Caries Management System
- 1. CARIES MANAGEMENT SYSTEM DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS 1
- 2. Contents • Introduction • Model of Caries Management • Ten step Caries Management Systems • Principle of Caries Management Systems • Lesion Management Protocol • Strategies for Caries Prevention and Caries Management • References 2
- 3. Introduction • The principles of modern operative dental care were established by GV Black one century ago, long before it became evident that dental caries could be arrested or prevented. • The Caries Management System is a ten step non‐invasive strategy to arrest and remineralize early lesions . 3
- 4. Model of Caries Management Surgical model of caries management • Historically, involved the biomechanical removal of caries lesions and the restoration of the resultant tooth preparation to form and function with a restorative material. • Consisted of waiting until cavitations were detected and treating the cavitations with restorations. • Deals only with the end result of the disease and not addressing its etiology for each individual patient • Was not successful in controlling the caries disease process. 4
- 5. Mechanical model of caries risk assessment and management • An evidence-based system has been developed using caries management strategies. • These assessments look at each patient’s unique set of pathologic factors and protective factors. • Looks at individualized caries risk assessments and uses this information to design treatment plans according to the risk assessment findings . 5
- 6. Ten steps of the Caries Management System 1. Diet assessment 2. Plaque assessment 3. Bitewing radiographic survey 4. Diagnosis and caries risk assessment 5. Preparation of treatment plan 6. Case presentation at which patient is informed about: • Dental caries: ○ Arrest ○ Reversal/natural repair (remineralisation) 6
- 7. ○ Prevention ○ Number and status of current lesions ○ Role of dental practitioner in caries management ○ Role of home care in caries prevention ○ Current caries risk status • Result of diet assessment and recommendations 7. Oral hygiene coaching 8. Topical fluoride application (both professional and home care) 9. Monitoring of plaque control and treatment outcomes at each visit 10. Recall program tailored to caries risk status 7
- 8. Principle of the Caries Management System • The governing principle of the Caries Management System is that caries management must include consideration of: (a) the patient at risk; (b) the status of each lesion; (c) patient management; (d) clinical management; and (e) monitoring. 8
- 9. A) The patient at risk of caries The case history and clinical examination provides an overview of unfavourable exposures to potential caries risk factors, namely: sucrose intake, fluoride use, dental plaque, tooth morphology, and salivary characteristics. Diet assessment • One of the main risk factors for caries is frequent exposure to refined dietary sugar. • As part of the dental history, a Usual 24‐hour Diet Questionnaire is completed • A thorough analysis of the frequency of consumption of between‐meal sugar‐containing snacks and beverages will give an insight into the burden of diet‐related caries risk. 9
- 10. Assessment of dental plaque control • At the initial clinical examination and at every appointment thereafter, dental plaque distribution is recorded according to the Plaque Index. 10
- 11. B) The status of each lesion Final assessment of the patient at risk follows completion of the clinical examination and bitewing radiographic survey. Clinical examination • Smooth surfaces and fissures are dried and explored with sharp eyes and a blunt probe to reveal incipient lesions and enamel breaks. • These are recorded on standard dental charts. • Unless frank cavitation is evident, the diagnosis of dentine caries is via a radiographic bitewing survey. 11
- 12. Bitewing radiographic survey • Radiolucencies are scored according to the five category system proposed by Mejare . 12
- 13. Criteria for scoring bitewing radiolucencies on occlusal and approximal surfaces • C0- No radiolucency evident (not recorded) • C1- Radiolucency is evident within the outer half of enamel • C2- Radiolucency extends to the inner half of enamel and may reach the DEJ • C3- Radiolucency extends just beyond the DEJ • C4- Radiolucency is evident within the outer third of dentine • C5- Radiolucency extends to the inner two thirds of dentine and may reach the pulp 13
- 14. Assessment of the patient’s caries risk status • Risk of caries, according to the Caries Management System, is determined at the first visit solely according to the clinical presentation of the dentition . • At later follow‐up appointments, risk is determined according to the incidence rate of new lesions and progression status of existing lesions. Table :Criteria for assigning caries risk status 14
- 15. s Caries risk New patient Recall patient Low 1. No clinical signs of caries 1. <1 new lesion per year 2. May have bitewing radiolucencies not greater than C3 2. Or no progression of existing radiolucencies Medium 1. No frank cavitation 1. 1 new lesion per year 2. May have sticky pits or fissures 2. And/or progression of existing radiolucencies 3. And/or bitewing radiolucencies not greater than C4 High 1. Untreated frank cavities 1. >1 new lesion per year 2. And/or extensive white spot lesions 3. And/or C5 bitewing radiolucencies 15
- 16. C) Patient management Based on caries risk assessment To obtain cooperation -> deliver a package of non‐invasive measures designed to arrest active non‐cavitated lesions and, once arrested, to maintain them in that condition. Case presentation and treatment planning • The caries findings are presented to the patient . • Explanation of the diagnosis and related treatment need. 16
- 17. Diet advice • It is important that patients understand the diet‐caries relationship. • The probability that caries risk will be reduced by reducing refined sugar is strong only in the case where there is close to complete absence of sugar in the diet. • But since sugar use is ubiquitous in processed food, it cannot be avoided. • Dental practitioners accept responsibility for: (a) assessing this dietary risk; (b) bringing this risk to the attention of patients; and (c) providing appropriate advice. 17
- 18. Oral hygiene instruction and coaching • It’s objective the reduction in the Plaque Index score (or bleeding on probing). • Patients are trained to recognize plaque and gingivitis and to observe how quickly gingivitis will resolve following the institution of regular and careful toothbrushing. • For very high risk patients, the use of chlorhexidine is indicated. 18
- 19. D) Clinical management • The risk‐based caries management options are: preventive, preservative (non‐invasive) and operative (invasive). • Cavitated lesions are managed using operative procedures. • Sealants should be placed, without the removal of any tooth structure, over pre‐cavitated incipient or friable, fissure lesion. • The application of fluorides (professional and home care use) . 19
- 20. Protocol for the management of lesions following caries diagnosis based on the bitewing radiographic survey Lesion Management Protocol Lesion Score and Treatment • C1- Do not restore – apply topical fluoride and monitor • C2- Do not restore – apply topical fluoride and monitor • C3- Do not restore – apply topical fluoride and monitor • C4- Do not restore without further consideration • C5- Restore now – it is almost certain that the cavity has breached the DEJ 20
- 21. Further consideration for surfaces scored C4 Low and Medium Caries Risk • Restore only if the radiolucency extends fully 1/3 into dentine, or following tooth separation when cavitation is confirmed Otherwise do not restore because it is most likely: ○ that the approximal surface is not cavitated, and ○ that the lesion has arrested • Apply topical fluoride and monitor: ○ to arrest and remineralise active lesions, or ○ to maintain arrested lesions 21
- 22. High Caries Risk • Restore now • Apply topical fluoride and monitor: ○ to arrest and remineralise lesions not yet showing radiographically, and ○ to prevent recurrent caries 22
- 23. E) Monitoring • Patients are recalled for monitoring caries activity and oral hygiene competency. • Comprises the assessment of: clinical status, dental bitewing radiolucency progression, diet control, plaque control, fluoride exposure and, in extreme cases of hyposalivation, saliva control . 23
- 24. Strategies for Caries Prevention and Caries Management • Preventive treatment methods are designed to limit tooth demineralization caused by cariogenic bacteria, preventing cavitated lesions. • These methods include (1) limiting pathogen growth and altering metabolism, (2) increasing the resistance of the tooth surface to demineralization, and (3) increasing biofilm pH. 24
- 25. Clinical considerations in caries prevention 1. General health 2. Diet 3. Oral hygiene 4. Fluoride exposure 5. Anti- caries vaccine 6. Functions of saliva 7. Antimicrobial agents: chlorhexidine , xylitol 8. Calcium and calcium phosphate compounds:CPP-ACP 9. Probiotics 10. Sealants 11. Existing restorations 12. Caries control restorations 25
- 26. Calcium and Phosphate Compounds 26
- 27. References • Sturdevant’s art and science of operative dentistry sixth edition • Australian Dental Journal Volume 53 Issue 1 27
- 28. THANK YOU 28