Dental Caries Not Just a Hole in a Tooth, page 1 Perio Reports Vol. 24 No. 2 Caries, page 2 February 2012 Message Board Rampant Root Caries page 10
in this issue Dental Caries Not Just a Hole in a Tooth by Trisha O Hehir, RDH, MS Editorial Director, Hygienetown In the 1700s, it was thought that tooth decay began inside the tooth with tooth worms eating their way out of the tooth. Ivory tooth carvings depicted these tooth worms. It made sense at the time. However, the dental caries process is not as simple as tooth worms. Scientific research confirms that dental caries is in fact, a complex, multi-factorial process. It was once thought that only two bacteria were involved Streptococcus mutans and Lactobacillus acidophilus. Acid production creates an environment conducive to the growth of many bacteria that prefer living at low ph while non-acid-producing commensal oral bacteria can adapt to an acid environment and begin to produce acid. Estimates suggest the number of bacterial species in the mouth is as high as 800. Some researchers studying DNA implications suggest the numbers are actually 3,600 to 6,800, while other researchers suggest the number of oral bacteria is as high as 19,000. Perio Reports includes summaries of important caries research. In the past, a sharp explorer and radiographs were all that was needed to diagnose dental caries, as all we looked for was a hole in the tooth. Today, the incorporation of Caries Risk Assessment (CRA) focuses on the entire caries process and not simply the resulting hole that requires repair. Determining why someone has dental caries is as important as providing the restorative care after the disease has damaged tooth structure. In this section devoted to dental caries, the message board discusses root caries. In the Profile in Oral Health, Townie Tim Ives, RDH from the U.K. presents his initial reluctance to accept CRA. Next month s Part 2 will cover technology involved in evaluating oral bacteria, measuring ph, flow and buffering levels of saliva and appropriate measures to stop dental caries. Dealing with dental caries provides a challenge to evaluate and manage risk factors and not simply focus on the resulting tooth holes. Inside This Issue 2 Perio Reports 6 Profile in Oral Health: My Reluctance to Accept CAMBRA 10 Message Board: Rampant Root Caries» hygienetown.com «FEBRUARY 2012 1
perio reports Bacteria Involved in the Caries Process For several reasons, mutans Streptococci (MS) are generally considered the primary pathogenic bacteria in biofilm responsible for acid production leading to dental caries. First, MS are frequently isolated from carious lesions. Second, laboratory studies repeatedly show that MS can produce caries in animals fed a high sucrose diet. And third, MS are both acidogenic (acid forming) and aciduric (can live in a highly acidic environment). A researcher from the Tohoku University in Japan, and one from the University of Aarhus in Denmark, collaborated on a review of the literature regarding caries-associated bacteria and their roles in the caries process on smooth tooth surfaces. An extension of the ecological plaque hypothesis proposes three reversible stages in caries to explain the dynamic demineralization and remineralization process prior to cavitation. Stage 1 is Dynamic Stability with biofilm dominated by non-mutans Streptococci and Actinomyces. Acid production is mild and infrequent in this stage with the balance of demin/remin shifting to a net mineral gain. Next comes the Acidogenic stage when sugar is eaten frequently and acid production becomes moderate and frequent. Increased acid in the biofilm encourages selective replication of lowph non-mutans Streptococci and over time encourages bacteria that don t usually produce acid to begin producing acid. Under severe and prolonged acidic conditions, aciduric bacteria dominate, making this the Aciduric stage. Mutans Streptococci and Lactobacilli as well as aciduric strains of non-mutans Strep, Actinomyces, Bifidobacteria and yeasts dominate the biofilm. Many acidogenic and aciduric bacteria take part in the caries process. Perio Reports Vol. 24, No. 2 Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians. Perio Reports research summaries will be included in each issue to keep you on the cutting edge of dental hygiene science. Clinical Implications: The ph of biofilm will dictate which bacteria will proliferate and if they will produce acids. Takahashi, N., Nyvad, B.: The Role of Bacteria in the Caries Process: Ecological Perspectives. J Dent Res 90(3):294-303, 2011. Caries-associated Bacteria in the Caries Process www.hygienetown.com Surface feature Net mineral gain (lesion regression/arrest) { Surface feature shiny/smooth (enamel) shiny/hard (dentin) Dynamic Stability Stage Dominance of non-ms and actinomyces Mild/Infrequent acidification Acid-induced adaptation/selection Acidogenic Stage Low ph non-ms and actinomyces Moderate/Frequent acidification Acid-induced adaptation/selection Acidogenicity of Representative Cariesassociated Bacteria Net mineral loss (lesion initiation/progression) dull/rough (enamel) {dull/soft (dentin) Aciduric Stage Increase in MS and non-mutans aciduric bacteria Severe/Prolonged acidification Bacteria Final ph Non-mutans Streptococci 4.2-5.2 Actinomyces 4.3-5.7 Mutans Streptococci 4.0-4.4 Lactobacillus 3.6-4.0 Bifidobacterium 3.9-4.0 2 FEBRUARY 2012» hygienetown.com
perio reports Taste Genes Influence Caries Rates in Children Dental caries is a chronic disease affecting people worldwide and is the most prevalent childhood disease. Caries is influenced by many factors: bacterial flora, dietary habits, fluoride exposure, oral hygiene, salivary flow, salivary composition and tooth structure. Recent research evaluating caries susceptibility in twins suggests genetics should also be considered. Researchers from the University of Pittsburgh and West Virginia University in Morgantown, West Virginia, collaborated with researchers at the Center for Oral Health Research in Appalachia where an ongoing study pairs parents and children for long-term oral health evaluations. It was hypothesized that genes associated with taste might play a role in the caries process, since dietary habits are a significant risk factor in caries. DNA samples were collected from blood, buccal cheek tissue or saliva from 496 children with primary dentition, 562 children with mixed dentition and 1,391 adults. Caries assessments were done on all subjects by trained and calibrated dentists and hygienists. Specific amino acid substitutions on the genes were analyzed relative to taste. Those highly sensitive to bitter tastes are called super tasters. Those insensitive to bitter tastes are called non-tasters. Each presents with different amino acid patterns. In relation to caries levels, these genes seem to influence caries rates in children and not adults. Those with genes indicative of super tasters seem to experience a caries protective effect. Those with genes of nontasters are associated with increased caries risk. Clinical Implications: The future might bring testing to identify super tasters and non-tasters in young children leading to targeted caries preventive measures. Genetic Markers for Caries Identified Monomeric and dimeric representations of human beta-defensin HBD-2 Genetic factors might account for 40 to 65 percent of the risk for dental caries. Defensins are elements of the innate immune system that provide a broad spectrum of defense against pathogenic bacteria. Beta defensin 1 (DEFB1) is a chemoattractant for T-cells and dendritic cells of the acquired immune system. Research evaluating the genetic markers for DEFB1 suggests it might predict susceptibility to dental caries. Researchers at the University of Pittsburgh evaluated saliva samples of 296 individuals. Three fairly uncommon polymorphisms on the genes for DEFB1 were studied. When the DEFB1 G-20A polymorphism was present, caries levels increased five-fold. When a different pattern is evident, DEFB1 G-52A, the caries rate is decreased two-fold. These are important genetic markers. DEFB1 is located on chromosome 8, where other researchers also found signals relating to increased susceptibility to caries. These polymorphic variants on the chromosomes provide important risk information. Wendell, S., Wang, X., Brown, M., Cooper, M., DeSensi, R., Weyant, R., Crout, R., McNeil, D., Marazita, M.: Taste Genes Associated with Dental Caries. J Dent Res 89 (11): 1198-1202, 2010. Clinical Implications: Genetic susceptibility to caries tested in salivary DNA samples will soon be considered a part of caries risk assessment. Ozturk, A., Famili, P., Vieira, A.: The Antimicrobial Peptide DEFB1 is Associated with Caries. J Dent Res 89 (6) 631-636, 2010. continued on page 4 hygienetown.com «FEBRUARY 2012 3
perio reports continued from page 3 Root Caries in Periodontal Patients The rate of root caries in adults is reported between 43 to 63 percent. High salivary levels of Strep mutans and Lactobacilli, reduced salivary flow and buffering capacity, smoking and poor oral hygiene are risk factors for root caries. The root caries index (RCI) is calculated by dividing the number of exposed root surfaces by the total number of decayed or filled root surfaces to determine a percentage. For example: six decayed/filled surfaces divided by 60 root surfaces equals 0.1 x 100 equals a RCI of 10 percent. Past studies show RCI rates between six and 10 percent. Researchers in Holland evaluated 45 periodontal maintenance patients to determine RCI and risk factors. The average age of this group was 55 years and the average RCI was eight percent. The actual number of root surface lesions per patient ranged from zero to 19, with an average of 4.3 per patient. The number of exposed root surfaces ranged from 10 to 119 with an average of 65 per patient. The average number of coronal caries/fillings was 42, ranging from nine to 83. The number of coronal caries/fillings did not correlate to root caries levels. High levels of salivary Strep mutans correlated with root caries incidence, while Lactobacilli counts did not. Poor oral hygiene was significantly correlated. Average plaque levels were 29 percent on facial surfaces, 45 percent on approximal surfaces and 50 percent on lingual surfaces. The overall average plaque score was 41 percent ranging from eight to 88 percent. Clinical Implications: Periodontal therapy exposes root surfaces, increasing the risk for root caries. Reiker, J., van der Velden, U., Barendregt, D., Loos, B.: A Cross-Sectional Study Into the Prevalence of Root Caries in Periodontal Maintenance Patients. J of Clin Perio 26: 26, 1999. The Iceberg of Dental Caries Diagnostic Thresholds in Clinical Trials and Practice Diagnostic threshold determines what is recorded as diseased or sound Threshold used in classical clinical trials and in survey examinations D 3 D 4 Lesions into pulp D 3 + Clinically detectable lesions in dentin (both open and closed) Threshold used in many clinical practices, in research exams and in modern clinical trial exams (D 3 + enamel) D 1 D 1 + additional diagnostic aids used in clinical practice and in research exams D 2 + Clinically detectable cavities in enamel D 1 + Clinically detectable enamel lesions with intact surfaces + Lesions detectable only with traditional diagnostic aids (eg. FOTI & Bitewings) Mis-labeled as caries free at the D 3 threshold Threshold achievable by new diagnostic tools now and in the future + Sub-clinical initial lesions in a dynamic state of progression/regression 4 FEBRUARY 2012» hygienetown.com
profile in oral health When I graduated in 1990, a large proportion of my UK diploma in dental hygiene was related to aspects of dental caries, fluoride, fissure sealants, dietary advice and analysis and oral hygiene instruction. For the next 18 years, it was an exponential year-on-year decline in the amount of time I dedicated to the prevention of tooth-related problems and in 2008, almost all of my working day related to periodontal disease. Why was this? My treatment of periodontal disease was continually being updated. My skills with various instruments were constantly being fine-tuned. I had a genuine interest in perio and it was an easy path to follow. My treatment and prevention by Timothy Ives, RDH of caries had not changed in 18 years. In 2008 I was giving, more or less, the same advice that I was giving in 1990. I m not blaming anyone but myself for this approach, but in my defense, I had regularly attended clinical update meetings and scientific courses, but I do not recall reading many scientific articles or attending many lectures on the subject. Was it available then or was I not looking hard enough? I allowed myself to be steered down a path where I was in my comfort zone and the dentists 6 FEBRUARY 2012» hygienetown.com
profile in oral health absence of any preventive approach to caries risk management. His fellow dental therapists perceived their responsibility to be addressing the vast flood of caries restoratively, especially in the indigenous Maori population and outer lying settlements of Northland. It appeared that to them, their only option was restorative dentistry! Mark realized how fortunate he was to be working in a clinic following the CAMBRA model and working to prevent caries, not just repair the damage. He was in a completely different environment than those hard-pressed therapists who focused only on restorative care. After a year of listening to Mark I still wasn t changing my approach. It was then he persuaded me to go to the Greater New York Dental Meeting to listen to an eminent speaker on the subject of CAMBRA. The room was crammed with hygienists, people were sitting on the floor and some stood up at the back. During this lecture, I had my Eureka! moment. With all the science laid out before me, CAMBRA did make sense and was something I felt obligated to offer my patients. My enthusiasm to completely change the practice overnight had to be tempered by reality. CAMBRA requires a significant change in mindset and CAMBRA conversion affects all systems within the practice, from scheduling and fees to diagnostics, treatment and patient education. Rome wasn t built in a day. I m happy that my working life is moving in the right direction. and periodontists who were referring patients to me were obviously happy for me to continue along this path. Did dentists, the government, professional or governing bodies, or even the general public realize that hygienists have an important role to play in caries management? Why and how did I change? My colleague, Mark, and I, were discussing caries management by risk assessment (CAMBRA) upon his return from practicing in New Zealand, where far from being a backwater, they appeared to be years ahead of the U.K. in caries management. I have the greatest respect for Mark, but I was skeptical about this new approach to caries. Mark confided that he too was skeptical at first, but one event changed his mind. While in New Zealand, he was invited to a dental peer group meeting where the Regional Dental Officer gathered the community dental therapists together to calibrate their reading of dental radiographs in children. They were all asked to bring examples to compare and discuss. Mark was shocked at the Dental Caries The prevalence of dental caries in the U.S. is described as a silent epidemic affecting the most vulnerable citizens: poor children, the elderly and many members of racial and ethnic minority groups. Statistics vary from 50 percent of children experiencing caries in deciduous teeth to 25 percent of adolescents experiencing caries in 80 percent of permanent teeth. In the U.K., statistics aren t much different. Caries is a transmissible disease that requires primary prevention, strategies and agents to forestall the onset of disease and reverse or arrest the process of disease before secondary reparative treatment becomes necessary. Despite evidence that caries can be prevented, caries rates seem to be ever increasing. The concept that dental caries is a process rather than a categorical disease with cavitated and non-cavitated states was reported more than 100 years ago, in 1886. Dr. Magitot divided the disease into three stages: caries of enamel, caries of dentine and deep caries. Two years later, Dr. Morsman stressed the importance of diagnosis as the first step in the management of dental caries. Dental caries is now defined as a transmissible bacterial infection that should be curable and preventable and whose etiological agents are specific bacteria that generate acids from fermentable carbohydrates. New paradigms are being sought to address deep concerns among health-care professionals to meet these challenges. continued on page 8 hygienetown.com «FEBRUARY 2012 7
profile in oral health continued from page 7 CAMBRA was developed in the United States and is presently being embraced throughout the world. CAMBRA is an evidence-based caries management system that is founded on a team approach and an understanding of the nature, prevention and treatment of dental caries. It incorporates the ethos that risk assessment and interventions are based on the concept of altering the caries balance in favor of health by identifying and treating pathological (risk) factors such as pathogenic bacteria, unhealthy saliva and poor dietary habits (i.e. frequent ingestion of fermentable carbohydrates) and promoting protective factors including saliva, sealants, antimicrobials, fluoride, oral probiotics and a healthy diet. It is also clear that the current concept of caries is constantly being redefined as new evidence and information is presented. It should now be looked upon as an infectious transmissible disease process where a cariogenic biofilm, in the presence of an oral status that is more pathological than protective leads to the demineralization of the dental hard tissues. Caries Risk Assessment Caries risk assessment (CRA) is defined as the procedure to predict future caries development before the clinical onset of the disease. The CRA can be carried out as part of the dentist s clinical examination in conjunction with the medical history or by the hygienist/therapist when referred by a dentist. CRA forms consist of a questionnaire that collects information on the existing pathogenic and protective factors present. These factors would include various stages of carious lesions, diet, fluoride, health, medication, socio-economic, age, oral hygiene, saliva, plaque and bacterial balance. Gathering as much information as accurately as possible is essential for the success of the treatment, engagement and education of the patient. After completing these forms, the clinician can determine the level of risk that these factors indicate to the individual. Forms can be completed for child and adult groups. The Californian Dental Association (CDA) suggests placing patients in either a high-, medium- or low-risk category. Determining the risk is not an exact science but a clinical determination based upon visible (intra-oral and screening) and radiographic evidence, the individuals health and dental histories and lifestyle factors. The imperative is to understand the individual s balance of risk against the protective factors and identify his or her status accordingly. Then a process of management can begin to alter or modify risk and protective factors accordingly. These are managed by the clinician and patient and reviewed at appropriate intervals depending upon risk. Author s Bio The completed assessment will help structure the data collected and shed light upon the management of the individual where treatment options are challenging. For example, think about two caries-free children with different mutans Streptococci levels in their saliva. Assuming each has the same diet, it is very likely that the child with higher counts will develop more caries than the other with low levels. However, if the child with low levels eats sugary foods frequently and the higher one doesn t, who has the greatest chance of developing caries? Imagine that the low bacterial count child supplements sugary foods with fluoride and the other does not, again, who will develop more caries, and so forth? In this way, by adding several aggravating and counteracting risk factors the permutations are potentially vast. The risk assessments intention is to help unlock this puzzle. The development of CRA and caries risk management (CRM) have proved to be a continually evolving experience. Surprisingly the challenge was not that of critically appraising research and creating a strategy but of discovering the agents and materials to complement and implement the assessment and guidelines scattered amongst the dental profession and dental suppliers and not unified under one umbrella. If such a strategy is to evolve, then not only should the profession embrace developing acceptable guidelines but also the corporate industry coming together unified as part of this collaboration. Professionally, I feel like I ve been given a new lease of life. I m now looking at all of my patients through different eyes. I have a much greater understanding of the importance of balancing oral health, looking at each individual patient holistically and I spend as much time listening and gathering information now as I do talking. My appointment book looks much more interesting and the whole team is really enjoying getting involved in something new. My own resistance to change makes me realize that making changes in the practice and with patients is going to be a rocky, yet exciting and rewarding road ahead. Next Month: Part 2 Technologies Used in Caries Risk Assessment and Prevention Timothy Ives, RDH, spent 22 years in the Royal Air Force, much of that time providing dental hygiene services. His tours of duty included Hong Kong, Cyprus, Germany, New Zealand, Holland and the U.K. Besides clinical practice, he also has a certificate in appraisal of dental practices. He has a passion for minimally invasive dentistry (MID) and co-runs an MID-based Web site with his friend, Dave Bridges, RDH: www.dentalvillage.co.uk. Tim is an active Townie, member of the Hygientown.com Advisory Board and available for in-office CAMBRA training. 8 FEBRUARY 2012» hygienetown.com
message board» Rampant Root Caries As people keep their teeth longer, root caries becomes a serious problem. Hygienetown.com > Message Boards > Prevention > Fluoride > Rampant Root Caries Member Since: 12/03/06 Post: 1 of 9 We are seeing a very high percentage of our patients getting root caries. Some penetrate so quickly that by the time it is caught it is into root canal territory! We have been prescribing fluoride trays for home use (nightly), but compliance has been an issue. What is the current protocol for adult root caries prevention? I have heard xylitol, MI Paste, fluoride varnish at recare appointments and over-the-counter fluoride. Please point us in the right direction! Thanks. APR 13 2011 Member Since: 12/13/08 Post: 2 of 9 My favorite subject. As you know, every patient is different and there is no onesize-fits-all protocol. Your best approach is to carry out a risk assessment and gather as much information about each individual as possible. This, in the ideal world, would involve testing their saliva. When you have all this information at hand, you can then provide patients with a prevention plan specific to their needs, which relates to the saliva test and risk assessment. The treatment plan focuses on re-balancing their saliva and stopping the caries. Anything else is guessing. APR 13 2011 Member Since: 06/17/07 Post: 5 of 9 CAMBRA is the first approach to identify what etiology you should be addressing (diet, behavior, meds, etc.). Tim, do you have any links to a CAMBRA form? Root caries is almost always related to chronic high liquid sugar intake and might be exacerbated by xerostomia (I know RDH82 will write a fantastic post of sour acid candy so I ll leave that to her. She s the guru on that subject). Assuming the above, I would place the patient on CloSYS toothpaste and rinse immediately. CariFree has the best treatment rinse, but it s very intense. Xylitol products can be used to reduce that effects of cariogenic bacteria and promote an alkaline or neutral healthy ph. I would advise Fluoridex or MI Paste for remineralization and evaluate the homecare regimen. A conversation on diet is crucial. If you don t address this behavior, then this process will continue to repeat itself, regardless of how much fluoride, rinses, MI Paste, xylitol, etc. you use. APR 14 2011 Member Since: 12/13/08 Post: 2 of 9 Yes, if you register on my Web site, www.dentalvillage.co.uk (it s free) there are different types risk assessment forms to download (free). The whole point of undertaking a risk assessment and saliva test is to find out where the caries balance lies and to find out exactly which products to recommend in order to redress the oral balance. I would only recommend MI Paste (for a caries patient) if there was a buffering issue. Don t forget that saliva is supersaturated with calcium and phosphate if the saliva is healthy and this would be a wasted expense on the patient s behalf. The buffering test is much 10 FEBRUARY 2012» hygienetown.com
message board cheaper than a tube of MI Paste and they would then be on MI Paste for some time. One more point regarding MI Paste don t forget to check for casein (milk) allergies and renal problems before prescribing it. APR 15 2011 Perio Reports, Vol 23, No 4 The Use of Caries-preventive Agents Member Since: 03/05/05 Post: 8 of 9 Caries risk assessment protocols suggest the use of in-office fluorides, sealants, prescription and nonprescription fluorides, chlorhexidine rinses, and sugarless or xylitol gums as techniques to prevent caries. Several things keep clinicians from using and recommending these agents for patients, including lack of knowledge of the value, lack of financial reimbursement, prevention philosophy, patient pools and overall caries risk. A written survey was sent to members of the Dental Practice-Based Research Network (DPBRN) to determine use of caries preventive agents. The DPBRN includes three areas of private and public health practices in Alabama/Mississippi, Florida/Georgia and Denmark/Norway/Sweden SK; and two large group practices networks in Minnesota Health Partners and PDA Kaiser Permanante. Surveys were sent to 932 network practices with 509 usable surveys returned from 419 male and 90 female practitioners with 98 percent being in general practice. Questions were asked about preventive services and recommendations for patients six to 18 years of age. Use of caries risk assessment by DPBRN practices was reported in 75 percent. In-office fluoride treatments were used most often by 82 percent of practices, followed by sealants in 69 percent. Sugarless or xylitol chewing gum was recommended by 36 percent of practices, with non-prescription fluoride at 32 percent and prescription fluoride at 21 percent. The least recommended preventive agent was at home chlorhexidine. Clinical Implications: Preventive measures are used, but perhaps not as widely or as often as they could be to reduce the current level of caries in children. Riley, J., Richman, S., Rindal, B., Fellows, J., Qvist, V., Gilbert, G., Gordan, V.: Use of Caries-Preventive Agents in Children: Findings from the Dental Practice-Based Research Network. Oral Health Prev Dent 8: 351-359, 2010. APR 19 2011 Three points: 1. I d like to see the definition of a caries risk assessment. 2. Not happy that xylitol and sugarless gum are bracketed together. 3. I m glad that chlorhexidine is the least-recommended preventive agent. APR 19 2011 Member Since: 12/13/08 Post: 9 of 9 Find it online at: www.hygienetown.com search» hygienetown.com «FEBRUARY 2012 11