caries risk assessment in young children and its...

CARIES RISK ASSESSMENT IN

YOUNG CHILDREN AND ITS

SIGNIFICANCE IN CARIES

PREVENTION

By: Dr. Nick Lekic DMD, M.Dent, FRCD(C)

Introduction

Completed all my studies at the University of

Manitoba

DMD Degree in 2010

Pediatric hospital dentistry residency in 2011

Master of Dentistry-Pediatric Dentistry Graduate

Program in 2014

Fellow of the Royal College of Dentists of

Canada in 2014

Joined Children’s Dental World in July 2014

Permission given by Natalie Lekic

Course objectives

Comprehending the multi-factorial

nature of caries development and

the association between presence of

risk factors and caries susceptibility

Understanding the principles and

application of caries-risk assessment

for caries prevention in everyday

clinical practice

Introduction

Early childhood caries (ECC) has been

found to be the most prevalent chronic

disease

ECC is rapidly progressing and

significantly affecting a child’s growth and

developmental

Early assessment and identification for

presence of caries-risk factors is critical for

prevention of ECC

Restorative treatment alone may not be

sufficient and overall requires modification

to a child’s daily life practices

University of Manitoba Pediatric Dentistry Graduate Program

Introduction

The American Academy of Pediatric

Dentistry (AAPD) and Canadian Academy

of Pediatric Dentistry (CAPD) advise that

the first dental check up should occur

within 6 months of the eruption of the first

tooth and no later than 12 months of age

Importance of establishing a dental home

is to provide a continuous relationship

between the dentist and the family

Allowing for timely assessment and

application of caries-risk assessment,

individualized prevention strategies and

disease management

Google Images of Baby and teeth

Caries development

• Understanding caries etiology may

lead to improved provision of

preventive measures

• Caries is a multifactorial disease

• Pathologic factors include: cariogenic

bacteria, salivary dysfunction and

carbohydrates intake

• Additional risk factors include

sociodemographic, presence of plaque,

lack of fluoride and environmental

effects (ie. enamel hypoplasia)

http://www.ohiodentalclinics.com/curricula/sealant/mod3_1.html

S. Mutans and caries-risk

• Presence of Streptococcus mutans in

young caries-free children has been

associated with a considerable caries

risk

• Its has also been shown to be a reliable

indicator of future caries status

• S. mutans may invade oral cavity

soon after birth

• Two modes of transmission with a

window of infectivity seen as early as

birth

• Eruption of primary teeth increases the

number and complexity of bacteria

http://microbiologyfall2010.wikispaces.com/file/view/

Streptococcus-mutans.jpg/185899615/Streptococcus-mutans.jpg

S. Mutans and caries-risk

Bacterial and host factors affect

transmission and colonization of

Streptococcus mutans

S. mutans are acidogenic, aciduric,

adherent to teeth and capable of

secreting carbohydrates

Screening for S. mutans may identify

caries risk

Google Images of Streptococcus Mutans

Salivary dysfunction and caries-risk

Saliva contains minerals, proteins, immunologic factors and

buffers which all play a part in caries prevention

Saliva also has a mechanical role of washing away debris

from the oral cavity

Google images of Saliva

Salivary dysfunction and caries-risk

Studies have found salivary dysfunction to be associated with

an increased caries risk

Salivary flow rate less than 0.8-1.0 ml/min is an indicator of caries

risk

Salivary flow may be reduced by illnesses, medications and

radiation therapy

Google images of Saliva

Diet and caries-risk

Refined carbohydrates cause a measurable drop in pH and

increase a child’s caries risk

Carbohydrates that are a greater risk for caries development

in particular are:

Retentive,

Increased sugar content,

Result in decreased salivary flow,

Consumed more frequently

Google Images of Sugar and Teeth


Children with delayed weaning from the bottle and

with prolonged nighttime feeding with sugar

containing products are at an increased risk for

dental decay

Studies reported as high as 86 % caries in the maxillary

primary incisors

Google Images of Baby bottle decay


Although no study has found human

breast milk as cariogenic, its

combination with sugar may increase

caries risk

A systematic review reported that

prolonged breast-feeding at night for

greater than a year following the eruption

of the primary teeth may be associated

with ECC

Google images of breast-feeding

Diet and Caries Risk

Recent studies have shown that although

sugar consumption has a proven role in

the development of caries, the increased

exposure to systemic fluoride has

lessened its affect

Water fluoridation may decrease the caries risk of

carbohydrate intake

Google Images of Water fluoridation

Caries-risk assessment

A risk-based approach to caries management enables

identification of patients who are most vulnerable to the

development of this disease

Caries-risk assessment should be predictable, repeatable and

easily accomplished by all members of the dental team

Google images of dental examination


The goal of the caries risk assessment is to minimize causative

factors and maximize protective factors

The current best predictor of future caries is past caries

experience

Google image of caries risk factors

Caries-risk assessment tools

Several Caries-risk assessment tools have been created for

everyday clinical practice

AAPD Caries-risk assessment

AAP – Oral Health Risk assessment Tool

ADA – Caries-risk assessment form

CAMBRA (Caries management by risk assessment)


The AAPD Caries-risk assessment

tool has become the principle

guide for early assessment of

children

The three main factors for

caries risk assessment in

children include biological,

protective, and clinical findings

Google images of caries and primary teeth


Biological risk factors

Mother/primary caregiver with carious lesions

Socioeconomic status of the family

Child has 3 or more between meal sugar

containing snacks or beverages a day

Child is put to bed with a bottle containing sugar

Special health care needs child

Child is a recent immigrant

Google images of pregnant women and dental exam


Protective risk factors

Child’s water fluoridation or fluoride

supplements consumption

Daily oral hygiene with fluoridated

toothpaste use

Professional topical fluoride application

Child has regular dental recall

appointments

Additional preventive measures (i.e.xylitol)


Clinical risk factors

Child has one or more

decayed/missing/filled tooth surface

Child has active white spot lesions or

enamel defects

Child has elevated S. mutans levels

Child has visible plaque on teeth

Google image of white spot lesions


In our study, higher levels of S. mutans were associated with

increased caries experience

Contrary, children with low Streptococcus mutans levels were

significantly less likely to develop new dental caries

Findings suggest that chair-side Immunoassay tests for

Streptococcus Mutans counts could be used to assess caries risk

and encourages clinicians to provide anticipatory guidance to

their patients to help avoid the development of new caries


A simple and quick 15 minute chair-side Immunoassay test was

conducted to determine levels of S. mutans using Saliva-Check

Mutans

The test was positive with the levels for S. mutans determined

as high at >5x105 CFU/ml

Saliva-Check Mutans

Caries-Risk assessment

Video of chair-side Immunoassay test with Saliva-Check

Mutans performed by myself to be inserted here

Factors

High Risk Moderate Risk Low Risk Biological

Mother/primary caregiver with carious lesions

Yes

Low Socioeconomic status of the family

Yes

Child has 3 or more between meal sugar containing snacks or beverages a day

Yes

Child is put to bed with a bottle containing sugar Yes

Special health care needs child

Yes

Child is a recent immigrant

Yes

Protective

Child’s water fluoridation or fluoride supplements consumption

Yes

Daily oral hygiene with fluoridated toothpaste use

Yes

Daily oral hygiene with fluoridated toothpaste use

Yes

Child has regular dental recall appointments

Yes

Additional preventive measures (i.e.xylitol)

Yes

Clinical

Child has one or more decayed/missing/filled tooth surface

Yes

Child has active white spot lesions or enamel defects

Yes

Child has elevated S. mutans levels

Yes

Child has visible plaque on teeth

Yes

Clinical implications of caries-risk

assessment

Caries management and determined time period for recalls is

dependent on the caries-risk status of the patient, age and

compliance

Efficient caries management requires self-management goals

and with proper identification and prevention of risk factors,

caries progression may be hindered or stopped entirely

Patients that are at higher risk should be followed-up more

frequently (i.e. every 3 months) with professional application

of topical fluoride, whereas patients in the low risk group can

be seen less frequently (i.e. every 12 months)

Caries-risk management

Risk

Category

Diagnostic Fluoride Diet Sealants Restorative

Low Recall 6-12

months

Radiographs 12-

24 months

Baseline MS

Twice daily with

fluoridated

toothpaste

No Yes Surveillance

Moderate Recall 6 months

Radiographs 6-

12 months

Baseline MS

Twice daily with

fluoridated

toothpaste

Professional

topical fluoride

every 6 months

Counseling Yes Active

surveillance of

incipent lesions

Restoration of

cavitated or

enlarging lesions

High Recall 3 months

Radiographs 6

months

Baseline and

follow-up MS

Twice daily with

fluoridated

toothpaste

Professional

topical fluoride

every 3 months

Fluoride

supplements

Counseling Yes Active

surveillance of

incipent lesions if

parents engaged,

otherwise

restoration of

incipient,

cavitated or

enlarging lesions

Conclusion

Reducing caries-risk is the most important element in caries

prevention

Proper oral hygiene, decreased presence of cariogenic

bacteria, reduced carbohydrate intake, adequate fluoride

exposure and adequate salivary flow are all important

components in caries prevention

To achieve this goal, frequent dental visits that begin at latest

by 12 months of age is essential for implementation of all

preventive and caries management measures

References

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Graduate Program

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