Study Guide

1. Caries Risk Assessment (CRA) & Management

Based on Cariology, Risk Assessment, and Chemical Agents slides

  

CRA Purpose

•  Identifies patients at risk for caries, perio, oral cancer, nutrition issues, sleep apnea.

    •    Determines risk-based interventions rather than generic product recommendations.

Modifiable Risk Factors

High sugar/fermentable carb intake

    •    Poor OH → biofilm accumulation

    •    Xerostomia

    •    Orthodontics

    •    Frequent snacking

    •    Inadequate fluoride exposure

Non-modifiable Risk Factors

   

    Age

    •    Sex

    •    Race

    •    Genetics

    •    Previous disease history

Therapeutic Management Strategies

Patient-Level Interventions

Patient-Level Interventions

    •    Diet counseling (reduce simple carbs)

    •    Fluoridated toothpaste

    •    Daily interdental cleaning

    •    Improve saliva flow (water, sugar-free gum, xylitol)

Therapeutic Management Strategies

Lesion-Level Interventions

Lesion-Level Interventions

• Non-restorative / minimally invasive treatments

    •    Fluoride varnish, SDF, Rx fluoride toothpaste

    •    Remineralization strategies

2. Interventions + Mechanism of Action / Rationale

Silver Diamine Fluoride (SDF)

  Mechanism:

    •    Silver = antimicrobial

    •    Fluoride = arrests demineralization, promotes remineralization

  Indications:

• High-risk patients, uncooperative children, medically compromised, root caries

    •    Frequency: 2×/year

    •    Effectiveness:

    •    Arrests 65–91% of caries

    •    Prevents ~78% new lesions

    Side effects:

• Permanent black staining of arrested lesions

 Xylitol

From Dentifrices slides

Mechanism:

    •    Non-fermentable sweetener → reduces S. mutans levels

    •    Stimulates salivary flow

    •    Rationale: rebalances biofilm, protects against caries

    •    Dosage: 6–10 g/day divided doses

    •    Side effects: GI upset if overconsumed

Sodium Fluoride (NaF)

 Mechanism: remineralization via Ca-F formation

    •    Dosage:

    •    Toothpaste: 1000–1500 ppm

    •    Rinses: 0.05% daily

    •    Frequency: 2×/day brushing

    •    Use: anti-caries

    •    Duration of action: depends on retention—bioavailable for hours in plaque/saliva.

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Stannous Fluoride (SnF₂)

Mechanisms:

    1.    Anti-caries: remineralization

    2.    Anti-gingivitis/biofilm: bactericidal; inhibits metabolic enzymes

    3.    Anti-sensitivity: occludes dentinal tubules

    •    Side Effects: possible minor brown staining (modern formulas reduce this)

Acidulated Phosphate Fluoride (APF)

Acidulated Phosphate Fluoride (APF)

    •    Mechanism: fluoride uptake enhanced by acidic pH

    •    Notes: Avoid with porcelain/composites due to etching

    •    Use: high potency clinical fluoride

3. Dentifrices (Toothpaste)

Active Ingredients + Uses

From Dentifrices Slide table

Category    Active Ingredients    Purpose / MOA

Anti-caries    NaF, SnF₂, SMFP    Remineralization

Supplemental    Xylitol, ACP, TCP, CSP    Rebuild enamel, enhance Ca/P delivery

Anti-gingivitis / anti-plaque    Stannous fluoride, Triclosan*    Antibacterial; reduces inflammation

Desensitizing    Potassium nitrate, SnF₂, oxalate salts    Tubule occlusion or nerve depolarization

Anti-calculus    Pyrophosphates, zincs    Inhibit crystal growth

Whitening    Peroxides, abrasives (silica)    Oxidation / stain removal

*Triclosan phased out due to endocrine-disrupting concerns.

Dosage & Frequency

    • 

Adults: pea-size amount, 2 min, 2×/day

    •    Ages 2–6: pea-size, supervised

    •    Under 2: smear (rice-size) if needed

4. Mouth Rinses

Therapeutic Rinses

From Chemical Agents slides

Chlorhexidine Gluconate (0.12%) — Rx

Chlorhexidine Gluconate (0.12%) — Rx

    •    Use: anti-gingivitis / anti-bleeding

    •    Mechanism: disrupts bacterial membranes

    •    Substantivity: ~30% remains active

    •    Dosage: 60 mL, 30 sec, 2×/day for 6 months

    •    Side effects: significant staining, altered taste

    •    Note: Toothpaste inactivates it → separate by 30 minutes

Cetylpyridinium Chloride (CPC)

• Mouth Rinses: From Chemical Agents slides

Cetylpyridinium Chloride (CPC)

  Use: OTC biofilm disruption

    •    Mechanism: punctures bacterial membranes

    •    Side effects: mild staining possible

Essential Oils (EO – Listerine)

Mouth Rinses-From Chemical Agents slides

Essential Oils (EO – Listerine)

    •    Ingredients: eucalyptol, menthol, thymol, methyl salicylate

    •    Use: anti-plaque/gingivitis

    •    Mechanism: disrupts cell walls

    •    Notes: alcohol/no-alcohol options

Fluoride Mouth Rinses

Mouth Rinses- From Chemical Agents slides

Daily low-potency NaF (0.05%)

    •    0.2% NaF office rinse

    •    APF 0.02%

Important Emerging Evidence

• From Chemical Agents slides

Important Emerging Evidence

Frequent antimicrobial mouthwash use may → oral dysbiosis

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5.  Antimicrobial & Remineralizing Agents Summary

ntimicrobial & Remineralizing Agents Summary

Agent    Antimicrobial?    Remineralization?

SDF    ✔ (silver)    ✔ high fluoride

NaF    ✖    ✔

SnF₂    ✔    ✔

Xylitol    ✔ reduces S. mutans    Indirect via salivary flow

CPC / EO / CHX    ✔ strong    ✖

ACP/TCP/CSP    ✖    ✔ enamel repair

6. Oral Physiotherapy Aids (Interdental Devices)

From Mechanical Devices II slides

General Rules

    •    Select based on embrasure type, dexterity, anatomy

    •    DO NOT give more than 2 new aids per appointment

    •    Reassess at recall

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Device Effectiveness & Indications

Dental floss

Dental Floss

    •    Use: healthy papilla, tight contacts (≤3 mm pocket)

    •    Effectiveness: reduces inflammation/BOP

    •    Limitations: minimal anti-caries effect without fluoride

Interdental Brushes

Interdental Brushes

    •    Most effective for gingivitis

    •    Best for:

    •    Exposed roots

    •    Open embrasures

    •    Ortho

    •    Implants

End-tufted Brushes

Uses:

    •    Last molar (terminal tooth)

    •    Distal of 2nd/3rd molars

    •    Diastemas

    •    Missing teeth spaces

    •    Orthodontic bands

Woodsticks

    • 

 

For larger embrasures, exposed roots

    •    Less effective than brushes but helpful for patients with limited dexterity

Oral Irrigator / Water Flosser

Oral Irrigator / Water Flosser

    •    Use: implants, ortho, deep pockets, bleeding pts

    •    Effectiveness: reduces BOP and inflammation when used daily

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Tongue Cleaners

Tongue Cleaners

    •    Reduce halitosis; remove coating

    •    Daily use recommended

7. Toothbrushing Methods (Manual & Powered)

From Mechanical Devices I

Bass Technique (Preferred)

 Bristles at 45° into sulcus

    •    Vibrate small strokes

    •    Best for biofilm removal

    •    Indicated for all patients, especially gingivitis

Modified Bass

Modified Bass

    •    Same as Bass → sweep away

    •    Good for general OH improvement

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Stillman

•   45° angle on gingiva → vibrate → sweep

    •    For gingival stimulation, recession

Charter’s

• Bristles angled toward occlusal/incisal

    •    Use for:

    •    Orthodontics

 Fixed prosthetics

    •    Post-surgical sites (after healing)

Fones Method

    •    Circular motion

    •    For children or limited dexterity adults

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Circular motion

    •    For children or limited dexterity adults

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8. Brushing Techniques for Special Conditions

Orthodontic Patients

    •    Charter’s technique

    •    Powered brush recommended

    •    Interdental brushes around brackets

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8. Brushing Techniques for Special Conditions

Orthodontic Patients

    •    Charter’s technique

    •    Powered brush recommended

    •    Interdental brushes around brackets

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Implants

    •    Soft brushes

    •    Interdental brushes with nylon-coated wire

    •    Water flosser helpful

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Pediatrics

    •    Fones method

    •    Assist brushing until age 8–9

    •    Child-size brush, fun colors

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Limited Dexterity

    •    Powered toothbrushes (oscillating-rotary best evidence)

    •    Wide-handled grips or foam modifications

    •    Floss holders, interdental brushes

Implants

    •    Soft brushes

    •    Interdental brushes with nylon-coated wire

    •    Water flosser helpful

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  Soft brushes

    •    Interdental brushes with nylon-coated wire

    •    Water flosser helpful

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Pediatrics

Pediatrics

    •    Fones method

    •    Assist brushing until age 8–9

    •    Child-size brush, fun colors

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Limited Dexterity

Limited Dexterity

    •    Powered toothbrushes (oscillating-rotary best evidence)

    •    Wide-handled grips or foam modifications

    •    Floss holders, interdental brushes

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9. Proper Flossing & Brushing Technique Summary

Flossing Steps

Brushing

    1.    Use 18 inches

    2.    Wrap around middle fingers

    3.    Slide gently between teeth

    4.    C-shape around each tooth

    5.    Clean under papilla

    6.    Use new clean section each contact

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Brushing

    •    2 minutes, 2×/day

    •    Soft bristles only

    •    Replace brush every 3–4 months