Patient-Centered Patient-Centered Explanation of Risk-Based Explanation of Risk-Based

TreatmentTreatment

Tooth DecayTooth Decay

Tooth Decay DefinedTooth Decay Defined

An An infectioninfection caused by bacteria caused by bacteria commonly found in the mouth that commonly found in the mouth that destroys the toothdestroys the tooth

The bacteria are The bacteria are transmissibletransmissible from from parent or caregiver to child, child to parent or caregiver to child, child to child, and adult to adultchild, and adult to adult

The disease has The disease has many factorsmany factors and and many stages many stages

Experimental DecayExperimental Decay

0 days 21 days 51 days Timeline

• No oral hygiene• Rinse 9x/day with 50% sucrose solution

• Regular oral hygiene• Fluoride use

Development of enamel decay

Decay arrested

Proof that:• bacteria causes decay• sugar increases risk• oral hygiene can prevent decay

von der Fehr et al 1970

Stages of DecayStages of Decay

The disease process begins with an The disease process begins with an infection, advances to demineralization, infection, advances to demineralization, and ends with a cavityand ends with a cavity

The process does not progress at a The process does not progress at a uniform rate but is cyclic and intermittentuniform rate but is cyclic and intermittent

Demineralization occurs when decay-Demineralization occurs when decay-causing bacteria produce acids from foodcausing bacteria produce acids from food

Cyclic Process of DecayCyclic Process of Decay

Demineralization

Remineralization

Bacteria plus foodmakes the salivavery acidic within

5 minutes

Saliva is normal30 minutesafter eating

Tipping the BalanceTipping the BalanceRemineralization Demineralization

• Infrequent or inadequate tooth cleaning• Frequent meals and snacks• Large amount of decay causing bacteria• Deficient fluoride in saliva

Cavity

Decay ProgressionDecay Progression

0%10%

20%30%

40%50%

60%70%80%

90%100%

Decay No change Healed

Progression of 72 white spot lesions followed for 7 years

Backer-Dirks 1966

Diagnosis of DecayDiagnosis of Decay

HealthHealth DecalcificatiDecalcificationon DecayDecay

VisualVisual Normal Normal tooth colortooth color White spotWhite spot Black or Black or

brownbrown

FeelFeel HardHard HardHard SoftSoft

X-RayX-Ray NormalNormal NormalNormal Black areaBlack area

None of these methods can detect all lesions early enough to implement treatment to reverse the disease

process

Occurrence of SymptomsOccurrence of Symptoms

0 1 hour ? years 30 years

Time lineAnaphylacticShock

Toothache Heart Attack

• Each symptom occurs at the end of the colored bar• Each disease process is invisible to diagnostic methods for most or all of the time within the colored bar• Risk predicts chronic disease occurrence

The Realm of Diagnosis, The Realm of Diagnosis, which requires the which requires the

disease is sufficiently disease is sufficiently advanced to be “Visible”advanced to be “Visible”

The Early Stages of Decay are Indistinguishable from Health

Disease State

Cavity

““Invisible” to diagnostic Invisible” to diagnostic techniquestechniques

Health

Decalcification

Risk DefinedRisk Defined

Risk is a prediction that disease will Risk is a prediction that disease will occur or progressoccur or progress

Risk is distinct from disease and Risk is distinct from disease and cannot be accurately predicted from cannot be accurately predicted from the disease statethe disease state

Risk is determined by risk factorsRisk is determined by risk factors

Risk-based treatment Risk-based treatment prevents disease prevents disease

progressionprogression

Risk-Based Treatment

Disease State

Cavity

Risk-based treatment Risk-based treatment prevents disease prevents disease

occurrenceoccurrenceHealth

Decalcification

RepairRepair treats the treats the consequences of consequences of

disease, which may disease, which may increase the risk of new increase the risk of new

diseasedisease

Repair and Prevention

Disease State

Cavity

PreventionPrevention maintains a maintains a clinically healthy stateclinically healthy state

Health

Decalcification

FillingsFillings

Fillings have no measurable effect on Fillings have no measurable effect on decay-causing bacteria present on tooth decay-causing bacteria present on tooth surfacessurfaces

Fillings have a finite life span and where Fillings have a finite life span and where each replacement filling leaves less tooth each replacement filling leaves less tooth structurestructure

Fillings increase the risk of an abscessFillings increase the risk of an abscess Fillings may increase the risk of tooth Fillings may increase the risk of tooth

fracture and gum diseasefracture and gum disease

PreventionPrevention

Preventive treatment can be effective at Preventive treatment can be effective at any time and ageany time and age

A diagnosis of decay could be indicative A diagnosis of decay could be indicative that additional lesions not yet visible existthat additional lesions not yet visible exist

Apparently healthy teeth might be in the Apparently healthy teeth might be in the early undetectable stages of decayearly undetectable stages of decay

Risk assessment can identify when risk is Risk assessment can identify when risk is high and preventive treatment is high and preventive treatment is beneficialbeneficial

Tooth Decay RiskTooth Decay Risk

Tooth decay risk varies between Tooth decay risk varies between individuals and over time coincident individuals and over time coincident with a change in risk factorswith a change in risk factors

The highest decay-susceptible time is The highest decay-susceptible time is the first 2 years after tooth eruption, the first 2 years after tooth eruption, but can be high at any timebut can be high at any time

Determining Risk and Determining Risk and TreatmentTreatment

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PreViser Corporation provides web-enabled diagnostic decision support tools for dentists. The tools are simple, inexpensive and easy to use. The first clinically proven application is within dental care, where the use of PreViser technology will assist oral health care professionals to more effectively plan treatment responses to disease.

The tools are built under protection of U.S. patent number 6,484,144 with an exclusive license to PreViser Corporation. This intellectual property protects a self-updating system of diagnosis that uses easily collected clinical measurements to calculate the risk of disease development or deterioration of a current disease state, and identifies therapies most likely to reduce risk and disease severity.

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Supplemental andSupplemental andNew Diagnostic MethodsNew Diagnostic Methods

Plaque Formation Rate (PFRI)Plaque Formation Rate (PFRI) Salivary level of mutans streptococci Salivary level of mutans streptococci

(SM)(SM) New Diagnostic MethodsNew Diagnostic Methods

Digital X-raysDigital X-rays Fiber-optic transillumination (FOTI)Fiber-optic transillumination (FOTI) Laser fluorescence (LF)Laser fluorescence (LF) Electrical conductance (EC)Electrical conductance (EC) UltrasoundUltrasound

Plaque Formation RatePlaque Formation Rate

ScorScoree

DescriptionDescription

11 1%-10% of surfaces1%-10% of surfaces

2211%-20% of 11%-20% of surfacessurfaces

3321%-30% of 21%-30% of surfacessurfaces

4431%-40% of 31%-40% of surfacessurfaces

55 >40% of surfaces>40% of surfaces

Amount of new plaque accumulated in 24 hours following tooth cleaning where patient refrains from oral hygiene

Axelsson 1991

Caries Risk Based on SM and Caries Risk Based on SM and PFRIPFRI

PFRIPFRI

SM/mlSM/ml11 22 33 44 55

00 Very Low RiskVery Low Risk

<0.5 mill<0.5 mill

Low RiskLow Risk

Moderate RiskModerate Risk

0.5-0.9 0.5-0.9 millmill High RiskHigh Risk

>0.9 mill>0.9 mill

Axelsson 1991

New Diagnostic MethodsNew Diagnostic Methods

Very little clinical data are available to Very little clinical data are available to validate these technologiesvalidate these technologies

Goal is better accuracy over traditional Goal is better accuracy over traditional methods to detect true cavities that should methods to detect true cavities that should be filledbe filled

Goal is detection of currently “invisible” Goal is detection of currently “invisible” lesions that are in a state of dynamic lesions that are in a state of dynamic decalcification and recalcificationdecalcification and recalcification Enhances risk assessment and application of Enhances risk assessment and application of

preventive treatment preventive treatment

Preventing Tooth DecayPreventing Tooth Decay

Reduction of decay-causing bacteriaReduction of decay-causing bacteria Health promoting dietary practicesHealth promoting dietary practices Exposure to fluorideExposure to fluoride Sealing susceptible tooth defectsSealing susceptible tooth defects Proper frequency of dental visitsProper frequency of dental visits

Reducing Decay-Causing Reducing Decay-Causing BacteriaBacteria

Personal teeth cleaningPersonal teeth cleaning Twice daily tooth brushing and flossing or Twice daily tooth brushing and flossing or

an equivalent aid for between the teethan equivalent aid for between the teeth Antibacterial rinses (chlorhexidene)Antibacterial rinses (chlorhexidene)

Rinse with 10 ml for 1 minute at bedtime Rinse with 10 ml for 1 minute at bedtime for 2 weeks repeating the cycle 2 months for 2 weeks repeating the cycle 2 months laterlater

Fluoride toothpasteFluoride toothpaste Treat all family membersTreat all family members

““Teeth Cleaned” ClarifiedTeeth Cleaned” Clarified

All tooth surfaces including between teethAll tooth surfaces including between teeth About half of all decay affects the tooth About half of all decay affects the tooth

surfaces of adjacent teeth where a tooth surfaces of adjacent teeth where a tooth brush and oral rinse does not reachbrush and oral rinse does not reach

The equivalent of not cleaning between The equivalent of not cleaning between teeth is washing the palm and back of teeth is washing the palm and back of your hands but not between your fingersyour hands but not between your fingers Rinsing hands with water is not an effective Rinsing hands with water is not an effective

alternative to scrubbing with soapalternative to scrubbing with soap

Dietary PracticesDietary Practices

Foods that are especially harmful contain Foods that are especially harmful contain sugars like sucrose, glucose, and sugars like sucrose, glucose, and fructose, cooked starch, and other fructose, cooked starch, and other carbohydratescarbohydrates

Eat and drink no more than 3 meals and Eat and drink no more than 3 meals and 3 snacks per day3 snacks per day

Sugar-free gum and mints, especially Sugar-free gum and mints, especially those that contain xylitol can be those that contain xylitol can be beneficialbeneficial

FluorideFluoride

The incorporation of fluoride into The incorporation of fluoride into developing enamel inhibits tooth developing enamel inhibits tooth decay, however its primary decay, however its primary effectiveness occurs by its effectiveness occurs by its concentration in plaque and saliva to concentration in plaque and saliva to inhibit demineralization and enhance inhibit demineralization and enhance remineralizationremineralization

Fluoride inhibits plaque bacteriaFluoride inhibits plaque bacteria

Fluoride, cont.Fluoride, cont.

Fluoride is released from dental plaque Fluoride is released from dental plaque during the acidic conditions of eatingduring the acidic conditions of eating

Released fluoride combines with calcium Released fluoride combines with calcium and phosphate to create a more decay-and phosphate to create a more decay-resistant enamel crystal structureresistant enamel crystal structure

Fluoride is available in water, toothpaste, Fluoride is available in water, toothpaste, over-the-counter rinses, prescription over-the-counter rinses, prescription toothpaste and rinses, professional gels, toothpaste and rinses, professional gels, foams, and varnishesfoams, and varnishes

Fluoride, cont.Fluoride, cont.

Fluoridated toothpaste should be used twice Fluoridated toothpaste should be used twice dailydaily

Professional applications of fluoride is based Professional applications of fluoride is based on riskon risk High-risk patients should have this done 2 to 3 High-risk patients should have this done 2 to 3

times per yeartimes per year More fluoride is not necessarily better, More fluoride is not necessarily better,

especially for children younger than 6 years especially for children younger than 6 years as fluorosis can affect cosmetically visible as fluorosis can affect cosmetically visible developing teethdeveloping teeth

Tooth SealantsTooth Sealants

Plastic coating bonded to the biting Plastic coating bonded to the biting surfaces of the back teethsurfaces of the back teeth

Susceptible tooth defects should be Susceptible tooth defects should be sealed regardless of agesealed regardless of age

Frequency of Dental VisitsFrequency of Dental Visits

Twice annual professional tooth Twice annual professional tooth cleaning as the sole method to prevent cleaning as the sole method to prevent cavities is unlikely to be effective cavities is unlikely to be effective especially when risk is highespecially when risk is high

Frequency of dental visits can be Frequency of dental visits can be increased for closer monitoring of oral increased for closer monitoring of oral hygiene and dietary practices in hygiene and dietary practices in addition to applying fluoride and addition to applying fluoride and sealantssealants

Dealing with ObjectionsDealing with Objections

Prevention doesn’t workPrevention doesn’t work Studies have shown that more than 90% of tooth Studies have shown that more than 90% of tooth

decay can be preventeddecay can be prevented Prevention is only for the youngPrevention is only for the young

Studies have shown that prevention works at any Studies have shown that prevention works at any ageage

The benefits of prevention take many yearsThe benefits of prevention take many years The benefits are immediate as prevention heals The benefits are immediate as prevention heals

the invisible lesionsthe invisible lesions

Objections, cont.Objections, cont.

It costs too much; My insurance doesn’t cover It costs too much; My insurance doesn’t cover itit Filling cavities costs more than preventing themFilling cavities costs more than preventing them Cavities can result in a root canal, cap, or extractionCavities can result in a root canal, cap, or extraction Dentures could ultimately cost more than “saving” Dentures could ultimately cost more than “saving”

your teethyour teeth Insurance doesn’t care if you have denturesInsurance doesn’t care if you have dentures

Dentures are OKDentures are OK Dentures, especially lower ones, are not always Dentures, especially lower ones, are not always

successful, which then requires implantssuccessful, which then requires implants

Objections, cont.Objections, cont.

Flossing is too hard; no time to flossFlossing is too hard; no time to floss Tying shoelaces for a child is difficult but Tying shoelaces for a child is difficult but

they learn the skillthey learn the skill Flossing takes only a minute or two after Flossing takes only a minute or two after

the skill is learnedthe skill is learned Fillings prevent decayFillings prevent decay

Fillings have no effect on decay-causing Fillings have no effect on decay-causing bacteria and hence do not reduce the bacteria and hence do not reduce the risk of having more cavitiesrisk of having more cavities