi/10.1902/annals.1999.4.1.1 6 Page