Escolar Documentos
Profissional Documentos
Cultura Documentos
INTRODUCTION
Demographic and epidemiological evidence show a decreasing trend of edentulism amongst elderly
subjects1'2. Despite various preventative measures case studies have shown that root caries are
concomitant in subjects 50 years and older, often developing as multiple lesions1>2. Several studies
have associated the acidic bacteria mutans streptococci (MS) and lactobacilli (L) and the acidic organism
yeast to the development of dental caries 1'3-5'14'10'15i |n addition other studies have related
these cariogenic microorganisms as risk indicators in the development of root caries in the elderly 1>3>5'7'8.
The prevalence of moderate to severe periodontal conditions, gingival recession, polypharmacia, full and
partial dentures inhibit and promote the retention of plaque thereby increasing salivary concentrations of
MS, L and yeasts 1>3~6. These conditions create an increased need for treatment and preventive care by
placing the remaining dentition at risk through the exposure of root surfaces and the harbouring of
bacteria around vital and healthy abutments 6 Billings et al, findings indicate that there are no conclusive
evidence to suggest any differences between the formation and disease process of coronal and root
caries lesions 1>7. Indeed, continual research has significantly altered and improved the clinicians
understanding of this disease process. Despite this prevention remains a primary treatment modality9'22.
The current basis of prevention constitutes plaque removal from root surfaces and dietary education9
Unfortunately the clinical diagnosis, treatment and management of primary root caries has proven to be
difficult due to continual uncertainty behind its aetiology and pathogenesis therefore education on the
process and formation of primary root caries remains a barrier1>5>7. Joshi et al, performed an analysis of
the diagnosis, treatment and filling of root caries lesions and noted that lesions identified by the dental
professional did not meet the epidemiological criteria requiring them to be filled2. It was also noted that
the filling may exceed the actual surfaces occupied by the lesion2. Hence, the accurate identification of
these lesions continues to be problematic. Consequently, the improvement in diagnostic aids for primary
Other studies have found that the effectiveness of antimicrobial agents and fluoride rely on their ability to
inhibit bacterial metabolism therefore, the employment of these chemotherapeutic agents has shown
promise towards the further prevention of root caries5>7'9-11. For example, chlorhexidine (CHX) has been
demonstrated to decrease salivary concentrations of MS, L and yeasts8>10>12'16. Nonetheless, the primary
goal of the dental professional still remains prevention and/or intervention in the formation of primary root
caries. Although antimicrobial agents have been available and prescribed for many years their potential
therapeutic benefits have not yet been fully appreciated and dental professionals continue to strictly
employ the use of fluoride at regular maintenance intervals. The purpose of this paper is to establish a
comprehensive model for the clinician in the assessment and identification of risk indicators in the
development of primary root caries. In addition, promote the efficacy of antimicrobial agents, specifically
chlorhexidine in the prevention and intervention of primary root caries in geriatric clients.
PREVENTION
Research groups have currently used salivary levels of mutans streptococci (MS) and lactobacilli (L) to
identify at risk dentate geriatric subjects3. A common bacteria found in root caries lesions are MS 1<7'10>14.
This may be associated with their various biochemical factors enabling them to metabolize sucrose to
produce extracellular water- insoluble polysaccharides and use carbohydrates to synthesize intracellular
polysaccharides 1. Without effective removal of bacteria their by-products adhere and accumulate on
exposed smooth surfaces making teeth vulnerable to primary root caries and after it is diagnosed the
prognosis of infected teeth declines as this disease progresses rapidly 1. Additional findings suggest that
the incorporation of chlorhexidine (CHX) into various treatment modalities and methods of delivery may
further suppress salivary levels of MS, L, and yeasts 1>3'9'16 For example, various case studies have
shown that supervised daily or weekly rinsing with CHX, and/or CHX/xylitol gum may control root caries in
the dentate elderly by decreasing salivary concentrations of MS, L and yeasts 10l13> 15~17> 19'21'23-24. other
studies, involving a 1% CHX gel or CHX gel coupled with stannous fluoride gel suggest that it may be
effective in suppressing primary and recurrent root caries in the margins of restorations by inhibiting the
presence of MS1'3'8'9'11'12'18.
CONCLUSIONS
Table 2 presents risk indicators associated with root caries they can be seen to have biological,
physiological, behavioural and social determinants, hence root caries can be viewed as a lifestyle
disease2>5'6. The inadequate removal of cariogenic microorganisms and their production of cariogenic
substrates leads to the continual presence of plaque on gingivally recessed and abutment teeth of partial
dentures. However, exposure to potential pathogenic risk indicators does not necessarily predict the
occurrence or recurrence of this disease. We must bear in mind that the formation of primary root caries
is multi-factorial by nature and the sequelae of this disease is periapical lesion therefore, it is
essential to utilize a multi-focused approach towards its treatment and prevention. Billings & Bantings
state that once the disease process of root caries is understood it will provide clinicians with a greater
opportunity towards successful prevention and therapeutic outcomes, until then the development of
Socio-economic factors may preventing access to the services a dental professional is capable of
providing therefore, a simplistic approach to prevention should be sought. The first approach to
prevention should be a risk assessment of the geriatric client (Table 1) followed by education on their diet.
For example, xerostomia may relate to an increase in the consumption of fluids such as, soft drinks and
fruit juices - increasing exposure to sugar-containing substances. The second approach should be the
habitual use of oral hygiene aids to ensure the adequate removal of retained plaque from root surfaces.
Unfortunately, the effective removal of plaque may be compromised due to elderly subjects experiencing
In closing, it is a well-documented fact that chlorhexidine is successful in reducing dental plaque, caries
and gingivitis in humans the reasons for this are its bactericidal action against gram-positive and gram-
negative bacteria and yeasts9. It is therefore likely that the supplemental use of chlorhexidine in the form
of rinses, gels, varnishes and gums may be either specifically or synergistically employed as a part of a
multi-focused approach in the prevention of root caries in the elderly dentate population.
REFERENCES
1. Lynch E, Beighton D. Relationships between mutans streptococci and perceived treatment need of
primary root-caries lesions. Gerodontology 1993; 10(2): 98-104.
2. Joshi A, Papas A S, Giunta J. Root caries incidence and associated risk factors in middle-aged and
older adults. Gerodontology 1993; 10(2): 83-89.
4. Steele J G, Sheiham A, Marcened W, Fay N, Walls A W G. Clinical and behavioural risk indicators
for root caries in older people. Gerodontology 2001; 18(2): 95-101.
5. MacEntee M I, Clark D C, Click N. Predictors of caries in old age. Gerodontology 1993; 10: 80-97.
6. Steele J G, Walls A W G, Murray J J. Partial dentures as an independent indicator of root caries risk
in a group of older adults. Gerodontology 1998; 14: 67-74.
7. Billings R J, Banting D W. Future directions for root caries research. Gerodontology 1993; 10(2):
114-119.
8. Lynch E. Antimicrobial management of primary root caries lesions: a review. Gerodontology 1996;
13(2): 118-129.
11 Schaeken M J, van der Hoeven J S, van den Kieboom C W. Effect of chlorhexidine varnish on
streptococci in dental plaque from occlusal fissures. Caries Res 1994; 28(4): 262-266.
12 Wallman C, Krasse B, Birkhed D, Diacono S. The effect of monitored chlorhexidine gel treatment
on mutans streptococci in margins of restorations. J Dent 1998; 26(1): 25-30.
14 Bowden G H. Mutans streptococci caries and chlorhexidine. J Can DentAssoc 1996; 62(9): 700.
18 Wallman C, Krasse B, Birkhed D. Effect of chlorhexidine treatment followed by stannous fluoride gel
application on mutans streptococci in margins of restorations. Caries Res 1994; 28(6): 435-440.
21 .Pure S, Emilson C G. Effect of chlorhexidine gel treatment supplemented with chlorhexidine varnish
and resin on mutans streptococci and Actinomyces on root surfaces. Caries Res 1990; 24(4): 242-247.
23 Schaeken M J, Keltjens H M, van der Hoeven JS. Effects of fluoride and chlorhexidine on the
microflora of dental root surfaces and progression of root-surafce caries. J Dent Res 1991; 70(2):
150-153.
24. Yanover L, Banting D, Grainger R, Sandhu H. Effect of a daily 0.2% chlorhexidine rinse on the oral
health of an institutionalized elderly population. J Can DentAssoc 1988; 54(8): 595-598.