Case 5
Dental Hygiene Treatment Strategies
Medical History
The patient’s medical history revealed no significant findings and vital signs were within normal limits.
Dental History
Patient has not had a dental exam or prophylaxis in three years. He just moved to the area and previously did not visit the dentist on a regular basis. He brushes once a day with a soft toothbrush and nonfluoridated toothpaste and does not use interdental cleaners or mouthrinses. He frequently snacks during school and drinks sugary beverages throughout the day.
Social History
Patient lives with his mother and three younger siblings. He has started a new job after school at a convenience store to help with family finances.
Dental Examination
Extraoral exam revealed no significant findings. Intraorally the patient presents with cheek biting and Class II malocclusion. Gingiva appears red, enlarged with generalized moderate biofilm with bleeding upon probing. Patient has posterior occlusal deep pits and fissures and Class V white spot lesions on teeth #5, #6, #11 and #12.
Dental Hygiene Diagnosis
| Problems | Related to Risks and Etiology |
| Gingival bleeding/inflammation | Biofilm accumulation |
| Increased caries risk (CAMBRA) level high | Consumption of sugar‐sweetened foods and beverages frequently throughout the day |
| Irregular dental visits | |
| Irregular personal oral‐care habits | |
| Frequent sugar intake | |
| Current cavitated lesions |
Planned Interventions
| Planned Interventions (to arrest or control disease and regenerate, restore or maintain health) |
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| Clinical | Education/Counseling | Oral Hygiene Instruction |
| CAMBRA assessment Adult Prophylaxis every 3–4 months NaF varnish every 3–4 months BTW x‐rays every 6–18 months until no cavitated lesions are evident Baseline salivary flow and bacterial culture and again at every recare appt. Sealants posterior teeth (ICDAS [International Caries Detection and Assessment System] protocol) |
Importance of regular dental visits Educate about the relationship between fermentable carbohydrates and caries; recommend dietary analysis Educate and motivate on the importance of biofilm management Educate and motivate on the importance of a healthy lifestyle |
Proper use of toothbrush and interdental cleaning 1.1% NaF toothpaste b.i.d. Xylitol (6–10 g day) 2 tabs of gum or candies four times a day Chlorhexidine gluconate 0.12% mouthrinse, 10 ml for 1 minute daily, 1 week each month Optional: 0.2% NaF rinse daily OTC 0.05% NaF rinse daily CPP paste daily |
Progress Notes
The patient was seated for his appointment, and a complete medical, social, and dental history was taken. An initial exam, FMS, dental exam, and periodontal exam was performed and revealed white spot lesions, deep pits, and fissures. Radiographs revealed interproximal decay on teeth #30 and #19. The periodontal exam revealed generalized gingival inflammation with probing depths of 1–4 mm. A caries management by risk assessment (CAMBRA) was performed, and the patient was determined to be at high risk. The treatment plan was explained, and consent obtained. Bacterial culture and salivary flow rate were obtained. Caries risk and biofilm management were explained, and oral hygiene methods were demonstrated and reviewed with patient. An adult prophylaxis was performed, and topical fluoride varnish was applied. It was recommended that the patient brush twice a day with a high fluoride toothpaste, rinse with an antibacterial mouth rinse for one week each month and suck or chew xylitol candies or gum four times a day. Dietary recommendations were explained and patient was put on a three‐month recall. The patient was scheduled for his next appointment.
Discussion
A cornerstone model of disease progression is the epidemiological triad. This model proposes that disease does not occur randomly – disease is only spread among populations at risk for the disease. Risk factors include the immune status of the host, the presence of the infectious agent, and the environment in which the disease is most likely to occur (CDC.gov 2012). The likelihood for and the extent that dental caries causes destruction in healthy teeth is also dependent on risk factors and can be viewed in a similar manner. Dental caries is an infectious, and communicable, disease that is dependent on several variables, each of which can be modulated to arrest further progression or occurrence. These risk factors include the ability of the tooth to resist demineralization (immunity), the presence of infectious organisms (agent), the consumption of cariogenic foods, and the quality and quantity of salivary components (environment) (Diagnosis and Management of Dental Caries Throughout Life 2001; Wilkins et al. 2016).
Historically, the incidence of dental caries in children 13–15 years of age declined 68% by 1970 after fluoridated water was adopted as a public health measure in 1962. The rate of decline in caries slowed in the 1980s and left a significant number of children aged 5–17 years with caries in their permanent teeth. Dental caries continues to be a significant global problem, and the risk for dental caries is exacerbated in populations who are limited or without access to care. Research then revealed that fluoride alone was not sufficient in controlling the disease and other risk factors needed to be addressed (CDC.gov 1999; Featherstone 2000; Diagnosis and Management of Dental Caries Throughout Life 2001).
A seminal article written by Featherstone (2000) presented a compelling argument to support the stance that the risk for progression of dental caries may be assessed as a balance between “pathological factors” and “protective factors” (Featherstone 2000). Pathological factors include elements that increase the propensity for the disease, for example, cariogenic bacteria and the presence of fermentable carbohydrates. Protective factors are elements that may provide protection or arrest the caries process, for example, fluoride and adequate saliva. It is this balance between pathological factors and protective factors, which mitigate the tooth’s ability to resist the development of dental caries. Featherstone appreciated the need for prevention of the disease through caries risk management and refuted the premise that caries can be stopped by surgical removal or restoration. He instead provided evidence that fluoride by way of the saliva can interrupt the demineralization of tooth enamel and become a vehicle for calcium and phosphorus to remineralize the affected area (Featherstone 2000).
Subsequently, the National Institutes of Health (NIH) convened a panel of experts to review research on the best practices for diagnosis and the management of dental caries. The panel identified many disease indicators (Table 3.5.1) and provided a list of recommended treatment modalities to prevent, arrest, or reverse the disease process, for example, fluoride, chlorhexidine, sealants, salivary enhancers, and oral‐health education (Diagnosis and Management of Dental Caries Throughout Life 2001). In addition, research suggested increased remineralization of the tooth surface by application of amorphous calcium phosphate (ACP) and complex casein phosphopeptides (CPP) on the tooth surface (Zero et al. 2009).
Table 3.5.1: Indicators for increased risk of dental caries.
Source: Adapted from Diagnosis and Management of Dental Caries Throughout Life (2001).
| Indicator | Example |
| Past caries experience | Most consistent predictor |
| Presence of caries in the mother and siblings | Matrilineal transmission |
| Inadequate exposure to fluoride | Use of fluoride dentifrice |
| Conditions that compromise maintenance of good oral hygiene practices | Illness, physical, and mental challenges, existing restorations, oral appliances |
| Fermentable carbohydrates consumption associated with acid formation and demineralization | Amount, consistency, frequency |
| Xerostomia | Saliva provides calcium, phosphate, and neutralizes acids formed by bacterial metabolism |
These findings were later used in the development of a clinical protocol so named for its purpose: caries management by risk assessment (CAMBRA). The protocol included a form and diagram that would enable the clinician to identify risk factors, disease indicators, and protective factors, which would ultimately determine the level of caries risk for the patient and recommended treatment strategies (Featherstone et al. 2007). An illustration (Figure 3.5.1) assigning acronyms for the three elements included in caries risk assessment (WREC, BAD, SAFE), captures the essence of the disease process and the balance of attenuating factors (Featherstone et al. 2007). The risk factors are tallied and categorized at extreme, high, moderate, or low risk. For example, patients with severe salivary hypofunction are automatically deemed at extreme risk for developing caries and patients with current dental caries are deemed at high risk. Moderate risk includes patients who have some disease indicators and risk factors that without intervention could move into the high‐risk category. Low‐risk patients have no history of dental caries and whose protective factors outweigh any disease indicators (Table 3.5.2). The patient referenced in this case was found to have interproximal cavitated lesions on radiographs, which would place him in the high‐risk category. Existing caries or restorations, along with the observation of white spot lesions, are strong indicators that the likelihood or risk for developing caries will continue to progress (Featherstone et al. 2007).
Figure 3.5.1: The caries “imbalance.” The balance among disease indicators, risk factors, and protective factors determines whether dental caries progresses, halts, or reverses. Cavities/dentin refers to frank cavities or lesions to the dentin by radiograph. Restorations < three years means restorations placed in the previous three years. This figure has been updated from previous versions of the “caries balance” with the very important addition of the disease indicators. If these indicators are present they weigh heavily on the side of predicting caries progression unless therapeutic intervention is carried out. The abbreviations that help recall of the imbalance (WREC; BAD; SAFE) are shown as well as sealants as a protective factor. Dietary habits (poor) indicate frequent ingestion of fermentable carbohydrates (greater than three times daily between meals).
Source: Reprinted with permission from the California Dental Association, copyright October 2007.
Table 3.5.2: Caries Risk Assessment Form — Children Age 6 and Over/Adults. Featherstone et al. (2007).
| Patient Name:______________ Chart #:_________________ Date:______________________ Assessment Date: Is this (please circle) base line or recall |
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| Disease Indicators (Any one “YES” signifies likely “High Risk” and to do a bacteria test**) | YES = CIRCLE | YES = CRCLE | YES = CRCLE |
| Visible cavities or radiographic penetration of the dentin | YES | ||
| Radiographic approximal enamel lesions (not in dentin) | YES | ||
| White spots on smooth surfaces | YES | ||
| Restorations last three years | YES | ||
| Risk Factors (Biological predisposing factors) | |||
| MS and LB both medium or high (by culture**) | YES | ||
| Visible heavy plaque on teeth | YES | ||
| Frequent snack (> 3x daily between meals) | YES | ||
| Deep pits and fissures | YES | ||
| Recreational drug use | YES | ||
| Inadequate saliva flow by observation or measurement (**If measured note the flow rate below) | YES | ||
| Saliva reducing factors (medications/radiation/systemic) | YES | ||
| Exposed roots | YES | ||
| Orthodontic appliances | YES | ||
| Protective Factors | |||
| Lives/work/school fluoridated community | YES | ||
| Fluoride toothpaste at least once daily | YES | ||
| Fluoride toothpaste at least 2x daily | YES | ||
| Fluoride mouthrinse (0.05% NaF] daily | YES | ||
| 5000 ppm F fluoride toothpaste daily | YES | ||
| Fluoride varnish in last six months | YES | ||
| Office F topical in last six months | YES | ||
| Chlorhexidine prescribed/used one week each of last six months | YES | ||
| Xylitol gum/lozenges four times daily last six months | YES | ||
| Calcium and phosphate paste during last six months | YES | ||
| Adequate saliva flow (> 1 ml/min stimulated) | YES | ||
| **Bacteria/Saliva Test Results: MS: LB; Flow Rate: ml/min. Date: | |||
| VISUALIZE CARES BALANCE (Use circled indicators/factors above) (EXTREME RSK − HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION) CARIES RISK ASSESSMENT (CIRCLE): EXTREME HIGH MOOERATE LOW Doctor signature/#:_______________________________ Date:__________________ |
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Once a risk level is identified, the CAMBRA protocol recommends specific therapeutic interventions and strategies (Jenson et al. 2007). Clinical guidelines for patients in the high‐risk category are reflected in the Dental Hygiene Care Plan Recommended Interventions for this patient. Guidelines for patients in other risk levels are presented in Table 3.5.3 (Jenson et al. 2007).
Table 3.5.3: Clinical guidelines for patients age six and older. Jenson et al. (2007).
Source: Reprinted with permission of the California Dental Association, copyright October 2007.
| Risk Level###,*** | Frequency of Radiographs | Frequency of Caries Recall Exams | Saliva Test (Saliva Flow and Bacterial Culture) | Antibacterials Chlorhexidine Xylitol**** | Fluoride | pH Control | Calcium Phosphate Topical Supplements | Sealants (Resin‐based or Glass Ionomer) |
| Low risk | Bitewing radiographs every 24–36 months | Every 6–12 months to re‐evaluate caries risk | May be done as a base line reference for new patients | Per saliva test if done | OTC fluoride‐containing toothpaste twice daily, after breakfast and at bedtime. Optional: NaF varnish if excessive root exposure or sensitivity | Not required | Not required Optional: for excessive root exposure or sensitivity | Optional or as per ICDAS sealant protocol (TABLE 2 [in original]) |
| Moderate risk | Bitewing radiographs every 18–24 months | Every 4–6 months to re‐evaluate caries risk | May be done as a base line reference for new patients or if there is suspicion of high bacterial challenge and to assess efficacy and patient cooperation | Per saliva test if done Xylitol (6–10 grams/day) gum or candies. Two tabs of gum or two candies four times dally | OTC fluoride‐containing toothpaste twice daily plus: 0.05% NaF rinse daily. Initially, 1–2 app of NaF varnish; 1 app at 4–6 month recall | Not required | Not required Optional: for excessive root exposure or sensitivity | As per ICDAS sealant protocol (TABLE 2 [in original]) |
| High risk* | Bitewing radiographs every 6–18 months or until no cavitated lesions are evident | Every 3–4 months to re‐evaluate caries risk and apply fluoride varnish | Saliva flow test and bacterial culture initially and at every caries recall appt. to assess efficacy and patient cooperation | Chlorhexidine gluconate 0.12% 10 ml rinse for one minute daily for one week each month. Xylitol (6–10 grams/day) gum or candies. Two tabs of gum or two candies four times daily | 1.1% NaF toothpaste twice dally instead of regular fluoride toothpaste. Optional: 0.2% NaF rinse daily (1 bottle) then OTC 0.05% NaF rinse 2X daily. Initially, 1–3 app of NaF varnish; 1 app at 3–4 month recall | Not required | Optional: Apply calcium/phosphate paste several times daily | As per ICDAS sealant protocol (TABLE 2 [in original]) |
| Extreme risk** (High risk plus dry mouth or special needs) | Bitewing radiographs every 6 months or until no cavitated lesions are evident | Every 3 months to re‐evaluate caries risk and apply fluoride varnish. | Saliva flow test and bacterial culture initially and at every caries recall appt. to assess efficacy and patient cooperation | Chlorhexidine 0.12% (preferably CHX in water base rinse) 10 ml rinse for one minute daily for one week each month. Xylitol (6–10 grams/day) gum or candies. Two tabs of gum or two candies four times dally | 1.1% NaF toothpaste twice daily instead of regular fluoride toothpaste. OTC 0.05% NaF rinse when mouth feels dry, after snacking, breakfast and lunch. Initially, 1–3 app. NaF varnish; 1 app at 3 month recall. | Acid‐neutralizing rinses as needed if mouth feels dry, after snacking bedtime and after breakfast. Baking soda gum as needed | Required Apply calcium/phosphate paste twice daily | As per ICDAS sealant protocol (TABLE 2 [in original]) |
*Patients with one (or more) cavitated lesion(s) are high‐risk patients.
**Patients with one (or more) cavitated lesion(s) and severe hyposalivation are extreme‐risk patients.
***All restorative work to be done with the minimally invasive philosophy in mind. Existing smooth surface lesions that do not penetrate the DEJ and are not cavitated should be treated chemically, not surgically. For extreme‐risk patients, use holding care with glass ionomer materials until caries progression is controlled. Patients with appliances (RPDs, prosthodontics) require excellent oral hygiene together with intensive fluoride therapy e.g., high fluoride toothpaste and fluoride varnish every three months. Where indicated, antibacterial therapy to be done in conjunction with restorative work.
****Xylitol is not good for pets (especially dogs).
###For all risk levels: Patients must maintain good oral hygiene and a diet low in frequency of fermentable carbohydrates.
Research to support or refute the therapeutic interventions recommended in the CAMBRA protocol is ongoing. The clinical efficacy of fluoride and sealants in the prevention of dental caries is well‐documented. Definitive clinical evidence to support additional therapeutic strategies, for example, CPP‐ACP, xylitol, chlorhexidine, are not confirmed. The clinician must use reasonable care when proposing a treatment plan that is not completely grounded in evidence‐based research and weigh the risks, and costs against the benefits for the patient (Jenson et al. 2007; Fontana et al. 2009; Zero et al. 2009). With this in mind, Hurlbutt and Young (2014) provide a literature review of CAMBRA best practices and current research on the efficacy of each of the recommended treatment strategies for the dental hygienist. The traditional caries imbalance graphic is wisely updated to include “Risk Based Reassessment” as a protective factor and offers guidance when research to support clinical efficacy for a marketing claim is not available. A revised CAMBRA clinical protocol (Table 3.5.4) includes these considerations in treatment planning (Hurlbutt and Young 2014).
Table 3.5.4: SAFER Protocol: An example of clinical guidelines based on caries risk for patients 6 years through adult.
Source: © Michelle Hurlbutt
| S | A | F | E | R | ||||
| Caries Risk Level | Sealants | Saliva | Antibacterials | Fluoride (Topical) | Factors favorable for remineralization (pH, Ca2+ & PO43−) | Effective Lifestyle Habits | Radiographs | Recare Interval |
| Low Risk | Not indicated. (Optional for primary prevention of at risk deep pits and fissures). |
Saliva testing is optional or may be done for purposes of baseline records. | Not indicated. | OTC fluoride toothpaste used b.i.d. | Recession or sensitive roots may indicate need for supplementation. | Encourage healthy dietary habits, low frequency of fermentable carbohydrates, adequate protein intake & effective oral hygiene practices using motivational interviewing techniques. Substitute xylitol for sucrose. | Every 24–36 months. | Every 6 months. |
| Moderate Risk | Sealants have been proven to be effective. | Measure resting and stimulated flow and pH, especially if hypo salivation is suspected. Objective measurement of acidogenic bacterial load via culturing or direct measurement of plaque ATP. |
Xylitol therapy at least 2–3 times/day for a total daily dose of 6–10 grams It must be understood the evidence is limited for antibacterials and pH neutralization with agents such as chlorhexidine, sodium hypochlorite, povidone iodine, and essential oils. If high levels of acidogenic bacteria are present, using such agents, per manufacturer’s instructions, should be monitored closely. Retest bacterial load after initial treatment, discuss and motivate patient, and repeat as needed. |
OTC fluoride toothpaste used b.i.d. NaF rinse b.i.d. Varnish applied every 4–6 months. | Low resting pH, low stimulated flow or pH may indicate need for supplementation. | Every 18–24 months. | Every 4–6 months. | |
| High Risk | 5000 ppm toothpaste used qd or b.i.d. NaF rinse b.i.d. Varnish applied every 3 to 4 months | Consider supplementing if topical fluoride alone is not effective. | Every 6–18 months. | Every 3–4 months. | ||||
| Extreme Risk | Required if hyposalivation is present. | Every 6 months until no new caries lesions. | Every 3 months. | |||||
Note: Patients with one (or more) cavitated lesion(s) are High Risk patients. Patients with one (or more) cavitated lesion(s) and hyposalivation are Extreme Risk patients. All restorative work to be done with the minimally invasive philosophy in mind. Existing smooth surface lesions that do not significantly penetrate the DEJ and are not cavitated should be treated chemically not surgically. For Extreme Risk patients with multiple cavitations, caries control procedures with glass ionomer materials until caries progression is halted and/or reversed may be used and followed with more permanent restorative care. Patients at risk with appliances (RPDs, Orthodontics) require excellent oral hygiene together with intensive fluoride therapy (e.g. high fluoride toothpaste and fluoride varnish every 3 months). If antibacterial therapy is tried, it should be done in conjunction with fluoride therapy (and every attempt be made not to interfere with the fluoride intervention). A 1‐month initial treatment evaluation may be helpful for positive reinforcement. Patients must maintain good oral hygiene (a powered toothbrush may be helpful for High and Extreme Risk patients). A diet low in frequency of fermentable carbohydrates is recommended. It is important to know the amount of xylitol in the product being recommended. Xylitol products should contain 100% xylitol (daily dosages of a total of 6–10 grams across the day for antimicrobial effects).
Take‐Home Hints
- The role of the dental hygienist in CAMBRA includes medical history review, risk assessment, radiographs, intraoral photos, saliva assessment and bacterial testing, patient education in biofilm management, and fluoride varnish and sealant application.
- Dental caries is an infectious and communicable disease that is dependent on several variables, each of which can be modulated to arrest further progression or occurrence.
- The most consistent predictor of caries risk in children is past caries experience.
- Salivary gland hypofunction poses an extreme risk for dental caries. Subjective complaints of xerostomia must be corroborated with a differential diagnosis and salivary flow rate test.
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