1. Patient-Centered Explanation of Risk-Based Treatment
Tooth Decay

2. 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

3. 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 days days
Timeline
Proof that:
bacteria causes decay
sugar increases risk
oral hygiene can prevent decay
von der Fehr et al 1970

4. 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

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

6. 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

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

8. 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

9. Occurrence of Symptoms
0 1 hour ? years 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.
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19. 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

20. Plaque Formation Rate Score Description 1 1%-10% of surfaces 23
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

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

22. 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

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

24. 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

25. “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

26. 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

27. 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

28. 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

29. 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

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

31. 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

32. 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

33. 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

34. 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