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. Home maintenance
B. Office Recall/Continuing Care
C. 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) 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).
2) CHX = Chlorhexidine Rinse 0.12% take ½ oz. before
bed for 2 weeks. Repeat in 2-3 months
3) 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
1) At Home – Fluoride
a) 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.
b) 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.
2) Xylitol gum 2 pieces 5 times a day.
3) Decreased use of sucrose between meals
4) Calcium Source.
4. Long Term Follow Up
B. In Office Continuing Care
1) 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)
2) 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)
3) 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)
4) 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 Filling Temp Seal # Per Xylitol CC CC Remin Home
GROUP Cr 1st Yr Interval FLV Ca Fluoride
FLV CHX Months

Low Risk 1000 ppm Paste

LR
6
Moderate Risk 5000 ppm Paste
Inactive
+ 6 + Rinse

MRI
Moderate Risk 5000 ppm Paste
Active
3 2 + 3 + + + Rinse

MRA
High Risk 5000 ppm Paste
Cavitated
+ + + 1 2 + 6 + + Rinse

HRA
High Risk 5000 ppm Paste
Cavitated Active
+ + + 3 2 + 3 + + + Rinse

HRCA
High Risk 5000 ppm Paste
Inactive
+ 6 + + Rinse

HRI
Very High Risk 5000 ppm Paste
VHR
+ + ++ 3 12 + 3 + + In a Tray
+ Rinse