24 Diagnostics, Treatment Decision, and Documentation
The theoretical fundamentals of modern caries diagnosis and therapy were discussed in the preceding chapters. In the following chapters which deal with practical application, the implementation of this knowledge will be illustrated with reference to clinical cases and individual treatments. This introductory chapter will therefore present standard forms for documentation and findings tailored to risk assessment, dental diagnostics, and treatment planning. These forms will also be used in the subsequent clinical cases.
When describing clinical cases, several treatments will be described step by step in the following chapters:
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Fissure sealing (adult): Chapter 25, Case 1, Fig. 25.7 , Page 344
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Fissure sealing (child): Chapter 26, Case 1, Fig. 26.9 , Page 380
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Composite restoration (molars): Chapter 25, Case 1, Fig. 25.8 , Page 345
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Composite restoration (anterior teeth): Chapter 25, Case 3, Page 361
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Composite restoration (primary molars): Chapter 25, Case 2, Fig. 25.21 , Page 356
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Infiltration (arresting caries, permanent): Chapter 26, Case 3, Fig. 26.26 , Page 391
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Infiltration (arresting caries, primary molars): Chapter 26, Case 1, Page 374
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Infiltration (masking caries): Chapter 25, Case 4, Page 367
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Stepwise caries excavation (adult): Chapter 25, Case 5, Page 371
Caries Diagnostics at the Patient Level
As presented in Chapters 7 and 9, the goal of caries risk analysis is to estimate the patient′s risk of experiencing new caries lesions in the future followed by an assessment of the patient′s need for risk-related interventions, and to initiate noninvasive or microinvasive therapy with those methods which are most beneficial for this particular patient to lower his or her risk. In addition, the general caries risk should also be taken into consideration for the diagnosis of caries at the tooth level. If the patient is assessed as being at high risk, the probability that his or her questionable lesions are progressing is higher than if the risk were assessed as low.
For reasons of practicality, the caries risk should be assessed as quickly and simply as possible. It is therefore recommended to concentrate on easy-to-determine risk factors with a high predictive value. Several factors or predictors that are useful in assessing the caries risk were cited in Chapter 7. Software programs such as the Cariogram1 that can be downloaded free of charge from the Internet are useful for summarizing and weighting the various risk factors ( Fig. 24.1 ). If a computer is not available at the site of treatment, the caries risk can also be determined using a simple form. Figure 24.2 shows a form for assessing the caries risk which is based on the Cariogram software.
Determining the Risk Factors
The form shown in Fig. 24.2 is restricted to four parameters relating to patient history, and two to three clinical parameters for determining the caries risk. Generally, it takes no more than three minutes to fill out the form, and this can be done by the assistant. In the following, the assessment of the various risk factors will be addressed.
Caries Experience
The patient′s DMFT value (taken from the examination form) is entered and weighted based on the patient′s age. From the diagram, we can determine whether the patient′s DMFT is appropriate for his or her age, or whether it is higher or lower than average for the age group. For children up to 13 years of age the number of initial caries lesions (only visual-tactile assessment) plus restorations and teeth extracted due to caries in deciduous (d1mft) and permanent (D1MFT) teeth is used instead of DMFT (see also Chapter 8).
Sugar Consumption
The patient is asked about the frequency at which he or she consumes fermentable carbohydrates (sugar). Ask about hidden sugars in foods and beverages of which the patient is frequently not aware (see Chapter 11).
Frequency of Food Consumption
Here the patient is asked how many meals and snacks (including sweetened beverages) he or she consumes over the course of the day. By asking specific questions, many patients become aware for the first time how many snacks they consume daily that may contain hidden carbohydrates. The estimated average number of snacks is documented.
Oral Hygiene
The patient′s oral hygiene is evaluated using an easy-to-determine plaque index. In the presented form sheet the Approximal Plaque Index (API) is used. The buccal and oral interproximal regions are checked for the presence of plaque in two quadrants using a probe without staining the plaque beforehand, and the percentage of plaquecovered approximal surfaces is calculated. If other, more detailed plaque or gingiva indexes are utilized during prophylaxis sessions, these can be used as alternatives (Chapter 10).
Fluoride Sources
This item is used to identify and document the different sources of fluoride to which the patient is exposed and to evaluate if additional fluoridation methods should be used for caries prevention. It is important to ask specific questions to determine whether patients are exposed to certain sources of fluoride of which they might not be aware (such as fluoridated table salt, water fluoridation, etc.) to avoid overdosage (Chapter 12).
Salivary Flow
The salivary flow rate normally only has an appreciable effect on the individual caries risk in extremes (e.g., patients with hyposalivation). Since it is comparatively timeconsuming to evaluate the salivary flow rate, this item might only be filled out in the case of suspected hyposalivation (dry mucosa, xerostomia, medications, radiation therapy). In this form, generally the stimulated saliva flow rate (SSFR) is determined. The patient chews on a paraffin pellet for a specific period (e.g., 5 minutes). The amount of saliva produced is collected, measured, and the amount of saliva produced per minute (SSFR) is calculated.
Calculating the Caries Risk and Consequences
The different risk factors that are recorded have different predictive values and therefore need to be weighted differently. A “risk value” is assigned corresponding to the different weighting of each risk factor. The different risk values are then added up, and a percentage caries risk is calculated. The calculated number does not equal the specific probability of whether the patient will experience new caries lesions over a specific period; rather, this value provides a rough estimation of the general caries risk, and the patient is categorized as having a small, average, or great need of risk-related non- and microinvasive intervention. Depending on the dentist′s experience, it may be useful to correct the calculated value upward or downward based on the personal, subjective estimation of the caries risk. The Cariogram software program also provides a similar function.
In the table in the lower part of the form sheet (see Fig. 24.2 ), the individual examination interval as well as intervals for various noninvasive interventions can be determined from the patient′s caries risk. The periods can be individually adapted according to the treatment philosophy and the approach of the dental practice. In any case, this categorization helps you select reasonable, demand-oriented follow-up intervals.
When selecting the risk-related intervention, the different weighting of the various parameters (“risk value” in the form sheet) should be taken into consideration. In the example in Fig. 24.2 , recommendations regarding nutrition and the optimization of oral hygiene are especially useful to lower the patient′s risk of caries.
CLINICAL PEARL
It is useful to determine the caries risk of the patient so that the noninvasive therapy can be adapted to the individual risk factors. Moreover, the intervals of the patient′s follow-up examinations can be adapted to the individual caries risk. In terms of quality management, the follow-up interval can be rationally identified on the basis of individual need.
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