Paving the Way to Tomorrow How technology is changing delivery of care for Caries patients Judy Bendit RDH, BS JudyBendit.com Judy@JudyBendit.com
Course Description: Throughout history, mankind has constantly been in search of a better way. A better way to travel. A better way to communicate. A better way to educate. Finding a better way requires a plan that involves mapping out ones destination, setting a course, carving out a path, and ultimately paving the way. This program focuses on the innovations and advancements in remineralization products and technologies that will influence and change the delivery of care we provide to our patients tomorrow. We introduce a suggested Caries Risk Assessment survey to help identify individual patient risk level, and then mapping out a treatment plan that takes into consideration all factors that can influence the caries pattern and prevalence. Case studies will illustrate how CAMBRA can be used to help develop a treatment plan that incorporates appropriate modalities and patient applied practices, along with the latest technologies, to diagnosis and reverse early caries patterns. So let s pave the way to a caries free practice. Objectives: Engaging in this program, the participant will be able to: Execute a CAMBRA (risk assessment) within their practice protocol Utilize a Caries Detection System (according to the International Caries Detection Assessment System) to assess stages of the caries lesion Analyze Cases to individualize their risk level to guide appropriate therapies Implement and recommend a Calcium Phosphate Fluoride plan Course Outline I. The New Paradigm in Preventive Dentistry a. Shift from a repair model to a health-oriented model b. Why do we resist change? How can we accomplish new protocols and gain staff acceptance? c. 80% of all dental caries occurs in only 20% of the U.S. Population d. Economic Burden: mean spending in dental care in adults ages 55-64 i. Spent est. 108 billion dollars in dental half of this was treating dental caries ii. Projection to $180 billion within next 10 years. e. Balancing the ethical treatment decisions with third party payment choices? i. ADA center for evidence-based decisions: www.ebd.ada.org/ f. Achieving the goals set by Healthy People 2010 and 2020 U.S. Surgeon General Report g. AAPD guideline for starting a dental home: Within 6 months of first tooth erupting. In order to prevent dental problems, your child should see a pediatric dentist when the first tooth appears, or no later than his/her first birthday. II. CAMBRA (Caries Management by Risk Assessment) Defined: A caries management by risk assessment represents an evidence-based approach to preventing, reversing and treating dental caries. It is an estimation or prediction of an event that may occur in the future.
CAMBRA forms: Assessment tool for ages 0 5: https://www.ada.org/~/media/ada/member%20center/files/topics_caries_under6.a shx Assessment tool for ages 6 adult: http://www.ada.org/~/media/ada/science%20and%20research/files/topic_caries_ove r6.ashx Caries Risk Assessment from ADA website: http://www.ada.org/en/member-center/oralhealth-topics/caries-risk-assessment-and-management Previser on-line options- https://www.previser.com My dental score: https://emds.previser.com/delta-z968he/estimate-my-dental-scores Carifree: https://carifree.com/product/forms/ AAPD- http://www.aapd.org/media/policies_guidelines/g_cariesriskassessment.pdf AAP https://brightfutures.aap.org/bright%20futures%20documents/oralhealthriskassessmenttool.pdf Elevate oral carehttp://www.elevateoralcare.com/site/images/elv15512tearpadsheet.pdf?vid=hh2b8blhanpc Mnqt&chrole=17&ck=e6IUQZxHAsVZHSOv&promocode=&cktime=149429&promocodeaction =overwrite http://www.elevateoralcare.com/site/images/elv15418oralhealthsheet.pdf?vid=hh2b 8blHAnPcMnqt&chrole=17&ck=e6IUQZxHAsVZHSOv&promocode=&cktime=149429&promoc odeaction=overwrite a. The CARIES BALANCE CHART Proposed by Featherstone in 1999 - Recognized the caries process as: Multifactorial Balance between factors (BAD) Pathological and (SAFE) Protective factors Balance is delicate and swings either way several times daily in most people If Pathological factors outweigh the Protective factors, the risk is greater that caries will initiate/progress The RISK FACTORS tell us HOW it happened? Additional reading: https://www.cda.org/portals/0/journal/journal_102007.pdf b. What clinicians NEED to know: i. Done on EVERY PATIENT! ii. Creating an individualized risk assessment on every patient iii. Evaluate early enamel changes, visually, and with the newest non-invasive detection devices iv. Becoming more proactive in reversing demineralized or carious lesions v. Utilizing an evidence-based approach in selecting effective remineralization plans vi. Building a staff approach in caries management for your practice setting c. Implementation of CAMBRA is process in managing dental caries prevention: i. Initial patient visit correlate to health/dental history documentation ii. Update on periodic visits to reassess current state of risk level
iii. 2014 ADA CDT codes for CAMBRA: D0601 caries risk assessment and documentation, with a finding of low risk D0602 caries risk assessment and documentation, with a finding of moderate risk D0603 caries risk assessment and documentation, with a finding of high risk d. Minimally-invasive technology i. Diagnostics: Laser, infra-red fluorescence or light-induced fluorescence, digital radiography (Diagnodent, SoproLife, Spectra, Canary, CariVu, and Ortek) See below for more information ii. Chairside tests: salivary, bacteria assays, oral cancer screening tools iii. Home-applied Rx or Professionally-applied remineralization therapies iv. Professional and home-applied (antibacterial) chemotherapeutics e. Caries is a multi-factorial disease process that involves: i. Time, Microflora, Host and Diet Current attention focused on 3 other dynamics in this model: Salivary flow, saliva buffering capacity and fluoride exposure ii. Role of Saliva: Buffering capacity Preserves integrity of dental and oral tissues Antimicrobial activity Immune surveillance Natural reservoir for fluoride, calcium and phosphate ions a. Fluoride is LESS effective in the absence of CA and P ions in saliva iii. Impact of Fluoride: Supports natural remineralization Inhibits bacterial metabolism Inhibits demineralization Promotes remineralization Fluoridated drinking water adds a strong protective value on CAMBRA Some bottled waters now contain fluoride check bottles for labeling a. Reference: Nelson T. Consequences of Convenience Dimensions of Dental Hygiene, Feb 2012: (10)2; 31-34. Chart on page 32 of all bottled water Fluoride Concentration a. Silver Diamine Fluoride 44,800 ppm b. Varnish 22,600 ppm c. APF (in office) 12,300 ppm d. NaF (Rx) 9,000 ppm e. Rinse (Rx) 3,300 ppm f. MI Paste w/f 900 ppm g. SnF w/acp (Enamalon) 970 ppm h. Act Fluoride Rinse 200 ppm JADA Reprint on Professionally-applied Topical Fluoride: Executive Summary of Evidence-based Clinical Recommendations
(http://www.ada.org/~/media/ada/science%20and%20research/files/repor t_fluoride.ashx) a. Recommendations based on patient risk level b. Patients classified as low risk receive no additional benefit with routine 2x/year fluoride applications (in-office) c. 4 Minute fluoride application is only acceptable therapy when gel/foam is used (1 minute is NOT recommended any longer) d. Fluoride varnish is highly effective in caries prevention and suggested every 6 months (or less) for higher risk children ADA Professional Product Review A service Provided by the council on Scientific Affairs for the members of ADA Fluoride Varnish & SDF: Fluoride Analysis & Clinical Guidance 11/2017 III. Review of Case Studies utilizing CAMBRA and Evidence-based Protocol i. Review patient profile: medical and dental histories ii. Conduct CAMBRA survey to determine RISK LEVEL for dental caries iii. Assess the patient using radiographic survey, diagnostic technology and visual examination of the oral cavity/teeth iv. Determine active treatment including fluoride recommendations based on risk level ICDAS (International Caries Detection & Assessment System ADA Caries Classification System
I Visible only after drying No enamel breakdown 1 Caries with Or II Visible wet No enamel breakdown Without Drying III Breakdown into dentine Dentine initial caries 2 Moderate Enamel IV Gray area showing through Dentine involved Only 5% Caries V Cavitation into Dentinal caries 3 Distinct Cavitation dentine IV Cavitation and breakdown Severe breakdown Extensive
IV. Visual Detection of Enamel and Dentin Changes: a. International Caries Detection and Assessment System (ICDAS) i. See above as the chart outlines changes with associated criteria b. ADA Caries Classification System an alternative system for classifying changes that differentiate early to late stages of the carious process and grouping last four stages of lesion activity c. Visual inspection of coronal aspect of the tooth i. Sound surface ii. Initial or Primary No clinically detectable loss of surface Pits/fissures: discoloration and rough spots but no catch subsurface loss of minerals Smooth surface: white or opaque area TREATMENT: Remineralization! d. Use of Explorers for caries detection: i. 62% sensitivity, ii. Eliminates the potential for lesion reversal by disrupting the intact surface layer iii. Recommended use of explorers: Clean debris from fissures, along gingival margins and interproximal spaces Confirm and assess cavitation Feel margins and defects Feel texture (roughness) of a white spot lesion Evaluate previously-placed dental sealants e. Diagnostic Technology to evaluate early changes: i. Laser fluorescence (DIAGNOdent Caries Detection Aid by KaVO ) Detects up to 2mm/occlusal with 80 sensitivity Requires a dry field; calibrated to a healthy tooth Quantifies results from 0-99 ii. Quantitative Light induced Fluorescence Products with this source: (QLF by Inspektor, SOPROLIFE by Acteon Group, Spectra Caries Detection Aid by Air Techniques ) 61% sensitivity with detection on occlusal surfaces only Spectra can be attached to laptop with handpiece; tracks bacterial presence by luminescence shown on monitor SOPRALIFE is a dual intra-oral camera and caries detection system iii. Infrared Fluorescence combined with Photo thermal Radiometry (The Canary System by Quantum Dental Technologies) Detection on occlusal and proximal surfaces Approved in Canada and now awaiting FDA approval for use in the United States. Can determine carious activity beneath existing restorations
Effective outcome measurement in conjunction with remineralization therapy iv. Transillumination Technology (Dexis CariVu) Detection of occlusal, interproximal and recurrent carious lesions and cracks V. Remineralization Technologies: ATTACHED CHART: Products formulated to strengthen enamel using Ca/P and Fluoride a. ACP: Amorphous Calcium Phosphate (ADA patented ACP) b. CPP-ACP: Casein Phosphopeptide; amorphous calcium phosphate (Recaldent) c. CSPS: Calcium Sodium Phosphosilicate (Novamin) d. TCP: Beta Tri-Calcium Phosphate Classified by: Mechanism of Action, Solubility/Bioavailability and Professional Brand Products utilizing the technology VI. ADA recommendations: OTC fluoride toothpaste Smear (0.125 g) as soon as first tooth erupts until age 3 Pea-sized amount (0.25 g) from age 3 to age 6 Age 6 onwards: Strip of toothpaste Consider spitting out. NOT rinsing. Dilutes the Fluoride. Product information- see my web site at JudyBendit.com http://judybendit.com/additionalproductlinks.htm Chemistry ACP Amorphous Calcium Phosphate CPP-ACP Casein Phosphopeptide - Amorphous Calcium Phosphate CSPS Calcium Sodium Phosphosilicate TCP Beta Tri-calcium Phosphate ADA licensed ACP (Recaldent ) (Novamin ) Mechanism of Action Specialized salt compounds binds Ca/P ions until delivery (amorphous) No defined or crystalline structure Casein binds to tooth surface& plaque until ph is lowered (acidic) This creates Ca/P ions to become available Silica binds Ca/P until sodium elevates ph to free CA/P ions Blended beta tri-calcium phosphate encapsulates the Ca/P ions until reactive with saliva
Solubility & Bioavailability Rapid delivery Highly soluble & Bioavailable Greatest fluoride uptake Becomes soluble only during lowered ph/acidity More effective with inclusion of Fluoride Becomes soluble when sodium buffers ph to release Ca/P ions Low to moderate rate of solubility Highly structured crystalline form Professional Products Premier Dental ENAMEL PRO 5% F Varnish/ACP Pro Paste/ACP Na F Gel /ACP GC America MI Paste MI Paste Plus MI Fluoride Varnish MI paste ONE DENTSPLY Professional NUPRO NuSolutions 5,000ppm 3M Vanish F varnish/tcp Clinpro 950/TCP Clinpro 5000/TCP Discus (Philips) Day/Nite White/ACP Relief Oral Gel/ACP Cadbury Trident chewing gum w/ Recaldent Arm & Hammer Truly Radient /ACP Enamel Care in Canada Bosworth Co. Aegis Sealant w/acp Adhesives w/acp Newest products: Silver Diamine Fluoride- http://www.elevateoralcare.com/ Code: D1354 - Interim caries arresting medicament application ($19.52 -Medicaid reimbursement) D1208 - Topical application of fluoride D9910 - Application of a desensitizing medicament, per visit D1999 - Unspecified preventive procedure by report Note: The ADA Code Revision Committee approved in March 2017 the change from per application to per tooth beginning January 1, 2018. Descriptor: Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries-inhibiting medicament and without mechanical removal of sound tooth structure. The procedure:
1. Wear standard personal protective equipment (PPE), and make sure the patient is wearing safety glasses and plastic-lined bib. 2. Dispense one to two drops of silver diamine fluoride into a plastic dappen dish, depending on how many teeth you are treating. One drop will treat five surfaces. 3. Apply scented lip balm to the patient's lips to help mask the smell of the silver diamine fluoride as it is placed in the mouth. 4. Use a saliva ejector when possible. 5. Isolate the tongue and cheek from the affected teeth using gauze or cotton rolls. Absorbent triangles work well. 6. Consider applying petroleum jelly to proximal gingival tissue with a cotton applicator for safety. This could help to prevent staining of the gingiva if the silver diamine fluoride touches it. 7. Dry affected tooth surfaces with air or a cotton swab. 8. Immerse a microbrush into the solution in your dappen dish and remove any excess on the side of the well. This is best done with a dental assistant to avoid spilling. Don t use glass dappen dish/etch glass. 9. Apply it directly onto the affected tooth surface(s) with the microbrush. 10. Allow the silver diamine fluoride to absorb for at least one minute. *** Consider adding Fluoride varnish over the SDF to keep it contained on surface*** 11. Remove the excess with gauze, a cotton roll, or a cotton-tip applicator. 12. Invert all used cotton, the microbrush, and the dappen dish into a glove so it can't drip on any surface or skin. Dispose of it in a trash can. Silver diamine fluoride became available in the United States in 2015. It is indicated as a treatment of tooth sensitivity, but has been used to treat and prevent caries in young children, in some parts of the world. In two controlled trials, application of silver diamine fluoride was reported to "arrest" caries lesions in 96 percent of cases References 1 Horst, JA, Ellenikiotis, H, Milgrom, PL, UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications and consent J Calif Dent Assoc 2016: 44:17. 2 Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries "silver-fluoride bullet". J Dent Res 2009; 88:116. 3 Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res 2002; 81:767.
4 Llodra JC, Rodriguez A, Ferrer B, et al. Efficacy of silver diamine fluoride for caries reduction in primary teeth and first permanent molars of schoolchildren: 36-month clinical trial. J Dent Res 2005; 84:721. 4. Duffin S. Back to the future: the medical management of caries introduction. J Calif Dent Assoc 2012; 40:852. 5. https://www.dentalacademyofce.com/dace/coursereview.aspx?url=3347%2fpdf%2f1707cei_bendit_young _web.pdf&scid=16774 6. http://www.mmclibrary.com/smart_2.html (amazing library of everything SDF) 7. https://www.cda.org/portals/0/journal/journal_012018.pdf 8. https://www.pbs.org/newshour/show/this-new-treatment-could-make-your-next-trip-to-the-dentist-morebearable BioCoat Sealant- SmartCap Microcapsule sealant enhances flowability acting like micro-ball bearings so deliverer is bubble-free and smooth. https://www.youtube.com/watch?v=vv2o3vyte_0 Notes: