caries predication, risk assessment and treatment planning

8/4/2019 Caries Predication, Risk Assessment and Treatment Planning

1/74

Pediatric Dentistry IPediatric Dentistry I

(Dent 361)(Dent 361)

Risk Assessment,Risk Assessment,

Caries Prediction &Caries Prediction &Treatment PlanningTreatment Planning

Dr FEDA ZAWAIDEHDr FEDA ZAWAIDEHBDS (Jordan) ,BDS (Jordan) , GradDipClinDentGradDipClinDent,, DClinDentDClinDent ((MelbMelb), JDB,), JDB,

FRACDS, FRACDS (FRACDS, FRACDS (PaedPaed))


2/74

INTRODUCTIONINTRODUCTION

Management of dental caries was basedManagement of dental caries was based

mainly on the identification of cariousmainly on the identification of carious

lesions followed by surgical intervention tolesions followed by surgical intervention to

remove and restore the infected toothremove and restore the infected toothstructure. Nowadays, caries managementstructure. Nowadays, caries management

includes various management options thatincludes various management options that

involve providing treatment, monitoring, ofinvolve providing treatment, monitoring, ofdemineralizeddemineralized, non, non--cavitatedcavitated tooth surfaces,tooth surfaces,

prevention, surgical intervention of primaryprevention, surgical intervention of primary

lesions and repair or replacement oflesions and repair or replacement of

defective and failed restorations.defective and failed restorations.


3/74

Clinical Decision Making forClinical Decision Making for

Caries Management in ChildrenCaries Management in Children

(Tinanoff D, 2002)


4/74

Natural History of CariesNatural History of Caries

ProgressionProgression Age of the child:Age of the child:The earlier that a child becomes colonizedThe earlier that a child becomes colonized

with thewith the cariogeniccariogenic bacterial group,bacterial group, mutansmutans streptococci, thestreptococci, the

greater is the childs caries risk.greater is the childs caries risk.

Those teeth that are first exposed to aThose teeth that are first exposed to a cariogeniccariogenicenvironment generally will be the first to show signs ofenvironment generally will be the first to show signs of

disease.disease.

Caries progression is dependent on the site of the lesionCaries progression is dependent on the site of the lesion

and level of risk and disease activity, as well as age.and level of risk and disease activity, as well as age.

Caries activity can be assessed by observing the speed ofCaries activity can be assessed by observing the speed of

progression of existing lesions or the incidence of newprogression of existing lesions or the incidence of new

lesions.lesions.

((TinanoffTinanoff D, 2002)D, 2002)


5/74

Caries ProgressionCaries Progression

Results indicate

that 72-81% of

lesions remain inenamel after 1

year.

Progression in low

risk groups took

3.5 yrs and in high

risk group 1.5years.


6/74

Caries ProgressionCaries Progression

Proximal lesion progression

in permanent teeth was

slower than that in primaryteeth.

Lesions may remain in

enamel for up to 3 years.

Evidence shows lesions

limited into enamel may

not require immediatesurgical intervention.


7/74

CARIESCARIES RISK ASSESSMENTRISK ASSESSMENT

All children should have an assessment ofAll children should have an assessment of

disease risk before the final treatmentdisease risk before the final treatment

plan is determinedplan is determined


8/74

Clinical decision making in theClinical decision making in themanagement of caries in children andmanagement of caries in children and

adolescents requires an understanding ofadolescents requires an understanding of

caries risk and risk indicators. Generallycaries risk and risk indicators. Generally

speaking,speaking, RiskRiskis defined as the probabilityis defined as the probabilityof incidence of an event within a certainof incidence of an event within a certain

period of time.period of time. Caries riskCaries riskis the probabilityis the probability

that a lesion will develop or that an existingthat a lesion will develop or that an existinglesion will progress during a specified periodlesion will progress during a specified period

((AnusaviceAnusavice K, 2003).K, 2003).


9/74

Determination of caries risk isDetermination of caries risk is

important for:important for: Assessment of the individual factors of existingAssessment of the individual factors of existing

carious lesions and of the caries risk situation.carious lesions and of the caries risk situation.

Repeated determination of the caries risk allows anRepeated determination of the caries risk allows an

evaluation of the success of, or the need for,evaluation of the success of, or the need for,modification of preventive measures.modification of preventive measures.

Indications of an increased caries risk in specificIndications of an increased caries risk in specific

children in community preventive programs willchildren in community preventive programs willallow selection of an individual preventive programallow selection of an individual preventive program

in order to minimize the development of cariousin order to minimize the development of carious

lesions.lesions.

(Reich et al, 1999)(Reich et al, 1999)


10/74

Goal of Risk AssessmentGoal of Risk Assessment

The ultimate goal of caries risk assessmentThe ultimate goal of caries risk assessment

in dentistry is to deliver preventive andin dentistry is to deliver preventive and

restorative care specific to an individualrestorative care specific to an individual

patient's need and to identify caries activepatient's need and to identify caries active

individuals and convert them to cariesindividuals and convert them to caries

inactive status and reduce their caries risk.inactive status and reduce their caries risk.


11/74

Risk FactorRisk Factor

AArisk factorrisk factor is defined as an environmentalis defined as an environmental

behavioral or biological factor confirmed bybehavioral or biological factor confirmed by

temporal sequence, usually in longitudinaltemporal sequence, usually in longitudinal

studies, which, if present, directly increasesstudies, which, if present, directly increasesthe probability of a disease occurring. Ifthe probability of a disease occurring. If

absent or removed, it reduces theabsent or removed, it reduces the

probability. Risk factors are part of theprobability. Risk factors are part of the

causal chain or they expose the host to thecausal chain or they expose the host to the

causal chain. Once the disease occurs,causal chain. Once the disease occurs,

removal of the risk factor may not result inremoval of the risk factor may not result in

cure.cure. (Anderson M, 2002)(Anderson M, 2002)


12/74

Diagrammatic view of caries risk factors in

children; The 3 primary factors and their

subcategories of risk. (Anderson M, 2002)


13/74

AAPDAAPD

Caries Assessment Tool (CAT)Caries Assessment Tool (CAT)


14/74

CARIES RISKCARIES RISK

LOWCARIES RISKLOWCARIES RISK

Caries free nowCaries free now

Access to water fluoridationAccess to water fluoridation Favorable history: appropriate diet, dentallyFavorable history: appropriate diet, dentally

healthy sibs, good oral hygiene, motivatedhealthy sibs, good oral hygiene, motivated

parentsparentsMODERATE CARIES RISKMODERATE CARIES RISK

One or two new lesions per yearOne or two new lesions per year


15/74

CARIES RISKCARIES RISK

HIGHCARIES RISKHIGHCARIES RISK

Three or more new lesions per yearThree or more new lesions per year

Commencing orthodontic treatmentCommencing orthodontic treatment Chronic illness or hospitalizationChronic illness or hospitalization

Medically compromised childrenMedically compromised children

Social risk factorsSocial risk factors


16/74

Prediction BasedOn Past CariesPrediction BasedOn Past Caries

ExperienceExperience The most powerful single predictor of future caries increment since it isThe most powerful single predictor of future caries increment since it is

a summary of the cumulative effect of all risk factors.a summary of the cumulative effect of all risk factors.

The significance of this factor as a single reliable predictor wasThe significance of this factor as a single reliable predictor was

confirmed in a study conducted byconfirmed in a study conducted by SaemundssonSaemundsson et al (1997) on 9690et al (1997) on 9690

children aged 5children aged 5--15 years of age who were ranked as low, medium and15 years of age who were ranked as low, medium andhigh risk by dentists or school dental therapists based on unrestoredhigh risk by dentists or school dental therapists based on unrestored

lesions on primary and permanent teeth and proximal caries scores.lesions on primary and permanent teeth and proximal caries scores.

On the other hand, in adults, existing DMFOn the other hand, in adults, existing DMF-- values are less sensitive forvalues are less sensitive for

predicting future coronal caries but have a close correlation with thepredicting future coronal caries but have a close correlation with the

development of root caries.development of root caries. The use of caries experience in the primary dentition for theThe use of caries experience in the primary dentition for the

assessment of future caries in permanent teeth has also been advised inassessment of future caries in permanent teeth has also been advised in

the literature based on the fact that the value ofthe literature based on the fact that the value of dmftdmft recorded at 6 yearsrecorded at 6 years

of age was a strong predictor of caries occurrence between the age 7of age was a strong predictor of caries occurrence between the age 7

and 13 years.and 13 years.


17/74

TREATMENT PLANNINGTREATMENT PLANNING

SEQUENCE FOR CHILDRENSEQUENCE FOR CHILDREN

Emergency care, relief of painEmergency care, relief of pain

Preventive carePreventive care

Surgical treatmentSurgical treatment Restorative treatmentRestorative treatment

Orthodontic treatmentOrthodontic treatment

Extensive restorative, further surgicalExtensive restorative, further surgicalmanagementmanagement

Recall and reviewRecall and review


18/74

STEPS IN DIAGNOSIS &STEPS IN DIAGNOSIS &


Collect general observations:Collect general observations:

Child/parent interactions, behaviorChild/parent interactions, behavior

Address reason for presenting FIRSTAddress reason for presenting FIRST Start with history:Start with history:

Medical, dental, family, socialMedical, dental, family, social

Record past dental careRecord past dental care


19/74


20/74

STEPS IN DIAGNOSIS &STEPS IN DIAGNOSIS &


Finalize diagnosis and treatment plsnFinalize diagnosis and treatment plsn

Present case to patient/parentsPresent case to patient/parents

Outline recommended treatment planOutline recommended treatment plan Involve parents in planningInvolve parents in planning

Secure parental consentSecure parental consent


21/74

TREATMENT PLAN SHOULDTREATMENT PLAN SHOULD

INCLUDE THESE FEATURESINCLUDE THESE FEATURES

Treat existing problemsTreat existing problems

Prevent progression of existing problemsPrevent progression of existing problems

Prevent anticipated future problemsPrevent anticipated future problems Plan periodic exams, preventive care andPlan periodic exams, preventive care and

treatmenttreatment


22/74


CONCEPTSCONCEPTS

Consider behavior (eg. DesensitizingConsider behavior (eg. Desensitizing

app/procedure, modeling)app/procedure, modeling)

Involve parent in treatment choices, butInvolve parent in treatment choices, butdont be dictated to!dont be dictated to!

Incorporate preventionIncorporate prevention


23/74


CONCEPTSCONCEPTS

Plan efficient use of LAPlan efficient use of LA

(QUADRANT THERAPY)(QUADRANT THERAPY)

Treat comprehensively with definitiveTreat comprehensively with definitivetreatment, not patchworktreatment, not patchwork

Consider full coverage if using GAConsider full coverage if using GA


24/74


CONCEPTSCONCEPTS

Establish a follow up/review/recall planEstablish a follow up/review/recall plan

based on established criteria (eg. AAPD)based on established criteria (eg. AAPD)

Make referrals in writing and expect aMake referrals in writing and expect awritten report backwritten report back


25/74

QUADRANT THERAPYQUADRANT THERAPY

First visit: Examination, Diagnosis and treatmentFirst visit: Examination, Diagnosis and treatment

planning, Prophylaxis, OHI, dietary adviceplanning, Prophylaxis, OHI, dietary advice

Second visit: Quadrant 1Second visit: Quadrant 1

Third visit: Quadrant 2Third visit: Quadrant 2

Fourth visit: Quadrant 3Fourth visit: Quadrant 3

Fifth visit: Quadrant 4, Fluoride applicationFifth visit: Quadrant 4, Fluoride application

Review and recallReview and recallSPACE MANAGEMENT IF EXTRACTIONISSPACE MANAGEMENT IF EXTRACTIONIS

DONEDONE


26/74

CASE PRESENTATION ANDCASE PRESENTATION AND



27/74

Biographic DataBiographic Data

InitialsInitials

DOBDOB

Initial examInitial exam Age at examAge at exam

ParentsParents

Marital statusMarital status SiblingsSiblings

ResidenceResidence

NHNH

13/11/199913/11/1999

23/05/200323/05/2003 3 years3 years

AO, AHAO, AH

MarriedMarried No siblingsNo siblings

MelbourneMelbourne


28/74

Medical HistoryMedical History

CVSCVS

EndocrineEndocrine

GITGIT BleedingBleeding

UGSUGS

RespiratoryRespiratory

CNSCNS AllergiesAllergies

Past surgeryPast surgery

Immunization up to dateImmunization up to date

NORMALNORMAL


29/74

Developmental HistoryDevelopmental History

BirthBirth

SpeechSpeech

LocomotionLocomotion

WeightWeight

HeightHeight

Full term, NormalFull term, Normal

deliverydelivery

NormalNormal NormalNormal

100.8 cm, (50100.8 cm, (50thth))

15 kg, (5015 kg, (50thth))


30/74

Social HistorySocial History

Recently moved from EritreaRecently moved from Eritrea

NonNon--English speaking familyEnglish speaking family

Single childSingle child

Goes to KinderGoes to Kinder

Good social developmentGood social development

BottleBottle--feeding at nightfeeding at night


31/74

Dental HistoryDental History

Past dental historyPast dental history

First dental visitFirst dental visit

ReferralReferral

Referred from North YarraReferred from North Yarra

community health services forcommunity health services for

management of dental cariesmanagement of dental caries


32/74

Chief ComplaintChief Complaint

Spontaneous pain in upper anteriorSpontaneous pain in upper anterior

teethteeth

Pain disturbing sleepPain disturbing sleep Pain interfering with eatingPain interfering with eating


33/74

Preventive HistoryPreventive History

Use of systemic FUse of systemic F

Water FluoridationWater Fluoridation

Use of topical FUse of topical F

Fluoridated toothpasteFluoridated toothpaste


34/74

Head & Neck ExamHead & Neck Exam

Facial symmetryFacial symmetry

EyesEyes

Skin colourSkin colour

NailsNails

HairHair

TMJTMJ

Lymph nodesLymph nodes

SymmetricalSymmetrical

BrownBrown

Dark complexionDark complexion

NormalNormal

NormalNormal

NormalNormal

NormalNormal


35/74


36/74


37/74

IntraIntra--oral Examoral Exam

SOFT TISSUESSOFT TISSUES

GingivaGingiva

Alveolar mucosaAlveolar mucosa PalatePalate

Buccal mucosaBuccal mucosa

TongueTongue Sublingual areaSublingual area

Soft palateSoft palate

OropharynxOropharynx

NORMALNORMAL


38/74

IntraIntra--oral Examoral Exam--ContCont

PeriodontalPeriodontal

tissuestissues

Oral hygieneOral hygiene

NormalNormal

FairFair


39/74

IntraIntra--oral Examoral Exam--ContCont

HARD TISSUESHARD TISSUES

Primary dentition stagePrimary dentition stage

Extensive dental cariesExtensive dental caries

Hypoplastic upper and lower centralHypoplastic upper and lower central

incisorsincisors


40/74


41/74


42/74


43/74


44/74


45/74

Occlusal AnalysisOcclusal Analysis

SOFT TISSUESSOFT TISSUES

Facial profileFacial profile

Lip lineLip line

Lip sealLip seal

HabitsHabits

TRANSVERSETRANSVERSE

RELATIONSHIPRELATIONSHIP

Slightly convexSlightly convex

Normal lip lineNormal lip line

Incompetent lipsIncompetent lips

EvertedEverted lipslips

NoneNone

NormalNormal


46/74

Occlusal Analysis ContOcclusal Analysis Cont

AA--P RELATIONP RELATION

Primary IsPrimary Is

Primary MsPrimary Ms OverjetOverjet

VERTICAL RELATIONVERTICAL RELATION

Facial typeFacial type OverbiteOverbite

SPACINGSPACING

Class IClass I

Flush terminalFlush terminal

2mm2mm

MesiofacialMesiofacial3mm3mm

Primate spacesPrimate spaces


47/74

Teeth PresentTeeth Present

E D C B A A B C D EE D C B A A B C D E

E D C B A A B C D EE D C B A A B C D E


48/74


49/74

DiagnosisDiagnosis

EARLY CHILDHOODEARLY CHILDHOOD

CARIESCARIES

Behaviour Frankle (Behaviour Frankle ( -- ))


50/74

Treatment planTreatment plan

PREVENTIVE PHASEPREVENTIVE PHASE

Oral hygiene instructionsOral hygiene instructions

Dietary counsellingDietary counselling

Dental prophylaxisDental prophylaxis

Topical fluoride applicationTopical fluoride application Antimicrobial therapy (CHX)Antimicrobial therapy (CHX)

RESTORATIVE PHASERESTORATIVE PHASE

Under GAUnder GA


51/74

TREATMENT PLANTREATMENT PLAN

Oral hygiene instructions, Dietary advice,Oral hygiene instructions, Dietary advice,Prophylaxis, Fluoride applicationProphylaxis, Fluoride application

Quadrant 1: Exo 51,52buccal, 54 MOD, 55Quadrant 1: Exo 51,52buccal, 54 MOD, 55

occlusalocclusalReview OH and diet changesReview OH and diet changes

Quadrant 2: Exo 61, 64 MOD, 65 occlusalQuadrant 2: Exo 61, 64 MOD, 65 occlusal

Quadrant 3: 74 MOD, 75 occlusalQuadrant 3: 74 MOD, 75 occlusal Quadrant 4: 84 DO, 85 occlusalQuadrant 4: 84 DO, 85 occlusal

Review 3/12 for Fluoride application, OHIReview 3/12 for Fluoride application, OHI

and monitoringand monitoring


52/74

Treatment PerformedTreatment Performed

Oral hygiene instructionsOral hygiene instructions

( Brushing and Flossing)( Brushing and Flossing)

Diet analysisDiet analysis

Parent education regarding feedingParent education regarding feeding

habitshabits


53/74

Dental TreatmentDental Treatment

PrePre--operative Rt & Lt BWoperative Rt & Lt BW

ProphylaxisProphylaxis

52 Buccal52 Buccal-- GICGIC

54 MOD54 MOD-- FormocresolFormocresol

pulpotomy, IRM, SSC,pulpotomy, IRM, SSC,

Ketac cementKetac cement 55 Occlusal55 Occlusal-- vitrebond liner,vitrebond liner,

GIC base, AmalgamGIC base, Amalgam

restorationrestoration


54/74


84 DO84 DO-- vitrebond liner,vitrebond liner,

GIC, SSC, Ketac cementGIC, SSC, Ketac cement 85 Occlusal85 Occlusal-- vitrebond liner,vitrebond liner,

GIC, SSC, Ketac cementGIC, SSC, Ketac cement


55/74


64 MOD64 MOD--vitrebond liner,vitrebond liner,

GIC, SSC, Ketac cementGIC, SSC, Ketac cement 65 Occlusal65 Occlusal-- vitrebondvitrebond

liner, Amalgamliner, Amalgam

restorationrestoration


56/74


74 MOD74 MOD-- vitrebond liner,vitrebond liner,

GIC, SSC, Ketac cementGIC, SSC, Ketac cement 75 Occlusal75 Occlusal-- FormocresolFormocresol

pulpotomy, IRM, SSC,pulpotomy, IRM, SSC,

Ketac cementKetac cement


57/74


Extraction of 51, 61Extraction of 51, 61

Duraphat applicationDuraphat application

PostPost--operative Rt & Lt BW.operative Rt & Lt BW.


58/74


59/74


60/74

Post GA ReviewPost GA Review

Good oral hygieneGood oral hygiene

Diet modifiedDiet modified

Improved feeding and sleepingImproved feeding and sleeping Overall improvement in the quality of lifeOverall improvement in the quality of life

Prescribed CHX GelPrescribed CHX Gel


61/74


62/74


63/74


64/74


65/74


66/74


67/74


68/74


69/74

PrognosisPrognosis

Very good prognosisVery good prognosis

Excellent patient and parentsExcellent patient and parents

compliancecompliance


70/74

Long Term TreatmentLong Term Treatment

Review 3/12Review 3/12

BW,BW,

OH and Diet monitoring,OH and Diet monitoring, Topical Fluoride applicationTopical Fluoride application

Monitor growth changesMonitor growth changes


71/74


EXCERCISESEXCERCISES


72/74


73/74


74/74

caries predication, risk assessment and treatment planning

Documents