management by risk assessment (CAMBRA) has been increasingly applied to the treatment of caries. This regimen involves the use of measurement and assessment tools to gauge a patient’s risk for developing caries. It is much more advantageous, especially in the pediatric population, to predict caries development before the effects of caries are clinically detected. Based on the assessment, a customized preventive treatment plan can be developed that takes into account individual risk factors, disease factors, and protective factors. The dental practitioner will become part of a multidisciplinary team taking care of the patient, with the goal of improving and maintaining optimal oral health by educating patients and families about the ways that medical interventions can affect the oral cavity.
younger than age 3, any sign of smooth-surface caries is indicative of severe ECC (S-ECC). From ages 3 through 5, one or more cavitated, missing (due to caries), or filled smooth surfaces in the primary maxillary anterior teeth or a decayed, missing, or filled score of age plus one surface also constitutes S-ECC (AAPD, 2016a). Early childhood caries is highly prevalent and disproportionately affects poor and near-poor children in the U.S. (AAPD, 2016a). However, teeth can be re-mineralized (Featherstone & Chaffee, 2018) and ECC is largely preventable (Folayan et al., 2020). The concepts of caries prevention and management employed for ECC can be applied to all patient populations, especially those with complex medical needs. Over the past several years, the concept of caries The importance of a dental home According to the AAPD, all children should have an established dental home by no later than age 12 months, with either a general dentist or pediatric dentist (AAPD, 2023). The AAPD defines the dental home as the “ongoing relationship between the dentist and the patient, inclusive of Usefulness of the caries risk assessment It is well established that caries is a dynamic process that depends on a multitude of factors that can alter the normal balance of demineralization and remineralization of the tooth structure. With proper education and guidance, patients and families can alter the balance in favor of protective factors to slow down or halt the disease process. Dental caries may be arrested—that is, caries can stop progressing—and it is to be hoped that new caries will be prevented by tipping the balance in favor of protective factors. However, if the balance is not altered in patients with active disease, new and recurrent caries are likely (Featherstone et al., 2021). It is known that the best predictor of future caries experience is previous caries experience. Caries risk assessment (CRA) needs to be conducted systematically and periodically to gain accurate information regarding a patient’s risk for dental caries. These assessments allow for the development of a patient- and family-centered and customizable preventive and restorative plan. Regardless of which CRA tool the dental provider chooses, three main areas will be documented (Featherstone et al., 2021): ● Risk/pathologic factors. Risk-based dental treatment Professional fluoride treatments should be based on caries risk status. Children at increased caries risk should receive a professional topical fluoride treatment (fluoride varnish) at least every 6 months (AAPD, 2022c). High-risk children should receive fluoride therapy every 3 to 6 months, and moderate-risk children should receive a treatment at a minimum of every 6 months. Guidelines indicate exposure to fluoridated drinking water should not preclude fluoride therapy application (Goff et al., 2022). Children with ECC who have demineralized enamel or cavitated carious lesions may benefit from professional topical fluoride applications more frequently than every 3 months to assist in controlling the caries process (AAPD, 2016b). Congenital heart diseases Congenital heart diseases, or defects (CHD), are among the most frequently encountered and clinically significant ● Protective factors. ● Clinical findings.
all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.” This relationship becomes an opportunity to influence a child’s caries experience.
A sample CRA tool can be found on the AAPD website at http://www.aapd.org/media/Policies_Guidelines/G_ CariesRiskAssessment.pdf (AAPD, 2022b). Questions are asked of the parent about risk and biologic factors such as continual bottle use, sleeping with a bottle, frequency and types of snacks, and any medications the child may be taking. It should be noted if medications are sweetened with sugars or result in hyposalivation. Protective factors are also explored, such as the use of fluoridated water, fluoridated toothpaste, or products containing xylitol. Disease indicators are determined from clinical findings such as the presence of early demineralized enamel surfaces, cavitated lesions, plaque, lack of salivary flow, and signs of caries activity (e.g., active versus inactive decay). When risk factors outweigh protective factors, the caries can be classified as high risk. When protective factors are greater than risk factors (i.e., risk factors are controlled) and clinical findings have improved, caries risk can be classified as moderate risk or low risk. Caries risk profiling via a CRA tool is an essential first step in aiding the provider in determining a preventive and restorative treatment plan, as well as the patient’s recall periodicity. Education and support from the dental team is determined by keeping in mind the desires and goals of the family. At subsequent visits following the initial visit, an abbreviated CRA should be performed, focusing on the specific known risk factors for the child. Patients with complex medical needs may initially be classified as high risk automatically, using a CRA tool. However, this classification should not discourage the dental team from educating parents and families while identifying modifiable risk factors. As the following sections will highlight, restorative treatment for the patient with complex needs poses unique challenges. Restorative visits carry high costs, not only from a monetary perspective, but also from a health perspective for the complex patient. Ideally, prevention should be enforced and highlighted in order to avoid the need for complex management.
pediatric disorders and a significant cause of mortality and morbidity. This group of disorders includes malformations
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