DENTAL CARIES:

RISK ASSESSMENT
AND MANAGEMENT

VANDHANA ANIL KUMAR

FINAL YEAR PART-B
Contents
 Dental caries
 surgical model of caries management
 medical model of risk assessment
 classification of patients according to degree of risk
 caries risk assessment
 Role of risk factors
 strategies for caries prevention and management
 clinical consideration caries control techniques
Dental caries
 is a multifactorial, transmissible, infectious oral
disease caused primarily by the complex
interaction of cariogenic oral flora (biofilm) with
fermentable dietary carbohydrates on the tooth
surface over time.
Medical model of caries risk
assessment and management
 This process provides an individualized evaluation
of a patient’s pathologic factors and protective
factors and assesses the patient’s risk for
developing future disease.
 manages the caries disease process using a
medical model.
 Risk assessments are important in determining the
frequency of re care visits and the treatment
protocols for follow-up visits.
 Restorative decisions in terms of material used and
cavity preparation design are also influenced by
the information gathered in the risk assessments.
occurring, or health.
 The systematic use of risk assessment profiles is
essential in uncovering risk factors that are present
before expression of the disease. This information
can be useful in the prevention of caries lesions in
patients who have risk factors present but no
disease expression and then experience a lifestyle
change that adds additional risk factors.
 Risk assessments lead to better treatment
outcomes for patients.
Surgical model of caries management
the biomechanical excision of caries lesions and
the restoration of the resultant tooth preparation
to form and function with a restorative material.
• dealing only with the end result of the disease
and not addressing its etiology for each
individual patient was not successful in
controlling the caries disease process.
Classification of patients according to
degree of risk
 Low caries risk: if clinician finds no detectable or active caries
lesions and minimum or no identifiable risk factors
 At risk: these are patients who might not be having any carious
lesions right now but are at risk to develop caries in the near future if
an imbalance occurs between the protective factors and risk factors
present in patient
 high risk: these are patients in whom the caries balance is tilted
towards demineralization. these patients in all probability will
develop caries in the near future. The strongest predictor for caries
risk for patients in the at risk and high risk categories are the number
of caries lesions being detected for the patient over the last2-3 years
along with past history of caries lesions in the patient s lifetime
CARIES RISK ASSESMENT

Risk factors- defined as an environmental,

behavioural or biological factor that directly
increases the probability that a disease will occur and
the absence or removal of which reduces the
possibility of disease
Role-it is a part of causal change of disease
process ,so its very important to spend time with
patient to uncover all the relevant risk factors .some
can be modified either by the patient or clinician
Identification of risk factors
Identification of risk indicators
Identification of caries lesion activity
Identification of risk factors
Risk factor occur before the disease occur
Factors contributing to caries risk in age above 6
Dietary habits
Caries
Flourides
Habits
General health
Age
Economic status and educational attainment
Risk Considerations for Children
Under 6 Years Old:-
risk factors and indicators for this age group include:
• presence of active caries in the primary caregiver in
the past year;
• feeding on demand past 1 year of age;
• bedtime bottle or sippy cup with anything other
than water;
• no supervised brushing; and
• severe enamel hypoplasia.
Identification of risk indicators
Existing sign of disease
Eg:visible cavitation in pit and fissures, brown spot,
active white spot, restorations placed in past 3 years
Assessment of caries lesion activity
Assessment of current carious lesion
Active caries lesion
Inactive caries lesion
Caries risk assessment is performed by doing
combination of
Dietary analysis
Dental clinical analysis
Bacterial biofilm analysis
Salivary analysis
Dietary Analysis
Sugar intake in the form of fermentable
carbohydrates and increased frequency of intake
are conditions that increase risk for caries.
1)by providing energy to the acidogenic and
aciduric bacteria
2) influencing the pH of the biofilm to support
cariogenic bacteria.
Dental Clinical Analysis (Dental
Exam)
The dental examination determines risk indicators
more than risk factors. This is also important as
many of the indicators are directly related to the
current caries activity. The indicators and
current caries activity drive the decision making
process for the type of intervention that the
clinician would prescribe.
Bacterial Biofilm Analysis
Use of supplemental tests to analyze the
bacterial component of the biofilm can help
determine the patient’s risk level.
the measurement of adenosine tri phosphate
(ATP) activity of the biofilm bacteria as a
surrogate measure of caries activity.
Salivary analysis
Following tests are performed
 Sal flow rate
 Sal buffering capacity
 Salivary PH
Strategies for caries prevention and
management
Caries risk assessment is only effective if used in
conjunction with a corresponding caries management program.
Methods include
Limiting pathogen growth and altering metabolism
Increasing resistance of tooth surface to
demineralisation
Increasing biofilm PH
CLINICAL CONSIDERATIOS
 General health
 diet
 Oral hygiene
 Antimicrobial Agents
 Calcium and Phosphate Compounds
 Restorations
 Sealants
 Probiotics
 Function of Saliva
 immunization
 Fluoride Exposure
Clinical considerations

general health

Medically compromised patients should be examined

for following- plaque index , salivary analysis, oral
mucosa ,gingiva and teeth
Early signs include- increased plaque biofilm puffy
bleeding gingiva, dry mouth with red glossy mucosa
and demineralisation of teeth
Dietary factors
Frequent ingestion of sucrose increase caries potential
Caries activity is most strongly stimulated by the frequency,
rather than the quantity of sucrose
ingested.
Evidence of new caries activity in adolescent and adult patients
indicates the need for dietary
counseling. The goals of dietary counseling
should be to identify the sources of sucrose and
acidic foods in the diet and to reduce the
frequency of ingestion of both.
• Rampant caries that is present primarily on inter
proximal surfaces may point more to diet as the
main causative factor, whereas rampant caries in
the cervical and inter proximal areas may point
to diet and hygiene as the causative factors.
• For high-risk patients, a formal diet analysis
should routinely be undertaken to identify
cariogenic foods and beverages that are
frequently ingested.
• This analysis should be conducted over a 4-day
period with 2 of the days surveyed being
weekend days.
oral hygiene
Biofilm free tooth surfaces do not decay
Daily removal of plaque biofilm by dental flossing,
tooth brushing, and rinsing is the best patient
based measure for preventing caries and
periodontal disease.
• Mechanical plaque biofilm disorganization by
brushing and flossing has the advantage of not
eliminating the normal oral flora.
Fluoride exposure
•Fluoride in trace amounts increases the resistance of
tooth structure to demineralization and is
particularly important for caries prevention
Optimal fluoride for public water supplies is 0.7 mg
per litre of water
Mechanism of action
(1)the presence of fluoride ion greatly enhances
the precipitation of fluorapatite from calcium
and phosphate ions present in saliva into tooth
structure .
(2) non cavitated caries lesions are remineralized
by the same process.
(3)fluoride has antimicrobial activity.
FLUORIDE TREATMENT PROTOCOLS-
Public water supply fluoridation
Professional application of fluoride-APF gel, stannous fluoride gel,
sodium fluoride varnish
Self administered fluoride- fluoride mouth rinses, fluoridated dentrifices.

• The availability of fluoride to reduce caries risk is

thought to be primarily achieved by fluoridated
community water systems but also may occur from
fluoride in the diet, toothpastes, mouth rinses, and
professional topical applications.
• Varnishes provide a high uptake of the fluoride
ion into enamel
• For patients with a high risk of caries, fluoride
varnish should be applied every 3 months.
• For moderate-risk patients, application every 6
months is indicated.
• Fluoride varnish is not needed for low risk
patients.
The main disadvantage of fluoride varnish is that
a temporary change in tooth color may occur.
Anti caries vaccine
Several prototypes have been tested in animals, but at this
time, neither the safety nor efficacy of such vaccines has
been demonstrated in humans.
Even if an anti-caries vaccine were developed, some
concerns remain, which may affect its widespread use.
(1)the potential adverse effects of a vaccine must be
identified. The concerns about a possible cross-reaction
with human heart tissue remain.
(2) its cost must be compared with that of public water
fluoridation, which is inexpensive and already effective
at reducing caries.
Limitations imposed by governmental regulatory agencies
Functions of saliva
Dilute acids produced in plaque biofilm
Washing acid away
Buffering the produced acid
Assisting in remineralisation
Assist in formation of pellicle
Function of Saliva
Saliva is nature’s first line of defense against
dental caries.
When attempting to improve salivary flow rates
• a consultation with the patient’s physician may
be in order.
• Prescribing salivary stimulants can be very
beneficial in patients with functioning salivary
glands but who have xerostomia because of
medications.
• chewing sugar-free candies or mints several
times a day and the use of xylitol chewing gum.
Antimicrobial agents
variety of antimicrobial agents are available to
help prevent caries .In rare cases, antibiotics
might be considered, but the systemic effects
must be considered.
(1)The traditional approach is the use of
chlorhexidine (CHX) mouthwash, varnish, or
both, along with prescription fluoride
toothpaste. 0.12% rinse to high risk periodontal patients, 30 sec rinse at bedtime-A
(2)The other approach is to use a twice-daily
mouth rinse containing sodium hypo chlorite
and xylitol . keeps sucrose molecule from binding with MS, S. mutans cannot ferment
xylitol, enhance remineralization and arrest caries.
Calcium and phosphate compounds
 ACP is a reactive and soluble calcium phosphate
 compound that releases calcium and phosphate
 ions to convert it to apatite and re mineralize
 the enamel when it comes in contact with saliva.
Amorphous calcium phosphate(ACP) along with
casein phophopeptide(CPP) have potential to
remineralise tooth structure have the potential to
remineralize tooth structure.
probiotics
• The fundamental concept is to inoculate the oral
cavity with bacteria that will compete with
cariogenic bacteria and eventually replace them.
• Obviously, the probiotic bacteria must not
produce significant adverse effects.
• It has been speculated that for the probiotic
microorganisms to gain dominance, existing
pathogens must first be eliminated.
sealents
It mechanically fill pits and fissures with acid
resistant resin
They deny microorganisms their preferred habitat
Renders pits and fissures easier to clean by tooth
brushing and mastication
extremely low-viscosity resin sealants
for the infiltration of white-spot caries
lesions on smooth surfaces.
Preventive functions

(1) sealants mechanically fill pits and fissures

with an acid-resistant resin.
(2) acts as a mechanical barrier against bacterial
accumulation.
(3) sealants make cleaning of pits and fissures
easier by tooth brushing and mastication.
Existing restoration
Old restorations that are rough and plaque retentive
should be smoothed and polished
Overhangs, open proximal contact, defective
contours should be corrected
Caries control restoration
refers to an operative procedure in which
multiple teeth with acute threatening caries are
treated quickly by:-
(1) removing the infected tooth structure,
(2) medicating the pulp, if necessary,
(3) restoring the defect(s) with a temporary
material.
indications
Caries control is an intermediate step
(1) the caries is extensive enough that adverse pulpal
sequelae are likely to occur soon,
(2) the goal of treatment is to remove the nidus of caries
infection in the patient’s mouth,
(3) a tooth has extensive carious involvement that
cannot or should not be permanently restored.
(4) during an operative procedure when a tooth is
unexpectedly found to have extensive caries.
(5) to avoid possible sequelae such as toothache, root canal therapy, or
more complex ultimate restorations.
Caries control technique
• 1)Anaesthesia
• (2) operating site must be isolated.
• (3)The primary objective of the caries-control
tooth procedure is to provide adequate visual and
mechanical access to facilitate the removal of
infected dentin.
• (4)Retaining unsupported enamel is permissible
in caries-control procedures
• (5)Retaining sound portions of old restorative
material
(6) the identification and removal of caries depends
primarily on the dentist’s interpretation of tactile
stimuli.
• Effective caries removal can be accomplished with
• (1) hand instrumentation using spoon excavators,
• (2) a slow-speed handpiece with a large round bur,
or
• (3) a high-speed handpiece using a round bur
operated just above stall-out speed (low speed).
1-MANAGEMENT OF PULPAL
EXPOSURE
 Definition: direct pulp capping is a tech for
treatment of pulp exposure with a material that
seals over the exposure site and promotes
reparative dentin formation
 Use of calcium hydroxide liner covered with glass
ionomer or resin modified glass ionomer liner
 Restored with amalgam gic, intermediate
restorative material
Types of pulpal exposure
 Carious pulpal exposure:consequence of infected
dentin extending into pulp
 Mecahnical pulpal exposure: carious exposure that
occur in an area of normal dentin
Prognosis of pulpal exposure
 The tooth has been asymptomatic before operative
procedure
 Exposure is small
 Hemorrhage from exposure site is easily
controlled
 Exposure occur in clean uncontaminated field
 Exposure was relatively atraumatic

(no aspiration of blood into dentin)

2-PARTIAL CARIES EXCAVATION
AND INDIRECT PULP CAPPING
 Concept:it is clinically appropriate to use partial
caries excavation and indirect pulp capping in the
context of caries control on any tooth with a large
carious lesion that is deemed rest or able and for
which the pulpal and periapical areas are deemed
healthy
Clinical protocol
 Preliminary assessment of pulpal and periapical
health(vital n periapically healthy)
 The responsibility of tooth is assessed (direct
restoration should be possible)
 Caries is completely excavated peripherally to a
sound caries free DEJ. Axially and pulpally,caries
wil be excavated to within 1 mm of pulp
 Re evaluation after 12weeks direct restoration
3- ROOT CARIES MANAGEMENT
Risk factors for root caries include the following:
1. Gingival recession
2. Poor oral hygiene
3. Cariogenic diet
4. Presence of multiple restorations or multiple
missing teeth
5. Existing caries
6. Xerogenic medications
7. Compromised salivary flow rates
The protocol for the prevention of root caries

 try to improve salivary flow rates and increase the buffering

capacity.
 to attempt to re mineralize non cavitated lesions and prevent new
lesions from developing
 reduce the quantity and numbers of exposures of ingested refined
carbohydrates
 try to reduce the numbers of cariogenic bacteria (S.mutans) in the
oral cavity.

 Restore all root caries lesions with a fluoride Releasing material.

 use of powered toothbrushes
Summary
 The caries prevention or management program
should comprise a menu of prevention therapies
and intervention that should be recommended on
basis of level of caries risk. Identifying and
eliminating the causative factors for caries must be
the primary focus, in addition to the restorative
repair of damage caused by dental caries.
Thank you