7: The Disease Control Phase of Treatment

CHAPTER 7

The Disease Control Phase of Treatment

Samuel Paul Nesbit

CHAPTER OUTLINE

Purpose of the Disease Control Phase
Structuring the Disease Control Phase
Common Disease Control Problems

Dental Caries

Caries Control: A Working Definition
Objectives, Strategies, and Rationale for the Caries Control Protocol
Basic Caries Control Protocol
Optional Caries Interventions
Patient Selection
Comprehensive Caries Management

   Patient With No Active Carious Lesions and at Low Risk for Future Caries
   Patient With Isolated Carious Lesions and at Low Risk for Future Caries
   Patient With Multiple Active Lesions or at High Risk for New Caries
   Seeking an End Point: The Disease Control Phase Posttreatment Assessment
Periodontal Disease

Causes of Periodontal Disease

   Local Factors Plaque, Calculus, and Pathogenic Microflora
   Heredity
   Systemic Factors and Immunoinflammatory Response
   Tobacco Use
   Other Deleterious Habits
   Defective Restorations
   Occlusal Trauma
Treatment of Active Periodontal Disease—Initial Therapy

   Systemic Considerations
   Oral Self-Care Instructions
   Extraction of Hopeless Teeth
   Elimination of Iatrogenic Restorations and Open Carious Lesions Contributing to Periodontal Disease
   Managing Other Dental Problems That Contribute to Periodontal Disease
   Scaling and Root Planing
   Pharmacotherapy
Post–Initial Therapy Evaluation
Pulpal and Periapical Disease

Reversible Pulpitis or a Healthy Pulp When the Caries, Fracture, or Defect Is of Moderate Depth and the Pulp Is Not Exposed
Reversible Pulpitis or a Healthy Pulp and Healthy Periapical Area When the Caries, Fracture, or Defect Is in Close Proximity to the Pulp
Reversible Pulpitis or a Healthy Pulp and Health Periapical Area When the Pulp Is Exposed
Irreversible Pulpitis or Necrotic Pulp
Patient Declines Treatment for an Asymptomatic Apical Periodontitis, Cyst, or Granuloma
Single Tooth Restoration in the Disease Control Phase of Care
Stabilization of Dental Malalignment, Malocclusion, or Occlusal Disharmony

Root Proximity Problem That Precludes Restoration of a Carious Lesion or Fracture
Plunger Cusp, Open Contact, and/or Marginal Ridge Discrepancy Contributing to Food Impaction and Periodontal Disease
Severe Crowding
Generalized Occlusal Trauma
Localized Occlusal Trauma or Isolated Occlusal Interferences
Supraerupted Tooth Extending into an Opposing Edentulous Space
Impacted Tooth Other Than a Third Molar
Decreased Vertical Dimension of Occlusion
Temporomandibular Joint Disorders

Reducing Anterior Disc Displacement
Nonreducing Anterior Disc Displacement
Degenerative Joint Disease
Myalgia
Other Forms of Oral Pathology
Replacement of a Missing Tooth or Teeth During the Disease Control Phase
Reassessment
Making the Transition to the Definitive Phase of Care

After a thorough examination and diagnostic workup of the patient, both the new and the experienced practitioner may be tempted to finalize the treatment plan and move on with actual treatment. Certainly, there is merit in having a single, clear, well-sequenced restorative plan of care. A fundamental question to consider at this point, however, is whether the plan (exclusive of the systemic and acute phase elements discussed in Chapters 5 and 6) should be one continuous successive list, including all periodontal, restorative, orthodontic, endodontic, or surgical treatments required, or does the patient’s oral health require a separate disease control phase of treatment to establish a stable foundation for future reconstruction?

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Figure 7-9 Deep carious lesions. (Courtesy Dr. C. Bentley, Chapel Hill, NC.)

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Figure 7-10 Mesio-occlusal amalgam restoration with a fracture across the isthmus.

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Figure 7-11 Tooth fracture. (Courtesy Dr. D. Shugars, Chapel Hill, NC.)

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Figure 7-12 Cracked tooth syndrome. A, Placement of a Toothsleuth to test for a cracked tooth. B, Fracture line evident on the mesiofacial aspect of the floor of the preparation. (A, Courtesy Dr. D. Shugars, Chapel Hill, NC; B, courtesy Dr. A. Wilder, Chapel Hill, NC.)

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Figure 7-13 Large metallic restorations. Note that the deep bases on the maxillary second premolar and first molar appear to be in close proximity to the pulp. (Courtesy Dr. J. Ludlow, Chapel Hill, NC.)

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Figure 7-14 Cervical notching. (Courtesy Dr. D. Shugars, Chapel Hill, NC.)

PURPOSE OF THE DISEASE CONTROL PHASE

Disease control is appropriate when in the dentist’s judgment the questionable status of the patient’s oral health suggests the need for further stabilization before making final decisions on treatment, that is, treatment uncertainty. Disease control is also warranted when an intentional reevaluation of the patient is necessary to ensure control of oral disease and infection, that is, disease status uncertainty. Finally, in problematic situations that could be characterized as patient commitment uncertainty, a disease control phase allows the dentist to preserve, for a time, the maximum number of treatment options while testing the patient’s desires, resolve, commitment, compliance with oral hygiene recommendations, financial status, and comfort in the dental chair.

The purpose of the disease control phase is:

1. To eradicate active disease and infection
2. To arrest occlusal, functional, and esthetic deterioration
3. To address, control, or eliminate causes and risk factors for future disease

The disease control phase allows the practitioner to determine the cause or causes of disease, to assess risk factors, and to estimate the prognosis for control of disease and for the various treatment options. The disease control phase also provides both the practitioner and the patient with crucial information on which to base treatment recommendations and decisions. In general, when conditions warrant a disease control phase, nonacute and elective orthodontic, endodontic, periodontic, and oral and maxillofacial surgical procedures and any definitive reconstruction are postponed until its conclusion.

A disease control phase is not necessary in the patient whose oral disease is controlled or who does not demonstrate significant risk factors for new disease. It also is not needed for the patient whose oral disease will be eliminated de facto during definitive treatment. For example, consider the patient with severe periodontal attachment loss whose treatment plan includes 14 extractions and the design, fabrication, and placement of complete maxillary and mandibular overdentures. Because this treatment generally has a predictable outcome, with disease essentially eliminated by the definitive treatment itself, a disease control phase is usually unnecessary. On the other hand, the patient with seven variously sized carious lesions and multiple risk factors for new caries would be likely to benefit from a separate disease control phase of treatment. In this case, it would be inappropriate for the dentist to provide crown restorations before the caries process has been controlled and caries risk factors neutralized or eliminated.

Minimally, the disease control phase should include plans for management of the following:

• Any active oral disease or infection, including but not limited to caries, periodontal disease, and pulpal pathology
• Teeth requiring stabilization before definitive reconstruction
• Risk factors that predispose the patient to the development of new or recurrent oral disease, such as smoking or a diet high in refined carbohydrates

The plan for the disease control phase includes a posttreatment assessment. Although the concept of posttreatment assessment is discussed in detail in Chapter 9, the unique aspects of assessment following a disease control phase merit discussion here because of importance and timing. Using quantifiable measures whenever possible, such an assessment provides an opportunity for the practitioner to confirm that disease and infection are under control. The patient with active caries for whom reduction in the concentration of cariogenic bacteria can be demonstrated represents one example. The patient with rapidly progressive periodontitis and a confirmed reduction in Actinobacillus actinomycetemcomitans counts is another.

An assessment at the conclusion of the disease control phase allows both patient and dentist to make a realistic evaluation of feasible and practical treatment options. Previously considered options can be revisited, and the prognosis can be determined with more certainty. In addition, the patient can have a clearer understanding of the level of financial resources, time, and energy he or she will need to invest in the process. With a track record already established for the patient, the dentist can make treatment recommendations with a better sense of the expected outcomes.

At the time of the assessment, new options for definitive treatment may also become apparent. The patient who, at the outset, only aspired to reparative treatment may now be prepared to consider other possibilities. Having successfully completed the disease control phase, the patient may have a new appreciation of self and the improvements that dental treatment can provide. For example, when periodontal tissues are no longer tender and anterior teeth have been restored to an esthetically pleasing shape and color, the patient may be prepared to consider orthodontic tooth movement to correct anterior crowding. Before disease control therapy, the patient may not have considered and probably would not have wanted orthodontic therapy. Furthermore the dentist may have been appropriately reluctant to even suggest orthodontic treatment to the patient before a successful outcome to the disease control phase was assured.

 

Dental Team Focus

The Oral Health Team and the Disease Control Phase

When the disease control plan has been established, the role of the dental team will be to execute the plan successfully and efficiently. If the patient and members of the team are all knowledgeable about and focused on the goals of the plan, then the probability for success will be greatly enhanced. The administrative assistant should focus on:

• Completing this phase in an appropriate time frame by scheduling a series of appointments
• Providing the patient with documentation of the plan, including the goals and measures that will be used to evaluate the effectiveness of disease control therapy
• Tracking progress during the course of treatment, including recording and summarizing the findings from any objective measures to be used at the posttreatment assessment

The clinical staff will be heavily involved in this stage of dental care. Their role is to help the patient meet these goals and stay motivated to complete this phase of care. This can be accomplished by:

• Assisting the dentist in all restorative, surgical, periodontal, and endodontic procedures that address the patient’s chief concerns
• Addressing all oral hygiene needs by scheduling the patient with the dental hygienist on a more frequent basis as needed to accomplish the formulation, activation, therapy, monitoring, and reevaluation aspects of treatment
• Assisting in the preparation and delivery of dental materials to be used in the disease control phase procedures
• Providing educational information concerning habits that may have contributed to dental disease (such as tobacco use, poor diet, and occlusal trauma)
• Encouraging and supporting the patient in his or her effort to improve oral self care and reaffirming to the patient that the benefits of a healthy oral condition are well worth the effort

STRUCTURING THE DISEASE CONTROL PHASE

When the dentist has determined the need for a disease control phase, the next step is to formulate and sequence that plan. Many of the principles that apply to the development of the overall plan of care also have application to disease control. During this phase, however, those principles may take on a unique importance. In addition, other principles are specific to disease control.

As the dentist begins to shape the plan for this phase, there must be consideration of all reasonable treatment options. In conversation with the patient, there will need to be a winnowing process that leads to a single mutually agreeable approach to the disease control plan. Once a general plan is agreed upon, the dentist helps the patient set achievable treatment goals and build realistic expectations for treatment outcomes. The dentist will need to establish clear, specific, and quantifiable standards for success (i.e., outcomes measures), such as setting a target plaque score and bleeding index. The dentist should specify, preferably in writing, the factors that will be evaluated at the posttreatment assessment that closes this phase of care. In addition, the dentist delineates the successive steps to be implemented both when the patient does and does not meet the standards for success. The dentist may also wish to share briefly with the patient various definitive phase options that may be relevant to consider upon completion of the disease control phase. This discussion should normally include options that may emerge (1) if the disease control therapy is successful, and (2) if disease control therapy is not successful. In this manner, the patient can be well prepared for either eventuality. Treatment during the disease control phase is sequenced by priority of patient need rather than by dental discipline. The accompanying In Clinical Practice box features the keys to a successful disease control phase of treatment.

 

In Clinical Practice

Keys to the Success of the Disease Control Phase

The disease control phase provides an ideal window of time and opportunity for both patient and practitioner to refine their visions about the best overall course of treatment, but that window must be framed and defined clearly. Before engaging in a disease control phase plan of care, it is imperative that the patient understand the purpose, benefits, cost, and time frame of the phase. Specific goals must be established and a definite end point must be set at which time an evaluation of the outcomes will occur. The dentist also needs to project a clear plan of what will follow both if the goals are met, and if they are not. Despite its numerous advantages, the patient may perceive the disease control phase as a waste of time if it is not carefully developed and properly explained. Without tangible progress or positive reinforcement, the patient may become frustrated and give up. Such a patient may arrive late for appointments, delay paying bills, become noncompliant with treatment recommendations, or leave the practice, blaming the dentist for the apparent failure to improve his or her oral condition. All of these problems can be prevented if a clear understanding of specific goals for the disease control plan is established between dentist and patient and if honest communication occurs throughout the process. When properly designed and executed, a disease control plan ensures that the patient has achieved and can maintain a healthy oral condition, and that definitive care, when provided, will have a high likelihood of success.

In addition to clear goals and ongoing communication with the patient, a key ingredient to the success of the disease control phase is the patient’s commitment to the plan. With that commitment, the disease control phase becomes an effective tool with which the dentist can provide the best quality care. Without that commitment, the pace of care slows, dental problems continue to develop, and both patient and practitioner become frustrated. Positive value can be achieved, however, even when early outcomes seem negative. When handled properly, the dentist and the patient should see this as an opportunity to redirect therapy in a manner more appropriate to the patient’s abilities and desires. If the patient and dentist share the perspective that the failed attempt was a good-faith effort—and that it effectively ruled out some unrealistic options—then the effort will have been worth the trouble. The patient who recognizes that the effort was made both in his or her best interests and at his or her behest will see the dentist’s efforts as ultimately beneficial, even in light of the short-term failure. Consequently, if handled effectively, even a negative outcome can strengthen rather than diminish the therapeutic relationship between the patient and the dental team as they work to define and accomplish the optimal plan of care.

General guidelines for sequencing elements of the treatment plan are discussed in Chapter 3. The following suggestions have particular relevance to the disease control phase.

• Address the patient’s chief concern as quickly as possible, as long as such treatment does not conflict with the primary goals of the disease control phase. Although the psychological value to the patient of addressing the chief concern in a timely fashion is obvious, that approach may sometimes conflict with the demands and goals of disease control treatment. For example, the patient with rampant caries whose primary request is placement of a maxillary anterior fixed partial denture presents the clinician with a dilemma. Although it would not be professionally responsible to place a definitive fixed partial denture before the caries infection is controlled, it may be possible to find a provisional solution that meets the patient’s needs but does not compromise the standard of care.
• Sequence by priority—preferably treating the most severe and urgent needs first. Some notable exceptions will, of course, be necessary. For example, to minimize pain and reduce the need for root canal therapy, it is sometimes preferable to restore a moderately large carious lesion on a vital tooth before initiating root canal therapy on a carious tooth with an asymptomatic necrotic pulp or extracting an asymptomatic tooth with a hopeless restorative prognosis (Figure 7-1).
• Sequence by quadrant/sextant. Once teeth with gross carious lesions or those with a questionable restorative prognosis have been extracted or stabilized using provisional (i.e., sedative) restorations, it is most efficient and productive to restore other carious lesions in the same area of the mouth at the same time. Placing direct-fill interim or definitive restorations on multiple teeth in the same quadrant or sextant greatly speeds completion of the disease control phase and may give the patient a much needed psychological boost as rapid and dramatic progress is experienced.
• Integrate periodontal therapy into the disease control phase plan. Many practitioners routinely sequence scaling and root planing as the first item on the treatment plan. Although it may be easier and more convenient for the dentist to have a hygienist or periodontist perform the initial periodontal therapy before restorations are attempted, this may not represent the ideal sequence (Figure 7-2). Often a better approach is to provide both scaling and caries control restorations at the same visit while that quadrant is anesthetized. In general, treatment of deep carious lesions in vital teeth, symptomatic pulpal problems, and acute oral infections take precedence over treatment for periodontitis.
• Keep definitive phase options open with minimalist treatment in the disease control phase. It is desirable during the disease control phase to look forward to what could be reasonable treatment options in the definitive phase treatment plan. Toward this end, a priority should be preservation of key teeth and other teeth that are salvageable but about which there is uncertainty as to whether it will be feasible or desirable for the patient to expend the necessary resources to restore them definitively. Generally, however, only those procedures necessary to arrest the deterioration and prevent infection should be undertaken in the disease control phase. In this context, moderate to long-term provisional restorations are preferred to definitive crowns. Pulp capping procedures (when clinically appropriate) are preferred to the initiation of endodontic therapy, and pulpotomy and pulpectomy procedures are preferred to definitive root canal treatment. Even in the disease control phase, however, placement of a definitive direct fill restoration is generally preferred over the use of a sedative or temporary restoration because of the increased durability and the efficiency of avoiding the necessity of re-restoring with a definitive restoration at a later date. For patients with numerous active carious lesions, fluoride releasing/fluoride rechargeable restorative materials are preferred.

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Figure 7-1 Patient with numerous carious lesions of varying size. The asymptomatic and nonrestorable lower right second molar and the asymptomatic and necrotic lower left first molar are not urgent needs. The management of the patient’s esthetic problems, the initiation of a caries control protocol, and the restoration of the numerous moderately sized carious lesions should take precedence over the treatment of these two teeth. (Courtesy Dr. Chai-U-Dom, Chapel Hill, NC.)

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Figure 7-2 Situation in which management of deep carious lesions should precede initial periodontal therapy. (Courtesy Dr. I Aukhil, Chapel Hill, NC.)

Specific circumstances and sound clinical judgment will of course create many exceptions to each of these general guidelines. Nevertheless the overarching priority should be saving key and salvageable, though questionable, teeth with the minimal necessary treatment for the simple reason that it would be inefficient and foolish to invest extensive time and resources in an attempt to save teeth that may eventually be lost. The sequencing of this minimalist approach is driven by many factors, including patient desires, symptoms, presence (or absence) of infection, and the other issues previously described in this section.

COMMON DISEASE CONTROL PROBLEMS

Dental Caries

The etiology, natural history, and the incidence and prevalence of dental caries are better understood today than they were 2 decades ago. Restorative materials and techniques continue to improve. New diagnostic methods are promising, but have not yet fully eliminated clinical controversies and confusion, as clinicians continue to disagree about how and when carious lesions should be treated. Although the public health benefits of fluoridated water have been well documented and fluoridation has effectively slowed the incidence of caries, the disease is far from eradicated. Although caries rates in the population at large have stabilized or declined, significant and growing segments of the U.S. population continue to develop high rates of decay and, despite the efforts of clinicians, researchers, and public health specialists, dental caries continues to afflict humankind.

A functional framework for the overall management of the patient with serious dental caries problems includes the following elements:

• Comprehensive caries diagnosis, including an evaluation of number of teeth involved, caries location by surface, and degree of activity
• An assessment of caries risk—for purposes of this discussion, classified as low or high (see Chapter 2 for more detail)
• A basic caries intervention protocol for all patients with active lesions or those who are at risk for developing new lesions
• A supplemental intervention protocol or menu designed to address the specific needs of the patient who at the outset is known to need additional measures beyond those in the basic caries control protocol, or the patient who following the initial caries control efforts and remains caries active
• Maintenance and reevaluation at appropriate intervals to identify new lesions and reevaluate the risk for future caries activity

Undergirding this framework is the recognition that caries is an infectious disease and that the fundamental objective of any caries control program is to reduce the burden of pathogenic microbes and thereby limit, or preferably eliminate, the infectious process. Once the infection has been controlled, long-term monitoring is essential to ensure that the infection has not been returned.

Caries Control: A Working Definition

The term caries control is sometimes applied to individual restorations placed in teeth that have lesions of substantial size. It also is sometimes used to characterize the use of sealants or conservative composite restorations intended to prevent, control, and in some cases reverse new or incipient lesions. The term has been applied to dietary and/or behavioral approaches designed to prevent new caries, such as reducing refined carbohydrate and acid exposures between meals or increasing fluoride exposure. In this text, caries control means any and all efforts to prevent, arrest, remineralize, or restore carious lesions. A caries control protocol is a comprehensive organized plan designed to arrest or remineralize early carious lesions, to eradicate overt carious lesions, and to prevent the formation of new lesions in an individual who has a moderate or high rate of caries formation or is at significant risk for developing caries in the future.

Objectives, Strategies and Rationale for the Caries Control Protocol

The two primary objectives for the caries control protocol are:

• Eliminate the nidi of infection
• Reduce the microbial load of pathogenic bacteria

Conventional dental restorative procedures and placement of pit and fissure sealants can be effective in eliminating active carious lesions which are also important localized sites harboring the pathogenic bacteria. Sealants placed and effectively retained on pits and fissures and white spot lesions will effectively entomb the entrapped organisms. Sealants also help reduce the number of susceptible sites in the mouth that may become inoculated with cariogenic bacteria in the future. Without reducing the pathogenic bacterial load, however, these efforts are often fruitless as the disease process can continue unabated. A caries vaccine would be the ideal strategy to reduce the microbial load of pathogenic bacteria to insignificant numbers, but unfortunately, no such vac-cine as yet exists. Progress is being made on this front, but significant obstacles remain. Another approach that is being pursued currently is replacement therapy, which involves replacing pathogenic (acid producing) Streptococcus mutans with innocuous and noncariogenic (base producing) strep species. This is consistent with a “probiotic” approach in which pathogens are eliminated from the dental biofilm, and only “good” plaque remains. The concept is reasonable, but has not yet come to fruition.

Antibiotic therapies have been considered and attempted, but have significant limitations. Although the use of systemic antibiotics can effectively reduce the number of Streptococcus mutans the primary causative agent in dental caries the risks far outweigh the possible benefits. At present, no antibiotic specific for Streptococcus mutans has been identified, and with overuse of currently available antibiotics there is significant risk for the patient to develop drug sensitivity, drug resistant organisms, suprainfection, or superinfection. Furthermore, after the course of an antibiotic has been discontinued, there is no assurance that the mouth will not become repopulated with an even more aggressive strain of Streptococcus mutans. Topical antibiotics have demonstrated some usefulness, but as yet do not have either the desired substantivity or specificity. One of the many virtues of fluoride is that it does have an antimicrobial effect, particularly in high concentrations. When used at therapeutic levels, it can help diminish, but will not eliminate, Streptococcus mutans colonization. Chlorhexidine (CHX) is known to be a potent antimicrobial, but the effects are not permanent and patients may be discouraged by the unpleasant taste and the extrinsic tooth staining. CHX mouth rinses are effective against Streptococcus mutans, and CHX does have the desired substantivity. When used as a daily 30-second rinse at bedtime, the residual taste is less of an issue, and a 14-day regimen will provide Streptococcus mutans suppression for 12 to 26 weeks. It has been demonstrated that suppression of Streptococcus mutans can be maintained following cessation of rinsing with CHX mouthwash via the continued daily use of xylitol gum.1 The simultaneous use of CHX and fluoride rinses or gels has shown promise, but the efficacy of this regimen has not as yet been demonstrated.2 Povidone-iodine, a broad spectrum antibiotic, has been used effectively in infants with early childhood caries. It has been speculated, though not yet conclusively demonstrated, that this substance may have some usefulness in older adults who have dexterity problems and who are at high risk for root caries.

Given the limitations of currently available antimicrobial therapies, the following more traditional strategies continue to be important elements of the caries control protocol.

• Plaque elimination. With the discrediting of the nonspecific plaque hypothesis for caries development, it has been acknowledged that elimination of plaque will not in itself eliminate caries infection. It is now recognized that newly formed plaque can even have a potential benefit as a fluoride reservoir,3 but plaque that remains on the tooth surface is known to have significant deleterious effects. The dental biofilm produces acids, which are directly responsible for demineralization and erosion of tooth structure. The plaque, along with the adhesive glycans, provides the matrix for Streptococcus mutans colonization. It can also provide the substrate for proliferation of bacteria. Therefore the goal of removing plaque is logical and appropriate. Removal of plaque on a daily basis has the additional benefit of allowing fluoride uptake, which is significantly enhanced on a clean tooth surface. It must be recognized, however, that some patients will continue to harbor caries infection even in the absence of high plaque scores and that for some patients, there will never be ideal compliance with oral self-care recommendations.
• Limit refined carbohydrate (sucrose) and acid exposure. Refined carbohydrates are the primary substrate in which the Streptococcus mutans thrive. Eliminating refined sugars from the diet has been shown to significantly reduce or eliminate caries pathogens from the oral cavity. As with other strategies that are patient dependent, however, compliance is a major limitation. Nutritional modification has generally been shown to be a minimally effective tool for reducing caries prevalence. It is definitely appropriate on a patient specific basis, however, to encourage reduction of between meal exposures to refined carbohydrates. The daily use of xylitol based chewing gum has been shown to inhibit Streptococcus mutans and to be anticariogenic.4 The typical regimen is to chew two pieces for 5 minutes three to five times per day. Frequent exposure to acidic foods and beverages, especially between meals, can cause significant dental erosion and can be an important cofactor in caries development. Limiting the duration and frequency of between meal acidic exposures and rinsing with water after all such exposures should be encouraged.
• Provide fluoride exposure. The benefits of systemic fluoride in reducing caries incidence and prevalence are well established. For the individual adult patient, the topical use of fluorides in dentifrices, gels, varnishes, and rinses have all been shown to provide some reduction in caries incidence. A systematic review by Bader et al5 found that use of fluoride varnish has demonstrated “fair” strength in reduction of caries prevalence in caries-active or high-risk inviduals, whereas other methods of caries prevention examined showed “insufficient” evidence of efficacy. Potentially, fluoride can have multiple modes of action. It is known to be antibacterial. It aids in the remineralization of tooth structure and, during the remineralization process, forms acid-resistant carbonate apatite crystals.6 Chemotherapy, in the form of fluoride application, is preferred over restorative or surgical treatment in the management of reversible white spot lesions. Fluoride can be maintained as a reservoir in teeth, soft tissue, and plaque—to be released back into the oral cavity and bathed on the teeth in saliva. The reservoir and replenishment cycle is most effective when the fluoride exposure occurs in multiple doses over the course of the day. This is most easily accomplished by asking the patient to rinse with a fluoride mouth rinse between meals in addition to twice daily brushing with a fluoride dentifrice. Fluoride dentifrices have been shown to be effective in over-the-counter concentrations (1000 ppm) and are even more effective in higher concentrations (1500 to 5000 ppm) and when used by the patient more than once a day. It is logical to recommend use after breakfast and at bedtime when there can be a maximum uptake of the fluoride and minimum of dilution and evacuation. Fluoride retention and anticaries efficacy have been shown to improve inversely with the volume of water used to rinse after brushing.7 Ideally the patient should brush, expectorate the excess, and not rinse with water (or other beverage) for 30 minutes afterward. Use of a fluoride dentifrice along with the daily use of fluoride gel in a custom tray has been shown to be effective in reducing caries in postradiation therapy xerostomic patients. If left unsupervised, however, many patients tend to become noncompliant over time. Some investigators have therefore recommended the use of a daily, 2-minute brushing with a prescription dentifrice (e.g., Prevident) without rinsing after brushing, instead of the previously described two part regimen, citing similar benefits in caries reduction and better patient compliance.8 In general, the more frequent the fluoride exposures and the greater the concentration, the greater the benefit.9 Providers and patients need always be aware of the potential for toxicity, especially in children, if high concentration fluorides are ingested indiscriminately.

Basic Caries Control Protocol

The basic caries control protocol should be implemented for all patients who have more than three active lesions at the initial oral examination, or more than two new lesions at a periodic recall examination (Table 7-1). Designed for simplicity and effectiveness, most of the products used in the protocol are readily available over-the-counter and involve techniques that are no more difficult to master than routine oral self-care procedures. The dentist and staff require minimal chair time to explain the protocol and its use to the patient. A sample office handout for this purpose is shown in Figure 7-3.

Table 7-1

Basic Caries Control Protocol

Item Rationale
Caries activity tests (CATs) (See In Clinical Practice: Caries Activity Tests)
Oral prophylaxis (professional) Removes plaque and plaque retentive accretions; makes tooth surfaces more receptive to fluoride uptake
Oral self-care instructions* Removes plaque and reduces the potential for developing smooth surface caries
Professional fluoride gel or varnish† application at each scaling or preventive (recall/maintenance) visit Remineralization of hydroxyapatite with fluorapatite; antimictobial effect; short-term contribution to fluoride reservoir; reduced caries incidence; most effective when given at more frequent time intervals (less than 6 mo)
Reduce frequency and duration of acid and sucrose (refined carbohydrate) exposure Eliminates substrate for cariogenic bacteria; reduces acid-induced dissolution of tooth structure
Over-the-counter fluoride dentifrice and fluoride rinses (use daily) Antimicrobial effect; remineralizes tooth structure, replenishes intraoral fluoride reservoir, increases caries resistance
Restore carious lesions with direct-fill provisional or definitive restorations‡ (Note: definitive cast restorations are not recommended) Eliminates nidus of infection; improves cleansability; arrests caries progression
Sealants on susceptible pits and fissures (e.g., exposed pits and fissures in adolescents or in adults when other pits and fissures have needed restoration) Eliminates sites of infection and potential for inoculation of other sites; prevention of pit and fissure caries

*Flossing has not been shown to reduce caries incidence. It is logical for the dental team to encourage its use because of its many other proven benefits, including the reduction of plaque formation and gingivitis. Some patients continue to have carious lesions develop even in the absence of high plaque scores. For these patients, it is particularly important to consider specific forms of antimicrobial therapy as part of the caries control regimen.

†In general, professionally applied fluoride varnish applications have been shown to be more effective than professionally applied fluoride gel treatments (Bader et al: Community Dent Oral Epidemiol 29(6):399-411, 2001, and Peterson et al: Acta Odontol Scand 62(3):170-176, 2004.

‡The merits of glass ionomer restorations as a means of inhibiting secondary caries are reviewed in What’s the Evidence?: Do Glass-Ionomer Restorations Prevent Recurrent Caries?

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Figure 7-3 Sample office handout for a caries-active patient.

Optional Caries Interventions

Likely candidates for additional intervention include patients with unusually active or rampant caries, or those who have specific identifiable factors suggesting high risk for caries development. Suggestions or guidelines for possible interventions and their indications are listed in Table 7-2.

Table 7-2

Optional Caries Interventions

Problem Suggested Intervention
Decreased quantity or quality of saliva Oral hydration, salivary substitutes
Medication-induced xerostomia Substitute for xerostomic medications (usually requires consultation with patient’s physician)
Continued incidence of new caries activity in spite of previous intervention Custom fluoride trays for daily home use
Patient at risk for additional root or smooth surface caries Fluoride varnish application
Patient who would benefit from higher level fluoride exposure, but is unwilling or unable to accept custom trays Prescription dentifrice with high concentration fluoride
Any patient at risk for new caries who likes to chew gum Ad lib use of xylitol chewing gum (good alternative for persons who crave betweenmeal high-sucrose snacks or drinks)
Patients with concurrent marginal periodontal disease and/or patients with Streptococcus mutans counts that remain high despite previous intervention Chlorhexidine mouth rinses

Patient Selection

Many patients with rampant caries suffer from pain, infection, difficulty chewing, loss of function, an unappealing smile, and a poor self-image. Their oral problems are often accompanied by and associated with complex general health and psychosocial problems. In such cases, the likelihood for successful long-term eradication of the disease, even with the best efforts of the patient and the dental team, may be poor. (See Chapter 17 for more in-depth discussion of these issues.) In some cases, if the patient is fully aware of these limitations at the outset of treatment (as should be the case), he or she may decide not to embark on an aggressive caries control protocol. Similarly the dentist, knowing full well that the chances of success are limited and that some factors are not controllable, may decide that the task is not worth the effort. In some instances, the evaluation process may lead the practitioner to suggest more rather than fewer extractions, thereby simplifying the plan and reducing both the cost and the time required. (This approach has sometimes been labeled robust treatment planning.)

 

What’s the Evidence?

Do Glass-Ionomer Restorations Prevent Recurrent Caries?

Prevention of recurrent caries is a critical issue in managing the patient with high caries risk. Most patients would benefit from the advantages offered by a restorative material that, through the release of fluoride, would inhibit recurrent caries. Historically, silicate cements have had a proven track record in caries prevention, but are no longer available. Glass-ionomer cements have been shown to be effective in inhibiting recurrent caries in vitro, but are they effective in vivo?

After an extensive review of the literature and screening of available reports, Randall and Wilson identified 28 appropriately controlled prospective studies.1 The results were mixed and no clear conclusion could be drawn as to whether glass-ionomer restorative materials inhibit secondary caries. To date, the evidence suggests that, although glass ionomers, in general, perform no worse than other restorative materials, disappointingly, no caries-inhibiting benefit has been demonstrated.12

The initial amount of fluoride released from glass ionomers is highest within the first 24 hours of placement, but these high fluoride levels quickly decline over the next few days and then remain at a low constant level.3–11 In vitro glass ionomers, especially resin modified glass ionomers, have been shown to replenish their fluoride content on exposure to fluoride solutions. The glass ionomer subsequently releases the fluoride, which is characterized as a “burst effect.”31012–20 The amount of fluoride released from this burst effect declines quickly in a matter of days to a few weeks.111517 It has been concluded that the overall fluoride released from the glass ionomer may be effective for preventing secondary caries if there is frequent reuptake of fluoride over a long period of time.1719 Unfortunately, minimum fluoride concentrations necessary for caries inhibition have not been established,21 and levels of fluoride release after recharging have not been tested in terms of secondary caries prevention.

Prudent judgment suggests that where a glass-ionomer restoration would otherwise be a satisfactory choice as/>

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Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 7: The Disease Control Phase of Treatment

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