Cariology Lecture 9

What is the health care goal?

To provide relevant information to enable independent patient decisions that are considered appropriate by both the physician and patient and that are jointly implemented in a spirit of mutual responsibility

What has the doctor-pt relationship been historically?

Doctor knows best

Paternalistic

Ignored the pt perspective and caused communication problems

Pt has problems with acceptance if there is unsatisfaction or consequences

Shared decision making

The doctor and pt choose a therapy as partners based on the individual’s need

Particularly useful when several options can be discussed

Advantages of shared decision making

Greater pt satisfaction

Enhanced quality of life

Improved understanding of the disease

Control of the situation

Enhanced pt compliance

Reduction of fear

Steps in shared decision making

Agreement that a decision needs to be made

Offer of shared decision making

Presentation of treatment options

Risk/benefit analysis of the individual options

Patient response, expectations

Which options are preferred

Reasoning and decision making phase

A joint decision is reached

Individual commitment to implement the decision

Informed consent

A process and discussion that educated the pt about the treatment plan the provider is recommending based on their individual oral health status

What should the informed consent discussion include?

Any dental health problems that the dentist observed

The nature of any proposed treatment

The potential benefits and risks associated with that treatment

Any alternatives to the proposed treatment

The potential risks and benefits of alternative treatments, including not treating the condition

What is the correct time for invasive therapy?

Varies widely around the world

Non invasive methods are low cost in comparison to restorative that are more costly for the individual and the public

The time of the first minimally invasive intervention significantly influences the life expectancy of the tooth as well as the pts quality of life

Who’s approach was “extension for prevention”?

G.V. Black

“Drill and fill” approach

Classic invasive caries therapy based on extension for prevention

Results in substantial amount of sound tooth structure removal in initial treatment

All infected dentin should be completely removed so that the restoration could be placed on hard, presumably bacteria-free dentin

“Heal and seal” approach

The caries process can be arrested if the factors that promote caries are reduced

If accessibility and compliance are factors, enamel caries can be arrested by non-invasive measures

Adhesive filling materials can be used with less destruction of enamel and dentin

Limits to noninvasive therapies in the clinic

Tooth surface needs to be accessible to cleaning

Surface quality and the extent of the caries is important to evaluate

The frequency at which cariogenic biofilm regenerated should be considered

Pt understands which oral hygiene methods are appropriate to prevent further damage to the tooth

Limits to noninvasive therapies: age

Caries progression and development rate of new lesions is higher in adolescents than in young adults

Starting at age 20, proximal lesions increase in frequency in relation to occlusal lesions

Limits to noninvasive therapies: tooth type

The progression from radiologic enamel lesion (E2) to radiologic dentil lesion (D1) occurred much more frequently on the distal surface of the lower first molars than distal surface of lower first premolars

Limits to micro invasive therapies

Sealants represent a bridge between non and minimally invasive interventions and only a slight amount of dental hard tissues needs to be sacrificed during acid etching

The actual extent of caries tends to be underestimated, even on radiographs

Residual microorganisms may remain and continue to damage the dentin, especially if the seal is poor

Limits to invasive therapy

Adhesive restoration can be functional, esthetic and conservative

The survival rate of direst restorations is only about 10 years

An average 15 year old with a life expectancy of 80 will need the filling replaced 6 times

Do deciduous teeth have thicker or thinner enamel and dentin than permanent?

Thinner

Do deciduous teeth have a faster or slower caries progression than permanent teeth? Why?

Faster

Lower mineral density and more voluminous dentinal tubules

Are occlusal and approximal pulp processes reached and affected my caries faster in deciduous or permanent teeth?

Deciduous

When are resin based sealants recommended?

As the permanent 1st molars erupt around age 6 and 2nd molars around age 12 because the anatomy is harder to clean

When are fluoride varnish treatments recommended in pediatrics?

6-12 month recall appts

What is SMART?

Silver modified atraumatic restorative treatments

Who is SDF appropriate for?

Pts with high risk sites

All cavity-active pts

Primary prevention with SDF 38%

Used for primary prevention of high risk sites

Without discoloration, silver penetrated into and remains on the surface of healthy dentin and enamel, providing antimicrobial biofilm resistance

Particularly valuable in furcations, food traps, root surfaces, and newly erupted occlusal surfaces that are difficult to dry and isolate for sealants

How can you improve esthetics with SDF use?

Cover it with a glass ionomer and composite

No need for drills or adhesives