Transcript Patient-Centered Risk-Based Treatment Explanation

Patient-Centered Explanation
of Risk-Based Treatment
Tooth Decay
Tooth Decay Defined
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An infection caused by bacteria commonly
found in the mouth that destroys the tooth
The bacteria are transmissible from parent
or caregiver to child, child to child, and
adult to adult
The disease has many factors and many
stages
Experimental Decay
Development
of enamel decay
• No oral hygiene
• Rinse 9x/day with
50% sucrose solution
0 days
Decay
arrested
• Regular oral hygiene
• Fluoride use
21 days
Timeline
Proof that:
• bacteria causes decay
• sugar increases risk
• oral hygiene can prevent decay
51 days
von der Fehr et al 1970
Stages of Decay
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The disease process begins with an
infection, advances to demineralization,
and ends with a cavity
The process does not progress at a
uniform rate but is cyclic and intermittent
Demineralization occurs when decaycausing bacteria produce acids from food
Cyclic Process of Decay
Bacteria plus food
makes the saliva
very acidic within
5 minutes
Demineralization
Remineralization
Saliva is normal
30 minutes
after eating
Tipping the Balance
Remineralization
Demineralization
Cavity
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•
•
•
Infrequent or inadequate tooth cleaning
Frequent meals and snacks
Large amount of decay causing bacteria
Deficient fluoride in saliva
Decay Progression
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Decay
No change
Healed
Progression of 72 white spot
lesions followed for 7 years
Backer-Dirks 1966
Diagnosis of Decay
Health
Decalcification
Decay
Visual
Normal tooth
color
White spot
Black or
brown
Feel
Hard
Hard
Soft
X-Ray
Normal
Normal
Black area
None of these methods can detect all lesions early enough to
implement treatment to reverse the disease process
Occurrence of Symptoms
0 1 hour
Anaphylactic
Shock
? years
Time line
Toothache
30 years
Heart Attack
• Each symptom occurs at the end of the colored bar
• Each disease process is invisible to diagnostic methods
for most or all of the time within the colored bar
• Risk predicts chronic disease occurrence
The Early Stages of Decay are
Indistinguishable from Health
The Realm of Diagnosis,
which requires the disease is
sufficiently advanced to be
“Visible”
“Invisible” to diagnostic
techniques
Disease State
Cavity
Decalcification
Health
Risk Defined
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Risk is a prediction that disease will occur
or progress
Risk is distinct from disease and cannot be
accurately predicted from the disease
state
Risk is determined by risk factors
Risk-Based Treatment
Disease State
Risk-based treatment
prevents disease
progression
Risk-based treatment
prevents disease occurrence
Cavity
Decalcification
Health
Repair and Prevention
Repair treats the
consequences of disease,
which may increase the risk
of new disease
Prevention maintains a
clinically healthy state
Disease State
Cavity
Decalcification
Health
Fillings
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Fillings have no measurable effect on decaycausing bacteria present on tooth surfaces
Fillings have a finite life span and where each
replacement filling leaves less tooth structure
Fillings increase the risk of an abscess
Fillings may increase the risk of tooth fracture
and gum disease
Prevention
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Preventive treatment can be effective at
any time and age
A diagnosis of decay could be indicative
that additional lesions not yet visible exist
Apparently healthy teeth might be in the
early undetectable stages of decay
Risk assessment can identify when risk is
high and preventive treatment is beneficial
Tooth Decay Risk
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Tooth decay risk varies between
individuals and over time coincident with a
change in risk factors
The highest decay-susceptible time is the
first 2 years after tooth eruption, but can
be high at any time
Determining Risk and Treatment
About PreViser
PreViser Corporation provides web-enabled diagnostic
decision support tools for dentists. The tools are simple,
inexpensive and easy to use. The first clinically proven
application is within dental care, where the use of
PreViser technology will assist oral health care
professionals to more effectively plan treatment
responses to disease.
Find out more about the
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Download and Try it for Free.
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Corporation. This intellectual property protects a selfupdating system of diagnosis that uses easily collected
clinical measurements to calculate the risk of disease
development or deterioration of a current disease state,
and identifies therapies most likely to reduce risk and
disease severity.
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Supplemental and
New Diagnostic Methods
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Plaque Formation Rate (PFRI)
Salivary level of mutans streptococci (SM)
New Diagnostic Methods
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Digital X-rays
Fiber-optic transillumination (FOTI)
Laser fluorescence (LF)
Electrical conductance (EC)
Ultrasound
Plaque Formation Rate
Amount of new
plaque accumulated
in 24 hours
following tooth
cleaning where
patient refrains from
oral hygiene
Axelsson 1991
Score
Description
1
1%-10% of surfaces
2
11%-20% of surfaces
3
21%-30% of surfaces
4
31%-40% of surfaces
5
>40% of surfaces
Caries Risk Based on SM and PFRI
PFRI
SM/ml
1
2
0
>0.9 mill
Axelsson 1991
4
5
Very Low Risk
<0.5 mill
0.5-0.9 mill
3
Moderate Risk
Low Risk
High Risk
New Diagnostic Methods
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Very little clinical data are available to validate
these technologies
Goal is better accuracy over traditional methods
to detect true cavities that should be filled
Goal is detection of currently “invisible” lesions
that are in a state of dynamic decalcification and
recalcification
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Enhances risk assessment and application of
preventive treatment
Preventing Tooth Decay
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Reduction of decay-causing bacteria
Health promoting dietary practices
Exposure to fluoride
Sealing susceptible tooth defects
Proper frequency of dental visits
Reducing Decay-Causing Bacteria
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Personal teeth cleaning
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Antibacterial rinses (chlorhexidene)
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Twice daily tooth brushing and flossing or an
equivalent aid for between the teeth
Rinse with 10 ml for 1 minute at bedtime for 2
weeks repeating the cycle 2 months later
Fluoride toothpaste
Treat all family members
“Teeth Cleaned” Clarified
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All tooth surfaces including between teeth
About half of all decay affects the tooth surfaces
of adjacent teeth where a tooth brush and oral
rinse does not reach
The equivalent of not cleaning between teeth is
washing the palm and back of your hands but
not between your fingers
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Rinsing hands with water is not an effective
alternative to scrubbing with soap
Dietary Practices
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Foods that are especially harmful contain
sugars like sucrose, glucose, and fructose,
cooked starch, and other carbohydrates
Eat and drink no more than 3 meals and 3
snacks per day
Sugar-free gum and mints, especially
those that contain xylitol can be beneficial
Fluoride
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The incorporation of fluoride into
developing enamel inhibits tooth decay,
however its primary effectiveness occurs
by its concentration in plaque and saliva to
inhibit demineralization and enhance
remineralization
Fluoride inhibits plaque bacteria
Fluoride, cont.
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Fluoride is released from dental plaque during
the acidic conditions of eating
Released fluoride combines with calcium and
phosphate to create a more decay-resistant
enamel crystal structure
Fluoride is available in water, toothpaste, overthe-counter rinses, prescription toothpaste and
rinses, professional gels, foams, and varnishes
Fluoride, cont.
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Fluoridated toothpaste should be used twice
daily
Professional applications of fluoride is based on
risk
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High-risk patients should have this done 2 to 3 times
per year
More fluoride is not necessarily better, especially
for children younger than 6 years as fluorosis
can affect cosmetically visible developing teeth
Tooth Sealants
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Plastic coating bonded to the biting
surfaces of the back teeth
Susceptible tooth defects should be sealed
regardless of age
Frequency of Dental Visits
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Twice annual professional tooth cleaning
as the sole method to prevent cavities is
unlikely to be effective especially when
risk is high
Frequency of dental visits can be
increased for closer monitoring of oral
hygiene and dietary practices in addition
to applying fluoride and sealants
Dealing with Objections
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Prevention doesn’t work
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Prevention is only for the young
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Studies have shown that more than 90% of tooth
decay can be prevented
Studies have shown that prevention works at any age
The benefits of prevention take many years
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The benefits are immediate as prevention heals the
invisible lesions
Objections, cont.
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It costs too much; My insurance doesn’t cover it
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Filling cavities costs more than preventing them
Cavities can result in a root canal, cap, or extraction
Dentures could ultimately cost more than “saving”
your teeth
Insurance doesn’t care if you have dentures
Dentures are OK
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Dentures, especially lower ones, are not always
successful, which then requires implants
Objections, cont.
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Flossing is too hard; no time to floss
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Tying shoelaces for a child is difficult but they
learn the skill
Flossing takes only a minute or two after the
skill is learned
Fillings prevent decay
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Fillings have no effect on decay-causing
bacteria and hence do not reduce the risk of
having more cavities