Dental Caries Management by Risk Assessment (CAMBRA)

Dental Caries Process:

biofilm-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues

The term “dental caries”can be used to describe both

the disease process and the lesion (noncavitated or cavitated) that is formed as a result of the disease process.

True or False: Dental caries is the most common noncommunicable disease worldwide. The WHO Global Oral Health Status Report (2022) estimated that oral diseases affect close to 3.5 billion people worldwide.

True

Demineralization Process:

1. Dental caries is ignited by mutans streptococci and lactobacilli that live in the plaque biofilm that attach to teeth.

2. These bacteria metabolize dietary fermentable carbohydrates (sugars and cooked starch) to produce acids.

3. These acids cause a substantial change in the plaque biofilm pH, creating an acidic environment.

   1. The acids diffuse into the tooth to dissolve the calcium and phosphate minerals (carbonated hydroxyapatite).

Common sources of acid exposure:

• Acidic Foods and Drinks: Consuming acidic foods and beverages, such as citrus fruits, sodas, fruit juices, and certain types of vinegar, can expose teeth to acid.

• Stomach Acid: Individuals with conditions like acid reflux or gastroesophageal reflux disease (GERD) may experience stomach acid entering the mouth, leading to acid exposure on the teeth.

Bacterial Acid Production

bacteria in the mouth produce acids as byproducts when they feed on sugars

Remineralization Process:

1. After the ingestion of fermentable carbohydrates stops, the pH gradually returns to neutral in 30 to 60 minutes provided there is adequate saliva.

2. Remineralization is the process of rebuilding the mineral content of tooth enamel, primarily through the actions of saliva and the presence of fluoride.

What pH is most vulnerable for demineralization on root surfaces?

6.2-6.4

What pH is most vulnerable for demineralization on enamel?

5.5

Common Symptoms of Dental Caries:

• Persistent or intermitten pain/sensitivity

• Visible cavitation

• Staining (white, brown, black)

• Halitosis (bad breath)

• ⚠Not all individuals with dental caries experience noticeable symptoms, especially in the early stages of demineralization

The Caries Balance:

the goal of caries management is to restore and maintain a balance, known as the caries balance, between protective factors and pathologic factors to remineralize early carious lesions and/or prevent future caries

Pathological Factors:

• acid-producing bacteria

• frequent eating/drinking of fermentable carbohydrates

• subnormal salivary flow and function

Protective Factors:

• saliva flow and components

• fluoride; remineralization

• antibacterials; chlorhexidine, xylitol

Saliva’s Beneficial Actions:

• Provides calcium and phosphate for remineralization

• Carries topical fluoride around the mouth for remineralization

• Neutralizes organic acids produced in plaque biofilm

• Discourages the growth of bacteria

• Recycles ingested fluoride into the mouth

• Facilitates chewing and swallowing

• Speeds oral clearance of food

Fluoride Mechanisms of Action:

• Inhibits demineralization: reducing the solubility of the tooth mineral

• Enhances remineralization: adsorbing to mineral crystals within the tooth and attracting calcium ions.

• Inhibits bacterial growth: Fluoride present in plaque biofilm is taken up by bacteria and interferes with acid production

Stages of Dental Caries: White Spot lesion

• is a demineralized area of enamel that usually has an intact surface remaining over the body of the demineralized early carious lesion

• The white spot lesion is a signal to intervene to avoid the development of an obvious carious lesion.

Class I:

Caries affecting pits and fissures on occlusal third of molars and premolars, occlusal two thirds of molars and premolars and lingual part of anterior teeth

Class II:

caries affecting proximal surfaces of molars and premolars

Class III:

Caries affecting proximal surfaces of central/lateral incisors, and cuspids without involving the incisal angles

Class IV:

Caries affecting proximal including incisal angles of anterior teeth

Class V:

Caries affecting gingival one-third of facial or lingual surfaces of anterior or posterior teeth

Class VI:

Caries affecting cusp tips of molars, premolars. and cuspids

Caries Risk Assessment:

Identify individualized risk factors, guide preventive strategies, and tailor treatment plans to effectively manage and prevent dental caries

A disease indicator is

a measurable and observable sign or symptom that suggests the presence of a disease

A disease risk factor is

a characteristic or exposure that increases the likelihood of developing a disease but may not necessarily indicate its current presence.

Caries Disease Indicators:

1. Teeth with obvious cavitations or lesions that radiographically show penetration into dentin

2. Approximal radiographic lesions confined to the enamel only

3. Visual white spots on smooth surfaces

4. Any restorations placed in the last 3 years (history of past caries)

⚠Presence of any one of these four indicators automatically places the client at high caries risk

⚠The presence of any one of these caries disease indicators in the presence of inadequate salivary flow automatically indicates extreme caries risk

Caries Risk Factors:

1. Medium or high mutans streptococci and lactobacilli counts

2. Visible heavy plaque biofilm on teeth

3. Frequent (more than three times daily) snacking between meals

4. Deep pits and fissures

5. Recreational drug use

6. Inadequate salivary flow by observation or measurement

7. Saliva-reducing factors (medication, radiation, systemic condition)

8. Exposed roots

9. Orthodontic appliances

Guiding Principles for Caries Management:

• Placing restorations does not reduce the bacterial challenge.

• Fluoride use and concentration should be increased for remineralization.

• Bacterial challenge can be reduced through antibacterial therapy.

• Pathologic factors should be balanced with protective factors.