Daily oral care is important for your overall health to oral healthcare that requires the judicious and well-being for several reasons: integration of systematic assessments of clinically relevant scientific evidence relating to the patient's - It helps prevent cavities and gum disease, protecting your oral and medical condition and history, together with teeth and gums. Untreated gum disease is linked to heart the dentist's clinical expertise and the patient’s disease and other health problems. treatment needs and preferences. - Good oral hygiene can help reduce bad breath. The practice of evidence-based dentistry means - Cleaning your teeth and gums daily reduces the bacteria integrating: in your mouth

1. C116
MANAGEMENT OF DENTAL CARIES IN
OLDER PATIENTS
GRETCHEN GIBSON, DDS, MPH
THURSDAY, FEBRUARY 21
DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission has
been granted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide right
to distribute solely as an educational material at the scientific program being presented at the 2011 Midwinter Meeting. Permission has been
granted for this work to be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in any
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does not assume any responsibility or liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Society
shall not be sued for any claim involving the distribution of this work.

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3. 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.gibson@sbcglobal.net
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

4. 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

5. 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 structure
Ericson 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

6. 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

7. 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 Forms
ADA Form CAMBRA
Available on ADA Children Age 6 and
website for free Over/Adults
download
Featherstone JDB, et
0= low risk al. CDA
Journal.2007;35(10)
1-10= mod risk
10+= high risk
5

8. 2/8/2013
Oral assessment tools Oral assessment tools
Open Wide mouth prop
DenLite
www.miltex.com
Beyond 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

9. 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 sugar
clearance 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

10. 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;103:223-30
Sreebny 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

11. 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

12. 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

13. 2/8/2013
1.1% Neutral sodium fluoride 1.1% Neutral sodium fluoride
paste (cream) gel
1.1% NaF cream 1.1% NaF gel
Disp: 1 tube (51 g) Disp: 1 tube (56 g)
Sig: Use thin ribbon on toothbrush at Sig: Use thin ribbon on toothbrush at
bedtime to brush teeth. Spit, but do not bedtime and spread on teeth after brushing
rinse 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 and
1.1% NaF gel emerging science with a need for increased research in
Disp: 1 tube (56 g) adults- specifically high risk groups
Sig: Place small ribbon in fluoride trays and • Medical management continues beyond preventive
wear for 5 minutes daily. Spit, but do not products with the use of glass ionomers, bonded
rinse 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