Fig. 3.1
(a) Table from the American Dental Association, this form and detailed instructions can be found athttp://www.ada.org/en/~/media/ADA/Member%20Center/FIles/topics_caries_instructions (Accessed on March 5, 2016) (“Copyright © 2009, 2011, American Dental Association. All rights reserved. Reprinted with permission”) (b) Fig. 3.1a Table from the American Dental Association, this form and detailed instructions can be found at: http://www.ada.org/en/~/media/ADA/Member%20Center/FIles/topics_caries_instructions (Accessed on March 5, 2016) (“Copyright © 2009, 2011, American Dental Association. All rights reserved. Reprinted with permission”)
Clinical treatment recommendations after patients have been classified through use of CAMBRA forms have been developed and are as follows. These recommendations were adapted from those published by a number of authors (Jenson et al. 2007; Ramos-Gomez et al. 2010; American Academy of Pediatrics 2014). A comprehensive article that is available online can be found at http://www.rdhmag.com/etc/medialib/new-lib/rdh/site-images/volume-31/issue-10/1110RDH095-109.pdf (Accessed on March 6, 2016) (Table 3.1A, 3.1B, and 3.1C).
Table 3.1A
Clinical recommendations for low-risk patients
|
Low risk
|
Recall exam
|
Radiographs
|
Saliva testing
|
Fluoride
|
Xylitol
|
Antimicrobials
|
Calcium phosphate
|
|---|---|---|---|---|---|---|---|
|
Age: under 6 years
|
Annual exam
|
Bitewings every 12–24 months
|
Optional
|
3–5 year old smear of toothpaste; twice dailya
|
No
|
No
|
|
|
Age: 6+ years
|
Every 6–12 months
|
Bitewings every 24–36 months
|
Optional
|
Twice daily brush with fluoridated toothpaste
|
Optional
|
If required
|
Adults for root sensitivity
|
Table 3.1B
Clinical recommendations for moderate-risk patients
|
Moderate risk
|
Recall exam
|
Radiographs
|
Saliva testing
|
Fluoride
|
Xylitol
|
Antimicrobials
|
Calcium phosphate
|
|---|---|---|---|---|---|---|---|
|
aAge: under 6 years
|
Every 3–6 months
|
BW every 6–12 months
|
Recommended at baseline and recall
|
Brushing twice daily with F toothpaste
Supervised daily use of over-the-counter fluoride rinse
In office fluoride varnish at initial visit and recall
|
Xylitol wipes can be used especially when unable to brush
|
None
|
AAPD states: consider fluoride levels in the drinking water prior to prescribing
|
|
Age: 6+ years
|
Every 4–6 months
|
BW every 18–24 months
|
Recommended at baseline and recall
|
Brushing twice daily with F toothpaste and fluoride rinse
In office F varnish application 1–3 times initially then at recall appts.
|
6–10 g/day = 2 sticks of xylitol gum
|
Chlorhexidine if required
|
Adults for root sensitivity
|
Table 3.1C
Clinical recommendations for high- and extreme-risk patients
|
High risk and extreme risk
|
Recall exam
|
Radiographs
|
Saliva testing
|
Fluoride
|
Xylitol
|
Antimicrobials
|
Calcium phosphate
|
|---|---|---|---|---|---|---|---|
|
Age: under 6 years
|
Every 1–3 months
|
Every 6–12 months
|
At baseline and recall exams
|
Brushing twice daily with F toothpaste
Supervised daily use of over-the-counter fluoride rinse
In office fluoride varnish at initial visit and recall
|
Xylitol wipes can be used especially when unable to brush
|
Recommended use of chlorhexidine for the caregiver to prevent transmission of bacteria
|
AAPD states: consider fluoride levels in the drinking water prior to prescribing
|
|
Age: 6+ years
|
Every 3–4 months
|
Every 6–12 months
|
At baseline and recall exams
|
Brushing twice daily with F toothpaste and fluoride rinse
In office F varnish application 1–3 times initially then at recall appts
|
6–10 g/day = 2 sticks of xylitol gum
|
0.12% chlorhexidine gluconate 10 ml rinse for 1 min/day for one week each month
|
If required
|
In the United States, there are a number of insurance companies that provide coverage for CAMBRA-related dental procedure codes (Table 3.2). This is not a complete list of possible procedures, but it is a start in encouraging patients in the importance of caries risk assessment and prevention.
Table 3.2
An example of ADA codes that are covered by insurance companies when performing caries risk assessment of a patient
|
ADA code number
|
Description
|
|---|---|
|
D0425
|
Caries susceptibility testing (CariScreen)
|
|
D1206
|
Therapeutic applications of fluoride varnish for moderate- or high-caries-risk patients
|
|
D1310
|
Nutritional counseling for the control of dental disease
|
|
D9630
|
Other drugs, medicaments, or fluoride dispensed by the office for at-home use
|
3.2 Current Therapeutics Available on the Market to Remineralize Active White Spot Lesions
What Are White Spot Lesions?
As an outcome of an ecological imbalance in the physiological equilibrium between tooth minerals and oral microbial biofilms (Fejerskov 2004; Scheie and Petersen 2004; Pitts-Fejerskov 2004; Scheie and Peterson 2004), white spot lesions (WSL) may be found when active caries develops on smooth surfaces of the tooth (Fig. 3.2). These lesions typically are the first manifestation of caries lesions. They are characterized as small areas of subsurface demineralization beneath the dental plaque, and present themselves as “milk white opacity” on smooth surfaces (Selwitz et al. 2007; Hilton et al. 2013). Whether dental caries progresses, stops, or reverses is dependent on the undergoing balance between demineralization and remineralization in the oral environment. Management to repair these demineralized enamel lesions can be done with several preventive approaches such as reduction of dietary sugar intake, oral hygiene education, and delivery of remineralizing/repair products.
Fig. 3.2
Digital images of a patient undergoing a unbalanced diet and poor tooth brushing technique. Upon application of the disclosing agent, the dental biofilm became evident. The patient was given oral hygiene instruction followed by biofilm removal with mid-grit prophylaxis paste, the white spot became visible then facilitating its diagnosis
Can Fluoride Remineralize Active White Spot Lesions (WSL)?
According to Kutsch (2014), prescriptive strategies can be organized into three categories: reparative nonsurgical strategies, therapeutic materials, and behavioral changes. Reparative nonsurgical strategies are well developed by the dental profession and include remineralization and restoration.
Patients at high risk for caries such as those undergoing orthodontic treatment have poor oral hygiene, and non-advised diet are in great risk of developing enamel white spot lesions. If not well cleaned, fixed orthodontic appliances facilitate increase in volume and therefore have reduction in biofilm ph. Development of WSL during fixed appliance therapy can occur rapidly and becomes clinically visible in 4 weeks or even less (Oreilly and Featherstone 1987; Ogaard et al. 1988). Recent studies indicate a prevalence of almost 70 % of WSL in those patients (Benkaddour et al. 2014; Julien et al. 2013; Hadler-Olsen et al. 2012). Fluoride varnish, resin infiltrants, and silver diamine fluoride are a few ways that have promise in remineralizing teeth.
3.2.1 Fluoride Varnish
Although clinical studies on WSL have been performed mostly on children, current scientific evidence points for effective remineralization/repair when fluoride is used, and the best form is fluoride varnish (Lenzi et al. 2016; Gibson et al. 2011). In high-caries-risk patients, recommendation is an application of fluoride varnish every 3–4 months (Newbrun 2001; Garcia et al. 2015). Below is a sequence that might be considered for clinical application of fluoride varnish. A number of fluoride varnish materials available in the market are UltraThin (WaterPik), Duraphat (Colgate), Vanish™ 5 % Sodium Fluoride White Varnish with Tri-Calcium Phosphate (3 M-ESPE), Duraflor Fluoride Varnish Tube (Medicom), PreviDent® 5 % Sodium Fluoride Varnish (Colgate).
Procedure for Application of Fluoride Varnish:
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