Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition __________________________
tooth surfaces [72]. Erupted teeth accrue the most benefit from fluoride when its salivary concentration is incorporated into the biofilm that adheres to the teeth [72]. Although it is a bit controversial, water fluoridation is one method of achieving these conditions [70; 72]. Approximately 72.7 of U.S. com- munities have fluoridated water as of 2020 [55]. Bottled water does not contain enough fluoride to prevent dental caries, so patients who drink only bottled water must be educated about the benefits of the topical fluoride found in toothpaste, oral rinses, and prescription-strength fluoride supplements [70; 73]. Parents of young children should be aware that multiple forms of fluoride ingestion can lead to fluorosis, that is, detectable changes in the tooth surface that can discolor the tooth but that do not adversely affect tooth strength [72]. Fluoridated water, toothpastes, and mouth rinses are advis- able for the general population and especially for caries-prone patients because the use of a fluoride mouth rinse in conjunc- tion with the use of a fluoridated toothpaste enhances enamel fluoridation and remineralization [72]. The use of prescription- strength fluoride toothpaste (1.1% neutral sodium fluoride) may be advantageous to and is usually well tolerated by patients consuming caries-promoting foods, orthodontic patients, patients with xerostomia, and those demonstrating substan- dard oral hygiene [72]. In-office fluoride treatments may help patients reduce dental caries. Treatments come in a variety of forms, including foams, gels, rinses, and varnishes. The application of 5% sodium fluoride varnish twice a year on the primary and permanent teeth of children ages 6 months through 15 years is beneficial in preventing caries in this age group as well as for the per- manent teeth of adult patients [10; 70]. The use of in-office professionally applied fluoride gel or foam at 3- to 12-month intervals provides the most preventive benefit for those do not consume fluoridated water and/or whose at-home oral hygiene is substandard [74]. XYLITOL Xylitol, a sugar alcohol (polyol), is a sugar substitute that helps to prevent dental caries because oral bacteria are unable to break it down to an acid [49; 75]. Xylitol also inhibits plaque formation, especially that of mutans streptococci, and has been shown to contribute to remineralization [76; 77]. Nutritionally, xylitol has fewer calories than sugar—2.4 calories per gram versus approximately 4.0 calories per gram of sugar [76]. It is also safe for diabetic patients to consume, making it a wise choice for replacing sugar in patients’ diets for rea- sons beyond caries control because xylitol lowers the insulin response compared to foods sweetened with sorbitol or ordi- nary sugar [78]. Replacing sugar with xylitol has been shown to cause a statistically significant reduction in S. mutans, which is the primary cariogenic bacterial species [79].
New studies are seeking to determine the efficacy and optimal dosage of erythritol, another polyol, for caries prevention. The efficacy of polyols to prevent caries when used to sweeten gum, candy, and food may be confounded by the presence of natu- ral and added fluoride in the diets of the study participants. Some studies have revealed that the combination of xylitol and fluoride can reduce the biofilm in which the cariogenic bacteria reside [80]. Dosage recommendations for xylitol as an anticaries agent include several small exposures during the day, with a plateau effect for the reduction of the cariogenic bacterium S. mutans noted between 6.88 grams per day and 10.32 grams per day [76]. This can be accomplished by using toothpastes, gums, and mints that contain xylitol and using xylitol as a sugar replacement to sweeten foods and drinks. Xylitol can also be used in place of sugar in baking, but patients should be cautioned that consuming large quantities of xylitol may cause gastrointestinal upset. SEALANTS The pits and fissures of teeth can be especially caries prone, and applying sealants here is a component of a comprehensive approach to caries management [4]. Pits and fissures in the occlusal, buccal, and lingual surfaces retain food particles and plaque, thus complicating oral hygiene efforts. Consequently, these surfaces are the predominant areas of dental caries. Pit and fissure sealants have been employed to prevent pit and fissure dental caries since the 1960s and remain an excellent method of reducing risk for dental caries. A 2016 systematic review suggests that well-placed occlusal sealants protect the pits and fissures from caries development better than fluoride varnish application does [4]. The review in no way recommends forgoing fluoride application to protect occlusal surfaces from caries. Rather, it states that the available evidence supports the use of both preventive measures where appropriate. Clinicians need to use a combination of assessment and diagnostic tools to determine the best treatment plan for preventing decay and preserving tooth structure in individual patients. In order to identify pits and fissures that are suitable for the application of preventive sealants or other minimally invasive procedures, dental examinations should include the clinical evaluation of tooth surfaces visually and with the use of a blunt explorer; laser detecting device; compressed air; and the new- est addition to caries classification, the International Caries Detection and Assessment System [81]. The ICDAS system is an evidence-based process for identifying and classifying dental caries lesions using visual cues [82]. This method of classifying carious lesions allows clinicians to apply appropriate evidence-based preventive and minimally invasive treatment methods to affected tooth surfaces. Using a scale of 0 (sound) to 6 (extremely decayed) to classify each pit and fissure, clini- cians can safely determine the best practice for treating the surface, which can include no treatment, fluoride application, sealants, or restorative procedures [82].
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