Medical History, Review of Systems, Social History, Extra/Intraoral Examination, Occlusion, and Radiographic Examination
The patient is healthy in all aspects. She uses oral contraceptives and occasional antihistamines for seasonal allergies. Her past medical history and her review of systems are unremarkable. Her social history is positive for social intake of alcohol and patient denies use of recreational drugs or tobacco. The patient’s extra/intraoral examinations are within normal limits and current clinical examination of teeth reveals no evidence of caries and excellent occlusion without evidence of excessive wear or physical damage. Radiographic examination is positive for initial to moderate approximal caries as highlighted below
Though caries penetration to the dentoenamel junction is only obvious on the lower second premolar, early caries is noted on the approximal surfaces of both first molars and the maxillary premolars.
Dental caries and high caries risk.
Nonsurgical Caries Management
- Improvement in oral hygiene including twice per day brushing with fluoride toothpaste (1000 ppm).
- Diet counseling to reduce the frequency of sugar containing foods and drinks (particularly drinks).
- High‐concentration fluoride paste (5000 ppm) just prior to bedtime.
- Dental recall with professionally applied fluoride varnish three to four times per year.
This patient presents with early active dental caries. In order to determine the proper therapeutic approach to treat these lesions, it is first necessary to classify the lesions by depth and activity of the disease (Ismail et al. 2013a). It is recognized that caries is a bidirectional disease with demineralization resulting in cavitation and remineralization resulting in lesion arrest or reversal (Pitts 2004). Cavitation is a continuum of a disease that starts with simple demineralization and if left untreated continues to deep cavitation and eventual loss of the tooth. Initial demineralization lesions penetrating as deep as one third the distance into the dentin (radiographically) may still have an intact outer enamel surface, have no bacterial penetration, and may be remineralizable (Ekstrand 1995; Ekstrand et al. 2007). The approximal lesions are classified by depth of penetration through the enamel. The decay is active as it did not exist three years ago (Ismail et al. 2013a). The causation of dental caries can be due to many factors. Changes in oral hygiene, diet, and systemic factors (particularly as they relate to salivary flow) are conditions most frequently associated with increased caries risk (Hara and Zero 2010). As there have been no changes in this patient’s medical history and there is no clinical evidence of xerostomia on examination, changes in diet and oral hygiene are the most likely cause. The patient’s social history indicates a significant change in living conditions, associated with living at college. Marsh and others demonstrated that stresses on the previously stable dental plaque ecoenvironment can result in a shift in that biofilm from healthy to one that is acid producing and, in this case, likely to cause caries (Marsh 2010; Marsh and Bradshaw 1995). Further demonstrated is that change in homecare can result in shifting the biofilm to a more acid forming, cariogenic, biofilm. In this case, the young dentally healthy female leaving home where diet and homecare had permitted a healthy ecosystem to thrive, allowed a shift in the ecosystem toward acid production. Minor changes in the patient’s diet can result in significant acid production thereby creating an environment likely to produce caries (Newbrun 1979, 1982). Inquiry as to homecare patterns and diet with the patient is appropriate to confirm why the shift in ecosystem has occurred. The college experience is replete in habit changes including sleep, hygiene, and eating. The frequently discussed “freshman 15” weight gain is an example of a shift in dietary habits, whereby college students in their first‐year gain 15 lbs. The changes in oral hygiene associated with changes in the student schedule are legendary (Levitsky et al. 2004).
Management of these initial caries lesions has shifted from surgical intervention to a medical management (Wolff and Larson 2009). Fluoride therapies represent the most common intervention for remineralization of initial lesions. Fluoride therapies can be divided into two categories, preventive and remineralization, with the therapeutic mechanisms often overlapping. Public water fluoridation is the mainstay of public health caries prevention therapies (Newbrun 1989; O’Mullane et al. 1988; Rozier 1995; Rugg‐Gunn and Do 2012). Though highly effective in reducing new caries, fluoridated public water is unlikely to remineralize early lesions (particularly with changes in the local environment with improved hygiene and reduced carbohydrate consumption). Fluoride containing toothpastes (900–1500 ppm fluoride) are also very effective caries preventive methodologies with increased frequency of utilization demonstrated to prevent caries (Marinho et al. 2003, 2004; Twetman et al. 2003). Remineralization of initial lesions requires the reduction of plaque, reduction of the frequency of fermentable carbohydrate consumption, and the use of higher concentration fluorides. These high concentration fluoride products are being utilized as active therapeutics (not preventives) that are expected to reverse the active disease damage by remineralizing the initial lesions with calcium, phosphate, and fluoride. The most common therapies recommended for remineralization are 5000 ppm pastes for daily homecare and high concentration varnish products three to four times per year (Bailey et al. 2009; Ismail et al. 2013a, 2015; Marinho et al. 2013; Tellez and Wolff 2016). The products must be utilized for six months to multiple years after the initial caries is discovered. The lesions can be expected to reverse, arrest, or (at worst) stay the same (Featherstone 1996, 2009; Lynch and Baysan 2001). This program requires patient education, patient participation, and professional persistence with the remineralization program.
- Dental caries is preventable.
- Dental caries is frequently treatable without a drill.
- The dental team is integral in controlling this disease.
- High‐concentration fluoride (particularly varnish) frequently applied is a critical portion of nonsurgical caries management.