Caries Diagnosis and MIOC Care Plan

Caries I

MIOC Care Plan (4 domains)

• Identify
  • Involves verbal history and oral examination to detect lesions using indices.
  • Includes specialist procedures like radiographs and vitality testing.
  • Aims to determine the etiology of the condition
  • Establishes a diagnosis and prognosis.
  • Assesses caries susceptibility or risk.
• Prevent & Control
  • Focuses on developing a personalized care plan.
  • Evaluates the presence or absence of lesions and their cavitation status.
  • Considers the patient's susceptibility to caries.
  • Decides between standard and active preventative care.
• MI Restoration
  • Includes micro-invasive, minimally invasive, or non-invasive treatment options.
• Recall (Check-up)
  • Patient-focused recall consultation.

Definitions

• Caries process is a reversible disease process in dental hard tissues.
  • It's instigated by bacteria acting on fermentable carbohydrates in plaque biofilm on susceptible tooth surfaces.
  • Leads to the formation of carious lesions if the biofilm isn't modified.
  • Carious lesions result from acid demineralization and the proteolytic destruction of the organic component of dental tissues.
• Carious lesion: signs of disease on dental hard tissues such as early lesions, discoloration, opacities, and cavities.
• Caries risk/susceptibility assessment: process of gathering information through clinical and radiological exams to determine the patient's risk potential.
• Cariogenic Symbiosis: harmonious relationship between microbes and their host where dental health is maintained.
• Cariogenic Dysbiosis: imbalance in the oral microbial community that leads to tooth decay or dental caries.

Causative Factors - Acidogenic Theory

• Bacterial Colonization
  • Bacteria like Streptococcus mutans, Lactobacillus species, and Bifidobacterium are involved.
  • These bacteria colonize tooth surfaces and become embedded in dental plaque.
  • A biofilm forms on the teeth, leading to plaque accumulation and calcification hardening.
• Susceptible Tooth Surface
  • Carious lesions tend to occur on tooth surfaces with accumulated plaque, which stagnates for prolonged periods.
  • Examples include pits, fissures, proximal surfaces, and smooth surfaces adjacent to the gingival margin.
• Fermentable Carbohydrates
  • Bacteria metabolize fermentable carbohydrates, like sucrose, glucose, and fructose, producing acid by-products.
  • This process lowers pH within 1-3 minutes.
  • The acid produced lowers the pH of the tooth surface.
  • pH may drop below the critical level for enamel (5.5) or dentine (6.2).
  • Calcium and phosphate dissolve from the tooth surface, leading to demineralization.
  • Saliva buffering can take 60 minutes to return pH to normal levels.
• Time and Frequency
  • Despite the quick pH drop following carbohydrate consumption, a net mineral loss needs sufficient time to manifest as hard tissue damage.
  • Continued acidic challenge without sufficient remineralization leads to cavity formation.

Stephans Curve

• Exposure of dentine leads to acidic pH closer to 7.0, making susceptible carious lesions for extended period rather than compared with enamel.
• Frequent Snacking prolongs acidity level of enamel surface is under critical level

Caries Diagnostic Regime

• A clean, dry tooth surface is essential for effective caries diagnosis. Polishing, calculus, stain and plaque removal is important before inspection
• Removal of stain, plaque and calculus during oral examination needs precise assessment as important determinant for minimally invasive tooth preparation

Visual Detection

• Sharp eyes and magnification are needed
• Good illumination is necessary
• Tooth surface must be clean and dry
• Use a blunt dental explorer (periodontal probe)
• Detection takes time
• A sharp explorer could trigger cavitation, accelerating caries.
  • It can disturb the fragile surface of incipient lesions, turning non-cavitated lesions into cavitated ones.
  • Breaking the surface with sharp explorer allows bacteria to inhabit and potentially accelerate decay
  • Disruption may hinder natural remineralization.
  • Cleaning is more difficult with cavitated surfaces, fostering plaque accumulation and increasing caries risk.

Caries Diagnosis

• Caries history/ susceptibility assessment is important
• Detection of lesion signs
• Identify the symptoms such as pain and previous medical condition
• Special investigations, such as radiographs and sensibility tests are important

Evaluation of Caries Risk/Susceptibility

• Increased susceptibility factors:
  • Medical: Drug therapy, sucrose-based medication.
  • Social: Stress, lifestyle changes.
  • Dietary: Prolonged breastfeeding, grazing habits.
  • Host resistance: Prior caries, lesions on specific tooth surfaces, soft/ light-colored lesions.
  • Salivary: Low secretion and buffering capacity.
  • Microbiology: High numbers of S. mutans and lactobacilli.

Caries Risk/Susceptibility Levels

• LOW:
  • Caries is inactive/controlled.
  • 0-1 active lesion.
  • No recent restorations.
• MEDIUM:
  • Caries is active/modifiable.
  • >1 active lesion.
  • >2 new/progressive/filled lesions in the last 2 years.
• HIGH:
  • Caries is active/unmodifiable or has unidentifiable risk factors.
  • >1 active lesion.
  • >2 new/progressive/filled lesions in the last 2 years.

Control of Caries Risk/Activity

• LOW RISK:
  • Caries inactive/controlled with oral hygiene (OH).
  • Fluoride (F-) / standard home care.
• MEDIUM RISK:
  • Caries is active/modifiable with OH.
  • Supplementary fluoride mouthwash (F- m/w), Gels and dietary modifications can be considered.
• HIGH RISK:
  • Control at the individual patient level, similar to medium risk plus salivary flow stimulation is needed.

Role of Plaque Biofilm

• Specific Plaque Hypothesis (Loesche, 1976)
  • Concept: Certain bacteria like Streptococcus mutans are linked to specific diseases like dental caries
  • Implication: Targeting specific microbes could prevent/manage dental diseases
• Non-Specific Plaque Hypothesis (Theilade, 1986)
  • Concept: The overall quantity of plaque is the main contributor to dental diseases
  • Implication: Treatment should aim at reducing total plaque volume
• Ecological Plaque Hypothesis (Marsh, 1994)
  • Concept: Oral diseases are due to environmental shifts that favour pathogenic bacteria
  • Implication: Modifying oral conditions can prevent harmful microbial growth
• Extended Ecological Plaque Hypothesis (Takahashi and Nyvad, 2008)
  • Concept: Caries progression is linked to microbial acid production and tolerance
  • Implication: Strategies could shift microbial metabolism towards alkali production for caries prevention

Plaque Biofilm Significance

• Healthy biofilm is crucial for oral balance
• Stagnation and undisturbed biofilm can lead to ecological changes
• Cariogenic dysbiosis results from an imbalance of bacterial species
• Changes in bacterial balance alter the environment of the tooth surface, increasing caries risk

Caries Management

• Involves standard and active care tailored to high caries-risk patients, targeting specific factors identified through risk assessment.
• Combines the following strategies:

Standard Care

• Oral hygiene instruction: Brush twice daily with fluoride toothpaste.
  • Use age-appropriate fluoridated toothpaste (<3 years: 1000ppm, >3yr 1350-1500ppm)
  • Spit, and don't rinse.
  • Encourage patients to bring their toothbrushes to appointments so brush heads can been seen for wear.
• Plaque control: Electric toothbrush preferred, interdental cleaning, plaque disclosing.
  • Interdental cleaning with floss or interdental brush.
  • Use super floss for patients with bridges, crown margins, and implants.
• Fluoride: Delays lesion progression. Fluoride toothpaste and mouthwash are recommended.
• Diet: Reduce sugar frequency and amount.
• Patient motivation and cooperation for sustained care.
  • Use disclosing the mouth with a suitable plaque staining dye to use as a visual aid.
  • Assess whether the patient needs help cleaning, especially in young children and adults with arthritis.

Active Care

• Professional mechanical tooth cleaning: Scaling, ultrasonic, air-polishing.
• Antimicrobial agents: Chlorhexidine rinses affect plaque biofilm and bacterial diversity.
  • These agents minimise plaque formation, reduce bacterial growth, and modify enzymes controlling acid production.
• Xylitol: Reduces Streptococcus mutans in plaque after about 5 weeks of chewing
• Remineralisation procedures:
  • Beneficical High concentration fluoride (2800/5000 ppm) can benefit high-risk patients.
  • Fluoride mouthwash can be used for patients over 8 years old.
  • Fluoride varnish can be applied at a concentration of 22,600 ppm F or 2.2% F, repeated every 3-6 months.
  • Topical remineralisation:
    • Solutions rich in calcium and phosphate are currently being researched.
    • These solutions encourage surface remineralisation deposits to combat and prevent caries.
• Preventative fissure sealants: Use for deep fissures and pits, resin- or GIC-based.

This lesson covers caries diagnosis, the Stephan curve, and the MIOC (Minimal Intervention Oral Care) care plan. It includes identifying caries causes, assessing patient risk, and determining preventive care strategies based on caries susceptibility.