caries risk + protocols 06
TRANSCRIPT
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Caries Risk Assessment Caries Risk Assessment
and its interaction with Preventiveand its interaction with Preventiveand Restorative Protocolsand Restorative Protocols
Richard Ehrlich DDSwww.elmtreedental.com
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Introduction
Introduction
Caries Risk is used by most general
dentists daily, usually on an intuitivelevel.
The first part of this presentation will
attempt to help quantify this, and thesecond part will use this information formore systematic preventive, diagnosticand restorative protocols.
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Applications of Caries Risk Applications of Caries Risk
Assessment Assessment
Caries Risk Assessment Caries Risk Assessment assists in predicting andassists in predicting and
diagnosing this type of diagnosing this type of casecase--
Should you observe this?Should you observe this?
Or does it conceal this?Or does it conceal this?
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Applications of Caries Risk Applications of Caries Risk
Assessment Assessment
Caries Risk Assessment Caries Risk Assessment
assists in predictingassists in predictingand diagnosing thisand diagnosing thistype of casetype of case--
Should you replaceShould you replace
these restorations orthese restorations orobserve them?observe them?
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Overview of Caries RiskOverview of Caries Risk
Assessment (CRA) Assessment (CRA) Caries Risk Assessment (CRA) is a simple, quickCaries Risk Assessment (CRA) is a simple, quick
method for assigning a number to an individualsmethod for assigning a number to an individuals
risk for decay.risk for decay.
Using this data, custom preventive and restorativeUsing this data, custom preventive and restorativeprograms can be used, with more reliance onprograms can be used, with more reliance onevidenceevidence--based dentistry and less on intuition andbased dentistry and less on intuition and
experience alone.experience alone.
This simplified version is based on practicalThis simplified version is based on practicalapplication of the U of T Caries Risk Assessment inapplication of the U of T Caries Risk Assessment inactual clinical practice in a preventiveactual clinical practice in a preventive--orientedoriented
dental office.dental office.
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Categories for Simplified CRACategories for Simplified CRA
These are all given numerical scoresThese are all given numerical scores::
Existing DecayExisting Decay
Previous DecayPrevious Decay
Root CariesRoot Caries
Fluoride ExposureFluoride Exposure
Diet FactorsDiet Factors Oral HygieneOral Hygiene
Additional Tests Additional Tests
S.mutans and LactobacillusS.mutans and Lactobacillus
Saliva FlowSaliva Flow
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Categories for Simplified CRACategories for Simplified CRA
Existing DecayExisting Decay
No Decay = 0No Decay = 0
Some early Pit andSome early Pit andFissure Decay = 0.5Fissure Decay = 0.5
11--2 Existing Lesions =12 Existing Lesions =1
>2 Lesions =2>2 Lesions =2
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Categories for Simplified CRACategories for Simplified CRA
Previous DecayPrevious Decay
No Decay = 0No Decay = 0
Some early Pit andSome early Pit andFissure Decay = 0.5Fissure Decay = 0.5
Interproximal PosteriorInterproximal PosteriorDecay =1Decay =1
Anterior or Smooth Anterior or SmoothSurface Decay =2Surface Decay =2
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Categories for Simplified CRACategories for Simplified CRA
Existing DecayExisting Decay
Previous DecayPrevious Decay
Root CariesRoot Caries
Ratio of exposed root Ratio of exposed root surfaces to decaysurfaces to decay
<25% of root <25% of root surfaces decayedsurfaces decayed= 0= 0
25%25%--50% of 50% of surfaces decayedsurfaces decayed=1=1
>50% of surfaces>50% of surfacesdecayed =2decayed =2
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Categories for Simplified CRACategories for Simplified CRA
Existing DecayExisting Decay
Previous DecayPrevious Decay
Root CariesRoot Caries
Fluoride ExposureFluoride Exposure
Using FluorideUsing FluorideToothpaste BID = 0Toothpaste BID = 0
Using FluorideUsing FluorideToothpaste once dailyToothpaste once daily= 1= 1
Not using FluorideNot using FluorideToothpaste or RinseToothpaste or Rinse= 2= 2
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Categories for Simplified CRACategories for Simplified CRA
Existing DecayExisting Decay
Previous DecayPrevious Decay
Root CariesRoot Caries
Fluoride ExposureFluoride Exposure
Diet FactorsDiet Factors
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Diet Factors:Diet Factors:
The Diet Questionnaire is presented.The Diet Questionnaire is presented.
Total sugar exposures are totaled, andTotal sugar exposures are totaled, and
divided by 3 for the Caries Index Dietdivided by 3 for the Caries Index Diet
ScoreScore
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Diet Questionnaire:Diet Questionnaire:
Drink Factors:Drink Factors: How many times a day do you drink:How many times a day do you drink:
± ± 1. Coffee or tea1. Coffee or tea with sugar with sugar between mealsbetween meals?? ± ± 2. Pop, Kool2. Pop, Kool--aid, lemonade, sports drinks, fruit juice,aid, lemonade, sports drinks, fruit juice,
iced tea with sugar iced tea with sugar between meals?between meals?» Total the number of these
How many glasses of water or How many glasses of water or dilutedilute drinks do you have adrinks do you have a
day? This does not include coffee, soft drinks, full strengthday? This does not include coffee, soft drinks, full strength juice or sports drinks. juice or sports drinks. ± ± Chronic Dehydration can increase caries riskChronic Dehydration can increase caries risk
»» Count 2 if the patient is dehydratedCount 2 if the patient is dehydrated
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Diet Questionnaire:Diet Questionnaire: Drink Factors cont¶d:Drink Factors cont¶d:
Important trend: Cariogenic drinks are on aImportant trend: Cariogenic drinks are on a
great increase!great increase!Huge marketing efforts have been made, and often soft drinkHuge marketing efforts have been made, and often soft drinkcompanies have a monopoly on vending machines incompanies have a monopoly on vending machines inschools. This has paid off with a corresponding increase inschools. This has paid off with a corresponding increase indecay and acid erosion.decay and acid erosion.
Consumption of soft drinks, sports drinks, fruit juices andConsumption of soft drinks, sports drinks, fruit juices andiced tea have skyrocketed in recent years, especially amongiced tea have skyrocketed in recent years, especially among
teens and adolescents. Sports drinks are meant for athletesteens and adolescents. Sports drinks are meant for athletesinvolved in over 60 minutes of aerobic activity. Sedentaryinvolved in over 60 minutes of aerobic activity. Sedentarykids are drinking sports drinks after mild activity, thanks tokids are drinking sports drinks after mild activity, thanks togood marketing.good marketing.
Water and milk consumption is dropping.Water and milk consumption is dropping.
Link toLink to Acid Erosion Page Acid Erosion Page
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Diet Questionnaire:Diet Questionnaire:Food Factors:Food Factors:
How many times a day do you:How many times a day do you:
1. Chew regular gum (Not sugarless)?1. Chew regular gum (Not sugarless)?
2.2. Eat mints, lozenges, candies or candy bars, driedEat mints, lozenges, candies or candy bars, dried
fruit, energy barsfruit, energy bars between mealsbetween meals??
3.3. Eat sweetened baked goods (Donuts, cookies,Eat sweetened baked goods (Donuts, cookies,
pastries)pastries) between meals?between meals?
Total the number of all of these.
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Diet Questionnaire:Diet Questionnaire: Do you have a habit of sipping a
sweetened drink (Coffee, cola, juice) or
eating a sweet snack over an extendedperiod of time, 45 minutes or more?
± If yes, add 2
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Diet Questionnaire:Diet Questionnaire: Total diet scores are added up, divided
by 3 and this is the number used for the
Caries Risk Assessment score for DietFactors.
0-2 Sugar exposures=0
3-4 Sugar exposures =1
5-6 Sugar Exposures =2
>6 exposures =3
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Categories for Simplified CRACategories for Simplified CRA
Existing DecayExisting Decay
Previous DecayPrevious Decay
Root CariesRoot Caries
Fluoride ExposureFluoride Exposure
Diet FactorsDiet Factors
Oral HygieneOral Hygiene
0=Good OH0=Good OH
1=Fair OH1=Fair OH PSRs <3PSRs <3
Mod PlaqueMod Plaque
2=Poor OH2=Poor OH PSRs >3PSRs >3
Heavy PlaqueHeavy Plaque
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Categories for Simplified CRACategories for Simplified CRA
Existing DecayExisting Decay
Previous DecayPrevious Decay
Root CariesRoot Caries
Fluoride ExposureFluoride Exposure
Diet FactorsDiet Factors
Oral HygieneOral Hygiene
Additional Tests Additional Tests
S.mutans and LactobacillusS.mutans and Lactobacillus
Saliva FlowSaliva Flow
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Categories for Simplified CRACategories for Simplified CRA
Bacterial testing is doneBacterial testing is done
only in cases whenonly in cases when
indicated, if other resultsindicated, if other resultsare not obvious.are not obvious.
>1,000,000 colonies>1,000,000 colonies
s.mutans or >100,000s.mutans or >100,000
lactobacillus = 2lactobacillus = 2 > 4 minutes for 3cc> 4 minutes for 3cc
saliva sample =2saliva sample =2
± ± Indicates possibleIndicates possible
XerostomiaXerostomia
Additional Tests Additional Tests
S.mutans andS.mutans andLactobacillusLactobacillus
Saliva FlowSaliva Flow
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The Simplified Caries IndexThe Simplified Caries Index
FormForm
CARIES INDEX TOTAL
Existing decay Diet Score
Previous Decay Oral HygieneRoot caries Bacterial Test
Fluoride Exposure Saliva Flow
This small form is in a digital template on the computer chart, butcan be printed on standard adhesive labels and attached to thedaily record portion of a paper chart.
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The Diet QuestionnaireThe Diet QuestionnaireDiet Questionnaire Number
How many times a day do you drink:
1. Coffee or tea with sugar between meals?
2. Pop, Kool-aid, lemonade, fruit juice, sports drinks, iced tea with sugar betweenmeals?
How many times a day do you:1. Chew regular gum (Not sugarless)?
2. Eat mints, lozenges, candiesor candy bars, dried fruit, energy bars?
3. Eat sweetened baked goods (Donuts, cookies, pastries) between meals?
Total
Do you have a habit of sipping a sweetened drink (Coffee, cola) or eating a sweet snackover an extended period of time, 45 minutes or more?
Yes = 2
How many glasses of water or dilute drinks do you have a day? This does not includecoffee, soft drinks, full strength juice or sports drinks.
<3 =2
Total divided by 3 = value for caries index
This form is either printed out or displayed on the monitor for thepatient to see during review
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CRA Score and Caries Risk:CRA Score and Caries Risk:
The Total ScoreThe Total Score
00--2 = Low Risk2 = Low Risk
33--4 = Medium Risk4 = Medium Risk
44--6 = High Risk6 = High Risk
>6 = Severe Risk of Caries>6 = Severe Risk of Caries
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CRA Score and Caries Risk:CRA Score and Caries Risk:
Applying the data Applying the data
From this data we can set up customFrom this data we can set up custom
protocols for the individual patients,protocols for the individual patients,includingincluding
Fluoride treatmentsFluoride treatments
Frequency of X Frequency of X--raysrays
Frequency of Recall visitsFrequency of Recall visits
Restorative decisions on borderline lesionsRestorative decisions on borderline lesions Whether to Observe, Seal or RestoreWhether to Observe, Seal or Restore
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Recare Report Recare Report-- Getting theGetting the
message out message out
Patients remember a percentage of what Patients remember a percentage of what
you tell them while in the chair. Theyyou tell them while in the chair. Theytake it far more seriously if they havetake it far more seriously if they havesomething they can take home.something they can take home.
We use a Recare report to give to patients,We use a Recare report to give to patients,or kids parents.or kids parents.
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Recare Report
Procedures done today:Medial History Update Blood Pressure Screening Oral Cancer Scan X-rays
Tooth Examination Periodontal (gum) Examination- TMJ Check
Cavity Risk Assessment PSR Full perio recording Oral Hygiene Evaluation
Recommendations: We would like to see you again in: 3 months 6 months 9 months 1 year
Oral Hygiene- Brushing Good! Too Hard Missing Areas Not Frequent Enough
Other Tools Flossing Sulcabrush Rubber Tip Rotapoints
Superfloss Peridex antibacterial mouthwash Power Floss unit
Diet Factors-
1. Coffee or tea with sugar between meals.
2. Pop, fruit juice, rice milk, sports drinks, Kool-aid or iced tea with sugar between meals.
3. Chewing gum (Not sugarless)?
4. Eating mints, lozenges, candies, dried fruit, chocolate bars.
5. Eating sweetened baked goods (Donuts, cookies, pastries) between meals?
Fluoride Program
Supplements-¼ tablet/day ½ tablet/day Prevident 5000 high-fluoride toothpaste
Fluoride Rinse Fluoride treatment: 3month/ 6 month/ Home treatment
Ongoing issues needing treatment: Decay Gum Disease Failing dental work
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Application In Practice Application In Practice--
TakeTake--home message:home message:
Caries Risk Assessment is an essential part of scientificallyCaries Risk Assessment is an essential part of scientificallybased dentistry in real general practicebased dentistry in real general practice
A practical Caries Risk Assessment takes less than 5 minutes A practical Caries Risk Assessment takes less than 5 minutesto do during a new patient exam, and contributes valuableto do during a new patient exam, and contributes valuabledatadata-- please use my version or your own in your practice, but please use my version or your own in your practice, but use it!use it! Identify your high, medium and low risk patients.Identify your high, medium and low risk patients.
The next part of the presentation will deal with use of this data forThe next part of the presentation will deal with use of this data fortreatment protocols.treatment protocols.
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Dr. Richard EhrlichDr. Richard Ehrlich
www.elmtreedental.comwww.elmtreedental.com
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Part 2:Part 2:Diagnostic, Restorative andDiagnostic, Restorative andPreventive Protocols usingPreventive Protocols usingRisk Analysis and High TechRisk Analysis and High Techinstrumentationinstrumentation
Richard Ehrlich DDSRichard Ehrlich [email protected]@elmtreedental.com
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Tools needed:Tools needed:
The Caries Index Form
CARIES INDEX TOTAL
Existing decay Diet Score
Previous Decay Oral Hygiene
Root caries Bacterial Test
Fluoride Exposure Saliva Flow
In addition to the usual instrumentation
and radiographs for diagnosis:
Diagnodent- DiagnosticLaser caries detector
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Diagnodent LaserDiagnodent Laser
This device can give a numerical reading of earlyThis device can give a numerical reading of early
decay in pits.decay in pits.
With practice, it can be more accurate than visual,With practice, it can be more accurate than visual,tactile or radiographic examinations.tactile or radiographic examinations.
Caution is required around hypocalcifications andCaution is required around hypocalcifications andexisting resins and sealants as the unit mayexisting resins and sealants as the unit maymisread.misread.
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Other adjunctsOther adjuncts-- MagnificationMagnification
LoupesLoupes
Operating MicroscopeOperating Microscope Intraoral CameraIntraoral Camera
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Diagnodent LaserDiagnodent Laser
Readings under 10 have noReadings under 10 have nodecay.decay.
Readings 10Readings 10--20 usually have20 usually havestain or enamel cariesstain or enamel caries
Readings over 35 generally havedecay in dentin.
Readings of 99 are decayed well into dentin.
Readings 20-35 need individual assessment
Diagnodent Readings alone are not sufficient for diagnosis (SeeLiterature Review)
New Technologies:
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Protocols using the toolsProtocols using the tools
At the initial diagnosis, the patient can At the initial diagnosis, the patient can
usually be assigned to a Risk group.usually be assigned to a Risk group. This is reThis is re--evaluated at the next recall, asevaluated at the next recall, as
often the status changes after the initialoften the status changes after the initial
treatment.treatment.
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Low RiskLow Risk-- Initial ProtocolInitial ProtocolCaries Index 0Caries Index 0--22
ObserveObserve pits and fissurespits and fissures
with stain or early decay,with stain or early decay,
decay in enamel, very earlydecay in enamel, very early
(stable) decay in dentin, old(stable) decay in dentin, old
restorations, poor margins.restorations, poor margins.
Diagnodent (DD) < 25Diagnodent (DD) < 25--3030
Restore fractured restorations,
obvious decay (DD>40).
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RestoreRestore old restorations withold restorations withcracks and broken margins,cracks and broken margins,
decay in pits with halo or decay in pits with halo or
shadow, any decay in dentin.shadow, any decay in dentin.
(DD>25(DD>25--30)30)
Medium RiskMedium Risk-- Initial ProtocolInitial ProtocolCaries Index 3Caries Index 3--44
ObserveObserve stained pits, deepstained pits, deep
pits, early decay inpits, early decay in
enamel.enamel. (DD<20)..
Diet Counseling IntroductionDiet Counseling Introduction(link to diet page)(link to diet page)Fluoride Supplements for childrenFluoride Supplements for childrenin non fluoridated areasin non fluoridated areas
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RestoreRestore early decay in enamel andearly decay in enamel anddentindentin..(DD>15(DD>15--20)20)
RestoreRestore old restorations withold restorations withcracks and broken marginscracks and broken margins
High RiskHigh Risk-- Initial ProtocolInitial ProtocolCaries Index >4Caries Index >4
ObserveObserve stainedstained pitspits
DD<10DD<10
Diet Counseling IntroductionDiet Counseling IntroductionFluoride Supplements for childrenFluoride Supplements for childrenPrevident 5000 for AdultsPrevident 5000 for AdultsFluoride varnish on incipient areasFluoride varnish on incipient areas
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First ReFirst Re--evaluationevaluation
All patients are re All patients are re--assessed after the initialassessed after the initialtreatment.treatment.
Many are at reduced risk once initial decayMany are at reduced risk once initial decayis removed, and diet/OH improvements areis removed, and diet/OH improvements areimplemented.implemented.
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High RiskHigh Risk-- First EvaluationFirst Evaluation3 month period3 month period
Caries Risk ReCaries Risk Re--Evaluation, includingEvaluation, including
s. mutans, lactobacillus test
Salivary flow measurement
33--month Topical Fluoride, OHI month Topical Fluoride, OHI
If risk reduced, proceed to Medium RiskIf risk reduced, proceed to Medium Risk
Recare protocolRecare protocol
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Low Risk Suggested ProtocolLow Risk Suggested Protocol
Recall Recall patient every 9 months, consider increasing if remaining lowpatient every 9 months, consider increasing if remaining lowrisk.risk.
No Topical FluorideNo Topical Fluoride
No Fluoride Supplement No Fluoride Supplement Take BW radiographs every 3 yearsTake BW radiographs every 3 years
OHI As neededOHI As needed
ObserveObserve pits and fissures with stain or early decay in enamel, verypits and fissures with stain or early decay in enamel, veryearly decay in dentin.early decay in dentin. (DD<25(DD<25--30)30)
Polish or seal Polish or seal old restorations with poor margins, and observeold restorations with poor margins, and observeSealantsSealants not requirednot required
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Medium Risk Suggested ProtocolMedium Risk Suggested Protocol Recall Recall patient every 6 monthspatient every 6 months
Topical Fluoride for childrenTopical Fluoride for children
Fluoride Supplement for areasFluoride Supplement for areas
without water Fwithout water F-- Take BW radiographs every 2Take BW radiographs every 2
yearsyears
OHI As neededOHI As needed
ObserveObserve stained pits, earlystained pits, earlydecay in enameldecay in enamel or optionallyor optionallysealseal. (DD<15. (DD<15--20)20)
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Medium Risk Suggested ProtocolMedium Risk Suggested Protocol
RestoreRestore pits and fissurespits and fissures
with early decay, anywith early decay, any
very early decay invery early decay in
dentin, old restorationsdentin, old restorations
with poor margins.with poor margins.
(DD>20)(DD>20)
Polish or sealPolish or seal oldold
restorations with fair restorations with fair
margins, and observe.margins, and observe.
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High Risk Suggested ProtocolHigh Risk Suggested Protocol
Full diet counsellingFull diet counselling with diarywith diary
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High Risk Suggested ProtocolHigh Risk Suggested Protocol Full diet counselingFull diet counseling with diarywith diary
RecallRecall patient every 3 months:patient every 3 months:
± ± Topical FluorideTopical Fluoride
± ± Fluoride Varnish on susceptible areasFluoride Varnish on susceptible areas
± ± Take BW radiographs yearlyTake BW radiographs yearly
± ± OHIOHI
Home Fluoride Trays or Prevident 5000Home Fluoride Trays or Prevident 5000
Chlorhexidine RinsesChlorhexidine Rinses ± ±Adult Adult-- 30 seconds before bed30 seconds before bed
XylitolXylitol--containing gumcontaining gum-- 3 pieces daily3 pieces daily
Fluoride SupplementsFluoride Supplements--ChildChild
EvaluateEvaluate for xerostomiafor xerostomia
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RestoreRestore pits with earlypits with early
decay, any very earlydecay, any very early
decay in dentin or decay in dentin or
enamel,enamel, (DD>20)(DD>20) oldoldrestorations with fair restorations with fair--
poor margins.poor margins.
Sealants/Preventve resinsSealants/Preventve resins--
all deep pits and fissures.all deep pits and fissures.
((DD>5DD>5--20)20)
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Often high risk kids present withOften high risk kids present with
early decay or deep pits inearly decay or deep pits inbarely erupted teeth.barely erupted teeth.
New Technologies:New Technologies:
These can be very hard to sealdue to access or co-operationissues. If there is any moisturecontamination, traditional
sealants will fail.
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FluorideFluoride--releasing sealantsreleasing sealants forfor
suspect pits with poor accesssuspect pits with poor access
Fuji Triage can be placed quickly andFuji Triage can be placed quickly andeasily, needing very little cooperation.easily, needing very little cooperation.
New Technologies:New Technologies:
Due to the fluoride release, it Due to the fluoride release, it is less likely than traditionalis less likely than traditionalsealants to allow decay belowsealants to allow decay belowif it leaks.if it leaks.
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Digital RadiographyDigital Radiography
New Technologies:New Technologies:
Allows lower dose exposures. Resistance from patients is reduced.Allows lower dose exposures. Resistance from patients is reduced.
Results are instant.Results are instant.
Patient Education is enhanced as they can see radiographs enlarged inPatient Education is enhanced as they can see radiographs enlarged in
front of them. Diagnosisfront of them. Diagnosis may may be enhanced.be enhanced.
Essential for online communication with specialists.Essential for online communication with specialists.
Complete offsite backup is possible.Complete offsite backup is possible.
Sensors are larger and placement takes some practice.Sensors are larger and placement takes some practice.
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Diagnodent PenDiagnodent Pen
New Technologies:New Technologies:
Smaller and more portable version released in 2006Smaller and more portable version released in 2006
Ability to read interproximal lesionsAbility to read interproximal lesions
Less fragile cable, less chance of damageLess fragile cable, less chance of damage
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Ozone Treatment of pitsOzone Treatment of pits A promising new technique A promising new technique
involves sterilizing the pitsinvolves sterilizing the pitsand fissures with ozone. Thisand fissures with ozone. Thishas been shown to stophas been shown to stopdecay and even allowdecay and even allowremineralizationremineralization
This may make cooperationThis may make cooperationeven easier in earlyeven easier in early
interventionintervention More research is neededMore research is needed
here.here.
New Technologies:New Technologies:
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1. Cleaning
2. Measurement
3. Treatment
4. Reductant Fluid
Promotes the immediate
remineralization of the tooth.
Proposed steps in Healozone Treatment
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DIFOTI (Digital Imaging Fiber DIFOTI (Digital Imaging Fiber--Optic TransOptic Trans--IlluminationIllumination))New Technologies:New Technologies:
This device createsThis device creates highhigh--resolution digital images of resolution digital images of
occlusal, interproximal and smooth surfaces. It enablesocclusal, interproximal and smooth surfaces. It enablesdentists to discover or confirm the presence of decay thatdentists to discover or confirm the presence of decay that
cannot be seen radiographically, visually or through use of cannot be seen radiographically, visually or through use of
an explorer an explorer
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DIFOTI (Digital Imaging Fiber DIFOTI (Digital Imaging Fiber--Optic TransOptic Trans--IlluminationIllumination))
New Technologies:New Technologies:
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Air AbrasionAir Abrasion
New Technologies:New Technologies:
This technology allows earlyintervention more conservatively thanrotary instruments.
Pits with stain, decay in enamel andvery early dentin decay (DD 5-30) can
be treated, almost always without localanaesthetic.
Any restorative prep can be cleaned out with this unit, allowing better bonding.
Air Abrasion is excellent for cleaningany prosthesis that needs bonding in the
mouth, from crowns and posts to fixedortho.
You cannot remove amalgams or treat larger lesions.
Auxilliary suction is needed.
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MicrobursMicroburs
New Technologies:New Technologies:
Low-tech way to access verysmall pits. ¼, 1/8 and 1/16round burs are available for highspeed handpieces.
Can treat some early pits andgrooves almost as well as lasersor air abrasion.
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Laser Laser-- Water unitsWater units
New Technologies:New Technologies:
This technology is similar in applicationto Air Abrasion units, but moreversatile.
Pits with stain, decay in enamel andearly dentin decay (DD 5-30) can be
treated, almost always without localanaesthetic.
Soft tissue can be trimmed as well.
There is less chance of injuring soft tissue with overspray.
There is no powder spray mess, soauxilliary suction is not needed.
Like Air Abrasion, you cannot removeamalgams or easily treat larger lesions.
These units cost 20-50X more than airabrasion units, and are much larger.
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Application In Practice Application In Practice--
TakeTake--home message:home message: Identify your high, medium and low risk patients.Identify your high, medium and low risk patients.
Treat them differently based on their risk levels.Treat them differently based on their risk levels.
Aim to convert all your patients to low risk, or at least reduce their Aim to convert all your patients to low risk, or at least reduce their
caries index.caries index.
Do not overDo not over--treat your lowtreat your low--risk patientsrisk patients. They need their own. They need their ownpreventive and restorative protocols.preventive and restorative protocols.
Do not underDo not under--treat your high risk patientstreat your high risk patients. They need every. They need everypreventive and early intervention restorative measure you can givepreventive and early intervention restorative measure you can give
them, especially if they cannot convert to lower risk.them, especially if they cannot convert to lower risk.
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Summary Flow Chart Summary Flow Chart--
This flow chart isThis flow chart isavailable from my webavailable from my webpage at page at
www.elmtreedental.comwww.elmtreedental.com
Caries Risk- Diagnostic, Restorative and Preventive Protocols
Low Risk Medium Risk High Risk
Low Risk Medium Risk High Risk
Initial DiagnosisCaries Risk Analysis
Observe pits and fissureswith stain or early decay,decay in enamel, very early(stable) decay in dentin, oldrestorations, poor margins.
(DD < 25-30)Restore fractured
restorations.
Observe stained pits, deeppits, early decay in enamel.(DD<20)Restore old restorations withcracks and broken margins,decay in pits with halo or shadow, any decay in dentin.(DD>25-30)
Diet Counselling Intro.
Initial ProtocolObservestained pits.Restore early decay inenamel and dentin.(DD>15-20) Restore old restorations withcracks and broken margins.Diet Counselling IntroFluoride- Supplements for children, Prevident 5000 for adults
3 Month RecareCaries Risk Re-Evaluations. mutans, lactobacillus testSalivary flow measurementFluoride, OHI
Caries Risk AnalysisRe-evaluation
Recall patient every 9months, consider increasing if remaininglow risk.No Topical FluorideNo Fluoride SupplementTake BW radiographsevery 3 yearsOHI As neededObservepits andfissures with stain or early decay in enamel,very early decay indentin. (DD<25-30) Polish or seal oldrestorations with poor
margins, and observeSealants not required
Recall patient every 6 monthsTopical Fluoride for childrenFluoride SupplementTake BW radiographs every 2yearsOHI As neededObservestained pits, earlydecay in enamel (DD<15-20) or optionally seal.Restore pits and fissures withearly decay, any very earlydecay in dentin, oldrestorations with poor margins. (DD>20) Polish or seal old restorations
with fair margins, and observe.Sealants are optional
Full diet counselling with diaryRecall patient every 3 months:Topical FluorideFluoride Varnish on prone areasHome Fluoride Trays,Chlorhexidine Rinses -AdultFluoride Supplements-ChildXylitol GumTake BW radiographs yearlyOHIEvaluate for xerostomiaRestore pits with any very earlydecay in dentin or enamel, (DD>20) old restorations with fair- poor margins.Sealants/Preventve resins- alldeep pits and fissures. (DD>5-20) Fluoride-releasing sealants wherepossible
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SummarySummary
A system of numerically rating a patients A system of numerically rating a patientscaries risk has been presentedcaries risk has been presented
Protocols for minimal invasive andProtocols for minimal invasive andpreventive treatment for low risk patientspreventive treatment for low risk patientsand maximal preventive and earlyand maximal preventive and early
restorative treatment for high riskrestorative treatment for high riskpatients have been demonstrated, topatients have been demonstrated, toallow custom treatment for eachallow custom treatment for each ppatient.atient.
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Thank youThank you
Dr. Richard EhrlichDr. Richard Ehrlichwww.elmtreedental.comwww.elmtreedental.comdre@[email protected]
905905--880880--70037003