CONTINUING EDUCATION 1

CARIES RISK ASSESSMENT

Bridging the Gap Between Preventive and
Restorative Dentistry: Identification of Caries
Risk Factors and Strategies for Minimizing Risk
Pamela Maragliano-Muniz, DMD
LEARNING OBJECTIVES
Abstract: Following the introduction of CAMBRA (Caries Management by Risk
Assessment) in 2007, a number of recommendations for office protocols were
introduced, and many companies have formulated products and procedures for
implementing CAMBRA. As a result, the implementation of a caries manage-
ment program can be confounding and overwhelming to a dental practitioner.
Understanding risk factors as they contribute to the caries process can help
mitigate confusion and guide the practitioner when selecting materials for their
practice. Ultimately, knowing how the risk factors play a role in the progression
of dental caries will lead to appropriate risk management and product recommendations. The purpose of
this article is to discuss the contribution of risk factors to the caries process and to introduce strategies that
restorative dentists can utilize to minimize caries risk.
list the risk factors asso-
ciated with dental caries
describe the role that
risk factors play in the
disease process
discuss how the use
of preventive and re-
storative materials can
minimize carles risk
C
AMBRA (Caries Management by Risk Assessment)
was introduced in the Journal of the California Dental
Association' in 2007, and recommendations for office
protocols have been subsequently introduced.^ Many
risk factors contribute to the development of dental
caries.''"* Some risk factors may mildly increase one's risk, while
some present an imminent risk. It is crucial to identify which risk
factors are present, and having an understanding of how risk factors
contribute to the disease process is highly useful to the practitioner.
Historically, it was understood that for caries to occur, a tooth, a
fermentable carbohydrate, and bacteria must to be present.'' Recent
research suggests that although this supposition is correct, as car-
bohydrates are metabolized by bacteria, the decrease in the pH will
greatly contribute to the caries process.""
pH and Dental Caries
Marsh' proposed the Ecological Plaque Hypothesis, which is a hy-
brid of the Non-specific and Specific Plaque Hypotheses." He stated
that cariogenic bacteria may occur naturally in dental plaque. In the
presence of a low pH, these potentially cariogenic bacteria become
increasingly competitive. It is prudent for the dental practitioner to
keep in mind that in health, the elements for disease (carbohydrate
metabolism by potentially cariogenicbacteria) are continually present.
Disease occurs when tlie environment shifts to facilitate the disease
process. These environmental shifts are implications of an oral cavity
with a lowpH for a prolonged period of time and increased numbers of
acidogenic bacteria. The increased acid due to the increased numbers
of acid-producing bacteria will lead to demineralization and caries.
Many risk factors predispose the oral cavity to increased levels of
bacteria and a prolonged oral environment with a low pH."^
Caries Risk Assessment
Risk Assessment and Documentation
There are several risk assessment questionnaires available. These
questionnaires are generally reviewed with the patient, who is sub-
sequently assigned to a caries risk category.'^ A simplified alterna-
tive to the risk assessment document is to assess a patient's medial
history, medications, habits, oral hygiene practices, and clinical
presentation, and document the findings into the clinical record.'"
Some factors contribute to a patient's overall caries risk but do not
place the patient at immediate risk. These factors include: diet high
in fermentable carbohydrates, gingival recession, poor oral hygiene.
664 COMPENDIUM October 2013
Volume 34, Number 9
deep pits and fissures (occlusal anatomy), and growing up without
access to fluoride. Conversely, there are other risk factors that place
a patient at an immediate risk for developing new dental caries.
These include: xerostomia (inchiding low salivary flow and/or poor
quality of saliva), caries within 3 years, presence of incipient caries
or demineralization, patients undergoing orthodontic treatment,
recreational drug use, extensive restorations, removable partial
dentures, fixed partial dentures, smoking, and direct contact with
people with infectious bacteria (Table 1).
Adjuncts for Determining Caries Risk
Practitioners may utilize adjunctive tools for aiding in determin-
ing caries risk. These include: salivaiy flow tests,"* caries bacterial
activity tests, pH tests," and plaque-disclosing agents. These tools
not only aid the practitioner determine caries risk, but they may
also motivate patients to improve their dietary habits, oral hygiene
practices, or product choices to create an oral environment that
is less favorable for the formation or progression of dental caries.
Cari es Risk Fact ors
Medical Conditions and Medications
There are numerous medical conditions that contribute to one's
caries risk. The impact of the patient's medical histoiy on dentistiy
Caries Risk Factors
INCREASES RISK
Poor oral hygiene
Growing up without access to fiuoride
Deep pits and fissures
Diet high in fermentable carbohydrates
HIGH RISK
Xerostomia (low salivary flow/poor quality of saliva)
Active caries
Caries incidence within 3 years
Incipient caries/demineralization
Orthodontics
Recreational drug use
Extensive restorations
Removable partial dentures
Fixed partial dentures
Smoking
Contact with cariogenic bacteria
Poor host response
Dental caries is a multifactorial infectious disease. Some factors contribute to caries
risk ("Increases Risk"), and some factors present an immediate high risk ("High
Risk") for the development of dental caries. If many high risk factors are present, the
patient will be at an extremely high risk for dental caries, and additional preventive
measures should be taken to prevent tbe development of disease.
is extraordinarily important; however, the impact of dental health
on a patient's systemic health must also be considered. Many sys-
temic conditions and medications can increase a patient's risk for
tooth decay. Conversely, research has discovered that cariogenic
bacteria has a role in systemic disease, specifically upper respira-
tory infections, pneumonia,'^ and cardiovascular disease.'^
Many systemic conditions or their treatment cause low salivary
flow, which leads to xerostomia, which greatly increases one's risk
for caries. Systemic conditions that lead to xerostomia include:
diabetes mellitus, hypertension, anxiety, depression, Sjgrens
syndrome, systemic lupus erythematosus, rheumatoid arthritis,
bells palsy, scleroderma, and HIV. Many treatments will addition-
ally lead to xerostomia, including, but not limited to, medications,
chemotherapy, or radiation therapy." Additionally, digestive dis-
orders such as helicohacterpylori,^^ uncontrolled acid reflux,"* and
the eating disorder bulimia nervosa" greatly lower oral pH or
erode the enamel surface, exposing dentin. Prolonged exposure to
an acidic oral environment will allow cariogenic bacteria to thrive
and will increase risk for demineralization or caries. Dentin is less
resistant than enamel to the acid insult of cariogenic bacteria, and
exposed dentin is more likely to develop caries than intact enamel.
More than 400 medications list xerostomia as a side effect. When
a patient is on multiple medications, the severity of xerostomia in-
creases exponentially. In 2003, Cassolato and Turnbull stated that
the following medications reduce the output of the salivary glands
due to the inhibition of signaling pathways: antipsychotics, tricyclic
antidepressants, selective serotonin reuptake inhibitors, antihyper-
tensives, sedatives, and antihistamines.'" It is worthwhile for the
dental practitioner to investigate the side effects of any medication a
patient is taking, as it often impacts dental treatment or predisposes
the patient to have dental caries secondary to xerostomia.
Clinical Considerations for Minimization of Caries Risk
Athorough medical history and an update of the patient's health
history, including medications or recreational drug use at each
appointment: Exploring for the presence of potential side effects
of prescribed, recreational, and over-the-counter medications
will aid the practitioner in evaluating whether the use of medica-
tion is a contributing factor in caries risk.
Evaluation of caries risk at each recare appointment: This is nec-
essary because a patient's medical history or list of prescribed
medications may change between visits, which may result in
changes in the patient's caries risk classification.
Xerostomia
A patient's subjective recognition of xerostomia may not be reliable.
This condition may be a gradual process and go unnoticed for some
patients, while others may experience a significantly diminished
quality of life due to the discomfort of severe xerostomia. To coun-
teract the discomfort, many patients opt for sugary candies, drinks,
or snacks in an attempt to stimulate salivation. When a patient in-
gests food or a beverage with an acidic pH, the result is an acidic oral
environment that is conducive to the progression of dental caries. A
healthy salivary flow vll help facilitate rebound of the pH back to
neutral in approximately 30 minutes. In contrast, when someone
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October 2013 COMPENDIUM 665
CONTINUING EDUCATION 1 I CARIES RISK ASSESSMENT
with xerostomia eats or drinks, the pH will drop, but it may take 2
or more hours for the pH to rebound.''^ Consider that when a patient
with xerostomia is sipping on juice or using lozenges or candies to
keep their mouth moist, these patients, in theoiy, may have an acidic
oral environment for considerable of periods of time (Figure 1).
The role of saliva is important to consider, because saliva has
immunoglobulins, buffering agents, calcium, and phosphate that
will protect teeth against dental caries.-" In patients with normal
salivary flow, the saliva can naturally help to reniineralize teeth,
especially when in the presence of fluoride, calcium, and phos-
phate. When patients do not have an adequate salivary flow, they
do not have the natural reserve of calcium and phosphate, leaving
them defenseless against the acid insult that occurs when eating
or drinking substances that have a low pH or contain fermentable
carbohydrates.
Lack of saliva also changes the consistency of dental plaque.
Wlien a patient has an inadequate salivaiy flow, the plaque becomes
stickier, thicker, and more diflicult to remove.-'-^- If a patient with
historically good oral hygiene presents to the oflice with an unchar-
acteristic amount of plaque on his or her teeth, it is prudent for the
clinician to consider the onset of xerostomia, as well as inquiring
about changes in oral hygiene practices.
Clinical Considerations for Minimization of Caries Risk
Patients that suflfer from xerostomia can benefit from the following:
Nutritional counseling: The clinician can help guide patients
to make diet selections that do not increase the risk for dental
caries, including non-cariogenic food and snack selections and
limiting sugar in the diet and drinks.
Xylitol: This naturally occurring sweetener is commonly found
Stephan Curve: Effect of Saliva
pH
6.5
6.0
5.5
5.0
_L
I I
5 10 15 20
Minutes after sucrose rinse
Saliva restricted
Saliva not restricted
Fig 1. Comparison of the rebound of oral pH after exposure to a sucrose
rinse in a patient with adequate salivary flow versus a patient with
restricted salivary flow. Note that after 20 minutes, the pH of the patient
with adequate saiivary flow returns to baseline; in the patient with re-
stricted salivary flow, the pH continues to drop after 20 minutes."
in chewing gum, mints, and oral sprays. Xylitol is recommended
as an adjunct for caries management due to its bacteriostatic
properties and ability to raise oral pH by stimulating saliva-
tion. For high- or extremely high-risk patients, 6 to 9 grams of
xylitol is recommended daily.* However, ingesting greater than
the recommended dosage may contribute to gastric distress
and should be discouraged. In addition, xylitol may be harmful
to dogs,^-' and patients should be encouraged to keep xylitol
products away from pets.
Restoration of minerals: To restore the lost minerals that natu-
rally occur in saliva, topical application of pastes containing fluo-
ride, calcium, and phosphate can promote remineralization, halt
the caries process, and prevent the occurrence of dental caries.-*
pH neutralization strategies: The use of products that contain
sodium bicarbonate is recommended to neutralize an acidic
oral environment.
Poor Oral Hygiene
Most people have caries-causing bacteria in their dental plaque. In
health, there tends to be low numbers of bacteria, and the frequent
disturbance of the biofilm during tooth brushing and fiossing will pre-
vent demincralization or cavitation of a tooth. Wlien large amounts
of plaque are present due to inadequate oral hygiene, the number of
anaerobic and acidogenic bacteria increases. According to Marsh, in
the presence of a low pH, coupled with a fermentable carbohydrate,
these bacteria thrive. The bacteria will produce acidic byproducts
from the metabolism of the fermentable carbohydrate, and demin-
eralization of a tooth can occur.*" Continuous demineralization of a
tooth without equal remineralization will lead to cavitation.
Optimal oral hygiene is challenged when a patient undergoes
fixed orthodontic therapy; it is essential, therefore, that the pa-
tient receive oral hygiene education to prevent the accumulation
of plaque and calculus on the teeth and around the orthodontic
appliances. Excessive plaque around orthodontic appliances often
results in the formation of white spots or demineralized areas of
the enamel surface (Figure 2).
Clinical Considerations for Minimization of Caries Risk
Indiwdualized oral hygiene instructions: Disruption of the col-
onies within the plaque biofilm will prohibit the formation of
virulent complexes that can potentially destroy the tooth and
periodontium.
Minimally invasive-" white spot removal: Demineralized enamel
often presents as a white or brown "spot" on the tooth surface.
Systematic treatment with pastes containing calcium and phos-
phate can remineralize these surfaces and result in the minimi-
zation or removal of the "spot"-'' (Figin"e 3).
Gingival Recession
A patient is at an increased risk for caries when root surfaces are ex-
posed to the oral cavity.-' Cementum is less mineralized then enamel
and, therefore, less resistant to caries. Early demineralization of root
surfaces may appear clinically as rough, dull, or discolored, whereas
occult root caries may present with significant discoloration and
cavitation of the root surface.^^
666 COMPENDIUM October 2013
Volume 34. Number 9
Clinical Considerations for Minimization of Caries Risk
Fluoride varnish: According to the American Dental Association
Council on Scientific Affairs, fluoride varnish treatments ai-e more
comfortable for patients, and the result is improved compliance.^''
Fluoride varnishes offer a concentrated application of fiuoride,
calcium, and phosphate and have been shown to consistently
reduce the risk for caries;'" Clinicians should be cognizant that
the application recommendations vaiy for different products and
that the manufacturer s instructions should be reviewed.
Individualized oral hygiene instructions: It is essential for pa-
tients to be instructed to clean root surfaces without damaging
cementum. Adjunct oral hygiene tools may be necessary for
efficient plaque removal in areas with wide embrasures or teeth
with fiu'cation involvement.
Deep Occlusal Anatomy
A tooth witli deep or well-defined occlusal anatomy presents a great-
er risk for caries, because it has a greater risk for plaque retention.''
Clinical Considerations for Minimization of Caries Risk
Sealants: It is well documented that glass ionomers offer a viable
option for pit and fissure sealants.^'"'" They have a similar longevity
to their resin-based counterparts; however, glass-ionomer-based
sealants offer the added benefit of 400 ppm fluoride release over 4 to
6 months.-''*'''"' Moreover, glass-ionomer sealants are "rechargeable"
and permeable to fluoride, calcium, and phosphate to the surface
of the tooth. In addition, glass ionomer is an inherently hydrophilic
material and is less technique-sensitive than resin-based sealants?*
Caries Incidence within 3 Years/Incipient Caries -
Radiographie or Clinical
When a patient presents with caries within a 3-year period it is
considered recent dental breakdown. Featherstone states that for
a restoration placed within the past 3 years, clinical caries, radio-
graphic interproximal lesions (into dentin or confined to enamel),
and white spots on smooth surfaces are "strong indicators for ftrture
caries activity and unless there is nonsurgical therapeutic interven-
tion, the likelihood of future cavities or the regression of existing
lesions is very high."' After a patient is caries-free for 3 years and
risk factors have been eliminated or controlled, a practitioner may
consider classifying the patient into a lower risk category.
Clinical Considerations for Minimization of Caries Risk
Fluoride varnish treatments.
Pastes containing calcium and phosphate.
Xylitol.
pH neutralization strategies.
Extensive Restorative History/Fixed or
Removable Prosthodontics
Patients with extensively restored teeth are at an increased risk
for caries. Despite a practitioner's best efforts, most restorations
fail at the tooth-restoration interface, and when a patient is at an
increased risk for dental caries it is likely that the lifespan of the
restoration will be greatly diminished. In addition, patients that
present with extensive dental treatment indicate a past history of
deterioration of dental health, and if the dental disease was arecent
occurrence there is a high likelihood of recurrence. Identification of
caries risk factors and minimization of risk is essential to improve
the lifespan of dental restorations and prevent recurrence of disease.
Removable Partial Dentures (RPDs)Patients that wear remov-
able partial dentures are at an increased risk for dental caries due to
the increased likelihood that caries^' will develop along the surfaces
on abutment teeth adjacent to the minor connectors and guide
planes of the RPD framework. According to Budtz-Jrgensen and
Isidor, the caries rate was six times higher for the RPD group than
the control groups -within their 5-year study.^**-^"*
Fixed Partial Dentures (FPDs)The average lifespan for fixed
partial dentures is approximately 10 years, and the long-term prog-
nosis of the FPD becomes less favorable as the span of the FPD
increases.'*" The most common mode of failure is dental carles'"
around the margins of abutment teeth; therefore, it is essential to
provide additional protection of the abutment teeth to minimize
restorative failures due to dental caries.
Clinical Considerations for Minimization of Caries Risk
Individualized oral hygiene instruction, specifically around abut-
ment teeth for RPDs and around the margins of fixed prosthetics.
Fig 2. Patient with demineralization on the enamei surfaces of the maxiiiary anterior teeth. These teeth were treated by etching the enamei with 35%
phosphoric acid and burnishing amorphous caicium phosphate-casein phosphopeptide (ACP-CPP) paste onto the tooth surfaces. Fig 3. Two months
postoperative after remineralization of the enamei surface with ACP-CPP paste. Note the fading of the white-spot iesions on the maxiiiary anterior teeth.
www.compendiumlive.com October 2013 COMPENDIUM 667
CONTINUING EDUCATION 1 | CARIES RISK ASSESSMENT
Frequent recare*^ visits to evaluate for demineralization of abut-
ment teeth or around margins of fixed restorations.
Paste containing calcium and phosphate.
Fluoride varnish treatments at recare visits.
Conclusion
Providing restorations that have long-lasting outcomes requires
more than exceptional clinical skills. The assessment of factors
that contribute to a patient's disease process and the minimization
of risk will aid the practitioner in providing restorations with the
most favorable outcome. Additionally, this approach to patient care
promotes cooperation between the dental practitioner and patient
and can thereby aid in achieving optimal oral health.
ABOUT THE AUTHOR
Pameta Maragliano-Muniz, DMD
Assistant Clinical Professor, Tufts University School of Dental Medicine, Boston,
Massachusetts; Private Practice specializing in Prosthodontics, Boston, Massachusetts
Queries to the author regarding this course may be submitted
toauthorqueries@aegiscomm.com.
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668 COMPENDIUM Octoher2013
Volume 34, Number 9
CONTINUING EDUCATION 1
Bridging the Gap Between Preventive and Restorative Dentistry:
Identification of Caries Risk Factors and Strategies for Minimizing Risk
Pamela Maragliano-Muniz, DMD
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1.
2.
3.
4.
5.
Recent research suggests that as carbohydrates are
metabolized by bacteria, the decrease in what will greatly
contribute to the caries process?
A. pH
B. demineralization
C. acid
D. dental plaque
Risk factors that place a patient at an imnfiediate risk for
developing new dental caries include:
A. gingival recession.
B. deep pits and fissures.
C. xerostomia.
D. ali of the above
Adjunctive tools for aiding in determining caries risk include:
A. salivary flow tests.
B. caries bacterial activity tests.
C. plaque-disclosing agents.
D. all of the above
Evaluation of caries risk should be done at each recare
appointment because:
A. the dental hygienist has time to do it.
B. patients are more likely to disclose information relating to their
habits to the dental hygienist.
C. caries risk factors may change between visits, which may
impact a patient's caries risk classification.
D. The dental hygienist will make product recommendations to
the patient.
A healthy salivary flow will help facilitate rebound of pH back to
neutral in approximately:
A. 30 seconds.
B. 30 minutes.
B. 2 hours.
C. 15 hours.
6.
7.
8.
9.
10.
Clinical considerations for minimization of caries risk for
patients with xerostomia include:
A. nutritional counseling.
B. use of xylitol.
C. restoration of minerals by topical application of pastes
containing fluoride, calcium, and phosphate.
D. all of the above
Excessive plaque around orthodontic appliances often results in:
A. the need for veneers.
B. the formation of white spots or demineralized areas of the
enamel surface.
C. gingivitis.
D. a conservative crown preparation.
Occult root caries may present:
A. as rough or dull.
B. with significant discoloration.
C. with cavitation of the root surface.
D. B and C
A practitioner may consider classifying a patient into a lower
risk category after the patient is caries-free for how long and
risk factors have been eliminated or controlled?
A. 3 years
B. 18 months
C. 6 months
D. 3 months
Patients that wear removable partial dentures are at an
increased risk for dental caries due to the increased likelihood:
A. that caries will develop along the surfaces on abutment teeth.
B. of periodontal disease.
C. that the denture teeth will fracture.
D. that the denture base will fracture.
Course is valid from 10/1/2013 to 10/31/2016. Participants
must attain a score of 70% on each quiz to receive credit. Par-
ticipants receivinga failing grade on any exam will he notified
and permitted to take one re-examination. Participants will
receive an annual report documenting their accumulated
credits, and are urged to contact their own state registry
boards for special CE requirements.
ComiNuiNG EDUCATION RECOGNITION PROGRAM
AEGIS Publications, LLC. is an ADA CERP Recognized
Provider. ADA CERP is a service of the American Dental
Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does not
approve or endorse individual courses or instructors, nor does
it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed
to the provider or to ADA CERP at www.ada.org/cerp.
A
Academy
of General Dentistry
PACE
Approved PACE Program Provider
FAGD/MAGD Credit
Approval does not imply acceptance
by a state or provincial board of
dentistry or AGD endorsement
1/1/2013 to 12/31/2016
Provider ID# 209722
www.compendiumlive.com October 2013 COMPENDIUM 669