Risk Assessment and Oral Diagnostics in Clinical Dentistry

Dena J. Fischer, Nathaniel S. Treister, Andres Pinto

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118483275
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

Many diseases can have an impact upon oral health and/or the safe delivery of dental care. Consequently, oral health care providers need to be comfortable with assessing the risk of providing dental care to their patients with systemic disease as well as the evaluation of oral conditions that may represent manifestations or consequences of systemic disease. Risk Assessment and Oral Diagnostics in Clinical Dentistry aims to enable the dental practitioner to comfortably and capably assess when medical conditions may impact dental care and diagnose oral conditions using routine testing modalities.

This clinical guide contains succinct and detailed text with visual aids regarding how to obtain and perform diagnostic tests, how to interpret these tests, and the implications of tests results upon the management of medically complex dental patients and patients with oral conditions. Color photographs show conditions, testing equipment, and test results. An appendix highlights the ten most common oral medicine disorders encountered in dental practice.

Part B

Guidelines for Diagnosis of Orofacial Conditions

6 Dental Caries and Periodontal Conditions

6.0 INTRODUCTIONM

Chronic infectious diseases of the oral cavity include dental caries and periodontal diseases. Dental caries causes destruction of the teeth, while periodontal disease is a group of inflammatory conditions that affect the supporting structures of the dentition. The role of the microbial challenge in the initiation and progression of these oral diseases is well established, ultimately leading to the destruction of teeth and/or periodontal structures. This chapter will discuss factors contributing to the diagnosis of dental caries and periodontal diseases.

6.1 Dental caries

Dental caries is a chronic, microbial disease caused by shifts from protective factors favoring tooth remineralization, such as good oral hygiene and fluoride exposure, to destructive factors leading to demineralization, such as plaque formation, frequent ingestion of foods with high carbohydrate contents, and salivary hypofunction. Carious lesions are in a dynamic state of demineralization and remineralization, with fluoride playing an important role in enhancing the remineralization process. Caries results from complex interactions among the tooth structure, the dental biofilm, and dietary, salivary, and genetic influences. Streptococcus mutans has been implicated in the etiology of dental caries to cause disease when extracellular polymer formation promotes bacterial attachment and the pH decreases to create a caries-promoting environment. Although S. mutans is one of the most researched cariogenic microorganisms, it is only one of more than 500 species found in dental plaque, supporting the hypothesis that S. mutans is one of many endogenous microorganisms involved in the complex biofilm that leads to caries activity.

The overall prevalence of dental caries has been declining in the past 40 years, primarily because of increased use of fluoride and more emphasis on oral hygiene, as well as disease prevention and control. Nevertheless, dental caries continues to be a major public health problem, particularly among certain segments of the U.S. population. People of lower socioeconomic status, in particular those who are minorities, homeless, migrants, and children with disabilities, have the highest prevalence and severity of dental caries.

Table 6.1 Factors contributing to caries risk assessment.^*

Caries disease indicators
Clinical	Cavitations into dentin on clinical or radiographic examination
	White spots on smooth enamel surfaces
	Restorations placed in the last 3 years due to caries activity
Radiographic	Radiographic enamel interproximal lesions
Caries Risk Factors
Clinical	Deep pits and fissures
	Root exposure
	Orthodontic appliances
Behavioral	Visible heavy plaque on teeth
	Frequent (>3× daily) snacking between meals
	Diet high in fermentable carbohydrates
	Recreational drug use
Salivary^†	Salivary hypofunction (< 1 mg/mL unstimulated)
	Saliva-reducing factors (medications/radiation/systemic)
Microbiological	Medium or high Mutans streptococci and Lactobacillus species bacteria counts by culture
Caries Protective Factors
Sealants	Sealants present on permanent molar teeth
Fluoride	Lives/works/school in a fluoridated community
	Fluoride toothpaste at least once daily
Topical supplements	Fluoride mouth rinse (0.05% NaF) daily
	5,000 ppm F fluoride toothpaste daily
	Fluoride varnish in last 6–12 months^‡
	Office fluoride topical in last 6–12 months^‡
	Calcium and phosphate supplement paste daily during the last 6–12 months^‡
Antimicrobial agents	Chlorhexidine prescribed/used daily for 1 week in the last 6–12 months^‡
	Xylitol gum/lozenges 4 times daily in the last 6–12 months^‡
Salivary	Adequate saliva flow (≥ 1 mL/min unstimulated)

*Modified from Dental Clinics of North America, 54(3), Young DA and Featherstone JDB, Implementing caries risk assessment and clinical interventions, pgs. 495–505, 2010 with permission from Elsevier.
^†See chapter 8.
^‡Based on routine annual or semi-annual dental visits.

6.1.1 Caries risk assessment

Caries risk assessment (CRA) determines an individual’s probability of developing new ­carious lesions during a specific period of time and the probability of a change in the size or activity of existing lesions over time. This assessment is useful in evaluating the effectiveness of attempts to control caries (e.g., sealants), whether additional diagnostic (e.g., salivary flow rate, diet analysis) and/or caries-control measures (e.g., plaque control, diet control, increased fluoride exposure, antimicrobial agents) are warranted, suitability of treatment plans, and frequency of dental recall appointments.

By assessing patient information, a clinician may be able to predict the risk of future demineralization by weighing all the disease indicators and risk factors against existing protective factors (Table 6.1). Caries disease indicators are clinical observations that indicate current caries disease or a history of caries disease. A positive disease indicator automatically places the patient at caries risk. Caries risk factors are biologic and behavioral factors thatcontribute to the level of risk for the patient of having new caries lesions in the future or having existing lesions progress. Caries protective factors are biologic and therapeutic factors that may collectively offset the pathologic challenge presented by caries risk factors. With more extensive and severe caries risk factors, the intensity of protective factors must be increased at an appropriate level to minimize the caries process. While there are numerous CRAs available in the literature that similarly measure etiologic and protective factors involved in the disease process, taken together they indicate that past caries experience is the strongest predictor of future caries disease. Examples of CRA tools have been developed and are available through the American Dental Association and American Academy of Pediatric Dentistry.

6.1.1.1 Caries risk groups

Implementation of a CRA in clinical practice can be accomplished in a single visit by assessing the CRA components and categorizing a patient as “low,” “moderate,” or “high” caries risk based upon the prediction of new caries development in the next 1–2 years. Low-risk patients have no active caries, have been caries-free for at least 5 years and have negligible risk factors indicating a very low risk of future dental caries disease. Patients at high risk for caries have active caries status (development of at least one new carious lesion or progression of an existing lesion in the previous 1–2 years), exhibit high-risk behaviors such as frequent ingestion of foods with high carbohydrate contents and poor oral hygiene, and may have additional risk factors such as low to no fluoride exposure and/or salivary hypofunction. Moderate-risk patients have a moderate likelihood of new caries development due to a recent history of caries activity and the presence of risk behaviors and additional risk factors.

Caries management by risk assessment (CAMBRA) is a clinically based approach to preventing, reversing, and, when necessary, repairing early damage to teeth. Clinical intervention protocols vary based upon the caries risk and should be individualized based upon a patient’s risk factors and behaviors. Interventions may involve the frequency of bitewing radiographs, frequency of caries recall examinations, choice of restorative materials, and use of salivary tests (flow rate and bacterial culture), antimicrobials (xylitol, a naturally occurring sugar alcohol that maintains the oral pH at 7.0 and inhibits S. mutans attachment in the oral environment), fluoride, pH control agents (acid-­neutralizing rinses, baking soda gum), calcium phosphate topical supplements, and dental ­sealants.

6.1.1.2 Plaque biofilms

The plaque biofilm is one contributor to the complex caries process, and only biofilm-­covered tooth surfaces have the potential to develop carious lesions. Within moments of erupting or being cleaned, tooth surfaces become coated with a protective barrier of molecules (proteins and glycoproteins) derived mainly from saliva, termed the acquired pellicle. Bacterial colonizers bind to the acquired pellicle via adhesins and multiply, and as the plaque biofilm develops, the attached bacteria produce extracellular polymers (the plaque matrix) that further consolidate attachment of the biofilm. The microbial composition of the biofilm varies at distinct sites on a tooth and reflects the inherent differences in the anatomy of the tooth and biology of the biofilm. Once established, the composition of the microflora remains stable over time unless there are marked changes to the oral environment. Importantly, the dental plaque bacteria interact and display increased tolerance to both host defenses as well as antimicrobial agents.

6.1.1.3 Diet

Dental caries has a strong association with the frequency of fermentable carbohydrate intake. Sticky complex carbohydrates that can remain in the grooves of teeth and simple sugars, particularly sucrose, are very cariogenic. These fermentable carbohydrates are freely diffusible in dental plaque and readily metabolized by oral bacteria, leading to the production of organic acids (e.g., lactic acid) in sufficient concentration to lower the pH of dental plaque enough to allow enamel demineralization to occur. Further, sucros...

Table of contents

• Cover
• Title page
• Copyright page
• Authors
• Preface
• Acknowledgements
• Part A: Guidelines for Risk Assessment of Systemic Conditions that may Complicate or be Complicated by Dental Treatment
• Part B: Guidelines for Diagnosis of Orofacial Conditions
• Appendix
• Index