Transcript A New Paradigm For The Treatment Of Dental Caries

Clinical Trends In The
Diagnosis And The
Treatment Of Dental
Caries
Steven Steinberg DDS
May-June, 2004
LOW RISK PATIENT
• No cavitated lesions
• May have inactive white spots
(smooth shiny).
• Bacteria MS levels are low
• Diet is normal sugar levels low
• Normal Saliva levels
• Low DMF (Hx)
MODERATE RISK PATIENT
• No cavitated lesions
• Some active white spot lesions
(rough/chalky)
• Bacterial MS levels elevated
• Moderate sugar use
• Saliva normal or reduced (xerostomia)
• Moderate DMF (Hx)
HIGH RISK PATIENT
• One or more cavitated lesions
• May have white spot lesions
(active or inactive)
• Bacterial MS levels are very high
• Sugar intake very high
• Saliva levels low (xerostomia)
• High DMF (Hx)
1. Bacterial Control
A. Surgical Antimicrobial Tx
•
•
•
•
Treat cavitated lesions first.
Fill with glass ionomer, compomer, composite or
IRM.
Very large lesions may require temporary
crowns (sub-gingival margins),RCT, or EXT.
Place sealants as needed:
1) Occlusal surfaces with chalky white spots
2) Deep grooves and Old fillings with poor margins
3) Molars > Premolars
•
Surgical choices based on Site(pit & fissures vs.
smooth surface), Activity and Risk.
Treatment Plan
Medical Model
1. Bacterial Control
A. Surgical Antimicrobial Tx (Restorations)
Wound debridement / I&D = Fill/Temporize cavitated
lesions/Place sealants
B. Chemotherapeutic Antimicrobial Tx(meds)
Fluoride Varnish, CHX, and Xylitol Gum
2. Reduce Risk Level of At-Risk Patients
3. Reverse Active Sites = Remineralization
4. Long Term Follow Up and Maintenance
A.
B.
C.
Home maintenance
Office Recall/Continuing Care
Heal Vs.Cure (Process/Relationship)
1. Bacterial Control
A. Surgical Antimicrobial Tx
•
•
•
•
Treat cavitated lesions first.
Fill with glass ionomer, compomer, composite or
IRM.
Very large lesions may require temporary
crowns (sub-gingival margins),RCT, or EXT.
Place sealants as needed:
1) Occlusal surfaces with chalky white spots
2) Deep grooves and Old fillings with poor margins
3) Molars > Premolars
•
Surgical choices based on Site(pit & fissures vs.
smooth surface), Activity and Risk.
1. Bacterial Control
B.Chemotherapeutic Antimicrobial Tx
1)
2)
3)

Fluoride Varnish 1-3 initial applications upon
completion of Surgical Tx. Use 3 applications in 10 day
period for patients who need remineralization or for
patients with CHX issues or compliance problems
(possible use of Iodine rinse).
CHX = Chlorhexidine Rinse 0.12% take ½ oz. before
bed for 2 weeks. Repeat in 2-3 months
Xylitol Gum. Use 2 pieces for 5 minutes minimum 5
times a day.
Mutans Test for Very High Risk patients
2. Reduce Risk Levels of
At Risk Patients
• Reduce Sugar !!!!!!!!!!!!!!!!!
(Xylitol/Sucrose substitutes)
• Reduce Bacteria (antimicrobials, Xylitol
gum, and OHI) and MS test PRN.
• Increase Saliva (Xylitol gum and mints,
Rinses, change medications if possible).
• Increase Home Fluoride use.
3. Reverse Active Sites
Remineralization Tx




In Office – Fluoride varnish 3 applications in 10 day period (if not
done as a part of Step 1B)
At Home – Fluoride
1)
Moderate or High Risk Patient: Toothpaste (1000 ppm) qd +
5000 ppm dentifrice or gel qd +OTC (over the counter) rinse
250 ppm several times a day especially hs.
2)
Very High risk Patient: Toothpaste 5000 ppm dentifrice or gel
qd + 5000 ppm dentifrice or gel in a tray qd +OTC (over the
counter) rinse 250 ppm several times a day especially hs.
Xylitol gum: 2 pieces 5 times a day.
Calcium Source: Cheese or new gums with amorphous Calcium
Phosphate.
4. Long Term Follow Up
A. Home Maintenance
At Home – Fluoride
1)
a)
b)
2)
3)
4)
Moderate or High Risk Patient: Toothpaste (1000 ppm) qd +
5000 ppm dentifrice or gel qd +OTC (over the counter) rinse
250 ppm several times a day especially hs.
Very High risk Patient: Toothpaste 5000 ppm dentifrice or gel
qd + 5000 ppm dentifrice or gel in a tray qd +OTC (over the
counter) rinse 250 ppm several times a day especially hs.
Xylitol gum 2 pieces 5 times a day.
Decreased use of sucrose between meals
Calcium Source.
4. Long Term Follow Up
B. In Office Continuing Care
1)
2)
3)
4)
3 Month Visit
a)
Polish (If this is also a 3 mo perio maint patient do perio probing/scaling first)
b)
Exam / evaluate white spots for remineralization / return to steps 1-3 PRN (D0140)
c)
Fluoride varnish (D1204)
6 Month Visit (3 months later)
a)
PSR or Perio Probing / Scaling / Polish
b)
Exam / evaluate white spots for remineralization / return to steps 1-3 PRN (D0120)
c)
Fluoride varnish (D1204)
9 Month Visit (3 months later)
a)
Polish (If this is also a 3 mo perio maint patient do perio probing/scaling first)
b)
Exam / evaluate white spots for remineralization / return to steps 1-3 PRN (D0140)
c)
Fluoride varnish (D1204)
1 Year Visit (3 months later)
a)
Bite wing + other x-rays PRN
b)
PSR or Perio Probing / Scaling / Polish
c)
Fluoride varnish (D1204)
d)
Exam / Evaluate Activity Levels I.e. white spot and interprox x-rays (D0120)
e)
Exam / Evaluate Risk Level for next years CC schedule (Low Risk 6mo CC / Moderate or
High risk 3mo CC if active: 6mo CC if inactive/ Very High Risk 3mo CC)
Treatment Groups by
Risk/Activity Status.
•
•
•
•
•
•
•
Low Risk (LR)
Moderate Risk Inactive (MRI)
Moderate Risk Active (MRA)
High Risk Cavitated (HRC)
High Risk Cavitated Active (HRCA)
High Risk Inactive (HRI)
Very High Risk (VHR)
TREATMENT
GROUP
Filling
Temp
Cr
Seal
#
1st
FLV
Per
Yr
CHX
Xylitol
Moderate Risk
Active
MRA
CC
FLV
+
6
5000 ppm Paste
+ Rinse
2
+
3
+
High Risk
Cavitated
HRA
+
+
+
1
2
+
6
+
High Risk
Cavitated Active
HRCA
+
+
+
3
2
+
3
+
+
6
+
+
3
+
Very High Risk
VHR
+
+
++
3
12
Home
Fluoride
1000 ppm Paste
3
High Risk
Inactive
HRI
Remin
Ca
6
Low Risk
LR
Moderate Risk
Inactive
MRI
CC
Interval
Months
+
5000 ppm Paste
+ Rinse
5000 ppm Paste
+ Rinse
+
5000 ppm Paste
+ Rinse
5000 ppm Paste
+ Rinse
+
5000 ppm Paste
In a Tray
+ Rinse