Caries-Prone Patients: Prevention, Assessment, and Intervention _____________________________________
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]. CARIES RISK ASSESSMENT Dental caries is a multifactorial disease. Counseling a patient who is at risk for caries requires the clinician to consider the various factors that can put patients at risk for, or protect them from, dental caries. In addition to caries-promoting diets and belonging to one or more of the high-risk populations dis- cussed previously, the following are factors that can increase an individual’s caries risk [15; 28; 83]: • Poor oral hygiene
• Family history of poor dental health • Prolonged bottle- or breastfeeding • High bacterial titers of S. mutans • Intermittent dental care • Mental or physical disabilities that limit oral hygiene ability • Numerous multisurface restorations • Restorations with open or overhanging margins • Orthodontic appliances • Enamel defects and genetic tooth abnormalities • Radiation or chemotherapy treatments • Eating disorders • Alcohol and drug abuse • Smoking and vaping
Determining a patient’s caries risk level, and therefore the rela- tive importance of nutritional counseling and other interven- tions, requires consideration of these factors and communica- tion with the patient and/or patient’s parent. Some of these factors can be identified during the dental examination, such as recession, multisurface restorations, and enamel defects. Other factors, such as personal and family dental history, are elusive and require an open dialogue with the patient and/or patient’s parent [84].
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