2 - Caries detection and risk diagnosis

To be able to describe how the detection of caries and classification of a patient’s caries risk status can aid in diagnosing dental caries.

title

how caries detection/risk assessment leads to our diagnosis

references

what sources of acids might cause dental caries?

fermentable carbohydrates, carbonated soft drinks - phosphoric acids, fruit juice, gastric reflux

carbonated soft drinks include phosphoric acid - what do dental professionals use phosphoric acids for?

37% phosphoric acid is used to ‘etch’ enamel to create a rough surface for bonding

diet + plaque =

plaque acids

plaque may have

varying thickness as the content of the plaque changes

cariogenic bacteria include

strep. mutans, strep. sobrinus, lactobacillus

bacterial plaque + refined carbohydrates =

demineralisation

plaque can be retained in 4

1. tooth contact areas

2. restoration overhangs

3. over-contoured pits and fissures

4. sticky foods

remineralisation depends on…

saliva + hygiene + fluoride + natural protective factors = remineralisation

saliva buffering, saliva flow, presence of fluoride and carbohydrate intake will influence plaque

mechanism for caries development

hydroxyapatite is reactive to H+ ions at or below the critical pH for any HA

H+ ions react preferentially with the phosphate group in an aqueous environment

this also results in buffering the H+ ions - this results in demineralisation

salivary protective factors

saliva plays a major role in protecting teeth against acid challenge as well as protecting the soft oral and alimentary tract tissues against dehydration and potential pathological irritants

salivary protective factors include 6

1. calcium and phosphate ions

2. pellicle

3. buffer and carbohydrates

4. salivary flow

5. oral clearance rate

6. fluoride ion content

remineralisation

• if there are sufficient Ca²⁺ ions and PO4^3- and pH is neutralised , the demineralisation process can be reversed

• this reaction can be enhanced by the presence of F- ions at the reaction site

what are we going to use to detect caries or any other pathology in a patient’s mouth?

our eyes! see things bigger and brighter

spot the caries

• lower right and left second molars

• are they the same colour? - the lower right has a fissure sealant

• black one indicates staining and possible caries

compare the distal aspect of the upper 5s and the mesial aspects of the upper 6s - what can you see?

in the black - areas within the lesion there are still areas of remineralisation

patient chipped tooth - cannot brush correctly - caries process

International caries detection and assessment system

ICDAS

modified ICDAS scoring system

often caries develops quite deep before any cavitation

use the sharp explorer

bitewing radiographs in caries detection

electrons need to hit the detector at 90 degrees so we get no crossover of the contact areas

distal of premolar

radiolucency

it is absolutely crucial to let the patient speak

the more we understand our patient - the better our chances of meeting their expectations

and them why’ve they come, and what they’d like us to do

questions to ask about their dental history

we have found caries - but what’s it’s activity?

is this arrested caries or is there an active lesion? is there cavitation? is it deep into dentine?

knowing the answer will help determine how much the patient is at risk of caries at the time you detect it

what information from our patient do we need to determine the caries risk? 11

lots!

1. what colour is the lesion

2. is the pt’s oral hygiene good or is there lots of plaque present

3. what’s the patient doing - if anything , to keep their teeth clean?

4. do they use fluoride toothpaste?

5. do they use fluoride mouth wash?

6. do they use floss/interdental brushes?

7. do you think the patient has a normal amount of saliva or do they have a dry mouth

8. are there any medically relevant factors?

9. what is the patient’s view of their own teeth?

10. how is their lifestyle/commitments?

11. how is their diet?

caries risk status

• are they low risk, high risk or medium risk?

• this is AN IMPORTANT STEP THAT MUSTN’T BE SKIPPED

• this will allow a diagnosis and allows us to create a care plan

do not separate your caries detection from your plaque detection

• both should be considered together

• no biofilm , no fermentable carbohydrates, no tooth = no caries

• first and foremost you must control the biofilm