Narumanas Korwanich Department of Community Dentistry Chiangmai University Dental Caries and Root Caries Risk Assessment and Prevention

Contents Introduction 1 Caries risk assessment 2 Caries prevention 3 Conclusion 4

WHO, 2002

UN, 2001

WHO, 2002

Active Ageing Health When the risk factors for chronic diseases and functional decline are kept low while the protective factors are kept high, people will enjoy both a longer quantity and quality of life Participation When labor market, employment, education, health and social policies and programs support their full participation in socio-economic, cultural and spiritual activities, people will continue to make a productive contribution to society Security When policies and program address the social, financial and physical security needs and rights of people as they age, elderly are ensured of protection, dignity and care in the event that they are no longer able to support and protect themselves

Oral health is an important component of ‘Active Ageing’ and is included in policy proposals related to health, one of the three basic pillars. Petersen & Yamamoto, 2005

Reduce risk factors associated with major diseases and increase factors that protect health throughout the life course - Tobacco- Physical activity - Nutrition- Healthy eating - Oral Health- Psychological factors - Alcohol and drugs- Medication

WHO, 2002

Oral Health Problem in Elderly Tooth loss 1 Denture related condition 2 Coronal and root caries 3 Periodontal disease 4 Xerostomia 5 Cancer and precancer 6 Petersen & Yamamoto, 2005

Dental Caries  Dental caries is an infectious, communicable disease resulting in destruction of tooth structure by acid-forming bacteria found in dental plaque, in the presence of sugar  During the past few decades, changes have been observed not only in the prevalence of dental caries, but also in the distribution and pattern of the disease in the population NIH, 2001

Dental Caries  It is identified a shift toward improved diagnosis of noncavitated, incipient lesions and treatment for prevention and arrest of such lesions  Restorations repair the tooth structure, do not stop caries, have a finite life span and are susceptible to disease Fontana and Zero, 2006

Company Logo Identify Risk Factor Dental Caries Distribution Diagnosis Pattern Prevalence

Risk factors  An environmental, behavioral, or biologic factor confirmed by temporal sequence, usually in longitudinal studies, which if present directly increases the probability of a disease occurring, and if absent or removed reduces the probability  Risk factors are part of the causal chain or expose the host to the causal chain  Once disease occurs, removal of a risk factor may not result in a cure Beck, 1996

Caries Risk Assessment  Caries risk assessment determines the probability of caries incidence in a certain period  Modern caries management also focuses on the detection of incipient, non-cavitated lesions and the practitioner’s ability to diagnose whether those lesions are active

Caries Risk Assessment  Evaluate the degree of patient’s risk of developing caries to determine the intensity of the treatment and frequency of recall appointments or treatment  Help identify the main etiologic agents that contribute to the disease or that, because of their recent onset, may contribute to future disease, to determine the type of treatment

Caries Risk Assessmemt  Determine if additional diagnostic procedures are required  Aid in restorative treatment decision  Improve the reliability of the prognosis of the planned treatment  Assess the efficacy of the proposed management and preventive treatment plan at recall visits

1234 Prediction based on socio- economic status, oral hygiene and dietary factors Prediction based on behavioral factors Prediction based on past caries experience Prediction based on salivary factors and microbial colonization Messer, 2000

Microbial Colonization Caries Experience Behavior SES, Oral Hygiene, Diet Saliva

Petersen, 2005

 Low indices of socioeconomic status (SES) have been associated with elevations in caries, although the extent to which this indicator may simply reflect previous correlates is unknown  Low SES is also associated with reduced access to care, reduced oral health aspirations, low self efficacy, and health behaviors that may be enhance caries risk NIH 2002

Diet  Sugar exposure is important factor in caries development  Frequency and amount of sugar intake has been shown related to dental caries incidence

Tooth Substrate Microorganism Keyes’s diagram

Moynihan & Petersen, 2004

 The best available evidence indicates that the level of dental caries is low in countries where the consumption of free sugar is below 15–20 kg/person/yr. This is equivalent to a daily intake of 40–55 g and the values equate to 6–10% of energy intake.  Individuals should be recommended to reduce the frequency with which they consume foods containing free sugars to four times a day and thereby limit the amount of free sugars consumed (European workshop on oral care and general health, 2003)

Vipeholm Study   964 mentally deficient patients  Sugars and potential in caries induction  Non sticky form  Sticky form  Between meal and sticky form  1 control and 6 main test groups

Vipeholm Study  Control group  Sucrose group  Bread group  Chocolate group  Caramel group  8 toffee group  24 toffee group

The Vipeholm Study

 Sugar has a topical effect on teeth  Bread is not as cariogenic as sugar  The amount of sugar is not critical  The frequency of eating is more important  Liquid sweet are not as cariogenic as retentive sweet  Carious lesions occurred despite avoidance of sugar

Stephan’s Curve

Saliva Microbial Colonization Caries Experience Behavior SES, Oral Hygiene, Diet

 Age  Nocturnal bottle usage  Additive  On pacifier during sleep  Breast feeding Ho and Messer, 1993  Breast feeding  Bottle feeding  Regularity of snacks  Drinking sweet beverage  Watching television during meal  Brushing by mother Kawabata et al., 1997

SES, Oral Hygiene, Diet Saliva Microbial Colonization Caries Experience Behavior

 Thus far, the most consistent predictor of caries risk in children is past caries experience NIH, 2001  Previous caries experience was an important predictor in most models tested for primary, permanent and root surface caries Zero et al., 2001

Miravet et al., 2007

Motohashi et al., 2006

Behavior SES, Oral Hygiene, Diet Saliva Microbial Colonization Caries Experience

Mutan streptococci Ecological Plaque Lactobacilli Association of Lactobacilli and dental caries. Association of Lactobacilli and fermentable carbohydrates. Innoculation of S.mutans shows higher caries activity. High acid production activity of S.mutans Other oral bacteria are sufficiently acidogenic. Adherence of plaque without mutan streptococci.

Scheie et al, 1996

Van Houte, 1993

 Overall, the data in the table indicate that the prediction of high caries risk in children, including the very young and adolescents, on the basis of a single microbial factor is problematic, whereas prediction of low caries risk is more reliable Van Houte, 1993

Caries Experience Behavior SES, Oral Hygiene, Diet Saliva Microbial Colonization

 Saliva affects all three of components of Keyes’ classic Venn Diagram of caries etiology Dodd et al., 2005

Lenander-Lumikari & Loimaranta, 2000

Xerostomia subjective report of oral dryness related to gender Salivary Flow Rate Hyposalivation Objective salivary flow rate that is under 0.1 or 0.16 ml/min (or 0.1 ml/min; relate to medication and systemic disease Tanathipanont & Korwanich, 2008

Lenander-Lumikari & Loimaranta, 2000 Buffer Capacity

Klienberg et al., 1973 Flow Rate

Commercial kits for saliva and microbial test

Resazurin Disc (RD) test

Other commercial kits  Caries Screen  Proflow  Oricult  Mucount

Consideration for Root Caries 1 Older people are a caries-active group, experiencing new disease at a rate which is as great as that of adolescents 2 The risk factor common to all studies about root caries was the wearing of a partial denture. Thompson, 2004

Unit : surface

Saunders & Meyerowitz, 2005

Putting them together

Fejerskov & Manji 1990

Cariogram

Miravet et al., 2007

Caries Prevention 1 Reduce the pathogenic potential of dental plaque 2 Increase the resistance of tooth structure to caries attack 3 Augment salivary factors Walsh, 2004

Reduce the pathogenic potential of dental plaque Mechanical plaque control 1 Chemotherapeutic method 2 Food intake restriction 3 Replacement sweetener 4 Sugar frequency reduction 5

Augment salivary factors Sugar free chewing gum 1 Supportive life style 2 Elevate salivary quality 3 Increase saliva mineralization 4 Enhance F in saliva 5

Increase tooth structure resistance to caries attack Community fluoride program 1 Professional fluoride 2 Self application fluoride 3 Sealant 4 Enamel treatment 5

Mode of Action Bactericide Crystallize Remineralize