Detailed risk profiles for dental caries

Detailed risk profiles for dental caries
If a patient is at high risk predominantly for either caries or periodontal disease, a more detailed risk profile is available for the specific disease. Box 19 shows a list of abbreviations for the most important variables related to caries risk. 
Figure 138 illustrates how a high-risk patient (C3) has been transformed to a low-risk patient (C1) by improved self-care supplemented by professional preventive measures. The greater the difference between the solid line and the dotted line, the greater the improvement. The absence of any change suggests that this particular factor cannot be influenced (eg, genetic factors, age, and some chronic diseases). 
The patient in question was a 40-year-old woman with the following clinical diagnosis and anamnestic data at the first visit:
1. Caries prevalence was very high. All occlusal surfaces, most approximal surfaces, and some buccal surfaces were restored. There were several recurrent lesions.
2. Caries incidence was very high; the patient was developing more than three new carious surfaces (more than 85% recurrent caries) per year.
3. Values for etiologic factors were extremely high:
a. The plaque formation rate was very high (PFRI score 5).
b. The amount of plaque was excessive (PI = 93%).
c. The level of salivary mutans streptococci was very high (> 1 million CFU/mL).
d. The salivary lactobacillus level was very high (> 500,000 CFU/mL).
4. The external modifying risk indicators, risk factors, and prognostic risk factors were:
a. Ongoing infectious disease, requiring medication with salivary depressive effects.
b. Mild rheumatoid arthritis, which occasionally required medication with salivary depressive side effects.
c. To date, very irregular dental attendance habits.
d. A very high frequency of intake of sticky, sugar-containing products, which
resulted in extremely prolonged sugar clearance time.
e. Poor dietary habits, with negligible intake of fiber-rich fresh vegetables and fruits,
accounting for the low Dietary Hygiene Index.
5. The most important observations with respect to internal modifying risk indicators,
risk factors, and prognostic risk factors were:
a. A chronic reduction of the immune response.
b. A reduced stimulated salivary secretion rate (0.5 mL/min).
c. A low salivary buffering effect (SBE).
6. The preventive factors were:
a. The absence of known genetic defects on tooth shape, saliva, etc.
b. A relatively high educational level.
c. An absence of preventive dental care habits.
d. A low level of cooperation.
e. A very low standard of oral hygiene.
f. A lack of fluoride toothpaste or other fluoride agents.
g. Very poor dietary control.
h. An absence of added salivary stimulation from chewing fiber-rich food.
During case presentation, the risk profile was used as a tool for communication with
the patient. Concurrently, the patient was instructed in self-diagnosis, to confirm the
diagnosis of her own oral health status and treatment needs. Thereafter, an agreement
was reached with respect to a treatment strategy, in which responsibility for the
patient’s oral health was shared between the patient and the oral health personnel at
the clinic.
This was followed by an initial intensive preventive period, including education in
self-care based on self-diagnosis, elimination of plaque-retentive factors,
semipermanent restoration of recurrent caries using resin-modified glass-ionomer
material, so-called complete-mouth disinfection, comprising professional mechanical
toothcleaning, tongue cleaning, and chlorhexidine therapy (varnish, gels, toothpaste,
or mouthrinse), and fluoride varnish applications. The first reevaluation was carried
out after 2 months. Thereafter, the patient began a maintenance program tailored to
her individual requirements.
The first detailed reexamination was carried out after 1 year. Most important at this
reexamination was that the patient was activated in self-evaluation. Again, the risk
profile was used as a tool for communication with the patient, to supplement selfevaluation
in the mouth and on radiographs. Figure 138 shows how successfully the
patient and the dental personnel had carried out their responsibilities.
The etiologic factors were dramatically reduced by improved mechanical plaque
control and intermittent use of chlorhexidine by self-care, supplemented by needsrelated
intervals of professional mechanical toothcleaning and chlorhexidine varnish:
1. The PFRI was reduced from score 5 to score 2.
2. The Plaque Index was reduced from 93% to 8%.
3. The MS count was reduced from > 1 million to < 10,000 CFU/mL.
4. The lactobacilli count was reduced from >500,000 to <10,000 CFU/mL.
Marked reductions in sugar clearance time and Dietary Hygiene Index were achieved
1. Elimination of sticky, sugar-containing products from the diet.
2. Reduction of the total number of meals and snacks from nine to four per day.
3. An increase in the intake of fiber-rich vegetables and fruits, to stimulate salivation
by chewing.
4. An increased in the intake of vegetarian proteins and fat and a reduction in the
intake of animal fat and proteins.
The salivary secretion rate was increased from 0.6 mL/min to 1.0 mL/min and the
buffering effect of saliva was improved from low to normal by:
1. Use of fluoride chewing gum for 20 minutes after every meal.
2. An improvement in dietary habits, particularly an increased intake of fiber-rich
products that require chewing, eg, fresh vegetables and fruits: The chewing stimulates
3. Use of cheese and fresh fruits as dessert.
4. Elimination of medicines with salivary depressive effects.
Fluoride supplementation, a modifying caries-preventive factor intended to retard
demineralization, enhance remineralization, and modify falls in plaque pH, was
achieved by:
1. Regular use of fluoride toothpaste.
2. Use of fluoride chewing gum for 20 minutes after every meal.
3. Application of fluoride varnish after professional mechanical toothcleaning, at
needs-related intervals.
4. Placement of glass-ionomer restorations, which function as slow-release agents for
fluoride and can be recharged with fluoride.
As an effect of the above improvements by self-care and dental visits at needs-related
intervals, for professional preventive measures and self-evaluation, the caries
incidence (CI) was 0 after 1 year; no new lesions had developed. If there are no new
lesions after a further 2 years of excellent self-care habits in combination with the
needs-related maintenance program, the patient will be classified as low risk (C1).
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Articles for theme “caries”:
Risk ProfilesIntroductionBy combining the symptoms of disease (prevalence, incidence, treatment needs, etc); etiologic factors; external modifying risk indicators, risk factors, and prognostic risk factors; internal modifying risk indicators, risk factors, and prognostic risk factors; and preventive factors, it is possible to present risk profiles for tooth loss, dental caries, and periodontal diseases in graphic form. This can be done manually or by computer. The degree of risk, 0, 1, 2, or 3, is visualized using green, blue, yellow, and red, respectively.
Key-risk surfacesAs mentioned earlier, depending on the age and caries prevalence of the population, there may be pronounced variations in the pattern of both lost teeth and decayed or filled surfaces. Figure 130 shows caries prevalence and the pattern of decayed or filled surfaces in 12-year-old children in the county of Varmland, Sweden, in 1964, 1974, 1984, and 1994. The molars are clearly the key-risk teeth. In a toothbrushing population, the key-risk surfaces are the fissures of the molars and the approximal surfaces, from the mesial aspect of the second molars to the distal aspect of the first premolars.
Key-risk teethThe factors determining future tooth loss are related to age, dental caries, periodontal  diseases, iatrogenic root fractures, trauma, orthodontic therapy, and so on. Therefore, it may be argued that it is difficult to analyze the true reasons for tooth loss in the adult, particularly in the elderly. The reasons for tooth loss may vary not only among different age groups but also among different populations and countries, depending on differences in prevalence of dental caries and periodontal diseases as well as the availability of resources for dental care.
Individual RiskBy combining etiologic factors, caries prevalence (experience), caries incidence (increment), external and internal modifying risk indicators, risk factors, and prognostic risk factors, as well as preventive factors, caries risk may be evaluated at the individual level, as no risk (C0), low risk (C1), risk (C2), and high risk (C3). As discussed earlier in this chapter, these conditions may vary in different age groups.  Therefore, the criteria for C0, C1, C2, and C3 should be defined for at least the following general groups: preschool children (primary teeth), schoolchildren (permanent teeth), adults, and the elderly.
Risk GroupsRisk age groupsRecent studies have shown that carious lesions are initiated more frequently at specific ages. This applies particularly to children but also to adults. In children, the key-risk periods for initiation of caries seem to be during eruption of the permanent molars and the period during which the enamel is undergoing secondary maturation.  In adults, most root caries develops in the elderly, partly because of the higher prevalence of exposed root surfaces.