Patient-Centered Explanation of Risk-Based Treatment Tooth Decay

Tooth Decay Defined An infection caused by bacteria commonly found in the mouth that destroys the tooth The bacteria are transmissible from parent or caregiver to child, child to child, and adult to adult The disease has many factors and many stages

Experimental Decay Development of enamel decay Decay arrested No oral hygiene Rinse 9x/day with 50% sucrose solution Regular oral hygiene Fluoride use 0 days 21 days 51 days Timeline Proof that: bacteria causes decay sugar increases risk oral hygiene can prevent decay von der Fehr et al 1970

Stages of Decay The disease process begins with an infection, advances to demineralization, and ends with a cavity The process does not progress at a uniform rate but is cyclic and intermittent Demineralization occurs when decay-causing bacteria produce acids from food

Cyclic Process of Decay Demineralization Bacteria plus food makes the saliva very acidic within 5 minutes Remineralization Saliva is normal 30 minutes after eating

Tipping the Balance Remineralization Demineralization Cavity Infrequent or inadequate tooth cleaning Frequent meals and snacks Large amount of decay causing bacteria Deficient fluoride in saliva

Decay Progression Progression of 72 white spot lesions followed for 7 years Backer-Dirks 1966

Diagnosis of Decay Health Decalcification Decay Visual Normal tooth color White spot Black or brown Feel Hard Soft X-Ray Normal Black area None of these methods can detect all lesions early enough to implement treatment to reverse the disease process

Occurrence of Symptoms 0 1 hour ? years 30 years Time line Heart Attack Anaphylactic Shock Toothache Each symptom occurs at the end of the colored bar Each disease process is invisible to diagnostic methods for most or all of the time within the colored bar Risk predicts chronic disease occurrence

The Early Stages of Decay are Indistinguishable from Health Disease State Cavity The Realm of Diagnosis, which requires the disease is sufficiently advanced to be “Visible” “Invisible” to diagnostic techniques Decalcification Health

Risk Defined Risk is a prediction that disease will occur or progress Risk is distinct from disease and cannot be accurately predicted from the disease state Risk is determined by risk factors

Risk-Based Treatment Risk-based treatment prevents disease progression Disease State Cavity Risk-based treatment prevents disease progression Risk-based treatment prevents disease occurrence Decalcification Health

Prevention maintains a clinically healthy state Repair and Prevention Disease State Cavity Repair treats the consequences of disease, which may increase the risk of new disease Prevention maintains a clinically healthy state Decalcification Health

Fillings Fillings have no measurable effect on decay-causing bacteria present on tooth surfaces Fillings have a finite life span and where each replacement filling leaves less tooth structure Fillings increase the risk of an abscess Fillings may increase the risk of tooth fracture and gum disease

Prevention Preventive treatment can be effective at any time and age A diagnosis of decay could be indicative that additional lesions not yet visible exist Apparently healthy teeth might be in the early undetectable stages of decay Risk assessment can identify when risk is high and preventive treatment is beneficial

Tooth Decay Risk Tooth decay risk varies between individuals and over time coincident with a change in risk factors The highest decay-susceptible time is the first 2 years after tooth eruption, but can be high at any time

Determining Risk and Treatment About PreViser PreViser Corporation provides web-enabled diagnostic decision support tools for dentists. The tools are simple, inexpensive and easy to use. The first clinically proven application is within dental care, where the use of PreViser technology will assist oral health care professionals to more effectively plan treatment responses to disease. The tools are built under protection of U.S. patent number 6,484,144 with an exclusive license to PreViser Corporation. This intellectual property protects a self-updating system of diagnosis that uses easily collected clinical measurements to calculate the risk of disease development or deterioration of a current disease state, and identifies therapies most likely to reduce risk and disease severity. Find out more about the PreViser Risk Calculator Download and Try it for Free.  All Content © 2003 PreViser | All Rights Reserved | info@PreViser.net Privacy Policy

Supplemental and New Diagnostic Methods Plaque Formation Rate (PFRI) Salivary level of mutans streptococci (SM) New Diagnostic Methods Digital X-rays Fiber-optic transillumination (FOTI) Laser fluorescence (LF) Electrical conductance (EC) Ultrasound

Plaque Formation Rate Score Description 1 1%-10% of surfaces 2 3 21%-30% of surfaces 4 31%-40% of surfaces 5 >40% of surfaces Amount of new plaque accumulated in 24 hours following tooth cleaning where patient refrains from oral hygiene Axelsson 1991

Caries Risk Based on SM and PFRI SM/ml 1 2 3 4 5 Very Low Risk <0.5 mill Low Risk Moderate Risk 0.5-0.9 mill High Risk >0.9 mill Axelsson 1991

New Diagnostic Methods Very little clinical data are available to validate these technologies Goal is better accuracy over traditional methods to detect true cavities that should be filled Goal is detection of currently “invisible” lesions that are in a state of dynamic decalcification and recalcification Enhances risk assessment and application of preventive treatment

Preventing Tooth Decay Reduction of decay-causing bacteria Health promoting dietary practices Exposure to fluoride Sealing susceptible tooth defects Proper frequency of dental visits

Reducing Decay-Causing Bacteria Personal teeth cleaning Twice daily tooth brushing and flossing or an equivalent aid for between the teeth Antibacterial rinses (chlorhexidene) Rinse with 10 ml for 1 minute at bedtime for 2 weeks repeating the cycle 2 months later Fluoride toothpaste Treat all family members

“Teeth Cleaned” Clarified All tooth surfaces including between teeth About half of all decay affects the tooth surfaces of adjacent teeth where a tooth brush and oral rinse does not reach The equivalent of not cleaning between teeth is washing the palm and back of your hands but not between your fingers Rinsing hands with water is not an effective alternative to scrubbing with soap

Dietary Practices Foods that are especially harmful contain sugars like sucrose, glucose, and fructose, cooked starch, and other carbohydrates Eat and drink no more than 3 meals and 3 snacks per day Sugar-free gum and mints, especially those that contain xylitol can be beneficial

Fluoride The incorporation of fluoride into developing enamel inhibits tooth decay, however its primary effectiveness occurs by its concentration in plaque and saliva to inhibit demineralization and enhance remineralization Fluoride inhibits plaque bacteria

Fluoride, cont. Fluoride is released from dental plaque during the acidic conditions of eating Released fluoride combines with calcium and phosphate to create a more decay-resistant enamel crystal structure Fluoride is available in water, toothpaste, over-the-counter rinses, prescription toothpaste and rinses, professional gels, foams, and varnishes

Fluoride, cont. Fluoridated toothpaste should be used twice daily Professional applications of fluoride is based on risk High-risk patients should have this done 2 to 3 times per year More fluoride is not necessarily better, especially for children younger than 6 years as fluorosis can affect cosmetically visible developing teeth

Tooth Sealants Plastic coating bonded to the biting surfaces of the back teeth Susceptible tooth defects should be sealed regardless of age

Frequency of Dental Visits Twice annual professional tooth cleaning as the sole method to prevent cavities is unlikely to be effective especially when risk is high Frequency of dental visits can be increased for closer monitoring of oral hygiene and dietary practices in addition to applying fluoride and sealants

Dealing with Objections Prevention doesn’t work Studies have shown that more than 90% of tooth decay can be prevented Prevention is only for the young Studies have shown that prevention works at any age The benefits of prevention take many years The benefits are immediate as prevention heals the invisible lesions

Objections, cont. It costs too much; My insurance doesn’t cover it Filling cavities costs more than preventing them Cavities can result in a root canal, cap, or extraction Dentures could ultimately cost more than “saving” your teeth Insurance doesn’t care if you have dentures Dentures are OK Dentures, especially lower ones, are not always successful, which then requires implants

Objections, cont. Flossing is too hard; no time to floss Tying shoelaces for a child is difficult but they learn the skill Flossing takes only a minute or two after the skill is learned Fillings prevent decay Fillings have no effect on decay-causing bacteria and hence do not reduce the risk of having more cavities