c116 management of dental caries in older patients

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C116MANAGEMENT OF DENTAL CARIES IN OLDER PATIENTSGRETCHEN GIBSON, DDS, MPH

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2/8/2013

1

Management of Dental Caries in

Geriatric Patients

Gretchen Gibson, DDS, MPH

[email protected]

148th Midwinter MeetingChicago Dental SocietThursday, February 21, 2013

Prevention for adults?

• Medical model, MID, CAMBRA----based on the

knowledge that caries is due to a bacterial

infection

• “Restorations repair the tooth structure, but

do not stop caries and have a finite life span”

NIH Consensus Statement

• Specific –plaque hypothesis

Loesche W. Dental Caries and periodontitis----. Inf Disease Clinics of North Am. 2007;21(2).

Caries Indicators and Caries Risks

• Active carious lesions

• White spots or rough demineralized areas

• History of recent caries experience

• Heavy plaque

• High MS counts

• Low salivary flow

• Frequent snacks or sweet and acidic drinks

• Appliances touching teeth

• Recession with exposed roots

• Systemic disease and treatment

Categorize as High ---Moderate---Low Risk

Best predictor of caries in adults

LOWRISK

No new cariesin 3 years

MODERATERISK

1-2 new lesionsin 3 years

HIGHRISK

3+ lesionsin 3 years

Clinical historyand Exam

Zero D, et al. J Dent Education. 2001

LOW Caries Risk in Adults

• No carious lesions within the last 3 years

• Good salivary flow

• Evidence of good daily oral care

• Regular dental visits (at least 1x/year)

Zero et al., 2001; Locker, 1996; Fontana, 2006; ADA 2006; Leone, 2001

MODERATE Caries Risk in Adults

• 1-2 new carious lesions within the last 3 years

• Evidence of moderate daily oral care

• Frequent carbohydrate or sugar intake

• Inadequate fluoride exposure (brushing less

than 2x/day and no other fluoride source)

Featherstone, 2007; Zero, 2001; Locker, 1996; Fonta na, 2006; ADA 2006; Leone, 2001; Joshi, 1993; Burt 2001; Ismail, 1984

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2

MODERATE Caries Risk in Adults

(continued)

• Use of meds that could cause reduced salivary

flow, but no clinical signs

• History of sporadic or no dental care

• Use of a removable partial denture

Featherstone, 2007; Zero, 2001; Locker, 1996; Fonta na, 2006; ADA 2006; Leone, 2001; Joshi, 1993; Burt 2001; Ismail, 1984

HIGH Caries Risk in Adults

• 3 or more carious

lesions within the last 3

years

• Reduced salivary flow

• Evidence of poor daily

oral care

• High S.mutans counts

Featherstone, 2007; Zero, 2001; Locker, 1996; Fonta na, 2006; ADA 2006; Leone, 2001; Joshi, 1993; Burt 2001; Ismail, 1984; Kitamur a 1986

HIGH Caries Risk in Adults

(continued)

• Medical conditions that contribute to caries susceptibility (e.g., head and neck radiation, psychiatric conditions, drug abuse and others)

• Exposed root surfaces

• Frequent carbohydrate or sugar intake along with low daily fluoride intake

• Inadequate fluoride exposure (brushing

< 2x/day and no other fluoride source)

• History of sporadic or no dental care

Featherstone, 2007; Zero, 2001; Locker, 1996; Fontana, 2006; ADA 2006; Leone, 2001; Joshi, 1993; Burt 2001; Ismail, 1984; Kitamura 1986

Caries Diagnosis

• Caries is a greater risk for

tooth loss than periodontal

disease in persons >70.

• Adults have an average of 1

carious lesion per year

• For patients age 30+, the

prevalence of root caries is

about 20-22% less the

persons age

GGGGGGGG

Leake JL. Clinical decision-making for caries management in root surfaces. J Dent Ed. 2001; 65(11):47-53

Enamel v. Dentin Caries• Enamel-hardest substance

in the body

• Dentin -mineralization similar to bone

• Cementum erodes away quickly after exposure in mouth

• pH for enamel demineralization-<5.4

• pH for dentin demineralization <6.5

Dentin

0102030405060708090

100

Enamel

%mineral

GG

Caries Detection• We most often make a dichotomous decision about caries

• Diagnosis is more than detection—the clinician must also decide if the lesion is active, progressing or remineralized (arrested)

• Explorer, mirror and radiographs

• Newer options:

– ICDAS (International Caries Detection and Assessment System)

– Fluorescence

– Fiber-optic transillumination

• “fewer restorations placed to treat 1° lesions result in fewer replacement of failed restorations” and lower DMFT *

Zandonà AF,ZeroDT.Diagnostic tools for early caries detection. JADA.2006;137:1675 *Mjör IA et al. Caries and restoration prevention. JADA 2008

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3

Tactile and Visual Detection• Tactile or texture

evaluation seems to

have more validity

than visual or color

classification when

assessing “active”

lesions

• Probing root surfaces

may leave defects in

the root that will not

fully remineralize

Warren et al. Explorer probing of root caries lesion: an in vitro study. Sp Care Dent. 2003;23(1):18-21. GG

Arrested Carious lesions

• Arrested lesions can be

thought of as scars and

more resistant to a

subsequent carious

attack

ActiveActive ArrestedArrested

Appearance Dull and Appearance Dull and Chalky Chalky

Appearance dark and Appearance dark and shiny shiny

Lesions found in Lesions found in plaque stagnant plaque stagnant areas (interprox, areas (interprox, occlusal, gingival occlusal, gingival

margins) margins)

Lesions found in Lesions found in interproximal areas interproximal areas

with missing with missing adjacent teeth and adjacent teeth and

no prosthesis no prosthesis

Smooth surface lesions Smooth surface lesions close to the close to the

gingival margins gingival margins

Smooth surface lesions Smooth surface lesions above the gingival above the gingival

margin margin

Leake JL. Clinical decision-making for caries management in root surfaces. J Dent Educ.2001;65(10):1147-53.

Recurrent Caries• History of caries is the greatest

predictor of future caries

• Is it primary vs recurrent caries—and

does it matter?

• “Replacement of defective

restorations has been the traditional

response; this study shows alternative

txs achieved similar responses during

3 yr f/u” *

GGGGGGGG

Ericson D, et al.. Minimally invasive dentistry-concepts and techniques in cariology. Oral Health Prev Dent. 2003

*Moncada G, et al. Sealing, refurb & repair of –def restorations. JADA, 2009

Non-surgical treatment

• Remineralization of root caries can be accomplished by adding fluoride

• Mineral supplementation beyond the saliva may also be helpful

• Consider smoothing with a slow speed or finishing bur prior to fluoride treatment

• Remineralized tooth structure is solid tooth structure (esthetics??)

Apical Margin Integrity

• Restorative failures are

most likely to occur at

apical margin

• Oral dryness may

increase risk of root

caries, but makes

restoring easier.

Isolation Techniques

Rubber Dam

• Hygienic # 212 or 14 A

clamps

• Isolate one or two teeth;

must be able to get

apical to margin

• Put clamp, dam and

frame on in one step

LCNLCNLCNLCN

Chan DCN, Adkins J. Technique on restoring sub-gingival cervical lesion. Op Dentistry. 2003; 28:350-53.

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4


Packing Cord

• Flat or spoon shaped packing instrument (Ultradent Ultrapak Packer UP171)

• 0-1 cord size, without vasoconstrictor

• If bleeding, dip in Hemodent (aluminum chloride-no epi)

GGGGGGGG


Electrosurgery

• Use to gain access to

apical margin

• Use when 3 mm of

attached gingival

tissue present

• Control hemostasis

GG

Root Caries Removal with a Laser

• Advantages

– Reduced need for

anesthesia (multi-

quadrant rest)

– Ability to easily

remove soft tissue

– Reduction of heme

at the margins

• Disadvantages

– Cost

– Learning curve

GG

Restorative Material Selection

• Meets patient’s esthetic requirements

• Can lower patient’s caries risk

• Operator skills• “In geriatric MID, the

choice of material cannot be made until caries are removed and field control is evaluated” Chalmers, JM.

GGChalmers JM. Minimal Intervention Dentistry: Part 2 . Strategies for addressing restorative challenges in older patients. JCDA. 2006. 72(5):435-40.

Glass Ionomers

• Advantages

– Caries inhibiting

– Easy to place

– Provides options for

multi surface root caries

lesion

– Fluoride recharges

– Fuji IX and Triage

• Disadvantages

– Higher wear rates than

composites or

RMGI/PAMC

– Contraindicated in

patients with dry mouth

– Esthetics

GG

Resin Modified Glass Ionomers

• Advantages

– bonds to tooth

– improved esthetics

over GI

– can finish right

away

– fluoride releasing

from glass particles

• Disadvantages

– Cost-more expensive

than amalgam; same as

composite

– Wear rates higher than

composites

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5

Poly-Acid Modified Composite

(Compomer)

• Advantages

– composite with glass

particles to provide some

fluoride releasing ability

– wear rates similar to

hybrid composite

– more flexural strength

than hybrid composites

• Disadvantages

– Cost-same as

composite

– Must maintain dry

field

LCNLCNLCNLCN

Composite Restoration

• Advantages

– Most esthetic

– Best wear resistance

(wear comparable to

amalgam for hybrids)

– Flowables have more

flex than traditional

hybrids

• Disadvantage

– Cost relative to amalgam

– Technique sensitive-

must be able to maintain

a dry field and get access

to apical margin

Classification of F- Releasing Materials

Material Classification Setting Mechanism(s)

Fluoride Release and Recharge

Ketak-Fill Conventional

GI

Acid/Base High

Fuji IX Densified GI Acid/Base High

Fuji II LC and

Vitremer

Resin

Modified Glass

Ionomer

(RMGI)

1° acid/base,

but also light cure

High

Dyract Compomer 1° light cure

(with a/b)

Medium

EsthetX Composite

Resin

Light Cure Low

Adapted from: Burgess, J. Dental Clinic of North America, 2002.

Dental Amalgam

• Advantages– Cost effective– Less time consuming

than composite (can place quickly when patient cannot cooperate for long periods)

– Works in presence of saliva

• Disadvantages– Not esthetic– Patients usually

prefer tooth colored restoration, if given a choice

– Requires enough tooth structure to gain retention

Caries Risk Assessment Forms

ADA Form

Available on ADA website for free download

0= low risk

1-10= mod risk

10+= high risk

Caries Risk Assessment Forms

CAMBRA

Children Age 6 and Over/Adults

Featherstone JDB, et al. CDA Journal.2007;35(10)

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6

Oral assessment tools

DenLite

www.miltex.com

Oral assessment tools

Open Wide mouth prop

Beyond the health of my teeth, why is daily

oral care important?

• 30-40% of infective endocarditis may be from the mouth (NOT from dental work)

• Approximately 1:10 deaths from AP may be prevented with good oral care

• There is a link between systemic diseases such as diabetes, stroke and arthrosclerosis and poor oral health

• Oral health is a component of positive quality of life

An Aside: Evidence Based Dentistry

According to the ADA…

Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration o f systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’sclinical expertise and the patient’s treatment needs and preferences

**EBD at ADA.orgwww.ada.org/goto/ebd

clinically relevantevidence

clinical skill& experience

patient needs

& preferences

Evidence-Based

Treatment

Definition of Evidence-Based Dentistry

Bader, 2008

Mature

Initial

Systematic Reviews

RCT’s

Cohort study

Case control study

Case series

Case report

Expert opinion

Animal research

Bench-top research

What are the levels of evidence?

Used by permission of the ADA. December, 2008

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7

EBD and Caries in Seniors

• Clinical decision-making for caries management in root surfacesLeake JL. J Dent Educ. 2001;65(10):1147-53

• Effectiveness of fluoride in preventing caries in adultsGriffin SO, Regnier E, Griffin PM, Huntley V. J Dent Res. 2007;86(5):410-5

• Fluoride interventions for root caries: a reviewHeijnsbroek M, Paraskevas S, Van der

• Glass-ionomer restoratives: a systematic review of a secondary caries treatment effectRandall RC, Wilson NH. J Dent Res. 1999;78(2):628-37 Weijden GA. Oral Health Prev Dent. 2007;5(2):145-52

• Complete or ultraconservative removal of decayed tissue in unfilled teethRicketts DN, Kidd EA, Innes N, Clarkson J. Cochrane Database Syst Rev. 2006;3():CD00380

• www.ada.org/goto/ebd

Environment

• Salivary flow---or lack of it!

• Diet conducive to caries formation

• Availability of minerals during the

remineralization process

Caries Risk Factors� Saliva -“A chronically

low salivary flow rate has been found to be one of the strongest salivary indicators for an increased risk of developing caries.”

� Measurement should include history and oral assessment

GGGGGGGGSource: M. Fontana and D. Zero. Assessing patient’s caries Source: M. Fontana and D. Zero. Assessing patient’s caries

risk. JADA; 137:1231risk. JADA; 137:1231--1239, Sept. 2006.1239, Sept. 2006.

Clinical Significance

Like other tissues in our Like other tissues in our body body –– salivary glands salivary glands change with agechange with age

In a healthy state, the In a healthy state, the human body can human body can compensate for these compensate for these changeschanges

Do not attribute xerostomia Do not attribute xerostomia to agingto aging

Baum BJ. Age related vulnerability. Otolaryngol Head Neck Surg.1992;106:730

Xerostomia-the patient described

symptom of oral dryness

Xerostomia vs. salivary Xerostomia vs. salivary

hypofunctionhypofunction

Clinically detectable at 50% Clinically detectable at 50%

loss of flowloss of flow

Prevalence in geriatric Prevalence in geriatric

population population --30%30%

•Dawes C. Physiological factors affecting salivary flow rate, oral sugar clearance and the sensation of dry mouth in man. J Dent Res. ’87; 66:648

•Ship JA, et al. Xerostomia in the geriatric patient. JAGS. ’02; 50:535

Differential Diagnosis for Xerostomia in

the Geriatric Population

MedicationMedication

Head and neck Head and neck

radiationradiation

SjSjöögren’s Syndromegren’s Syndrome

DehydrationDehydration

Systemic DiseaseSystemic Disease

Alzheimer’s diseaseAlzheimer’s disease

Diabetes MellitusDiabetes Mellitus

AmyloidosisAmyloidosis

Sarcoidosis Sarcoidosis

GraftGraft--vs.vs.--host disease host disease

Liver diseasesLiver diseases

Viral (HIV, Hep C)Viral (HIV, Hep C)

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8

Medication Induced Xerostomia

12% of population consume 12% of population consume 30% of meds30% of meds

5% (LTC) consume 60% of the 5% (LTC) consume 60% of the 30%30%

MechanismsMechanismsAnticholinergic affectAnticholinergic affect

Tissue dehydrationTissue dehydration

Persons who c/o oral Persons who c/o oral dryness take twice as many dryness take twice as many meds as those w/o this meds as those w/o this complaintcomplaint

ChemotherapyChemotherapy

Sreebny LM, et al. A reference guide for drugs and dry mouth.Gerodontology. ‘86;5(2):75

Sreebny LM. Salivary flow in health and disease. Compend Suppl.’89;13:S461-69


Janket et al (2003,2007)Janket et al (2003,2007)

Being on at least 1 xerost med meant sig Being on at least 1 xerost med meant sig

more mucosal lesionsmore mucosal lesions

xerostomic meds as a contributing factor xerostomic meds as a contributing factor

to oral diseaseto oral disease

Cardiovascular meds and sympathetic Cardiovascular meds and sympathetic

agonsists presented highly significant risk agonsists presented highly significant risk

increases for oral mucosal lesionsincreases for oral mucosal lesions

Janket S, et al. Xerostomic medications and oral health:The Veterans dental study(part 1).Gerodontology ‘03;20(1):41-49.

Janket S, et al. The effects of xerogenic medications on oral mucosa among the Veterans Dental Study participants. OOOOEndo.’07;103:223-30


Patient issuesPatient issues

Resting vs. Stimulated Resting vs. Stimulated

flowflow

ReversibleReversible

Consider as a default Consider as a default

diagnosisdiagnosis

Wu JA, et al. A characterization of major salivary gland flow rates in the presence of medications and systemic diseases.OOO. ‘93;76:301

Office Evaluation for XerostomiaYou don’t know the answers if you don’t ask the You don’t know the answers if you don’t ask the

questionsquestions-- Patient HistoryPatient History

Oral SymptomsOral Symptoms

Amount of saliva in your mouth (too little, too much, don’t Amount of saliva in your mouth (too little, too much, don’t

notice)notice)

Difficulties swallowing?Difficulties swallowing?

Dryness when eating?Dryness when eating?

Require sips of liquid to help swallow dry food?Require sips of liquid to help swallow dry food?

Ocular SymptomsOcular Symptoms

General Health ReviewGeneral Health Review

Al-Hashimi I, et al. Frequency of predictive value of the clinical manifestations of SS. J Oral Pathol Med. ‘01;30:1.

Navazesh M. How can oral health care providers determine if pts have dry mouth. JADA ’03; 134:613-20.

Treatment Options

Salivary Stimulation

Suggest salivary stimulation as a Suggest salivary stimulation as a prescription (q4 hrs for 10 minutes)prescription (q4 hrs for 10 minutes)

Sugarless gumsSugarless gums

Sugarless mintsSugarless mints

Citrus fruit juices (caution to use only Citrus fruit juices (caution to use only 11--2 times/day in 42 times/day in 4--6 oz servings)6 oz servings)

Avoid cinnamon, strong mint and too Avoid cinnamon, strong mint and too much lemonmuch lemon

Good evidence to support use of sf Good evidence to support use of sf gum as a “caries preventive” measure gum as a “caries preventive” measure in high risk kids. (Systematic review. in high risk kids. (Systematic review. Desphande A et al. JADA 2008)Desphande A et al. JADA 2008)

Diet Evaluation and Modification

Recommendations

• Some key components to diet evaluation:

– Number of meals and snack

– Amount and timing of consumption of sugared beverages

• Looking to decrease the exposure time to poor dietary choices

• Need to give patient strategies for change and options that meet their needs

Marshall TA. Chair side diet assessment for caries risk. JADA 09

Chapple ILC. Potential mechanisms underpinning the nutritional modulation of periodontal inflammation. JADA 09

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9

Calcium and Phosphate Delivery Products

• Recaldent technology - Amorphous calcium phosphate stabilized in casein phosphopeptides – Gum – 0.6% cpp-acp– MI paste – 10% cpp-acp

• Novamin technology – amorphous calcium sodium-phosphosilicate

Plaque control and specific oral organisms

• Caries requires plaque,

which is where bacteria resides

• For high risk pts, there is a need to identify the specific areas of high plaque retention

• Bacterial testing (SM) may be best used to determine initial bacterial loads and then monitor patients compliance or progress with a specific treatment regimen, such as chlorhexidine or plaque removal

Fontana M, Zero DT. Assessing patient’s caries risk. JADA. 2006;137.

Chemical Bacterial Control

• Chlorhexidine is a cationic agent that is effective in

controlling MS levels in the oral cavity

• CHX has substantivity not found in some other

chemoprophylactics (products with CPC and essential

oils)

• Available in the U.S as a 0.12% mouthrinse

• Xylitol may be an adjunct option to lower MS

Options for brushing

Benefit Toothbrush

www.benedent.com

Fluorides: % versus ppm

% ppm brand

0.05 NaF 226 ACT, Fluoriguard

0.4% SnF2 968 Gel Kam, Tin Gel

0.24% NaF 1100 Crest

0.76% MFP 1000 Aim, Aquafresh, Colgate

1.14% MFP 1500 Extra Strength Aim

Burt and Eklund, 1999

Fluorides: % versus ppm

% ppm brand

1.1% NaF ~5000 Rx, e.g., Prevident®

1.23% APF 12,300 Professional Application

2.0% NaF 9050 Professional Application

8.0% SnF2 19,363 Professional Application

5.0% NaF 22,600 Varnishes (Prof Appl)

Burt and Eklund, 1999

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10

All fluorides are equal…but some are

more equal than others

• Griffin SO, et al. Effectiveness of fluoride in preventing caries in adults. J Dent Res 2007

• Exposure to any mode of fluoride reduced caries by 25% in adults

• 6 studies after 1980 (3573 adults), summary difference = .27 surfaces

• 7 studies of root caries after 1980 (age 40+), summary difference = .22 surfaces

• Self applied only, difference = .3 surfaces

Ekstrand K. et al., 2008Study populationStudy population ::Homebound elderly (mean age Homebound elderly (mean age 81.6 yrs) (n=189)81.6 yrs) (n=189)DurationDuration : 8 months: 8 months

ProtocolProtocol : Comparison of 3 : Comparison of 3 groupsgroups--see table legendsee table legend

FindingsFindings : Both fluoride varnish : Both fluoride varnish and 1.1% NaF toothpaste and 1.1% NaF toothpaste groups had significantly fewer groups had significantly fewer root carious lesions at the end root carious lesions at the end of the study, compared to the of the study, compared to the OTC toothpaste group.OTC toothpaste group.No significant difference No significant difference between the varnish and 1.1% between the varnish and 1.1% NaF toothpaste groups.NaF toothpaste groups.

0

10

20

30

40

50

60

70

Better Stable Worse

Varnish Group (1X/month)

1.1% NaF Paste Group(2X/day)

OTC Paste Group(2/x/day)

Patients root caries status (%)

FLUORIDE VARNISHES

5% sodium fluoride

• used in Europe and Canada

• shown effective in children

• most caries reductions range 25-45%

• ease of application compared to trays for

2-4 minutes

• low ingestion of fluoride with varnish

• need clinical trials for root caries

Application of 5% NaF Varnish

q3-6 months for moderate risk

q3-4 months for high risk

Fure S. et al., 1998• Study population : moderate

to high risk community dwelling adults, fluoride in water 0.1-0.2 ppm (n=176)

• Duration : 2 years

• Protocol : comparison of 4 groups – see table legend

• Findings : Fluoride rinse demonstrated 24% reduction in overall caries, over 2 years. This was the only modality that was significantly different than the control group.

0

5

10

15

20

25

)%( Root Caries Reversals

Rinse 0.05% NaF (225 ppm, 2xday)

Tablet (1.66 mg NaF, 2xday)

Toothpaste slurry technique (3xday)

Control

DePaola, 1993

0102030405060708090

100

exp control

incipient shallow total

Incipient: well defined softened area, yellow/light brown, NO cavitation, penetration by explorer possible

Shallow: softened area, yellow/light brown, WITH disruption of surface contour, penetration by explorer possible

Study populationStudy population: Moderate to high : Moderate to high risk with at least 1 buccal root risk with at least 1 buccal root surface lesion at baseline. (n=71)surface lesion at baseline. (n=71)DurationDuration: 1 year: 1 year

ProtocolProtocol: 5,000ppm NaF gel : 5,000ppm NaF gel (Prevident) daily + 4x/year (Prevident) daily + 4x/year professional application of professional application of 12,000ppm NaF gel (Prevident Plus)12,000ppm NaF gel (Prevident Plus)

FindingsFindings: The combination of these : The combination of these two fluoride protocols led to over two fluoride protocols led to over twice as many carious lesion arrests twice as many carious lesion arrests or reversals than the control groupor reversals than the control group

% Remineralized

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11

1.1% Neutral sodium fluoride

paste (cream)

1.1% NaF creamDisp: 1 tube (51 g)Sig: Use thin ribbon on toothbrush at bedtime to brush teeth. Spit, but do not rinse after brushing

• Manufacturer states that 1 tube has ~ 100 doses. • Used once daily---this is approximately a 3 month supply


gel

1.1% NaF gelDisp: 1 tube (56 g)Sig: Use thin ribbon on toothbrush at bedtime and spread on teeth after brushing with a regular toothpaste. Spit, but do not rinse.

• Manufacturer states that 1 tube has ~ 130 doses. • Used once daily---this is approximately a 4 month supply


gel

1.1% NaF gelDisp: 1 tube (56 g)Sig: Place small ribbon in fluoride trays and wear for 5 minutes daily. Spit, but do not rinse after use.

• Manufacturer states that 1 tube has ~ 130 doses. • Used once daily in upper and lower trays---this is approximately a 3 month supply

Conclusions

• Risk assessment is the key to an optimal treatment plan

• The medical management of caries is a changing and

emerging science with a need for increased research in

adults- specifically high risk groups

• Medical management continues beyond preventive

products with the use of glass ionomers, bonded

materials and even lasers that retain as much natural

tooth structure as possible

Resolution 5H-2006

ADA House of Delegates UNANIMOUSLY

accepted a multifaceted resolution targeted at

vulnerable elderly issues.

Put ADA at the forefront of developing programs to address the needs of this fast growing group of Americans…vulnerable elders!