Chutinan Caries management plan PDF

CARIES RISK ASSESSMENT AND MANAGEMENT DR. SUPATTRIYA CHUTINAN  OLD CARIES MANAGEMENT MODULE “Dental caries was traditionally treated by surgical removal and replace the cavity with dental materials.” ETIOLOGY OF DENTAL CARIES Cariogenic...

CARIES RISK ASSESSMENT AND MANAGEMENT DR. SUPATTRIYA CHUTINAN  OLD CARIES MANAGEMENT MODULE “Dental caries was traditionally treated by surgical removal and replace the cavity with dental materials.” ETIOLOGY OF DENTAL CARIES Cariogenic Tooth Bacteria Agent Host -Enamel -Strep. Mutans -Dentin -Lactobacillus -Cementum Disease Environment Food - Fermentable Carbohydrates Courtesy of Dr. Dogon  Susan A. Fisher-Owens et al. Pediatrics 2007;120:e510- e520 ©2007 by American Academy of Pediatrics PARADIGM SHIFT “…a shift toward improved diagnosis of noncavitated, incipient lesions and treatment for prevention and arrest of such lesions. Restorations repair the tooth structure, do not stop caries, have a finite life span and are susceptible to disease.” National Institute of Health, 2001 CARIES CONTROL CONCEPT Noncaviated Cavity Restoration Endodontics Exposure Tooth Loss Early Diagnosis Late Diagnosis Primary Prevention Secondary Prevention Tertiary Prevention Maintaining Non Operative Operative physiological Treatment Treatment equilibrium Caries Control Nyvad and Fejerskov  CARIES MANAGEMENT BY RISK ASSESSMENT THE “MEDICAL MODEL,” WHERE THE ETIOLOGIC DISEASE-DRIVING AGENTS ARE BALANCED AGAINST PROTECTIVE FACTORS, IN COMBINATION WITH RISK ASSESSMENT, OFFERS THE POSSIBILITY OF PATIENT-CENTERED DISEASE PREVENTION AND MANAGEMENT BEFORE THERE IS IRREVERSIBLE DAMAGE DONE TO THE TEETH.” M. Fontana et al. Dent Clin N Am 53; 2009 MODERN CARIES MANAGEMENT Detection of caries lesions at an early stage Diagnosis of the disease process Identification of all risk and protective factors Caries management and Caries lesion management plan Goal: Risk factor modification or elimination Improving protective factors Arresting or reversing active noncavitated carious lesion Tooth restoration Preventing future caries CARIOUS LESION DETECTION A CARIES/CARIOUS LESION IS A DETECTABLE CHANGE IN THE TOOTH STRUCTURE THAT RESULTS FROM THE BIOFILM-TOOTH INTERACTIONS OCCURRING DUE TO THE DISEASE CARIES. CARIES/CARIOUS LESION DETECTION IS A PROCESS INVOLVING THE RECOGNITION AND RECORDING, TRADITIONALLY BY OPTICAL OR PHYSICAL MEANS, OF CHANGES IN ENAMEL, DENTIN, OR CEMENTUM, WHICH ARE CONSISTENT WITH HAVING BEEN CAUSED BY THE CARIES PROCESS.  Diagnosis Caries Diagnosis is the human professional summation of all the signs and symptoms of disease to arrive at an identification of the past or present occurrence of the disease caries. The diagnostic process is deductive and uses various sources of information (patient interview, clinical examination and supplementary tests). This is distinct from the detection of the signs and symptoms. CARIES RISK ASSESSMENT “…the probability of caries incidence (that is number of new cavities or incipient lesions) in a certain period. It also involves the probability that there will be a change in size or activity of lesions.”  ADVANTAGES OF CARIES RISK ASSESSMENT Evaluate degree of patient’s risk of developing caries to determine the intensity of the treatment. Help identify the main etiology of the disease and determine the type of the treatment. Determine of additional diagnosis procedures are required Aid in restorative treatment decisions Improve the reliability of the prognosis of the planned treatment Assess the efficacy of the proposed management and preventive treatment plan at recall visits CARIES RISK ASSESSMENT Risk Indicators Risk Factors Protective modifying factors Conditions that affect compliance Additional considerations during assessment  CAMBRA philosophy THE CARIES IMBALANCE No Caries Caries Progression Featherstone andYoung et. al., 2007 CARIES RISK ASSESSMENT FORM RISK (DISEASE) INDICATORS “A probable or putative risk factor, but the cross-sectional data upon which it is based is weaker than the results of longitudinal studies.” Caries experience Strongest predictors It included the known and unknown factors Active caries History of past caries activity in the last three years Increased caries risk is associated with the presence of restorations (or extractions). The level of evidence supporting the causal relationship between presence of restorations and increased caries risk is based on a small number of case-control or cohort studies. Other indicators DMFT/dmft, DMFS/dmfs CARIES RISK ASSESSMENT FORM CARIES RISK FACTORS “ An environmental, behavioral or biologic factor confirmed by temporal sequence, usually in longitudinal studies, which if present directly increases the probability of a disease occurring, and if absent or removed reduces the probability. Risk factors are part of the casual chain, or expose the host to the casual chain. Once disease occurs removal of a risk factor may not result in cure.” Local factors Medical/Demographic history Salivary Assessment for at risk Patients Dietary Habits  Plaque accumulation LOCAL At susceptible site; occlusal / cervical / interproximal / restoration margin FACTORS Presence of caries susceptible site Exposed root / Deep pit/fissure / Severe tooth development defect Wearing appliances/defective restorations Orthodontic braces / RPD / defective restoraton THICK AND UNDISTURBED BIOFILM Dental caries is now considered an endogenous infection caused by a change in the oral microbial ecology (microbiome) resulting in the selection of bacterial species that have the potential to ferment sugars and starch. The individual differences and complexity of the microbiome are influenced by transmission of bacterial species between infants and their caregivers as well as other environmental sources including foods, drinks, and all human contacts. Recent evidence indicates dental caries and periodontal diseases occur because of a shift in the microbial ecology and the reduction in bacterial diversity of the microbiome in the oral cavity. The level of evidence supporting the causal relationship between accumulation of a thick layer of biofilm or in stagnation areas and increased caries risk is based on several case control and cross-sectional studies. EXPOSED ROOT SURFACE Increased risk of root caries is associated with the number of exposed root surfaces. The level of evidence supporting the causal relationship between root caries and exposed root surfaces is supported by one systematic review, and a small number of case-control or cohort studies. Less inorganic component. Location which is close to gingival margin where plaque can be accumulated. Plaque retention APPLIANCE THAT MAY INCREASE DEVELOPMENT OF BIOFILM Increased caries risk is associated with the use of an oral appliance including partial dentures. The level of evidence supporting the causal relationship between use of the oral appliances and increased caries risk is based on a small number of case-control or cohort studies, as well as expert opinions. For example; Orthodontic appliance, Removable denture. Local Factor Bacteria counts MS > 106 CFU Lactobacillus > 105 CFU LOCAL FACTOR CRT Bacteria Bacteria counts MS > 106 CFU Lactobacillus > 105 CFU ATP Adenosine Triphosphate (ATP)= energy molecule in all living cells Measure bacterial load and biofilm activity level Measure light producing by the reaction between ATP and enzyme “Luciferase” (firefly enzyme) Luminometer; very sensitive light measuring device Aciduric/Acidogenic bacteria produce ATP to effectively transport H+ ion out of cell (To maintain intracellular neutrality) < 1500 is considered as low bacteria loading 1500-4000 is considered as moderate bacteria loading >4000 is considered as high bacteria loading MEDICAL/DEMOGRAPHIC HISTORY Conditions that decrease salivary flow Head and neck radiation / Chemotherapy / Sjögren syndrome / Uncontrolled diabetes / Salivary gland pathology / HIV / Medications with hyposalivatory side effects (Antianxiety, Antidepressants, Antihistamine, Antipsychotic), Other conditions (Dehydration etc.) ALTERING MEDICATION-INDUCED HYPOSALIVATION Although there is strong evidence on the role of certain drugs in reducing salivary flow, there is limited evidence on the effectiveness and practicality of changing such regimes to benefit oral health. Any such changes must clearly be undertaken in consultation with medical practitioner to ensure effective control of underlying medical conditions.  MEDICAL HEALTH Current use of medications, recreational drugs, or systemic conditions that may cause hyposalivation HEAD AND NECK RADIATION Patients undergoing radiotherapy for head and neck cancer are categorized as high risk for developing caries because of the side effects or sequelae of the treatment regimens. The symptoms include (but are not limited to) xerostomia and/or hyposalivation, mucositis (affecting eating and oral hygiene practices) and altered taste sensation (which may result in patients utilizing inappropriate or cariogenic means of addressing the issue). DRY MOUTH “There is an increased caries risk associated with xerostomia/hyposalivation. The level of evidence supporting the causal relationship between xerostomia/hyposalivation and increased caries risk is based a small number of case-control or cohort studies.” Xerostomia Subjective sensation of dry mouth, which is often (but not always) associated with hypofunction of the salivary glands. Hyposalivation The condition of having reduced saliva production which is different from xerostomia. SYMPTOMS & Symptoms associated with dry mouth Little saliva amount / Loss or diminished taste / Burning mouth / SIGNS OF DRY Need liquid to eat dry food / Other symptoms MOUTH Signs associated with dry mouth Erythematous tongue / Chelitis / Caries at atypical location / Lack of pool of saliva / Other signs SALIVA AND CARIES Salivary proteins contribute to the pellicle to protect the outer surface Salivary proteins maintain supersaturation of calcium phosphate Salivary calcium and phosphate inhibit demineralization and enhance remineralization Saliva carries fluoride around the mouth Salivary components buffer plaque acids Salivary proteins have antibacterial properties SALIVA FLOW ASSESSMENT  Saliva flow(stimulated/unstimulated) ◦ Watch, Electronic weight with two digits, plastic cup, paraffin(stimulated) ◦ Collecting for 15 mins for unstimulated saliva and 5 mins for stimulated saliva. ◦ Unstimulated saliva > 0.2 ml/min; normal 0.1-0.2 ml/min; moderate risk < 0.1 ml/min; high risk ◦ Stimulated saliva > 1 ml; normal 0.7-1.0 ml; moderate risk < 0.7 ml; high risk SALIVARY FLOW TEST SALIVARY FLOW TEST Materials Watch Electronic scale A plastic cup Paraffin tablet SALIVARY FLOW STIMULATE SALIVARY FLOW TEST The patient must be seated in a chair for a few minutes. Weigh the empty cup. Have the patient chew a tablet of paraffin for 5 minutes. Collect the saliva every 30 sec. The patient should let the saliva drip into the pre-weighed plastic cup. Weigh the saliva-containing plastic cup and subtract with the weight of the empty cup. The flow rate can be calculated in g/min, which is almost equivalent to ml/min (Navazesh & Christensen, 1982). SALIVA FLOW ASSESSMENT Schirmer test (tear test); ≤ 10 ml/three minutes-severe hyposalivation (Davis & Mark, 1986, Zunt et al, 2002, Fontana et al, 2005) SALIVARY ASSESSMENT Saliva buffer 1. Phosphate buffer system 2. Bicarbonate buffer system* 3. Protein buffer system Buffer capacity (Tritation); β=∆CA/ ∆pH; ∆CA = the increase in saliva acid concentration ∆pH = the change in saliva pH DIETARY HABITS Frequent snacking Snack between meals Sipping of sweetened beverages between meals SUGARY DRINK AND SNACK Based on the evidence from systematic reviews and several well-conducted cohort studies, it can be concluded that there is a significant association, though weaker than in the past under modern dietary practices and fluoride exposure, between higher risk of dental caries and high exposure to sugared beverages and snacks. Therefore, consumption of sugared beverages and snacks needs to be included as a part of a patient’s caries risk assessment. CONDITIONS THAT AFFECT COMPLIANCE Physical (Motor coordination/pain) Mental Use of illicit drugs Alcoholism Occupation/Lifestyle Others USE OF RECREATIONAL DRUGS There is limited evidence on the role of dental personnel other than referral to specialists. Necessary behavioral change has some unique characteristics, probably requiring specialized training. (Behavior Therapy, Psychotherapy, or a licensed alcohol and drug counselor) MOTHERS’ OR CARE GIVERS’ CARIES EXPERIENCE It is well accepted that development of early childhood caries is influenced by environmental factors beyond individual-level factors, including a mother or caregiver’s dental health. Several mother-child studies reported that there is a significant correlation between mothers and children’s caries status, thus suggesting a mother’s (or caregiver’s) caries status can be a predictor for child’s caries development. SOCIOECONOMIC STATUS Even though definitions of SES may vary, an individual’s SES is likely to be an important predictor of caries risk. However, the correlation between SES and dental caries has not always been negative. Data from several emerging economies or rich-developing countries show that caries is more prevalent in higher income groups. The same correlation existed in developed countries in the later part of the 19th and early part of the 20th centuries. Current evidence from the literature indicating a reverse relationship between one’s SES and caries level is mainly based on studies conducted in developed or industrialized countries. Therefore, the relationship might not be applicable to countries at different stages of development. In low-income developing countries, the SES-caries relationship might not be as clear, or can even be reversed (high SES individuals have a higher level of dental caries). Data from the Global Oral Health Data Bank, maintained by the World Health Organization (WHO), suggested that developing countries, where caries prevalence was low initially, experience a high level of caries prevalence as they are industrialized and exposed to refined ‘cariogenic’ foods. CARIES RISK ASSESSMENT FORM PROTECTIVE MODIFYING FACTORS Fluoride supplement Regular dental care Oral Hygiene Instruction Frequency of brushing Frequency of flossing FLUORIDE EXPOSURE Patients under certain conditions can be considered to have inadequate fluoride exposure if they have the following profiles: No daily use of fluoridated toothpaste (less than 2x daily) For children: tooth brushing with non-fluoridated toothpaste Concentration of fluoridated toothpaste less than 1000 ppm of fluoride. FLUORIDE Enhance the precipitation into tooth structure of fluorapatite from calcium and phosphate ions present in saliva Remineralize the incipient, non-cavitated, carious lesion Antimicrobial activity PROTECTIVE MODIFYING FACTORS “Fluoride” Fluoride tooth paste ≥ 2 times daily (1,000 ppm) Daily use of fluoride mouthrinse (Over the counter / Prescription) Daily use of high concentration fluoride gel/paste (5,000 ppm, Prescription)  ORAL HYGIENE Oral hygiene behaviors Poor oral hygiene status as evidenced by accumulated plaque on the dentition can be predictive of caries development and, hence, is a useful risk indicator. However, the relationship between presence of plaque and caries risk is complex because it depends on the presence of cariogenic bacterial species, which is the determinant factor, and, hence, its use in clinical risk assessment must be viewed with caution. A longitudinal study demonstrated that visible plaque on the labial surface of incisors in young children (19 months) was good predictor of caries development at 36 months of follow-up, demonstrating a sensitivity of 83% and specificity of 92%. The research team was able to correctly classify 91% of children with regard to future caries risk using plaque accumulation alone. Wendt et al. (1994) also demonstrated that oral hygiene (i.e., toothbrushing) status in infants and toddlers was associated with lower caries risk. In a 7-year follow up study, Tagliaferro et al. (2008) found that oral hygiene status was predictive of high caries at baseline but was not predictive of new caries incidence over the 7 year of the study. Mascarenhas (1998) reported oral hygiene status to be an important risk indicator for both enamel and dentinal caries in 12-year olds. Mathiesen et al. (1996) reported similar results for 14 year olds when brushing with a fluoride dentifrice. Similarly in adults Domejean et al. (2011) found that visible heavy plaque increased risk for future caries development. In assessing oral hygiene practices, ICCMSTM recommends evaluating the frequency and time spent during tooth brushing and flossing, and timing (after meals, before bedtime).  Caries Risk Categories At Risk Low Risk Extremely Moderate High Risk Low Risk high risk Risk DETERMINATION THE CARIES RISK LEVEL Caries detected Yes Initial No diagnosis (based on physical appearance and location) A Check for recent changes that could have influenced caries risk factors toward cariogenic challenge -new medical conditions or medication that decrease salivary flow -new oral appliances No - significance stress factors Caries active -occupational and sociodemographic changes Risk indicators (Questions 1-5*) B Check for recent changes in oral conditions -erupting teeth 5* caries experience within three years -recently placed restorations due to caries Questions 6-14 for 6 years old and above Questions A-D Yes At risk Recent changes Yes No High risk Moderate risk Low risk -Presenting of any risk indicator -No risk indicators -No risk indicators -And presenting of any risk factor -With any risk factor -No risk factors -With moderate/low - With low bacterial challenge bacterial challenge test test and adequate saliva flow Extremely high risk and -High risk combines with inadequate saliva test intermediate/adequate flow saliva flow test LOW CARIES RISK 1. No current active caries lesions 2. Have not had any caries lesions and disease activity in the past three years 3. No other risk factors Local factors; plaque, high bacterial count, improper dental anatomy, wearing appliance Medical conditions or medications that reduce salivary flow Low amount of saliva Poor dietary habits If they are present, there is evidence that over many years they have not results in caries lesions AT RISK (MODERATE CARIES RISK) 1. No current active caries lesion 2. No caries lesion development in previous 12 months 3. Presence of risk factors Local factors Medical conditions or medications that decrease salivary flow Presenting low amount of saliva Poor dietary habits Suboptimal fluoride AT RISK (HIGH CARIES RISK) 1. Development of new caries lesions 2. Presence of active lesions 3. Placement of restorations due to active disease since the last visit (1 year) 4. Presence of risk factors Local factors Medical conditions or medications that lower salivary flow Low amount of saliva Poor dietary habits Suboptimal fluoride *Extremely High Caries Risk = High Caries Risk + Dry mouth  CARIES RISK STATUS Low Caries Risk Modertae Caries High Caries Risk Extremely High No risk indicator (No Risk Presenting of Caries Caries Risk caries in the past three No caries development History of caries or new High Caries Risk and years) more than one year but restoration due to caries Xerostomia No risk factors less than three years within a year. Presenting of protective Presenting of the risk Risk factors factors factors No protective factors No protective factors CARIES MANAGEMENT Can restoration stop dental caries? What is the goal of dental caries treatment? How can dentist help the patient maintain good oral health? Is there any specific tool to treat dental caries? CARIES MANAGEMENT TERMINOLOGY “A term to describe the actions taken at a patient level—that is, demineralization and plaque/biofilm being managed not for one specific surface but for the whole person (e.g., plaque control/toothbrushing instruction, fluoride application, dietary interventions, and behavior change techniques).” Caries management aims to control the disease and to prevent a lesion from becoming clinically manifest and, for those lesions detectable clinically, prevent their advancement. CARIOUS LESION MANAGEMENT Any procedure that involves doing something to an established, noncleansable carious lesion to stop its progression. This might involve removing none, some, or all of the carious tissues from a noncleansable lesion. When do we need carious lesion management? 1. An active lesion that might require a noninvasive approach, such as biofilm removal or application of fluoride varnish, to limit progression. 2. Where a lesion is not cleansable and is vulnerable to progression even in the presence of a full preventive program. Aimed at controlling the symptoms of the disease at a tooth level. 1. Managing patient’s risk factors 2. Managing Individual Lesions MANAGING RISK FACTORS (ICCMS APPROACH)  Caries Management Plan Active Carious Lesion † Yes Caries Experience* Undermining shadow, cavity or enamel breakdown, No radiographically extend to dentine, loss of anatomical contour on root surface No Yes Diet Yes Caries Risk Local Factors Saliva Dentin Involvement, Systemic radiographically extend *Caries Experience = Active Behavioral No to middle third of carious lesions or restorations dentine due to carious lesion done within Yes No the last 3 years. No Yes †For multiple stages of caries lesion, use the most severity of caries management plan.  Caries Management Plan Active Carious Lesion † Yes Caries Experience* Undermining shadow, cavity or enamel breakdown, No radiographically extend to dentine, loss of anatomical contour on root surface No Yes Diet Yes Caries Risk Local Factors Saliva Dentin Involvement, Systemic radiographically extend *Caries Experience = Active Behavioral No to middle third of carious lesions or restorations dentine due to carious lesion done within Yes No the last 3 years. No Yes †For multiple stages of caries lesion, use the most severity of caries management plan.  Initial Moderate Advanced HSDM Caries Classification Proposal Appearance of occlusal surfaces Accessible smooth surfaces cervical surface and root Radiographic presentation  Initial HSDM Caries Classification Proposal Appearance of occlusal Carious discoloration or opacification seen emanating from the depth surfaces of enamel pits and fissures. Accessible smooth surfaces Buccal/lingual lesions typically seen along cervical margin or near cervical surface and root orthodontic/prosthodontic attachments as discoloration or opacification. Root caries appear as defined area of discoloration at or apical to CEJ. Radiographic presentation Triangular-shaped radiolucency within enamel but not extend to DEJ.  Moderate HSDM Caries Classification Proposal Appearance of occlusal surfaces Localized enamel microcavitation causes widening of pits/fissures. Grey, blue, or brown dentinal shadowing beneath enamel surface may occur regardless of enamel microcavitation. Accessible smooth surfaces Root caries present at or apical to CEJ as defined discolorations with cavitation cervical surface and root causing loss of surface contour 0.5-2mm in depth. Radiographic presentation Radiolucency reaches DEJ and extend to outer 1/3 of dentin.  Advanced HSDM Caries Classification Proposal Appearance of occlusal Obvious widening of pits/fissures due to cavitation into dentin. Dentin may be surfaces visualized at base or walls of cavitation after drying. Accessible smooth surfaces Root caries with large cavitation causing loss of surface contour greater than 2mm. cervical surface and root Radiographic presentation Radiolucency reaching middle and inner 1/3 of dentin or into pulp tissue.  Caries Management Plan Active Carious Lesion † Yes Caries Experience* Undermining shadow, cavity or enamel breakdown, No radiographically extend to dentine, loss of anatomical contour on root surface No Yes Diet Yes Caries Risk Local Factors Saliva Dentin Involvement, Systemic radiographically extend *Caries Experience = Active Behavioral No to middle third of carious lesions or restorations dentine due to carious lesion done within Yes No the last 3 years. No Yes †For multiple stages of caries lesion, use the most severity of caries management plan. Individual lesion management Clinical intervention Nonrestorative treatment Prophy Oral Hygiene Instruction Nutritional counseling Caries Management Plan 1 (Low Risk + Sound and Initial Caries Lesion) Home care instruction Recall Brush your teeth 2 X / Day with Fluoride Toothpaste 6-12 months Floss your teeth at least 1 X / Day Reduce snacks and drinks that contain sugar Reduce starchy foods Individual lesion management Clinical intervention Nonrestorative treatment Prophy Discuss risk factors modification/elimination Oral Hygiene Instruction Nutritional counseling Fluoride varnish 2 times/year Caries Management Plan 2 (Moderate Risk + Sound and Initial Caries Lesion) (High Risk + Initial Caries Lesion) Home care instruction Recall Brush your teeth 2 X / Day with OTC Fluoride Toothpaste 6 months Floss your teeth at least 1 X / Day Use a fluoride mouth rinse 1-2 X / Day (Such as ACT) Reduce snacks and drinks that contain sugar Reduce starchy foods Only chew gum that has xylitol Individual lesion management Clinical intervention Nonrestorative and microinvasive restorative treatment Prophy Restorative Treatment Discuss risk factors modification/elimination Endo consult if it is indicated Oral Hygiene Instruction Nutritional counseling Fluoride varnish 4 times/year Caries management plan 3 (High Risk/Extremely High + Moderate/Advanced Caries Lesion) Home care instruction Recall Brush your teeth 2 X / Day with Prescription Toothpaste 3 months Prescription fluoride gel with tray 10 mins 1 X per day (Extremely high) Floss your teeth at least 1 X / Day Use prescription mouth rinse 1-2 X / Day Reduce snacks and drinks that contain sugar Reduce starchy foods Only chew gum that has xylitol Individual lesion Clinical intervention management Caries Management Plan Home care instruction Recall INDIVIDUAL CARIES LESION MANAGEMENT “any procedure that involves doing something to an established, noncleansable carious lesion to stop its progression. This might involve removing none, some, or all of the carious tissues from a noncleansable lesion.”  Non restorative Restorative treatment for treatment for carious lesion carious lesion INDIVIDUAL 5% NaF varnish Preventive resin LESION 1.23% APF gel restoration MANAGEMENT Sealants Fillings Resin infiltration Crown 38% Silver diamine Root canal fluoride (interim treatment caries arresting Extraction medicament application) NONRESTORATIVE TREATMENT OF CARIOUS LESION JADA; October 2018 NONRESTORATIVE TREATMENT OF CARIOUS LESION JADA; October 2018 NONRESTORATIVE CARIES LESION MANAGEMENT Sealants Application of sealants is a recommended procedure to prevent or control caries. Sealing the occlusal surfaces of permanent molars in children and adolescents reduces caries up to 48 months when compared to no sealant, after longer follow-up the quantity and quality of the evidence is reduced.  RESIN INFILTRATION (ICON) Both sealants and resin infiltration have been shown to arrest the caries disease process and inhibit caries progression. (Sealant; Griffin et al. 2008) (RI; Paris et al. 2010; Meyer-Lueckel et al. 2016; Peters 2017), Systematic reviews are largely in support of proximal infiltration (Ammari et al. 2014; Dorri et al. 2015; Doméjean et al. 2015; Chatzimarkou et al. 2018; Krois et al. 2018; Liang et al. 2018). Three clinical studies of proximal lesion infiltration with different study designs reported a considerable benefit obtained with RI, resulting in a 3-y efficacy (relative risk reduction [RRR]) of 54% to 91% (Martignon et al. 2012; Meyer-Lueckel et al. 2012; Arthur et al. 2018).  SILVER DIAMINE FLUORIDE Silver ions Antimicrobial: Denature all proteins / Break Cell Wall and Membrane / Inhibit DNA SDI (RIVA STAR) replication Silver diamine fluoride + Potassium iodide Strengthens dentine: Protective layer forms by reaction with dentine proteins is acid resistant (Hill & Arnold 1973) Individual lesion Clinical intervention management Caries Management Plan Home care instruction Recall  HOME CARE Brush twice a day with F toothpaste (≥ 1000 ppm)-Low risk Brush twice a day with high efficacy F toothpaste (≥ 1450 ppm) or prescription for 5000 ppm F toothpaste (Following with dental team instruction)– Moderate, High risk 2% NaF Gel or Solution Behavioral modification – Moderate, High risk F mouth rinse – Moderate, High risk Xylitol gum-stimulate salivary flow rate TOOTH BRUSHING TWICE A DAY WITH ≥ 1000 PPM Reviews confirm the benefits of using fluoride toothpaste in preventing caries in children/adolescents, but only for higher efficacy toothpaste with F concentration of ≥ 1000 ppm.* The relative caries preventive effects of F toothpastes of different concentrations increase with higher F concentration.* Strong evidence that daily use of F toothpaste has increase a significant caries-preventive effect in children when compare with placebo. Effect was boosted by supervised tooth brushing, increased brushing frequency to twice daily, and use of F toothpaste of 1500 ppm.* Fluoride gels or solution (2% Sodium fluoride) Reviews confirm the efficacy of fluoride gels and solution with similar levels of efficacy to HIGH CONCENTRATION other fluoride interventions. FLUORIDE TOOTHPASTE High fluoride toothpastes (>1450 ppm F) and higher efficacy F toothpastes have been shown to be of added benefit to children and adults at risk of caries. 5000 F toothpaste are more efficacious for root caries remineralization (Wierichs and Meyer-Lueekel 2015) 5000 PPM FLUORIDE TOOTHPASTE Apply a thin ribbon of PreviDent® 5000 Booster Plus to a toothbrush. Brush teeth thoroughly once daily for two minutes, preferably at bedtime, in place of your regular toothpaste. After use, adults expectorate. For best results, do not eat, drink, or rinse for 30 minutes. F-MOUTHRINSE Both daily (226 ppm F) and weekly (900 ppm) rinses are efficacious in reducing caries.* COMBINATIONS OF FLUORIDE THERAPIES Topical fluorides (mouthrinses, gels, or varnishes) used in addition to fluoride toothpaste achieve a modest reduction in caries compared to toothpaste used alone. Combined use of Fluoride therapies for example F varnish and high fluoride toothpaste and mouthrinses may be appropriate for those at high risk (Expert opinion). USING FLUORIDE DENTRIFICE (1100 PPM F NAF), 012% CHLORHEXIDINE GLUCONATE RINSE AND 0.05% NAF RINSE There is evidence that daily use of fluoride toothpaste, 0.12% chlorhexidine rinse 1 minutes 1 week each month, and daily 0.05% F-rinse the other 3 weeks per month results in a statistically significant 24% reduction of mean DMFS between intervention and control (conventional dental care) group in two year. Individual lesion Clinical intervention management Caries Management Plan Home care instruction Recall  CLINICAL INTERVENTION Motivational engagement / interviewing (Low, Moderate and High Risk) Fluoride Varnish (5% NaF varnish) – 4 times / year (high caries risk), 2 times / year (moderate caries risk) One-on-one dietary intake intervention (Nutritional counseling) Oral hygiene instruction Altering medication – induced hyposalivation Reducing the use of recreational drug FLUORIDE VARNISH This updated review confirms a substantial caries-inhibiting effect of 5% fluoride varnish in both permanent (43%) and primary teeth (37%), however the quality of the evidence was assessed as moderate, as it included studies with a high risk of bias studies, with considerable heterogeneity. The benefit of more frequent applications is not clear, but may be beneficial for children at high risk of caries. 2x/year (Moderate Risk); 4x/year (High Risk); ORAL HYGEINE INSTRUCTION Oral hygiene instructions (D1330): “Documentation should include instructions for home care including but not limited to tooth brushing technique, flossing, use of oral hygiene aids as well as use of prescription and over the counter antimicrobial rinses, irrigants, or dentifrices for control of bacterial plaque or remineralization of tooth structure.” NUTRITIONAL COUNSELING There is some evidence that one-to-one dietary interventions in the dental setting can change behavior, although the evidence is greater for interventions aiming to change fruit/vegetable and alcohol consumption than for those aiming to change dietary sugar consumption. Nutritional counseling for control and prevention of oral disease (D1310): “Documentation should include the patient's current dietary habits including consumption of sugared beverages and other cariogenic foods and counseling on food selection and dietary habits as a part of the treatment and control of periodontal disease and caries. Include any specific recommendations for diet changes including the use of sugar free alternatives such as xylitol gum.” Reduce snacks and drinks that contain sugar Reduce starchy foods Only chew gum that has xylitol BAHAVIOR MANAGEMENT Motivational engagement Andlaw RJ. Int Dent J 1978 Ismail AI, et. Al. Community Dent Oral Epidemiol 2011 Motivational interviewing Motivational interviewing (MI) is an approach that uses collaborative and empathic interactions to develop a client’s internal and autonomous motivation to change. Yevlahova D, Satur J. Aust Dent J 2009 Individual lesion Clinical intervention management Caries Management Plan Home care instruction Recall  RECALL VISIT Every 3 months to every 2 years – Based on the frequency of professional fluoride application Low caries risk – every 6-12 months Moderate caries risk – every 6 months High / Extremely High caries risk –every 3 months For overall risk management, assessing preventive interventions and monitoring of initial lesions and reviews of behavioral and oral hygiene change plans MANAGING XEROSTOMIA AND SALIVARY GLAND HYPOFUNCTION Patient education—a patient-centered process emphasizing daily oral hygiene, regular dental visits, use of topical fluoride, tobacco-use cessation counseling and other interventions; Management of systemic conditions and medication use in consultation with the patient’s physician, oncologist or other health care provider; Preventive measures to reduce oral disease and associated complications; Pharmacological treatment with salivary stimulants (sialagogues); For patients who cannot tolerate sialagogues, palliative measures to improve salivary output, such as use of sugar-free salivary stimulants (for example, chewing gum). Plemons J.M. et. al. JADA 2014 HOW TO INCREASE SALIVA FLOW RATE? Boost Saliva Sugar-free chewing gum (Erythriol, Xylitol) Saliva stimulant medication (SALAGEN-Pilocarpine or EVOXAC-Cevimeline) Salagen Initial 5 mg P.O. 3 times/day (Head and Neck Radiation) Max 30 mg per day. 5 mg P.O. 4 times/day Max 10 mg/dose or 30 mg/day (Sjorgen Syndrome) Evosac 30 mg PO 3 times/day. Max 90 mg/day Caries No caries