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Management - Caries/Demineralisation

Management overview


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Risk Assessments and Profiles
Patients who possess risk factors and risk indicators should be considered to be at risk for dental caries even if the examination does not reveal any caries lesions. A patient at high risk for dental caries should receive aggressive intervention to remove or alter as many risk factors as possible. Alternatively, regular monitoring and reassessment might be appropriate for a patient at low risk for dental caries:

  • General Health
  • Diet Analysis
  • Salivary Analysis
  • Dental Clinical Analysis (Dental Exam)
  • Bacterial Biofilm Analysis



Prevention:

The patient's general health has a significant impact on overall caries risk
Medically compromised patients should be examined for changes in the following: plaque index, salivary analysis, oral mucosa, gingiva, and teeth
Dietary sucrose has two important detrimental effects on how biofilm affects caries. First, frequent ingestion of foods containing sucrose provides a change in the biofilm profile from a noncariogenic biofilm to a cariogenic biofilm. Second, mature biofilm exposed frequently to sucrose rapidly metabolizes it into organic acids, resulting in a profound and prolonged decline in pH. Caries activity is most strongly stimulated by the frequency, rather than the quantity, of sucrose ingested.
For high-risk patients, a formal diet analysis should routinely be undertaken to identify cariogenic foods and beverages that are frequently ingested.

Biofilm-free tooth surfaces do not decay. Daily removal of biofilm by dental flossing and tooth brushing with fluoridated toothpaste is the best patient-based measure for preventing caries and periodontal disease.

The highest level of evidence for caries prevention and reduction supports the exposure of teeth to fluoride. Fluoride in trace amounts increases the resistance of tooth structure to demineralization and is particularly important for caries prevention.
Saliva, as noted earlier in this chapter, provides an effective first line of defense against dental caries. Saliva works by diluting acid produced in biofilm, washing the acid away (swallowing), buffering the produced acid (bicarbonate + phosphate), and assisting in remineralization (calcium + phosphate). Saliva also works by forming a pellicle. When normal salivary flow rates are compromised, patients are usually at high risk for developing caries.
Various antimicrobial agents are available. . Two differing strategies have been suggested for reducing bacterial counts. The traditional approach is the use of chlorhexidine (CHX) mouthwash, varnish, or both, along with prescription fluoride toothpaste.

Amorphous calcium-phosphate (ACP) products have become commercially available and reportedly have the potential to remineralize tooth structure.  ACP is a reactive and soluble calcium phosphate compound that releases calcium and phosphate ions to convert to apatite and remineralize the enamel when it comes in contact with saliva. Forming on the tooth enamel and within the dentinal tubules, ACP provides a reservoir of calcium and phosphate ions in the saliva.
The fundamental concept is to inoculate the oral cavity with bacteria that will compete with cariogenic bacteria and eventually replace them
Sealants have three important preventive effects. First, sealants mechanically fill pits and fissures with a resin-based polymer. Second, because the pits and fissures are physically closed off from the oral environment with the sealant resin, MS(specific mutans streptococci (MS) and other cariogenic organisms no longer have access to their preferred habitat. Third, sealants render the surface of the tooth, where the pits and fissures are located, easier to clean by toothbrushing and mastication


Restorations

Caries-Control Restoration

Initial treatment

Initial treatment
Caries risk assessment
Education and motivation
Thorough evaluation and documentation of lesions
Temporization of all large cavitated lesions by caries-control restorations
Specific nonrestorative, therapeutic treatment (seeTable 2.10)
Plaque control (seeTable 2.10, technique C)
Dietary control (seeTable 2.10, technique A)

Preliminary assessment

Preliminary assessment
Gingival response as a marker of plaque biofilm control effectiveness
Arrest of cavitated lesions with SDF as indicated
Pulpal response of teeth with selective caries-excavation and restoration
Assessment of patient compliance with medications, oral hygiene, and dietary control measures

Follow-up care

Careful clinical evaluation of teeth
Replacement of caries-control restorations with permanent restorations
Monitoring of plaque biofilm and mutans streptococci (MS) levels
Further antimicrobial treatment and dietary reassessment as indicated by new cavitations, noncavitated lesions, or high MS levels



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