Transcript of "C116 management of dental caries in older patients"
C116 MANAGEMENT OF DENTAL CARIES IN OLDER PATIENTS GRETCHEN GIBSON, DDS, MPH THURSDAY, FEBRUARY 21DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission hasbeen granted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide rightto distribute solely as an educational material at the scientific program being presented at the 2011 Midwinter Meeting. Permission has beengranted for this work to be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in anyform or by any means or editing of the information may be made without the written permission of the author. The Chicago Dental Societydoes not assume any responsibility or liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Societyshall not be sued for any claim involving the distribution of this work.
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2/8/2013 Prevention for adults? • Medical model, MID, CAMBRA----based on the Management of Dental Caries in knowledge that caries is due to a bacterial Geriatric Patients infection Gretchen Gibson, DDS, MPH • “Restorations repair the tooth structure, but do not stop caries and have a finite life span” Gretchen.email@example.com NIH Consensus Statement 148th Midwinter Meeting Chicago Dental Societ • Specific –plaque hypothesis Thursday, February 21, 2013 Loesche W. Dental Caries and periodontitis----. Inf Disease Clinics of North Am. 2007;21(2). Best predictor of caries in adults Caries Indicators and Caries Risks Clinical history• Active carious lesions • Heavy plaque• White spots or rough • High MS counts and Exam demineralized areas • Low salivary flow• History of recent caries • Frequent snacks or sweet experience and acidic drinks No new caries 1-2 new lesions 3+ lesions • Appliances touching teeth • Recession with exposed in 3 years in 3 years in 3 years roots • Systemic disease and treatment LOW MODERATE HIGH RISK RISK RISK Categorize as High ---Moderate---Low Risk Zero D, et al. J Dent Education. 2001 LOW Caries Risk in Adults MODERATE Caries Risk in Adults • 1-2 new carious lesions within the last 3 years• No carious lesions within the last 3 years • Evidence of moderate daily oral care• Good salivary flow • Frequent carbohydrate or sugar intake• Evidence of good daily oral care • Inadequate fluoride exposure (brushing less than 2x/day and no other fluoride source)• Regular dental visits (at least 1x/year) Zero et al., 2001; Locker, 1996; Fontana, 2006; ADA 2006; Leone, 2001 Featherstone, 2007; Zero, 2001; Locker, 1996; Fontana, 2006; ADA 2006; Leone, 2001; Joshi, 1993; Burt 2001; Ismail, 1984 1
2/8/2013 MODERATE Caries Risk in Adults (continued) HIGH Caries Risk in Adults • 3 or more carious• Use of meds that could cause reduced salivary lesions within the last 3 flow, but no clinical signs years• History of sporadic or no dental care • Reduced salivary flow• Use of a removable partial denture • Evidence of poor daily oral care • High S.mutans counts Featherstone, 2007; Zero, 2001; Locker, 1996; Fontana, 2006; ADA 2006; Leone, Featherstone, 2007; Zero, 2001; Locker, 1996; Fontana, 2006; ADA 2006; Leone, 2001; Joshi, 1993; Burt 2001; Ismail, 1984 2001; Joshi, 1993; Burt 2001; Ismail, 1984; Kitamura 1986 HIGH Caries Risk in Adults (continued) Caries Diagnosis • Caries is a greater risk for• Medical conditions that contribute to caries tooth loss than periodontal susceptibility (e.g., head and neck radiation, psychiatric conditions, drug abuse and others) disease in persons >70.• Exposed root surfaces • Adults have an average of 1• Frequent carbohydrate or sugar intake along with carious lesion per year low daily fluoride intake • For patients age 30+, the• Inadequate fluoride exposure (brushing prevalence of root caries is < 2x/day and no other fluoride source) about 20-22% less the• History of sporadic or no dental care persons age Featherstone, 2007; Zero, 2001; Locker, 1996; Fontana, 2006; ADA 2006; Leone, 2001; Leake JL. Clinical decision-making for caries management in Joshi, 1993; Burt 2001; Ismail, 1984; Kitamura 1986 root surfaces. J Dent Ed. 2001; 65(11):47-53 GG Enamel v. Dentin Caries Caries Detection• Enamel-hardest substance • We most often make a dichotomous decision about caries in the body • Diagnosis is more than detection—the clinician must also decide if the• Dentin -mineralization 100 lesion is active, progressing or remineralized (arrested) similar to bone 90 • Explorer, mirror and radiographs 80 Dentin • Newer options:• Cementum erodes away 70 – ICDAS (International Caries Detection and Assessment System) quickly after exposure in 60 – Fluorescence mouth 50 % – Fiber-optic transillumination 40 mineral• pH for enamel • “fewer restorations placed to treat 1° lesions result in fewer replacement 30 of failed restorations” and lower DMFT * demineralization-<5.4 20• pH for dentin 10 demineralization <6.5 0 Enamel Zandonà AF,ZeroDT.Diagnostic tools for early caries detection. JADA.2006;137:1675 *Mjör IA et al. Caries and restoration prevention. JADA 2008 GG 2
2/8/2013 Tactile and Visual Detection Arrested Carious lesions • Tactile or texture evaluation seems to • Arrested lesions can be Active Arrested have more validity Appearance Dull and Appearance dark and than visual or color thought of as scars and Chalky shiny classification when more resistant to a Lesions found in Lesions found in assessing “active” subsequent carious plaque stagnant interproximal areas areas (interprox, with missing lesions attack occlusal, gingival margins) adjacent teeth and no prosthesis • Probing root surfaces Smooth surface lesions Smooth surface lesions may leave defects in close to the above the gingival the root that will not gingival margins margin fully remineralize Warren et al. Explorer probing of root caries lesion: an in vitro study. Leake JL. Clinical decision-making for caries management in root surfaces. J Dent Sp Care Dent. 2003;23(1):18-21. GG Educ.2001;65(10):1147-53. Recurrent Caries• History of caries is the greatest Non-surgical treatment predictor of future caries • Remineralization of root caries• Is it primary vs recurrent caries—and can be accomplished by adding does it matter? fluoride• “Replacement of defective • Mineral supplementation beyond restorations has been the traditional the saliva may also be helpful response; this study shows alternative • Consider smoothing with a slow txs achieved similar responses during speed or finishing bur prior to 3 yr f/u” * fluoride treatment • Remineralized tooth structure is solid tooth structureEricson D, et al.. Minimally invasive dentistry-concepts and (esthetics??)techniques in cariology. Oral Health Prev Dent. 2003*Moncada G, et al. Sealing, refurb & repair of –def restorations.JADA, 2009 GG Apical Margin Integrity Isolation Techniques • Restorative failures are Rubber Dam most likely to occur at • Hygienic # 212 or 14 A apical margin clamps • Oral dryness may • Isolate one or two teeth; increase risk of root must be able to get caries, but makes apical to margin restoring easier. • Put clamp, dam and frame on in one step Chan DCN, Adkins J. Technique on restoring sub-gingival cervical lesion. Op Dentistry. 2003; 28:350-53. LCN 3
2/8/2013 Isolation Techniques Isolation Techniques Packing Cord • Flat or spoon shaped Electrosurgery packing instrument • Use to gain access to (Ultradent Ultrapak Packer apical margin UP171) • 0-1 cord size, without • Use when 3 mm of vasoconstrictor attached gingival • If bleeding, dip in tissue present Hemodent (aluminum • Control hemostasis chloride-no epi) GG GG Root Caries Removal with a Laser Restorative Material Selection• Advantages • Disadvantages – Reduced need for – Cost anesthesia (multi- • Meets patient’s esthetic quadrant rest) – Learning curve requirements – Ability to easily • Can lower patient’s caries remove soft tissue risk – Reduction of heme • Operator skills at the margins • “In geriatric MID, the choice of material cannot be made until caries are removed and field control is evaluated” Chalmers, JM. GG GG Chalmers JM. Minimal Intervention Dentistry: Part 2. Strategies for addressing restorative challenges in older patients. JCDA. 2006. 72(5):435-40. Glass Ionomers Resin Modified Glass Ionomers• Advantages • Disadvantages • Advantages • Disadvantages – Caries inhibiting – Higher wear rates than – bonds to tooth – Cost-more expensive – Easy to place composites or – improved esthetics than amalgam; same as – Provides options for RMGI/PAMC over GI composite multi surface root caries – Contraindicated in – can finish right – Wear rates higher than lesion patients with dry mouth away composites – Fluoride recharges – Esthetics – fluoride releasing – Fuji IX and Triage from glass particles GG 4
2/8/2013 Poly-Acid Modified Composite Composite Restoration (Compomer) • Advantages • Disadvantage• Advantages • Disadvantages – Most esthetic – Cost relative to amalgam – composite with glass – Cost-same as – Best wear resistance – Technique sensitive- particles to provide some composite (wear comparable to must be able to maintain fluoride releasing ability – Must maintain dry amalgam for hybrids) a dry field and get access – wear rates similar to field to apical margin – Flowables have more hybrid composite flex than traditional – more flexural strength hybrids than hybrid composites LCN Classification of F- Releasing Materials Dental Amalgam Material Classification Setting Fluoride Release Mechanism(s) and Recharge Ketak-Fill Conventional Acid/Base High GI • Advantages • Disadvantages Fuji IX Densified GI Acid/Base High – Cost effective – Not esthetic Fuji II LC and Resin 1° acid/base, High – Less time consuming – Patients usually Vitremer Modified but also than composite (can prefer tooth Glass light cure place quickly when colored Ionomer patient cannot cooperate restoration, if (RMGI) for long periods) given a choice Dyract Compomer 1° light cure Medium – Works in presence of – Requires enough (with a/b) saliva tooth structure to EsthetX Composite Light Cure Low gain retention Resin Adapted from: Burgess, J. Dental Clinic of North America, 2002.Caries Risk Assessment Forms Caries Risk Assessment FormsADA Form CAMBRAAvailable on ADA Children Age 6 andwebsite for free Over/Adultsdownload Featherstone JDB, et0= low risk al. CDA Journal.2007;35(10)1-10= mod risk10+= high risk 5
2/8/2013 Oral assessment tools Oral assessment tools Open Wide mouth propDenLitewww.miltex.comBeyond the health of my teeth, why is daily An Aside: Evidence Based Dentistry oral care important? According to the ADA…• 30-40% of infective endocarditis may be from the mouth (NOT from dental work) Evidence-based dentistry (EBD) is an approach to oral• Approximately 1:10 deaths from AP may be health care that requires the judicious integration of systematic assessments of clinically relevant prevented with good oral care scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s• There is a link between systemic diseases such clinical expertise and the patient’s treatment needs as diabetes, stroke and arthrosclerosis and and preferences poor oral health **EBD at ADA.org• Oral health is a component of positive quality www.ada.org/goto/ebd of life What are the levels of evidence?Definition of Evidence-Based Mature Dentistry Systematic Reviews RCT’s clinically relevant clinical skill Cohort study evidence & experience Evidence- Case control study Based Treatment Case series Case report patient Expert opinion needs & Animal research preferences Bench-top research Initial Bader, 2008 Used by permission of the ADA. December, 2008 6
2/8/2013 EBD and Caries in Seniors Environment • Clinical decision-making for caries management in root surfaces Leake JL. J Dent Educ. 2001;65(10):1147-53 • Salivary flow---or lack of it! • Effectiveness of fluoride in preventing caries in adults • Griffin SO, Regnier E, Griffin PM, Huntley V. J Dent Res. 2007;86(5):410-5 Fluoride interventions for root caries: a review • Diet conducive to caries formation Heijnsbroek M, Paraskevas S, Van der • Glass-ionomer restoratives: a systematic review of a secondary caries treatment • Availability of minerals during the effect Randall RC, Wilson NH. J Dent Res. 1999;78(2):628-37 Weijden GA. Oral Health remineralization process Prev Dent. 2007;5(2):145-52 • Complete or ultraconservative removal of decayed tissue in unfilled teeth Ricketts DN, Kidd EA, Innes N, Clarkson J. Cochrane Database Syst Rev. 2006;3():CD00380 • www.ada.org/goto/ebd Clinical Significance Caries Risk Factors Saliva -“A chronically Like other tissues in our low salivary flow rate body – salivary glands has been found to be change with age one of the strongest In a healthy state, the salivary indicators for human body can compensate for these an increased risk of changes developing caries.” Do not attribute xerostomia to aging Measurement should include history and oral assessment Source: M. Fontana and D. Zero. Assessing patient’s caries Baum BJ. Age related vulnerability. Otolaryngol Head Neck risk. JADA; 137:1231-1239, Sept. 2006. 137:1231- GG Surg.1992;106:730 Xerostomia-the patient described Differential Diagnosis for Xerostomia in symptom of oral dryness the Geriatric Population Xerostomia vs. salivary Systemic Disease Medication hypofunction Alzheimer’s disease Clinically detectable at 50% Head and neck Diabetes Mellitus loss of flow radiation Amyloidosis Sarcoidosis Prevalence in geriatric Sjögren’s Syndrome Sjö Graft-vs.-host disease Graft-vs.- population -30% Dehydration Liver diseases Viral (HIV, Hep C)•Dawes C. Physiological factors affecting salivary flow rate, oral sugarclearance and the sensation of dry mouth in man. J Dent Res. ’87; 66:648•Ship JA, et al. Xerostomia in the geriatric patient. JAGS. ’02; 50:535 7
2/8/2013 Medication Induced Xerostomia Medication Induced Xerostomia 12% of population consume Janket et al (2003,2007) 30% of meds Being on at least 1 xerost med meant sig 5% (LTC) consume 60% of the more mucosal lesions 30% xerostomic meds as a contributing factor Mechanisms to oral disease Anticholinergic affect Cardiovascular meds and sympathetic Tissue dehydration agonsists presented highly significant risk Persons who c/o oral increases for oral mucosal lesions dryness take twice as many meds as those w/o this complaint Chemotherapy Janket S, et al. Xerostomic medications and oral health:The Veterans dental study(part 1).Gerodontology ‘03;20(1):41-49.Sreebny LM, et al. A reference guide for drugs and dry mouth.Gerodontology.‘86;5(2):75 Janket S, et al. The effects of xerogenic medications on oral mucosa among the Veterans Dental Study participants. OOOOEndo.’07;103:223-30Sreebny LM. Salivary flow in health and disease. Compend Suppl.’89;13:S461-69 Medication Induced Xerostomia Office Evaluation for Xerostomia You don’t know the answers if you don’t ask the questions- questions- Patient History Oral Symptoms Patient issues Amount of saliva in your mouth (too little, too much, don’t notice) Resting vs. Stimulated Difficulties swallowing? flow Dryness when eating? Reversible Require sips of liquid to help swallow dry food? Ocular Symptoms Consider as a default General Health Review diagnosis Al-Hashimi I, et al. Frequency of predictive value of the clinical manifestations of SS. J Oral Pathol Med. ‘01;30:1. Wu JA, et al. A characterization of major salivary gland flow rates in the Navazesh M. How can oral health care providers determine if pts have dry presence of medications and systemic diseases.OOO. ‘93;76:301 mouth. JADA ’03; 134:613-20. Treatment Options Diet Evaluation and Modification Salivary Stimulation Recommendations • Some key components to diet evaluation: Suggest salivary stimulation as a prescription (q4 hrs for 10 minutes) – Number of meals and snack Sugarless gums Sugarless mints – Amount and timing of consumption of sugared Citrus fruit juices (caution to use only beverages 1-2 times/day in 4-6 oz servings) 4- Avoid cinnamon, strong mint and too • Looking to decrease the exposure time to much lemon Good evidence to support use of sf poor dietary choices gum as a “caries preventive” measure in high risk kids. (Systematic review. • Need to give patient strategies for change and Desphande A et al. JADA 2008) options that meet their needs Marshall TA. Chair side diet assessment for caries risk. JADA 09 Chapple ILC. Potential mechanisms underpinning the nutritional modulation of periodontal inflammation. JADA 09 8
2/8/2013 Calcium and Phosphate Delivery Products Plaque control and specific oral organisms • Recaldent technology - Amorphous calcium phosphate stabilized in casein phosphopeptides • Caries requires plaque, – Gum – 0.6% cpp-acp which is where bacteria resides – MI paste – 10% cpp-acp • Novamin technology – amorphous calcium • For high risk pts, there is a need to identify the sodium-phosphosilicate specific areas of high plaque retention • Bacterial testing (SM) may be best used to determine initial bacterial loads and then monitor patients compliance or progress with a specific treatment regimen, such as chlorhexidine or plaque removal Fontana M, Zero DT. Assessing patient’s caries risk. JADA. 2006;137. Chemical Bacterial Control Options for brushing• Chlorhexidine is a cationic agent that is effective in Benefit Toothbrush controlling MS levels in the oral cavity www.benedent.com• CHX has substantivity not found in some other chemoprophylactics (products with CPC and essential oils)• Available in the U.S as a 0.12% mouthrinse• Xylitol may be an adjunct option to lower MS Fluorides: % versus ppm Fluorides: % versus ppm % ppm brand % ppm brand 0.05 NaF 226 ACT, Fluoriguard 1.1% NaF ~5000 Rx, e.g., Prevident® 0.4% SnF2 968 Gel Kam, Tin Gel 1.23% APF 12,300 Professional Application 0.24% NaF 1100 Crest 2.0% NaF 9050 Professional Application 0.76% MFP 1000 Aim, Aquafresh, 8.0% SnF2 19,363 Professional Application Colgate 1.14% MFP 1500 Extra Strength Aim 5.0% NaF 22,600 Varnishes (Prof Appl) Burt and Eklund, 1999 Burt and Eklund, 1999 9
2/8/2013 All fluorides are equal…but some are Ekstrand K. et al., 2008 Study population: population: Patients root caries status (%) more equal than others Homebound elderly (mean age 81.6 yrs) (n=189) 70• Griffin SO, et al. Effectiveness of fluoride in Duration: Duration: 8 months 60 preventing caries in adults. J Dent Res 2007 50 Protocol: Comparison of 3 Protocol:• Exposure to any mode of fluoride reduced groups- groups-see table legend 40 caries by 25% in adults 30• 6 studies after 1980 (3573 adults), summary Findings: Findings: Both fluoride varnish 20 and 1.1% NaF toothpaste 10 difference = .27 surfaces groups had significantly fewer root carious lesions at the end 0• 7 studies of root caries after 1980 (age 40+), of the study, compared to the Better Stable Worse summary difference = .22 surfaces OTC toothpaste group. No significant difference Varnish Group (1X/month)• Self applied only, difference = .3 surfaces between the varnish and 1.1% 1.1% NaF Paste Group(2X/day) NaF toothpaste groups. OTC Paste Group(2/x/day) FLUORIDE VARNISHES Application of 5% NaF Varnish 5% sodium fluoride q3-6 months for moderate risk q3-4 months for high risk • used in Europe and Canada • shown effective in children • most caries reductions range 25-45% • ease of application compared to trays for 2-4 minutes • low ingestion of fluoride with varnish • need clinical trials for root caries DePaola, 1993 Fure S. et al., 1998• Study population: moderate 25 % Remineralized to high risk community Study population: Moderate to high population: 100 dwelling adults, fluoride in 20 risk with at least 1 buccal root 90 80 water 0.1-0.2 ppm (n=176) surface lesion at baseline. (n=71) 70• Duration: 2 years 15 Duration: Duration: 1 year 60 50 10 Protocol: Protocol: 5,000ppm NaF gel 40• Protocol: comparison of 4 (Prevident) daily + 4x/year 30 groups – see table legend 5 professional application of 20 12,000ppm NaF gel (Prevident Plus) 10 0 0• Findings: Fluoride rinse )%( Root Caries Reversals exp control demonstrated 24% Findings: Findings: The combination of these reduction in overall caries, Rinse 0.05% NaF (225 ppm, 2xday) two fluoride protocols led to over incipient shallow total over 2 years. This was the Tablet (1.66 mg NaF, 2xday) twice as many carious lesion arrests Incipient: well defined softened area, yellow/light brown, NO cavitation, penetration by explorer only modality that was or reversals than the control group possible Toothpaste slurry technique (3xday) significantly different than Shallow: softened area, yellow/light brown, WITH the control group. Control disruption of surface contour, penetration by explorer possible 10
2/8/2013 1.1% Neutral sodium fluoride 1.1% Neutral sodium fluoride paste (cream) gel1.1% NaF cream 1.1% NaF gelDisp: 1 tube (51 g) Disp: 1 tube (56 g)Sig: Use thin ribbon on toothbrush at Sig: Use thin ribbon on toothbrush atbedtime to brush teeth. Spit, but do not bedtime and spread on teeth after brushingrinse after brushing with a regular toothpaste. Spit, but do not rinse.• Manufacturer states that 1 tube has ~ 100 doses. • Used once daily---this is approximately a 3 month • Manufacturer states that 1 tube has ~ 130 doses. supply • Used once daily---this is approximately a 4 month supply 1.1% Neutral sodium fluoride Conclusions gel • Risk assessment is the key to an optimal treatment plan • The medical management of caries is a changing and1.1% NaF gel emerging science with a need for increased research inDisp: 1 tube (56 g) adults- specifically high risk groupsSig: Place small ribbon in fluoride trays and • Medical management continues beyond preventivewear for 5 minutes daily. Spit, but do not products with the use of glass ionomers, bondedrinse after use. materials and even lasers that retain as much natural• Manufacturer states that 1 tube has ~ 130 doses. tooth structure as possible • Used once daily in upper and lower trays---this is approximately a 3 month supply Resolution 5H-2006 ADA House of Delegates UNANIMOUSLY accepted a multifaceted resolution targeted at vulnerable elderly issues. Put ADA at the forefront of developing programs to address the needs of this fast growing group of Americans…vulnerable elders! 11