CARIES RISK MANAGEMENT

pits & fissures of enamel

most susceptible sites for caries formation

smooth enamel surfaces

shelter cariogenic biofilm

clinical sites for caries initiation

pits & fissures of enamel

smooth enamel surfaces

root surfaces

gram + cocci — S. sanguis

bacteria inhabited the pits & fissures of newly erupted teeth

mutans streptococci

bacteria inhabited on carious pits & fissures

smooth surface caries

cariogenic biofilm usually develops only near the gingiva or are under proximal contacts

the path of ingress of the lesion is roughly parallel to the long axis of the enamel rods in the region

lesions starting on smooth enamel surfaces have a broad area of origin and a conical, or pointed, extension toward the DEJ

root surface caries

U-shaped cross section

less well-defined margins than coronal caries lesions

rougher than enamel, facilitating cariogenic biofilm formation

progress more rapidly than coronal caries lesions due to lack of enamel protection

thin cementum covering root surface provides little resistance to caries lesion activity

root caries

is a common issue among older adults, especially those over 60

increasingly prevalent among older adults, largely due to medication-induced dry mouth

between 6.2 - 6.7

root dentin demineralizes at a pH of ___ making it more susceptible to caries than enamel

—it progresses faster than coronal caries

risk factors of root caries

missing teeth

existing caries

cariogenic diets

low salivary flow

poor oral hygiene

gingival recession

multiple restorations

xerogenic medications

preventive measures for root caries

reducing refined carbohydrate intake

improving salivary flow and buffering capacity

modulating the cariogenic biofilm in the oral cavity

re-mineralizing initial lesions and preventing new ones

resin — modified GI materials

recommended for restoring active root caries lesions as they bond to enamel and dentin and release fluoride, which can be reloaded by the patient

18 months (± 6 months)

progression of a a non-cavitated caries lesion to a cavitated caries lesion on smooth surfaces

3 weeks

progression of poor oral hygiene and frequent exposures to sucrose-containing or acidic food

can produce non-cavitated initial (“white spot”) lesions (first clinical evidence of demineralization)

3 months from the onset of the radiation

progression from radiation-induced hyposalivation (dry mouth) can lead to development of caries lesions

zones of enamel

zone 1 — translucent zone

zone 2 — dark zone

zone 3 — body of lesion

zone 4 — surface zone

abnormal but not weakened

enamel structure of hypocalcified enamel

porous, weakened

enamel structure of non-cavitated caries

cavitated, very weak

enamel structure of active caries

remineralized, strong

enamel structure of inactive caries

zone 1

fatty degeneration

zone 2

dentinal sclerotic zone

zone 3

decalcification zone

zone 4

bacterial invasion

zone 5

decomposed dentin

affected

partially demineralized

firmer than infected dentin

has a leather-like consistency

darker in color than infected dentin

physiologically remineralizable

infected

highly demineralized

is softer than affected dentin

has a cottage cheese-like consistency

not physiologically remineralizable

hardness

can be a reliable way to differentiate between the affected & infected dentin

acid red in propylene glycol

a caries detection dye

can stain infected dentin but not affected dentin

risk assessment

identifies modifiable factors to prevent disease expression

risk factor

defined as an environmental, behavioral, or biologic factor

directly increases the probability that a disease will occur

the absence or removal of which reduces the possibility of disease

risk indicators

may refer to existing signs of the disease proces

signs that the disease process has occurred, but are not part of the disease causal chain

CAMBRA

caries management by risk assessment

represents a management philosophy that manages the caries disease process using a medical model

caries risk assessment process

utilizes predictive modeling to predict caries progression

gathers data from patient interviews and clinical examinations

identifies risk factors and indicator

determines appropriate treatment (nonsurgical vs surgical)

influences restorative decisions like materials and cavity design

sets baseline for future treatment effectiveness reassessment

lesions

may not require intervention if they are inactive or arrested due to positive changes in protective factors or oral hygiene

active lesions

indicate progression and need immediate attention

fluoride exposure

crucial for caries prevention by increasing tooth resistance to demineralization

effective via community water fluoridation, toothpaste, mouth rinses, and professional applications

0.7 mg/L

optimal water fluoride level

MOA of fluoride

remineralizes initial caries lesions

enhances formation of fluorapatite, making enamel more acid-resistant

antimicrobial activity: inhibits bacterial enzymes, reducing biofilm formation

contributes to remineralization and prevention of further caries development

2 methods of fluoride delivery

systemic fluoride

topical fluoride

systemic fluoride

best for children through water fluoridation & dietary supplements

examples of topical fluoride

gels

rinses

varnishes

high-concentration toothpaste

3 fluoride delivery systems

fluoride rinses

fluoride varnishes

fluoride toothpaste

fluoride varnishes

effective for high-risk patients; recommended every 3 months for high-risk and every 6 months for moderate-risk patients.

advantages: high fluoride concentration, ease of application, & safety

fluoride rinses

reduces caries risk, especially in high-risk patients

2 types of fluoride rinses

high-dose / low-frequency — weekly in schools

low-dose / high-frequency — daily at home

1450 ppm

otc fluoride

recommended 3x a day

5000 ppm

prescription fluoride for moderate / high-risk patients aged 6+

fluorosis — >10 ppm

excessive fluoride can cause enamel discoloration (mottled enamel)

silver diamine fluoride

used off-label for caries arrest

approved by the FDA for hypersensitivity

a topical solution used for caries arrest & tooth hypersensitivity

MOA of silver diamine fluoride

antibacterial action

slows demineralization

enhances remineralization

advantages of silver diamine fluoride

conservation of tooth structure — can arrest large cavitated lesions

ease of use — simple application, no need for extensive dental equipment

accessibility — provides treatment for patients without access to traditional restorative care

application process of silver diamine fluoride

biofilm removal

application of SDF with a microbrush for 3 minutes

area rinsed or covered with fluoride varnish

disadvantages of silver diamine fluoride

staining — carious dentin turns black due to silver precipitation

limited longevity — up to 50% of lesions reactivated within 24 months, necessitating additional treatment

indications of silver diamine fluoride

may require restoration of arrested lesions for function and aesthetic purposes

effective as a low-cost alternative for preserving dentition in underserved populations

immunization (anti-caries vaccine)

various prototypes tested in animals, but no proven safety or efficacy in humans yet

potential adverse effects, including concerns about cross-reactions with human heart tissue

may be considered in scenarios where public water fluoridation is impractical, especially in developing countries

saliva

forms a protective pellicle

buffers acid through bicarbonate and phosphate

dilutes and washes away acids produced in biofilm

assists in remineralization with calcium and phosphate

normal aging does not reduce salivary flow, but many medications can cause hyposalivation

chemical agents

modulate biofilm

reduces MS levels, but doesn't alter caries outcomes

bacterial testing is crucial before procedures

saliva samples tested for specific MS and lactobacilli levels

commercial devices can evaluate ATP levels in biofilm

calcium & phosphate compounds in remineralization

amorphous calcium-phosphate — ACP

casein phosphopeptide — CPP

amorphous calcium-phosphate — ACP

acts as a reservoir of calcium & phosphate ions in saliva

releases calcium and phosphate ions upon contact with saliva

forms apatite, aiding in the remineralization of enamel and dentinal tubules

casein phosphopeptide — CPP

a milk-derived protein that stabilizes ACP by binding to biofilm

maintains a supersaturation state of ACP at the tooth surface, enhancing remineralization

sealants

more effective for preventing pit-and-fissure caries

effective for preventing and arresting initial caries lesions

low-viscosity resin sealants / resin infiltrants

used for smooth surface white-spot lesions, helping to prevent further demineralization

shown to be more effective at preventing lesion progression compared to traditional oral hygiene methods

most effective for smooth-surface caries

fluoride

preventive effects of sealants

ease of cleaning

mechanical filling

isolation from oral environment

caries around restorations (CARS)

radiolucency of this may be masked by metallic restorations

discoloration adjacent to restorations may indicate potentials

detection of secondary caries around restorations can be challenging

2 extent of caries removal

moderate lesions

advanced lesions

moderate lesions

remove caries to a caries-free DEJ and firm dentin

advanced lesions

use selective caries removal (SCR) to avoid pulp exposure, removing caries to a caries-free DEJ and soft dentin near the pulp

selective caries removal (SCR) protocol

effective for teeth with healthy pulpal and periapical areas

utilizes temporary or definitive materials like glass ionomer

emphasizes caries removal peripherally to sound DEJ and leaves soft dentin near the pulp

considerations for selective caries removal

not all dentin compromised by caries needs removal if a good seal can arrest the lesion

staining solutions for detecting caries are less favored due to their non-specific staining of demineralized dentin, leading to larger preparations

caries-control restoration

aims to prevent pulpal disease and manage high caries risk effectively

involves rapid intervention for multiple acute lesions using medication (e.g., SDF) or temporary restorations