Disclosure Disclosure Caries Management by Risk Caries Management - PDF document

Disclosure Disclosure Caries Management by Risk Caries Management by Risk Assessment Assessment : I have no personal financial interest in any I have no personal financial interest in any The Caries Balance The Caries Balance company relevant to this presentation. company relevant to this presentation. I consult for, have consulted for, or have I consult for, have consulted for, or have done research funded or supported by: done research funded or supported by: John D.B. Featherstone John D.B. Featherstone Arm and Hammer, Beecham, Cadbury, GSK, Arm and Hammer, Beecham, Cadbury, GSK, Professor and Dean Professor and Dean KaVo, Novamin, Omnii Oral Pharmaceuticals, KaVo, Novamin, Omnii Oral Pharmaceuticals, Oral B, Philips Oralcare, Procter and Gamble, Oral B, Philips Oralcare, Procter and Gamble, E-mail jdbf@ucsf.edu mail jdbf@ucsf.edu 3M ESPE Preventive Care, Wrigley, and the 3M ESPE Preventive Care, Wrigley, and the School of Dentistry School of Dentistry National Institutes of Health. National Institutes of Health. University of California San Francisco University of California San Francisco What is Dental Caries? What is Dental Caries? � Dental caries is tooth decay Dental caries is tooth decay � Specific bacteria (Streptococcus mutans, Specific bacteria (Streptococcus mutans, Streptococcus sobrinus, and lactobacilli) on Streptococcus sobrinus, and lactobacilli) on Protective Factors the tooth surface feed on carbohydrates and the tooth surface feed on carbohydrates and make acids as waste products make acids as waste products � Acids travel into the tooth and dissolve Acids travel into the tooth and dissolve mineral mineral - if mineral loss is not halted or if mineral loss is not halted or reversed a cavity is formed reversed a cavity is formed � Dental caries is a transmissible bacterial Dental caries is a transmissible bacterial infection infection “White spot” lesion Protective Factors Protective Factors Frank occlusal cavity

The Caries Balance The Caries Balance Protective Factors • Saliva flow and components • Fluoride, Calcium, Phosphate: Pathological Factors remineralization Protective Factors • Antibacterials:- • Acid-producing bacteria chlorhexidine, xylitol, new? Childhood • Frequent eating/drinking of fermentable carbohydrates Caries • Sub-normal saliva flow and function No Caries Caries Featherstone, Community Dent Oral Epidem, 1999 Pathological Factors Pathological Factors � Cariogenic bacteria: mutans streptococci Cariogenic bacteria: mutans streptococci Protective Factors ( S. mutans and S. sobrinus) S. mutans and S. sobrinus) and and lactobacillus species lactobacillus species � Frequency of ingestion of fermentable Frequency of ingestion of fermentable Stay in carbohydrates: sucrose, glucose, carbohydrates: sucrose, glucose, balance to fructose, cooked starch fructose, cooked starch survive � Reduced salivary function (medication Reduced salivary function (medication induced; radiation therapy; disease; induced; radiation therapy; disease; genetic) genetic) Scanning Electron Micrograph of bacteria on Protective Factors a tooth surface Acid producing bacteria are usually less than 1 percent of the total flora in the plaque

Mutans Streptococci Mutans Streptococci This group of bacteria contains two primary species that appear in humans � Streptococcus mutans - almost universal � Streptococcus sobrinus - virulent, high risk Streptococcus mutans culture showing active cell Both species produce acids and can live in division. S. sobrinus is similar . Sucrose leads to acid extracellular polysaccharides that stick the plaque together What about Does drilling the clinical and filling relevance? really fix caries? Lactobacillus culture. Lactobacilli species produce predominantly lactic acid from fermentable carbohydrates Clinical Study Results Clinical Study Results Caries Management Study Caries Management Study NIH/NIDCR Grant NIH/NIDCR Grant high low Baseline Observations Caries Management By Risk Caries Management By Risk N=115 Control Saliva Sample Conventional All Final Observations MS, LB and F Treatment Plan Restorations Radiographs Assessment Assessment Radiographs Restorations Complete DMFS DMFS S2 S3 S4-S6 S7 1999-2004 1999 2004 1-7 cavities S1 Randomization ������� Principal Investigator: Principal Investigator: John Featherstone John Featherstone Intervention Co Co-investigators: investigators: S2 S3 S4-S6 S7 Chuck Hoover, Stuart Gansky, Marcia Rapozo-Hilo, Kim Tran, Chuck Hoover, Stuart Gansky, Marcia Rapozo Hilo, Kim Tran, N=116 Restorations All Final Observations Joel White, Jane Weintraub Joel White, Jane Weintraub +Anti-bacterial Restorations Radiographs and Fluoride Complete DMFS (CHX + F) Treatment

Mean (SE) logM S �������������������������������������� �������������������������������������� ! 5 Baseline Bacterial 4 Levels vs Decay 3 High Restorations Bacterial 2 Log MS Control Challenge 1 Log MS Intervention Chlorhexidine plus Fluoride 0 0 1 2 3 4 5 6 7 Existing Cavity = High Risk Visit # - 6 month intervals ∆ DMFS (SE) ∆ ∆ ∆ Patients With Frank cavities Patients With Frank cavities 24% reduction (p=0.02) � One or more frank cavities indicates high risk for future new carious lesions 5 � Moderate to high levels of mutans 4 streptococci � Moderate to high levels of lactobacilli 3 � Patients have a high bacterial challenge that 2 most likely can not be completely overcome by fluoride alone 1 � Placing restorations does not reduce the Placing restorations does not reduce the 0 bacterial loading in the rest of the mouth bacterial loading in the rest of the mouth Control Intervention Caries is a Transmissible Caries is a Transmissible Bacterial Infection Bacterial Infection � Time for a paradigm shift � Children infected by mother, caregiver, siblings � Fluoride is effective only up to a point � High bacterial challenge can not be completely overcome � Placing “fillings” has little effect on Would you put a new roof on while the house is burning? cariogenic bacterial loading in the mouth Placing a restoration does not significantly reduce the � Need to deal with the infection bacterial loading in the remainder of the mouth.

First Colonizable Hard Surface. First Colonizable Hard Surface. Soft tissues can also be colonized Soft tissues can also be colonized Pathological Factors Pathological Factors before before teeth erupt. teeth erupt. � Cariogenic bacteria: mutans streptococci Cariogenic bacteria: mutans streptococci ( S. mutans and S. sobrinus) S. mutans and S. sobrinus) and and lactobacillus species lactobacillus species � Frequency of ingestion of fermentable Frequency of ingestion of fermentable carbohydrates: sucrose, glucose, carbohydrates: sucrose, glucose, fructose, cooked starch fructose, cooked starch � Reduced salivary function (medication Reduced salivary function (medication induced; radiation therapy; disease; induced; radiation therapy; disease; genetic) genetic) Demineralization:- Step 1 Fermentable Organic Acids Cariogenic Carbohydrates Protective Factors Bacteria Which penetrate Sucrose enamel and S. Mutans + Glucose dentin S. Sobrinus Dissolve tooth Fructose mineral Lactobacilli Cooked starch Cariogenic foods contain fermentable carbohydrates such as sucrose, glucose, fructose and cooked starch Non Non-cariogenic Sweeteners cariogenic Sweeteners Pathological Factors Pathological Factors � Sorbitol Sorbitol � Cariogenic bacteria: mutans streptococci Cariogenic bacteria: mutans streptococci ( S. mutans and S. sobrinus) S. mutans and S. sobrinus) and and � Aspartame Aspartame lactobacillus species lactobacillus species � Saccharin Saccharin � Frequency of ingestion of fermentable Frequency of ingestion of fermentable carbohydrates: sucrose, glucose, carbohydrates: sucrose, glucose, � Sodium cyclamate Sodium cyclamate fructose, cooked starch fructose, cooked starch � Xylitol Xylitol � Reduced salivary function (medication Reduced salivary function (medication induced; radiation therapy; disease; induced; radiation therapy; disease; genetic) genetic)