1. Caries Risk Assessment and its interaction with Preventive and Restorative Protocols Richard Ehrlich DDS www.elmtreedental.com dre@elmtreedental.com

2. Introduction Caries Risk is used by most general dentists daily, usually on an intuitive level. The first part of this presentation will attempt to help quantify this, and the second part will use this information for more systematic preventive, diagnostic and restorative protocols.

3. Applications of Caries Risk Assessment Caries Risk Assessment assists in predicting and diagnosing this type of case- Should you observe this? Or does it conceal this?Or does it conceal this?

4. Applications of Caries Risk Assessment Caries Risk Assessment assists in predicting and diagnosing this type of case- Should you replace these restorations or observe them?

5. Overview of Caries Risk Assessment (CRA) Caries Risk Assessment (CRA) is a simple, quick method for assigning a number to an individual’s risk for decay.Caries Risk Assessment (CRA) is a simple, quick method for assigning a number to an individual’s risk for decay. Using this data, custom preventive and restorative programs can be used, with more reliance on evidence-based dentistry and less on intuition and experience alone.Using this data, custom preventive and restorative programs can be used, with more reliance on evidence-based dentistry and less on intuition and experience alone. This simplified version is based on practical application of the U of T Caries Risk Assessment in actual clinical practice in a preventive-oriented dental office.This simplified version is based on practical application of the U of T Caries Risk Assessment in actual clinical practice in a preventive-oriented dental office.

6. Categories for Simplified CRA These are all given numerical scores : Existing DecayExisting Decay Previous DecayPrevious Decay Root CariesRoot Caries Fluoride ExposureFluoride Exposure Diet FactorsDiet Factors Oral HygieneOral Hygiene Additional TestsAdditional Tests S.mutans and LactobacillusS.mutans and Lactobacillus Saliva FlowSaliva Flow

7. Categories for Simplified CRA Existing Decay No Decay = 0No Decay = 0 Some early Pit and Fissure Decay = 0.5Some early Pit and Fissure Decay = 0.5 1-2 Existing Lesions =11-2 Existing Lesions =1 >2 Lesions =2

8. Categories for Simplified CRA Previous Decay No Decay = 0No Decay = 0 Some early Pit and Fissure Decay = 0.5Some early Pit and Fissure Decay = 0.5 Interproximal Posterior Decay =1Interproximal Posterior Decay =1 Anterior or Smooth Surface Decay =2

9. Categories for Simplified CRA Existing DecayExisting Decay Previous DecayPrevious Decay Root CariesRoot Caries Ratio of exposed root surfaces to decay –<25% of root surfaces decayed = 0 –25%-50% of surfaces decayed =1 –>50% of surfaces decayed =2

10. Categories for Simplified CRA Existing DecayExisting Decay Previous DecayPrevious Decay Root CariesRoot Caries Fluoride ExposureFluoride Exposure Using Fluoride Toothpaste BID = 0 Using Fluoride Toothpaste once daily = 1 Not using Fluoride Toothpaste or Rinse = 2

11. Categories for Simplified CRA Existing DecayExisting Decay Previous DecayPrevious Decay Root CariesRoot Caries Fluoride ExposureFluoride Exposure Diet FactorsDiet Factors

12. Diet Factors: The Diet Questionnaire is presented.The Diet Questionnaire is presented. Total sugar exposures are totaled, and divided by 3 for the Caries Index Diet ScoreTotal sugar exposures are totaled, and divided by 3 for the Caries Index Diet Score

13. Diet Questionnaire: Drink Factors:Drink Factors: How many times a day do you drink:How many times a day do you drink: –1. Coffee or tea with sugar between meals? –2. Pop, Kool-aid, lemonade, sports drinks, fruit juice, iced tea with sugar between meals? » »Total the number of these How many glasses of water or dilute drinks do you have a day? This does not include coffee, soft drinks, full strength juice or sports drinks.How many glasses of water or dilute drinks do you have a day? This does not include coffee, soft drinks, full strength juice or sports drinks. –Chronic Dehydration can increase caries risk »Count 2 if the patient is dehydrated

14. Diet Questionnaire: Drink Factors cont’d:Drink Factors cont’d: Important trend: Cariogenic drinks are on a great increase!Important trend: Cariogenic drinks are on a great increase! Huge marketing efforts have been made, and often soft drink companies have a monopoly on vending machines in schools. This has paid off with a corresponding increase in decay and acid erosion. Huge marketing efforts have been made, and often soft drink companies have a monopoly on vending machines in schools. This has paid off with a corresponding increase in decay and acid erosion. Consumption of soft drinks, sports drinks, fruit juices and iced tea have skyrocketed in recent years, especially among teens and adolescents. Sports drinks are meant for athletes involved in over 60 minutes of aerobic activity. Sedentary kids are drinking sports drinks after mild activity, thanks to good marketing.Consumption of soft drinks, sports drinks, fruit juices and iced tea have skyrocketed in recent years, especially among teens and adolescents. Sports drinks are meant for athletes involved in over 60 minutes of aerobic activity. Sedentary kids are drinking sports drinks after mild activity, thanks to good marketing. Water and milk consumption is dropping. Link to Acid Erosion PageLink to Acid Erosion Page Acid Erosion Page Acid Erosion Page

15. Diet Questionnaire: Food Factors: How many times a day do you:How many times a day do you: 1. Chew regular gum (Not sugarless)? 2.Eat mints, lozenges, candies or candy bars, dried fruit, energy bars between meals? 3.Eat sweetened baked goods (Donuts, cookies, pastries) between meals? Total the number of all of these.

16. Diet Questionnaire: Do you have a habit of sipping a sweetened drink (Coffee, cola, juice) or eating a sweet snack over an extended period of time, 45 minutes or more? – –If yes, add 2

17. Diet Questionnaire: Total diet scores are added up, divided by 3 and this is the number used for the Caries Risk Assessment score for Diet Factors. 0-2 Sugar exposures=0 3-4 Sugar exposures =1 5-6 Sugar Exposures =2 >6 exposures =3

18. Categories for Simplified CRA Existing DecayExisting Decay Previous DecayPrevious Decay Root CariesRoot Caries Fluoride ExposureFluoride Exposure Diet FactorsDiet Factors Oral HygieneOral Hygiene 0=Good OH 1=Fair OH –PSRs <3 –Mod Plaque 2=Poor OH –PSRs >3 –Heavy Plaque

19. Categories for Simplified CRA Existing DecayExisting Decay Previous DecayPrevious Decay Root CariesRoot Caries Fluoride ExposureFluoride Exposure Diet FactorsDiet Factors Oral HygieneOral Hygiene Additional TestsAdditional Tests S.mutans and LactobacillusS.mutans and Lactobacillus Saliva FlowSaliva Flow

20. Categories for Simplified CRA Bacterial testing is done only in cases when indicated, if other results are not obvious.Bacterial testing is done only in cases when indicated, if other results are not obvious. >1,000,000 colonies s.mutans or >100,000 lactobacillus = 2>1,000,000 colonies s.mutans or >100,000 lactobacillus = 2 > 4 minutes for 3cc saliva sample =2> 4 minutes for 3cc saliva sample =2 –Indicates possible Xerostomia Additional Tests S.mutans and Lactobacillus Saliva Flow

21. The Simplified Caries Index Form

22. The Diet Questionnaire

23. CRA Score and Caries Risk: The Total Score 0-2 = Low Risk0-2 = Low Risk 3-4 = Medium Risk3-4 = Medium Risk 4-6 = High Risk4-6 = High Risk >6 = Severe Risk of Caries>6 = Severe Risk of Caries

24. CRA Score and Caries Risk: Applying the data From this data we can set up custom protocols for the individual patients, including Fluoride treatments Fluoride treatments Frequency of X-raysFrequency of X-rays Frequency of Recall visitsFrequency of Recall visits Restorative decisions on borderline lesionsRestorative decisions on borderline lesions –Whether to Observe, Seal or Restore

25. Recare Report- Getting the message out Patients remember a percentage of what you tell them while in the chair. They take it far more seriously if they have something they can take home. We use a Recare report to give to patients, or kid’s parents.

26. Recare Report Procedures done today: Medial History UpdateBlood Pressure Screening Oral Cancer ScanX-rays Tooth ExaminationPeriodontal (gum) Examination- TMJ Check Cavity Risk AssessmentPSRFull perio recordingOral Hygiene Evaluation Recommendations: We would like to see you again in: 3 months 6 months 9 months 1 year Oral Hygiene- Brushing Good! Too Hard Missing Areas Not Frequent Enough Other Tools FlossingSulcabrushRubber TipRotapoints SuperflossPeridex antibacterial mouthwash Power Floss unit Diet Factors- 1. Coffee or tea with sugar between meals. 2. Pop, fruit juice, rice milk, sports drinks, Kool-aid or iced tea with sugar between meals. 3. Chewing gum (Not sugarless)? 4. Eating mints, lozenges, candies, dried fruit, chocolate bars. 5. Eating sweetened baked goods (Donuts, cookies, pastries) between meals? Fluoride Program Supplements- ¼ tablet/day½ tablet/dayPrevident 5000 high-fluoride toothpaste Fluoride Rinse Fluoride treatment: 3month/ 6 month/ Home treatment Ongoing issues needing treatment: Decay Gum Disease Failing dental work

27. Application In Practice- Take-home message: Caries Risk Assessment is an essential part of scientifically based dentistry in real general practiceCaries Risk Assessment is an essential part of scientifically based dentistry in real general practice A practical Caries Risk Assessment takes less than 5 minutes to do during a new patient exam, and contributes valuable data- please use my version or your own in your practice, but use it! Identify your high, medium and low risk patients.A practical Caries Risk Assessment takes less than 5 minutes to do during a new patient exam, and contributes valuable data- please use my version or your own in your practice, but use it! Identify your high, medium and low risk patients. The next part of the presentation will deal with use of this data for treatment protocols.

28. Dr. Richard Ehrlich www.elmtreedental.com

29. Part 2: Diagnostic, Restorative and Preventive Protocols using Risk Analysis and High Tech instrumentation Richard Ehrlich DDS dre@elmtreedental.com

30. Tools needed: In addition to the usual instrumentation and radiographs for diagnosis: Diagnodent- Diagnostic Laser caries detector

31. Diagnodent Laser This device can give a numerical reading of early decay in pits.This device can give a numerical reading of early decay in pits. With practice, it can be more accurate than visual, tactile or radiographic examinations.With practice, it can be more accurate than visual, tactile or radiographic examinations. Caution is required around hypocalcifications and existing resins and sealants as the unit may misread.Caution is required around hypocalcifications and existing resins and sealants as the unit may misread.

32. Other adjuncts- Magnification LoupesLoupes Operating Microscope Operating Microscope Intraoral Camera Intraoral Camera

33. Diagnodent Laser Readings under 10 have no decay.Readings under 10 have no decay. Readings 10-20 usually have stain or enamel cariesReadings 10-20 usually have stain or enamel caries Readings over 35 generally have decay in dentin. Readings of 99 are decayed well into dentin. Readings 20-35 need individual assessment Diagnodent Readings alone are not sufficient for diagnosis (See Literature Review) New Technologies:

34. Protocols using the tools At the initial diagnosis, the patient can usually be assigned to a Risk group.At the initial diagnosis, the patient can usually be assigned to a Risk group. This is re-evaluated at the next recall, as often the status changes after the initial treatment.This is re-evaluated at the next recall, as often the status changes after the initial treatment.

35. Low Risk- Initial Protocol Caries Index 0-2 Observe pits and fissures with stain or early decay, decay in enamel, very early (stable) decay in dentin, old restorations, poor margins.Observe pits and fissures with stain or early decay, decay in enamel, very early (stable) decay in dentin, old restorations, poor margins. Diagnodent (DD) < 25-30 Restore fractured restorations, obvious decay (DD>40).

36. Restore old restorations with cracks and broken margins, decay in pits with halo or shadow, any decay in dentin. (DD>25-30) Medium Risk- Initial Protocol Caries Index 3-4 Observe stained pits, deep pits, early decay in enamel.. Observe stained pits, deep pits, early decay in enamel. (DD<20). Diet Counseling Introduction (link to diet page) (link to diet page) Fluoride Supplements for children in non fluoridated areas

37. Restore early decay in enamel and dentin. (DD>15-20) Restore old restorations with cracks and broken margins High Risk- Initial Protocol Caries Index >4 Observe stained pits DD<10 Diet Counseling Introduction Fluoride Supplements for children Prevident 5000 for Adults Fluoride varnish on incipient areas

38. First Re-evaluation All patients are re-assessed after the initial treatment.All patients are re-assessed after the initial treatment. Many are at reduced risk once initial decay is removed, and diet/OH improvements are implemented.Many are at reduced risk once initial decay is removed, and diet/OH improvements are implemented.

39. High Risk- First Evaluation 3 month period Caries Risk Re-Evaluation, including s. mutans, lactobacillus test Salivary flow measurement 3-month Topical Fluoride, OHI3-month Topical Fluoride, OHI If risk reduced, proceed to Medium Risk Recare protocolIf risk reduced, proceed to Medium Risk Recare protocol

40. Low Risk Suggested Protocol Recall patient every 9 months, consider increasing if remaining low risk.Recall patient every 9 months, consider increasing if remaining low risk. No Topical FluorideNo Topical Fluoride No Fluoride SupplementNo Fluoride Supplement Take BW radiographs every 3 yearsTake BW radiographs every 3 years OHI As neededOHI As needed Observe pits and fissures with stain or early decay in enamel, very early decay in dentin. (DD<25-30)Observe pits and fissures with stain or early decay in enamel, very early decay in dentin. (DD<25-30) Polish or seal old restorations with poor margins, and observePolish or seal old restorations with poor margins, and observe Sealants not requiredSealants not required

41. Medium Risk Suggested Protocol Recall patient every 6 monthsRecall patient every 6 months Topical Fluoride for childrenTopical Fluoride for children Fluoride Supplement for areas without water F-Fluoride Supplement for areas without water F- Take BW radiographs every 2 yearsTake BW radiographs every 2 years OHI As neededOHI As needed Observe stained pits, early decay in enamel or optionally seal. (DD<15-20)Observe stained pits, early decay in enamel or optionally seal. (DD<15-20)

42. Medium Risk Suggested Protocol Restore pits and fissures with early decay, any very early decay in dentin, old restorations with poor margins. (DD>20)Restore pits and fissures with early decay, any very early decay in dentin, old restorations with poor margins. (DD>20) Polish or seal old restorations with fair margins, and observe.Polish or seal old restorations with fair margins, and observe.

43. High Risk Suggested Protocol Full diet counselling with diaryFull diet counselling with diary

44. High Risk Suggested Protocol Full diet counseling with diaryFull diet counseling with diary Recall patient every 3 months:Recall patient every 3 months: –Topical Fluoride –Fluoride Varnish on susceptible areas –Take BW radiographs yearly –OHI Home Fluoride Trays or Prevident 5000Home Fluoride Trays or Prevident 5000 Chlorhexidine Rinses –Adult- 30 seconds before bedChlorhexidine Rinses –Adult- 30 seconds before bed Xylitol-containing gum- 3 pieces dailyXylitol-containing gum- 3 pieces daily Fluoride Supplements-ChildFluoride Supplements-Child Evaluate for xerostomiaEvaluate for xerostomia

45. Restore pits with early decay, any very early decay in dentin or enamel, (DD>20) old restorations with fair- poor margins.Restore pits with early decay, any very early decay in dentin or enamel, (DD>20) old restorations with fair- poor margins. Sealants/Preventve resins- all deep pits and fissures. (DD>5-20)

46. Often high risk kids present with early decay or deep pits in barely erupted teeth.Often high risk kids present with early decay or deep pits in barely erupted teeth. New Technologies:New Technologies: These can be very hard to seal due to access or co-operation issues. If there is any moisture contamination, traditional sealants will fail.

47. Fluoride-releasing sealants for suspect pits with poor accessFluoride-releasing sealants for suspect pits with poor access Fuji Triage can be placed quickly and easily, needing very little cooperation.Fuji Triage can be placed quickly and easily, needing very little cooperation. New Technologies:New Technologies: Due to the fluoride release, it is less likely than traditional sealants to allow decay below if it leaks.

48. Digital RadiographyDigital Radiography New Technologies:New Technologies: Allows lower dose exposures. Resistance from patients is reduced. Results are instant.Allows lower dose exposures. Resistance from patients is reduced. Results are instant. Patient Education is enhanced as they can see radiographs enlarged in front of them. Diagnosis may be enhanced.Patient Education is enhanced as they can see radiographs enlarged in front of them. Diagnosis may be enhanced. Essential for online communication with specialists.Essential for online communication with specialists. Complete offsite backup is possible.Complete offsite backup is possible. Sensors are larger and placement takes some practice.Sensors are larger and placement takes some practice.

49. Diagnodent PenDiagnodent Pen New Technologies:New Technologies: Smaller and more portable version released in 2006Smaller and more portable version released in 2006 Ability to read interproximal lesionsAbility to read interproximal lesions Less fragile cable, less chance of damage

50. Ozone Treatment of pitsOzone Treatment of pits A promising new technique involves sterilizing the pits and fissures with ozone. This has been shown to stop decay and even allow remineralizationA promising new technique involves sterilizing the pits and fissures with ozone. This has been shown to stop decay and even allow remineralization This may make cooperation even easier in early interventionThis may make cooperation even easier in early intervention More research is needed here.More research is needed here. New Technologies:New Technologies:

51. 1. Cleaning 2. Measurement 3. Treatment 4. Reductant Fluid Promotes the immediate remineralization of the tooth. Proposed steps in Healozone Treatment

52. DIFOTI (Digital Imaging Fiber-Optic Trans-Illumination )DIFOTI (Digital Imaging Fiber-Optic Trans-Illumination ) New Technologies:New Technologies: This device creates high-resolution digital images of occlusal, interproximal and smooth surfaces. It enables dentists to discover or confirm the presence of decay that cannot be seen radiographically, visually or through use of an explorerThis device creates high-resolution digital images of occlusal, interproximal and smooth surfaces. It enables dentists to discover or confirm the presence of decay that cannot be seen radiographically, visually or through use of an explorer

53. DIFOTI (Digital Imaging Fiber-Optic Trans- Illumination )DIFOTI (Digital Imaging Fiber-Optic Trans- Illumination ) New Technologies:New Technologies:

54. Air AbrasionAir Abrasion New Technologies:New Technologies: This technology allows early intervention more conservatively than rotary instruments. Pits with stain, decay in enamel and very early dentin decay (DD 5-30) can be treated, almost always without local anaesthetic. Any restorative prep can be cleaned out with this unit, allowing better bonding. Air Abrasion is excellent for cleaning any prosthesis that needs bonding in the mouth, from crowns and posts to fixed ortho. You cannot remove amalgams or treat larger lesions. Auxilliary suction is needed.

55. MicrobursMicroburs New Technologies:New Technologies: Low-tech way to access very small pits. ¼, 1/8 and 1/16 round burs are available for high speed handpieces. Can treat some early pits and grooves almost as well as lasers or air abrasion.

56. Laser- Water unitsLaser- Water units New Technologies:New Technologies: This technology is similar in application to Air Abrasion units, but more versatile. Pits with stain, decay in enamel and early dentin decay (DD 5-30) can be treated, almost always without local anaesthetic. Soft tissue can be trimmed as well. There is less chance of injuring soft tissue with overspray. There is no powder spray mess, so auxilliary suction is not needed. Like Air Abrasion, you cannot remove amalgams or easily treat larger lesions. These units cost 20-50X more than air abrasion units, and are much larger.

57. Application In Practice- Take-home message: Identify your high, medium and low risk patients.Identify your high, medium and low risk patients. Treat them differently based on their risk levels.Treat them differently based on their risk levels. Aim to convert all your patients to low risk, or at least reduce their caries index.Aim to convert all your patients to low risk, or at least reduce their caries index. Do not over-treat your low-risk patients. They need their own preventive and restorative protocols.Do not over-treat your low-risk patients. They need their own preventive and restorative protocols. Do not under-treat your high risk patients. They need every preventive and early intervention restorative measure you can give them, especially if they cannot convert to lower risk.Do not under-treat your high risk patients. They need every preventive and early intervention restorative measure you can give them, especially if they cannot convert to lower risk.

58. Summary Flow Chart- This flow chart is available from my web page atThis flow chart is available from my web page at www.elmtreedental.com www.elmtreedental.com

59. Summary A system of numerically rating a patient’s caries risk has been presentedA system of numerically rating a patient’s caries risk has been presented Protocols for minimal invasive and preventive treatment for low risk patients and maximal preventive and early restorative treatment for high risk patients have been demonstrated, to allow custom treatment for each p atient.Protocols for minimal invasive and preventive treatment for low risk patients and maximal preventive and early restorative treatment for high risk patients have been demonstrated, to allow custom treatment for each p atient.

60. Thank you Dr. Richard Ehrlich www.elmtreedental.comdre@elmtreedental.com905-880-7003