Beyond Straight Teeth! The Periodontic/Orthodontic

Beyond Straight Teeth! The Periodontic/Orthodontic Connection Kristy Menage Bernie, RDH, BS, RYT • info@EducationalDesigns.com On
‐ Orthodontic therapies are no longer confined to the adolescent population and as such the role of the dental hygienist in patient education has grown significantly in recent years. This course will review the exciting science of bio‐adaptive therapy; a process of working with nature and the body to move teeth while maximizing periodontal health and minimizing invasive procedures such as tooth extraction or palatal expansion, as well as the periodontic/orthodontic connection. A review of current tooth movement sciences will be included as well as methods to maximize oral health pre, during and post‐orthodontic therapy. Our Opportunities: • Understand and apply the principles of the periodontic/orthodontic connection, including review of the 2011 AAP treatment guidelines. • Integrate occlusal assessment and identify patients who would benefit from tooth movement therapy. • Maximize orthodontic success through collaborate practice and integration of the latest technologies designed for optimal oral health. Orthodontic Therapy: Current & Future Need Estimated % of patients who would benefit from orthodontic therapy = The Periodontal Orthodontic Connection: Biological & Synergistic Tooth Movement Identifying the Orthodontic Patient Orthodontic Six‐Point Quick Check System: Begin by examining each arch separetly and evaluating the following categoris: 1. Arch width (molar‐to‐molar transpalatal width of 36 mm is average). 2. Excessive spacing or crowding present. 3. Missing or ankylosed teeth. Then note the relationship between the upper and lower teeth in occlusion. Evaluate the following: 4. Angle’s classification. 5. The amount of overbite and overjet present. 6. Any openbite or crossbite present. Seven Signs & Symptoms of Occlusal Disease: 1. Pathological occlusal wear and fractures of teeth/restorations. 2. Cervical dentin hypersensitivity. 3. Tooth hypermobility. 4. Fremitus. 5. Abfractions. 6. Vertical bone loss or localized bone destruction (secondary to periodontal disease). 7. Pain and tired facial and masticatory muscles or TMJ pain. 1 www.EducationalDesigns.com © 2013
Facial Type: Mesocephalic – Jaw bones are in harmony with the rest of the face & with each other; teeth may be malposed & therefore need orthodontic treatment; most common facial type. Brachycephalic – Jaw bones, usually the mandible, are too large in proportion to the face; the face appears short & wide; mandible is usually strong, angular, and possibly prognathic; tendency to brux & grind teeth leading to excessive wear to incisal & occlusal surfaces; when smiling very little tooth structure shows; strong muscles of mastication; from profile perspective the mouth area appears concave; extractions are rarely performed; older in appearance than age suggests. Dolichocephalic – Jaw bones, usually the mandible, are too small in proportion to the face; the face appears long; mandible is usually retrognathic depicting a deficient horizontal growth; teeth can be long or appear large with a ‘gummy’ smile; weak muscles of mastication; from the profile perspective the mouth area appears convex; extractions are common in this facial type; appear younger than age would suggest; hereditary, thumb sucking, & mouth breathing are associated with this facial type; extractions are more commonly recommended with this facial type along with orthognathic surgery; considered more difficult to treat than other facial types. Caries Risk Management by Assessment (CAMBRA) – Active orthodontic patients are automatically considered moderate risk for caries. Periodontal Assessment – Visit www.perio.org for a patient self‐assessment. Orthodontic Therapy Options: U Traditional orthodontic fixed appliances, with ligation U Two‐Phase therapy includes early intervention and fixed traditional appliances U Bio‐Adaptive therapy considers tissue and bone while accelerating the tooth movement process, gaining arch width and generating oxygenation during tooth movement (self‐ligated systems) U Aligner technologies include a series of custom aligners worn sequentially over time U Accelerated osteogenic orthodontics includes a combination of periodontal surgery and fixed appliances to accelerate the tooth movement process by removing alveolar bone and using bone regenerative materials Active Orthodontic Considerations: Hard Tissue Fluoride: Mechanism of Action 1. Inhibits demineralization at the time of acid challenge. 2. Enhances remineralization when present by accelerating the formation of new mineral, combining calcium, phosphate, and fluoride forming a low soluble veneer. The resulting mineral is much less soluble then the original tooth mineral. 3. Generates antibacterial action through the formation of hydrogen fluoride (HF), which is a result of acid produced by bacteria combining with fluoride. HF diffuses through cell walls and interferes with enzyme pathways slowing down and even killing bacteria. 2 www.EducationalDesigns.com © 2013
Fluoride Options • Neutral Sodium Fluoride (NaF) • Acidulated Phosphate Fluoride (APF) – ‘Minute’ products • Stannous Fluoride (SnF) Professionally Applied Fluoride Options • Professionally applied o Tray systems – 2% NaF and 1.23% APF o Varnish – 5% NaF o Rinses – 2% NaF and APF/SnF combination • In‐Office Candidates (Wilkins) o Primary teeth o Posteruptive period o Active caries o Secondary/ recurrent caries o Wearing orthodontic appliance, bands, bonded brackets o Compromised salivary flow o Teeth supporting an overdenture o Exposed root surfaces following periodontal recession o Lack of compliance and conscientious efforts for daily dental biofilm removal o Low or no fluoride in drinking water o Early carious lesions ADA Resolution 37B ‐ Fluoride Varnish Resolved, that the ADA supports the use of fluoride varnishes as safe & efficacious within a caries prevention program that includes caries diagnosis, risk assessment, and regular dental care, and be it further Resolved, that the ADA encourage the FDA to consider approving professional applied fluoride varnish for reducing dental caries, based on substantial amount of available data supporting the safety and effectiveness of this indication. ADA Topical Fluoride Recommendations – 2006 – Summary Fluoride gel is effective in preventing caries in school‐age children Patients whose caries risk is low may not receive additional benefit from professional topical fluoride application There are considerable data on caries reduction for professionally applied topical fluoride gel treatments of 4 minutes or more Fluoride varnish applied every 6 months is effective in preventing caries in primary and permanent dentition of children and adolescents 2 or more applications of fluoride varnish per year are effective in preventing caries in high risk populations Fluoride varnish applications take less time, create less patient discomfort and achieve greater patient acceptability than fluoride gel especially in preschool children 4‐minute fluoride foam applications, every 6 months are effective in caries prevention in the primary dentition & newly erupted permanent first molars There is insufficient evidence to address whether or not there is a difference in the efficacy of NaF versus APF gels Full guideline document online at: http://www.ada.org/prof/resources/topics/evidencebased.asp 3 www.EducationalDesigns.com © 2013
Take Home Fluoride Options • NaF, APF, SnF toothpastes, gels & rinses • Rx • 5,000 ppm or Over‐the‐counter • 250 (rinses) – 1,500 ppm (toothpastes) Calcium & Phosphate (CP) – How do they work? • Building blocks for HAP • Improved surface appearance/ luster • Desensitization • Enhance fluoride ‘uptake’
• Remineralization Effective CP Systems must: • Be soluble to release Ca and phosphate • Not produce calculus ions • Not prevent remineralization • Not remove fluoride from the oral cavity Remineralization Requirements & Calcium Phosphate Systems • A substrate on which to precipitate • A source of calcium • Time • A source of phosphate • The proper pH to react 4 www.EducationalDesigns.com © 2013
CAMBRA – Remineralization/Antimicrobial Considerations: REMINERALIZATION: 5% Sodium Fluoride Varnish – Consider products containing xylitol and/or calcium phosphate; can replace fluoride tray treatments (see ADA Professional Fluoride Utilization). Calcium Phosphate Systems • Tri‐Calcium Phosphate (TCP): During the manufacturing process, a protective barrier is created around the calcium allowing it to coexist with the fluoride ions. As the toothpaste comes in contact with saliva during brushing, the barrier breaks down and makes the calcium, phosphate and fluoride readily available. o Clinical Application: Vanish XT Varnish • 3M ESPE & Vanish Varnish (5% NaF & TCP) o Daily Care Products: Clinpro 5000 (5,000 ppm NaF & TCP) Toothpaste • 3M ESPE & Prevident Booster Plus (5,000 ppm NaF & TCP) • Colgate • Casein Phosphopeptide Amorphous Calcium Phosphate (CPP‐ACP): Recaldent™ ‐ casein (milk protein) enclosed system that binds to oral tissues, plaque, etc. and then releases ACP at an acidic pH. o Clinical Application: MI 5% NaF Varnish • GC America o Daily Care Products: MI Paste & MI Paste Plus (950 ppm NaF) • GC America • Calcium Sodium Phosphosilicate (CSP): Novamin® ‐ bioactive glass assists in sustained release of calcium & phosphate while neutralizing the pH. o Clinical Application: Nupro Sensodyne Prophy Paste • Dentsply & Sylc Airpolishing Powder • OSSPRAY o Daily Care Products: Renew (5,000 ppm NaF & CSP) Toothpaste • Sultan Products • Amorphous Calcium Phosphate (ACP): ADA Foundation Technology ‐ Immediate release of CP upon contact with oral cavity, without dependency on pH or other oral factors. o Clinical Application: Enamel Pro Varnish (5% NaF & ACP); Enamel Pro Prophy Paste & Enamel Pro APF (1.23% non‐acidulated fluoride & ACP) • Premier Dental o Daily Application: Relief Oral Care Gel (1,000 ppm NaF, KNO3 & ACP) • Philips • Other: o MaxMin – Calcium Phosphate prophy paste • Preventech o Arginine Bicarbonate & Calcium Carbonate• Clinical Application: ProRelief • Colgate o Sodium Phosphate, Disodium Phosphate & Calcium Disodium (ACT Restoring MR) o Nano Hydroxyapitite • CariFree pHluorigel (5,000 NaF) by CariFree o Xylitol‐coated calcium phosphate • Embrace Varnish by Pulpdent ANTIMICROBIAL: Chlorhexidine • 0.12% CHX rinses • CHX varnish (10% once solvent dissipates) – Cervitec Plus by Ivoclar Xylitol • Various products, including mints, chewing gum, lollipops, etc. 5 www.EducationalDesigns.com © 2013
Active Orthodontic Considerations Soft Tissue: Full Mouth vs. Quadrant (Partial Mouth) Periodontal Therapy
Full-mouth disinfection (FMD) was introduced in 1995 and was designed to target
intraoral niches and periodontal pockets and reduce the likelihood of reinfection of
previously treated areas.
Partial Mouth Protocol:
ƒ Traditional quadrant scaling and root planing over a 6 week period of time at 2
week intervals
ƒ 4 – 6 consecutive sessions
ƒ Quadrant or sextant therapy
ƒ Reinfection potential?
ƒ Patient/ Client centered approach?
Research Protocol - FMD:
ƒ Scaling and root planing 4 quads in 24 hours with hand instruments
ƒ Application of chlorhexidine to all intra-oral niches
ƒ Tongue disinfection
ƒ 2x a day rinse and/or spray of buccal mucosa and tonsil area combined with daily
tongue disinfection
Research on the efficacy of FMD has proven that this protocol:
• Improves probing depth and increases clinical attachment for up to 8 months.
• Reduces oral malodor
• Decreases spirochetes and motile organisms in subgingival flora
• Eliminates P. gingivalis
FMD provides the following additional benefits:
• Fast-tracking of aesthetic treatment
• Rapid healing and/or assessment for surgical intervention
• Facilitates client-centered approach
• Minimizes time spent in Phase I therapy by facilitating control of treatment
planning and patient compliance
Contemporary research on adjunctive therapies always begins with full-mouth
therapy that is completed in one to two weeks using both hand and powered
instrumentation. This substantial body of research utilizing this process of care
provides the full rationale to accelerate periodontal instrumentation in daily practice.
™ Optimal Oral Health - A standard of health of the oral and related tissues which enable an
individual to eat, speak, or socialize without active disease, discomfort or embarrassment
and which contributes to general well-being and overall health – ADHA, 1999.
6 www.EducationalDesigns.com © 2013
PROPOSED ACCELERATED INSTRUMENTATION PROTOCOL:
2 appointments of appropriate length scheduled within 24 hours – to 2 weeks • ½ mouth per
appointment
1. Pre-procedural antimicrobial rinse for 30 seconds
2. Anesthesia administration/ pain control procedures
3. Instrumentation
a. Powered instrumentation with self-contained water / medicament reservoir and
antimicrobial irrigant
b. Hand instrumentation
4. Laser Therapy
a. Bacterial decontamination of pocket sites (prior and post instrumentation)
b. Removal of diseased epitheal lining (post instrumentation in sites greater than
5mm)
5. Placement of locally delivery/ control release medicaments
6. Tongue deplaquing/ scraping with antimicrobial/VSC neutralizing agent
7. Post-procedural rinse for 30 seconds with antimicrobial/VSC neutralizing agent
8. Professional fluoride treatment and/or CHX varnish application (Ivoclar/Vivadent)
9. 2 to 3 month evaluation
a. Utilization of diagnostic devices to assess clinical outcome
b. Placement of local delivery / controlled release agent for nonresponsive sites / or
prescription for subgingival dosage doxycycline:
i.
ii.
iii.
iv.
2.5 mg chlorhexidine chip
10% doxycycline gel
1 mg minocycline microsphere power
20 mg systemic/ subgingival dosage doxycycline bid
c. Appropriate recare schedule
10. Re-evaluation at appropriate time with referral for non-responsive cases.
•
Daily oral hygiene should include toothbrushing; interdental cleansing and tongue
deplaquing along with appropriate adjunctive chemotherapy for caries prevention,
sensitivity control and antimicrobial benefits.
IMPLEMENTING & INTEGRATION:
•
•
•
7 Full-mouth disinfection, or accelerated instrumentation, accounts for a client- and
clinician centered approach to periodontal therapy that maximizes clinical outcomes
while providing immediate benefits.
Utilization of ultrasonics in FMD protocols will greater increase the likelihood of success
and provide patients with the high-tech therapy they appreciate and deserve.
Completing periodontal instrumentation within 1 to 2 weeks is an easy factor to control
that will lend to fast-tracking aesthetic treatment plans, healing, and referral.
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Post Orthodontic Therapy Considerations: Additional Considerations: • Collaborate with referring orthodontics practices to determine systems, recommendations and patient needs • Promote orthodontic options for adults as well as children/teens • Utilize education resources provided through orthodontic manufacturers • Consider participating in motivation program • Offer to monitor periodontal response & health with adult patients Additional Action Plans for Orthodontic Treatment Considerations: Products ‐ Need to purchase: Orthodontist(s) to contact: Updates to Assessment Phase: Updates to Clinical Phase: Updates to Post‐treatment Phase: Seminar Resources/ Additional Reading: Home Study Course: Clinical Considerations for the Dental Hygienist in Orthodontic Therapy Hosted by the California Dental Hygienists’ Association • 2 hours CE credit • Download at: http://cdha.org/education/homestudy.htm Damon Orthodontists: www.damonbraces.com The Braces Cookbook: www.bracescookbook.com Floss Fish: www.flossfish.com Platypus Flosser: http://www.pdtdental.com/platypus.php ShowerFloss; www.showerfloss.com Lil’ Palates Sweepers: www.lilpalates.com 8 www.EducationalDesigns.com © 2013
J Periodontol • July 2011
Comprehensive Periodontal Therapy: A Statement by the
American Academy of Periodontology*
The American Academy of Periodontology (AAP)
periodically publishes reports, statements, and guidelines on a variety of topics relevant to periodontics.
These papers are developed by an appointed committee of experts, and the documents are reviewed and
approved by the AAP Board of Trustees.
T
he American Academy of Periodontology offers
the following statement that sets forth the
scope, objective, and procedures that constitute periodontal therapy. This statement is provided
to assist all members of the dental team who provide
periodontal care and should be considered in its
entirety. This statement may also be useful to those
who supervise, teach, or regulate the provision of
periodontal therapy.
SCOPE OF PERIODONTAL THERAPY
As a result of advances in knowledge and therapy, the
majority of patients can retain their dentition over their
lifetime with proper treatment, reasonable plaque/biofilm control, and continuing care. Periodontics is the
specialty of dentistry that encompasses prevention,
diagnosis, and treatment of diseases of the supporting
and surrounding tissues of teeth and dental implants.
The scope of the specialty of periodontics alsoencompasses maintenance of the health, function, comfort, and
esthetics of all supporting structures and tissues in the
mouth. The goals of periodontal therapy are to preserve,
improve, and maintain the natural dentition, dental implants, periodontium, and peri-implant tissues in order
to achieve health, comfort, esthetics, and function. A
healthy periodontium is characterized by the absence
of inflammation, which may appear clinically as redness,
swelling, suppuration, and bleeding on probing.
PERIODONTAL EVALUATION
A comprehensive assessment of a patient’s current
health status, history of disease, and risk characteris*This statement was developed under the direction of the Task Force to
Update the Guidelines for Periodontal Therapy and approved by the Board
of Trustees of the American Academy of Periodontology in November 2010.
DISCLAIMER: This statement represents the views of the Academy
regarding periodontal therapy and related procedures. It must be recognized, however, that decisions with respect to the treatment of patients must
be made by the individual practitioner in light of the condition and needs of
each specific patient. Such decisions should be made in the best judgment
of the practitioner, taking into account all relevant circumstances.
NOTE: The Academy updates guidelines and statements on a periodic
basis. All previous publications should be considered in light of their
historical context with regard to current knowledge and practices.
tics is essential to determine the periodontal diagnosis
and prognosis of the dentition and/or the suitability of
dental implants. Patients should receive a comprehensive periodontal evaluation and their risk factors
should be identified at least on an annual basis. Such
an evaluation includes discussion with the patient regarding his/her chief complaint, medical and dental
history review, clinical examination, and radiographic
analysis. Microbiologic, genetic, biochemical, or other
diagnostic tests may also be useful, on an individual basis, for assessing the periodontal status of selected individuals or sites. The following procedures
should be included in a comprehensive periodontal
evaluation:
1. Extra- and intraoral examination to detect nonperiodontal oral diseases or conditions.
2. Examination of teeth and dental implants to
evaluate the topography of the gingiva and related
structures; to measure probing depths, the width of
keratinized tissue, gingival recession, and attachment
level; to evaluate the health of the subgingival area
with measures such as bleeding on probing and
suppuration; to assess clinical furcation status; and
to detect endodontic–periodontal lesions.
3. Assessment of the presence, degree, and/or distribution of plaque/biofilm, calculus, and gingival inflammation.
4. Dental examination including caries assessment,
proximal contact relationships, the status of dental
restorations and prosthetic appliances, and other
tooth- or implant-related problems.
5. An occlusal examination that includes, but may
not be limited to, determining the degree of mobility of
teeth and dental implants, occlusal patterns and discrepancy, and determination of fremitus.
6. Interpretation of current and comprehensive diagnostic-quality radiographs to visualize each tooth
and/or implant in its entirety and assess the quality/
quantity of bone and establish bone loss patterns.
7. Evaluation of potential periodontal–systemic
interrelationships.
8. Assessment of the need for and suitability of
dental implants.
9. Determination and assessment of patient risk
factors such as age, diabetes, smoking, cardiovascular disease, and other systemic conditions associated
doi: 10.1902/jop.2011.117001
943
Comprehensive Periodontal Therapy
with development and/or progression of periodontal
disease.
ESTABLISHING A DIAGNOSIS, PROGNOSIS,
AND TREATMENT PLAN
Clinical findings together with a diagnosis and prognosis should be used to develop a logical plan of treatment to eliminate or alleviate the signs and symptoms
of periodontal diseases, thereby arresting or slowing
further disease progression. The treatment plan should
be used to establish the methods and sequence of delivering appropriate periodontal treatment, which may
include non-surgical, surgical, regenerative, and cosmetic periodontal therapy or dental implant placement. When indicated, the plan should include:
1. Medical and dental consultation or referral for
treatment, when appropriate.
2. Surgical and non-surgical periodontal and implant procedures to be performed.
3. Consideration of adjunctive restorative, prosthetic, orthodontic, and/or endodontic consultation or
treatment.
4. Provision for ongoing reevaluation during periodontal or dental implant therapy and throughout the
maintenance phase of treatment.
5. Consideration of diagnostic testing that may include microbiologic, genetic, or biochemical assessment or monitoring during the course of periodontal
therapy.
6. Consideration of risk factors including, but not
limited to, diabetes and smoking, which play a role
in development, progression, and management of
periodontal diseases.
7. Periodontal maintenance program including ongoing evaluation and reevaluation for treatment.
INFORMED CONSENT AND PATIENT RECORDS
Informed consent should be obtained prior to the
commencement of therapy. Complete records of
the periodontal examination (including full charting),
diagnosis, treatment, and recommended follow-up
are essential and should be maintained according to
state law. Information given to the patient should include the following:
1. The diagnosis, etiology, proposed therapy, possible alternative treatment(s), and the prognosis with
and without the proposed therapy or possible alternatives.
2. Recommendations for treatment to be performed by other dentists or physicians.
3. The reasonably foreseeable inherent risks and
potential complications associated with the proposed
therapy, including failure with the ultimate loss of
teeth or dental implants.
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Volume 82 • Number 7
4. The need for periodontal maintenance treatment
after active therapy due to the potential for disease recurrence.
TREATMENT PROCEDURES
When indicated, treatment should include:
1. Patient education, training in oral hygiene, and
counseling on control of risk factors (e.g., stress,
medical status, smoking, etc.) with appropriate referral if needed.
2. Management of periodontal–systemic interrelationships, when appropriate.
3. Removal of supra- and subgingival bacterial
plaque/biofilm and calculus by comprehensive, meticulous periodontal scaling and root planing. In some
instances, these procedures may be incorporated into
the surgical treatment.
4. Chemotherapeutic agents may be used as appropriate to reduce, eliminate, or change the quality
of microbial pathogens, or to alter the host response
through local or systemic delivery.
5. Resective procedures to reduce or eliminate
periodontal pockets and create an acceptable gingival form that facilitates oral hygiene and periodontal
maintenance. Soft tissue procedures include gingivectomy, gingivoplasty, and various mucogingival
flap procedures. Osseous procedures include ostectomy and osteoplasty. Dental tissue procedures
include root resection, tooth hemisection, and odontoplasty. Combined dental tissue and osseous procedures may be required.
6. Periodontal regenerative procedures including
bone replacement grafts, use of biologics, root biomodification, guided tissue regeneration, and combinations of these procedures for osseous, furcation, and
gingival recession defects. Periodontal/oral reconstructive procedures include guided bone regeneration, ridge augmentation, ridge preservation, implant
site development, and sinus grafting.
7. Periodontal plastic surgery for gingival augmentation, correction of recession or soft tissue deformities, or enhancement of oral esthetics.
8. Occlusal therapy that may include tooth movement, occlusal adjustment, splinting, periodontally accelerated osteogenic orthodontics, or biteguard therapy
as a means to establish and maintain occlusal health.
9. Preprosthetic periodontal procedures including
exploratory flap surgery, resective procedures, regenerative procedures, mucogingival procedures, or crown
lengthening.
10. Selective extraction of teeth, roots, or implants.
11. Surgical placement of dental implants and management of peri-implant disease.
12. Procedures to facilitate orthodontic treatment
including tooth exposure, frenulectomy, fiberotomy,
Comprehensive Periodontal Therapy
J Periodontol • July 2011
temporary anchorage devices, and gingival augmentation.
13. Finishing procedures, which include posttreatment evaluation with review and reinforcement
of daily oral hygiene when appropriate.
EVALUATION OF THERAPY
Upon completion of planned periodontal therapy, the
record should document that:
1. The patient has been counseled on why and how
to perform an effective daily personal oral hygiene
program including managing their own personal risk
factors associated with development and/or progression of periodontal diseases.
2. All indicated therapeutic procedures have been
performed.
3. The patient’s response to therapy has been evaluated, and treatment objectives have been met.
4. A recommendation has been made for the correction of any tooth form, tooth position, restoration,
or prosthesis considered to be contributing to the periodontal disease process.
5. An appropriate professional periodontal maintenance program, specific to individual circumstances,
has been recommended to the patient for long-term
control of his/her condition, as well as for the maintenance of dental implants, if present. This should include professional management of those risk factors
associated with development and/or progression of
periodontal diseases including, but not limited to,
smoking and diabetes.
FACTORS MODIFYING RESULTS
The results of periodontal therapy may be adversely
affected by factors that include systemic diseases; inadequate plaque/biofilm control; unknown or undeterminable etiologies; pulpal–periodontal problems;
inability or failure of the patient to follow the suggested
treatment or maintenance program; adverse environmental influences such as smoking and stress;
occlusal dysfunction; and uncorrectable anatomic,
structural, or iatrogenic causalities.
Patients with medical compromises, those who refuse or delay treatment, or those who present with
other limitations may be unable to undergo recommended procedures required to establish a completely
healthy periodontium. In those situations, appropriate
therapy to establish the best possible periodontal
health is indicated.
PERIODONTAL MAINTENANCE THERAPY
Upon completion of active periodontal therapy, periodontal maintenance visits should include:
1. Update of medical and dental histories.
2. Evaluation of current extra- and intraoral periodontal and peri-implant soft tissues as well as dental
hard tissues and referral when indicated (e.g., for
treatment of carious lesions, pulpal pathoses, or other
conditions) and diagnostic-quality radiographs when
appropriate.
3. Assessment of the oral hygiene status with reinstruction when indicated.
4. Mechanical tooth cleaning to disrupt/remove
dental plaque, biofilms, stain, and calculus. Local delivery or systemic chemotherapeutic agents may be
used as adjunctive treatment for recurrent or refractory disease.
5. Ongoing assessment of risk factors to identify an
individual who may be more highly susceptible to ongoing breakdown of the periodontal or peri-implant
tissues, with elimination or mitigation of new or persistent risk and etiologic factors with appropriate treatment.
6. Identification and treatment of new, recurrent, or
refractory areas of periodontal and peri-implant pathoses.
7. Establishment of an appropriate interval for periodontal maintenance.
The patient should be kept informed of:
1. Areas of persistent, recurrent, refractory, or newly
occurring periodontal or peri-implant disease.
2. Changes in the periodontal prognosis and risk
factors associated with periodontal diseases.
3. Advisability of further periodontal treatment or
retreatment of indicated sites.
4. Status of dental implants.
5. Other oral health problems that may include caries, defective restorations, and non-periodontal mucosal diseases or conditions.
6. Changes that would warrant referral to, or consultation with, other dental or medical specialists.
BIBLIOGRAPHY
Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE.
Defining the normal bacterial flora of the oral cavity. J
Clin Microbiol 2005;43:5721-5732.
Abdellatif HM, Burt BA. An epidemiological investigation
into the relative importance of age and oral hygiene
status as determinants of periodontitis. J Dent Res
1987;66:13-18.
Albandar JM, Brunelle JA, Kingman A. Destructive periodontal disease in adults 30 years of age and older in
the United States, 1988-1994 [published correction appears in J Periodontol 1999;70:351]. J Periodontol 1999;
70:13-29.
Albandar JM, Kingman A. Gingival recession, gingival
bleeding, and dental calculus in adults 30 years of age
and older in the United States, 1988-1994. J Periodontol
1999;70:30-43.
Albandar JM, Rams TE. Global epidemiology of periodontal diseases: An overview. Periodontol 2000 2002;29:
7-10.
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c da j o u r n a l , vo l 3 9 , n º 1 0
table 1
Caries Risk Assessment Form — Children Age 6 and Over/Adults
Patient Name: ___________________________________________________________________________________Chart #:________________________________Date:________________________________________________________
Assessment Date: Is this (please circle) baseline or recall
Disease Indicators
(Any one “YES” signifies likely “High Risk” and to do a bacteria test**)
YES = CIRCLE
Visible cavities or radiographic penetration of the dentin
YES
Radiographic approximal enamel lesions (not in dentin)
YES
White spots on smooth surfaces
YES
Restorations last 3 years
YES
YES = CIRCLE
Risk Factors (Biological predisposing factors)
YES
MS and LB both medium or high (by culture**)
YES
Visible heavy plaque on teeth
YES
Frequent snack (> 3x daily between meals)
YES
Deep pits and fissures
YES
Recreational drug use
YES
Inadequate saliva flow by observation or measurement (**If measured, note the flow
rate below)
YES
Saliva reducing factors (medications/radiation/systemic)
YES
Exposed roots
YES
Orthodontic appliances
YES
YES = CIRCLE
Protective Factors
Lives/work/school fluoridated community
YES
Fluoride toothpaste at least once daily
YES
Fluoride toothpaste at least 2x daily
YES
Fluoride mouthrinse (0.05% NaF) daily
YES
5,000 ppm F fluoride toothpaste daily
YES
Fluoride varnish in last 6 months
YES
Office F topical in last 6 months
YES
Chlorhexidine prescribed/used one week each of last 6 months
YES
Xylitol gum/lozenges 4x daily last 6 months
YES
Calcium and phosphate paste during last 6 months
YES
Adequate saliva flow (> 1 ml/min stimulated)
YES
**Bacteria/Saliva Test Results: MS: LB: Flow Rate: ml/min. Date:
VISUALIZE CARIES BALANCE
(Use circled indicators/factors above)
(EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION)
CARIES RISK ASSESSMENT (CIRCLE): EXTREME HIGH MODERATE LOW
Doctor signature/#: _______________________________________________________________________________________________________________________ Date:_________________________________________________________
o c t o b e r 2 0 1 1 711
Caries Risk Assessment Form (Age >6)
Patient Name:
Birth Date:
Date:
Age:
Initials:
Low Risk
Contributing Conditions
I.
Fluoride Exposure (through drinking water, supplements,
professional applications, toothpaste)
II.
Sugary Foods or Drinks (including juice, carbonated or
non-carbonated soft drinks, energy drinks, medicinal syrups)
III.
Caries Experience of Mother, Caregiver and/or
other Siblings (for patients ages 6-14)
IV.
Dental Home: established patient of record, receiving
regular dental care in a dental office
Moderate Risk
Check or Circle the conditions that apply
Yes
No
Frequent or
prolonged between
meal exposures/day
Primarily
at mealtimes
No carious lesions in
last 24 months
General Health Conditions
Carious lesions in
last 7-23 months
Yes
Check or Circle the conditions that apply
Special Health Care Needs (developmental, physical, medical or mental disabilities that prevent or limit performance of
adequate oral health care by themselves or caregivers)
No
II.
Chemo/Radiation Therapy
No
III.
Eating Disorders
No
Yes
IV.
Medications that Reduce Salivary Flow
No
Yes
V.
Drug/Alcohol Abuse
No
Yes
Clinical Conditions
Yes (over age 14)
Yes (ages 6-14)
Yes
Check or Circle the conditions that apply
No new carious lesions 1 or 2 new carious
3 or more carious
or restorations in
lesions or restorations lesions or restorations
last 36 months
in last 36 months
in last 36 months
I.
Cavitated or Non-Cavitated (incipient)
Carious Lesions or Restorations (visually or
radiographically evident)
II.
Teeth Missing Due to Caries in past 36 months
No
III.
Visible Plaque
No
Yes
IV.
Unusual Tooth Morphology that compromises
oral hygiene
No
Yes
V.
Interproximal Restorations - 1 or more
No
Yes
VI.
Exposed Root Surfaces Present
No
Yes
VII.
Restorations with Overhangs and/or Open Margins; Open
Contacts with Food Impaction
No
Yes
VIII. Dental/Orthodontic Appliances (fixed or removable)
No
Yes
IX.
No
Overall assessment of dental caries risk: Carious lesions in
last 6 months
No
I.
Severe Dry Mouth (Xerostomia)
High Risk
Low
Moderate
Yes
Yes
High
Patient Instructions:
© American Dental Association, 2009, 2011. All rights reserved.
Caries Risk Assessment Form (Age >6)
Circle or check the boxes of the conditions that apply. Low Risk = only conditions in “Low Risk” column present;
Moderate Risk = only conditions in “Low” and/or “Moderate Risk” columns present; High Risk = one or more
conditions in the “High Risk” column present.
The clinical judgment of the dentist may justify a change of the patient’s risk level (increased or decreased) based
on review of this form and other pertinent information. For example, missing teeth may not be regarded as high
risk for a follow up patient; or other risk factors not listed may be present.
The assessment cannot address every aspect of a patient’s health, and should not be used as a replacement for
the dentist’s inquiry and judgment. Additional or more focused assessment may be appropriate for patients with
specific health concerns. As with other forms, this assessment may be only a starting point for evaluating the
patient’s health status.
This is a tool provided for the use of ADA members. It is based on the opinion of experts who utilized the most
up-to-date scientific information available. The ADA plans to periodically update this tool based on: 1) member
feedback regarding its usefulness, and; 2) advances in science. ADA member-users are encouraged to share their
opinions regarding this tool with the Council on Dental Practice.
716 O C T O B E R 2 0 0 7
Acid-neutralizing
rinses as needed
if mouth feels dry,
after snacking,
bedtime and after
breakfast. Baking
soda gum as
needed
As per ICDAS
sealant protocol
(TABLE 2 )
As per ICDAS
sealant protocol
(TABLE 2 )
Required Apply
calcium/ phosphate paste
twice daily
As per ICDAS
sealant protocol
(TABLE 2 )
Optional:
Apply calcium/
phosphate paste
several times
daily
Optional: for
excessive root
exposure or sensitivity
Not required
(TABLE 2)
Optional or as
per ICDAS sealant protocol
Sealants
(Resin-based or
Glass Ionomer)
* Patients with one (or more) cavitated lesion(s) are high-risk patients. ** Patients with one (or more) cavitated lesion(s) and severe hyposalivation are extreme-risk patients. *** All restorative work to be done with
the minimally invasive philosophy in mind. Existing smooth surface lesions that do not penetrate the DEJ and are not cavitated should be treated chemically, not surgically. For extreme-risk patients, use holding care
with glass ionomer materials until caries progression is controlled. Patients with appliances (RPDs, prosthodontics) require excellent oral hygiene together with intensive fluoride therapy e.g., high fluoride toothpaste and fluoride varnish every three months. Where indicated, antibacterial therapy to be done in conjunction with restorative work. ### For all risk levels: Patients must maintain good oral hygiene and a diet low in
frequency of fermentable carbohydrates. **** Xylitol is not good for pets (especially dogs).
1.1% NaF toothpaste
twice daily instead of
regular fluoride toothpaste. OTC 0.05% NaF
rinse when mouth feels
dry, after snacking,
breakfast, and lunch.
Initially, 1-3 app. NaF
varnish; 1 app at 3 month
recall.
Chlorhexidine 0.12%
(preferably CHX in water
base rinse) 10 ml rinse
for one minute daily for
one week each month.
Xylitol (6-10 grams/day)
gum or candies. Two tabs
of gum or two candies
four times daily
Saliva flow test
and bacterial
culture initially
and at every caries recall appt. to
assess efficacy
and patient cooperation
Every 3 months
to re-evaluate
caries risk and
apply fluoride
varnish.
Bitewing radiographs every 6
months or until no
cavitated lesions
are evident
Extreme risk**
(High risk plus
dry mouth or
special needs)
Not required
1.1% NaF toothpaste
twice daily instead of
regular fluoride toothpaste. Optional: 0.2%
NaF rinse daily (1 bottle)
then OTC 0.05% NaF
rinse 2X daily. Initially, 1-3
app of NaF varnish; 1 app
at 3-4 month recall
Chlorhexidine gluconate
0.12%
10 ml rinse for one minute daily for one week
each month. Xylitol (6-10
grams/day) gum or candies. Two tabs of gum or
two candies four times
daily
Saliva flow test
and bacterial
culture initially
and at every caries recall appt. to
assess efficacy
and patient cooperation
Every 3-4
months to reevaluate caries
risk and apply
fluoride varnish
Bitewing radiographs every 6-18
months or until no
cavitated lesions
are evident
High risk*
Not required
OTC fluoride-containing
toothpaste twice daily
plus: 0.05% NaF rinse
daily. Initially, 1-2 app of
NaF varnish; 1 app at 4-6
month recall
Per saliva test if done
Xylitol (6-10 grams/day)
gum or candies. Two tabs
of gum or two candies
four times daily
May be done as
a base line reference for new
patients or if
there is suspicion
of high bacterial
challenge and to
assess efficacy
and patient cooperation
Every 4-6
months to reevaluate caries
risk
Bitewing radiographs every 1824 months
Moderate risk
Optional: for
excessive root
exposure or sensitivity
Not required
Not required
Calcium
Phosphate
Topical
Supplements
pH Control
OTC fluoride-containing
toothpaste twice daily,
after breakfast and at
bedtime. Optional: NaF
varnish if excessive root
exposure or sensitivity
Fluoride
Per saliva test if done
Antibacterials
Saliva Test
Chlorhexidine
(Saliva Flow &
Bacterial Culture) Xylitol
****
May be done as
a base line reference for new
patients
Bitewing radiographs every 2436 months
Low risk
Frequency of
Caries Recall
Exams
Every 6-12
months to reevaluate caries
risk
Frequency of
Radiographs
Risk Level
###
***
Caries Management by Risk Assessment
Clinical Guidelines for Patients Age 6 and Older
TABLE 1
C DA J O U R N A L , VO L 3 5 , N º 1 0
Professionally Applied Topical Fluoride: Evidence-based Clinical Recommendations1
Assess
Caries Risk
(see back for risk factors)
• Low
• Moderate
• High
Advise
6–18 years
Decide
Risk Group/Age
< 6 years
18+ years
• whether to apply
Patient may not receive Patient may not receive Patient may not receive fluoride
Low
any additional benefit* any additional benefit* any additional benefit* • type of fluoride
Moderate
Varnish every 6
months
Varnish or Fluoride gel
every 6 months
Varnish or Fluoride gel • frequency of
every 6 months
application
Varnish every 6 or 3
months
Varnish every 6 or 3
months
or
Fluoride gel every 6 or
3 months
• how often to
re-evaluate
& Patient Age
High
Varnish or Fluoride gel
every 6 or 3 months
* Fluoridated water and fluoride toothpastes may provide adequate caries prevention in this risk category.
• Application time for fluoride gel and foam should be 4 minutes.
• Due to limited evidence these recommendations have not been extrapolated to foams.
• There is limited evidence differentiating NaFand APF gels.
A
Recommendation based on higher
levels of evidence
B
C
D
Recommendation based on lower
levels of evidence
Levels of evidence and strength of recommendations:
Each recommendation is based on the best available evidence. The level of evidence available to support each recommendation may
differ. Lower levels of evidence do not mean the recommendation should not be applied for patient treatment.
Professionally Applied Topical Fluoride: Evidence-based Clinical Recommendations1
Determination of Caries Risk
There are many systems to determine caries risk.
One such system is offered below that can be used for caries risk assessment.
Individual risk factors increasing risk for developing caries may also include, but are not limited to:
• Many multisurface restorations • Cariogenic diet
• High titers of cariogenic bacteria
• Active orthodontic treatment
• Chemo/radiation therapy
• Poor oral hygiene
• Presence of exposed root surfaces
• Eating disorders
• Prolonged nursing (bottle or breast)
• Restoration overhangs and open margins
• Drug/alcohol abuse
• Poor family dental health
• Physical or mental disability with inability or
• Developmental or acquired enamel defects • Irregular dental care
unavailability of performing proper oral health care
• Genetic abnormality of teeth
Risk group
Age
Primary or Secondary Carious
lesions in the past three years
Low
All age groups
None
and
None
< 6 years
None
and
At least one risk factor
> 6 years
One or two
or
At least one risk factor
< 6 years
Any
or
Multiple risk factors or Low Socioeconomic status or
Xerostomia* or suboptimal fluoride exposure
> 6 years
Three or more
or
Multiple risk factors or Xerostomia* or
suboptimal fluoride exposure
Moderate
Risk factors listed above
High
* Medication, radiation or disease induced xerostomia.
1
ADA Council on Scientific Affairs. Professionally applied topical fluoride: Evidence-based clinical recommendations. JADA 2006;137(8):1151-59. Copyright ©2006 American Dental Association.
All rights reserved. Adapted 2008 with permission. To see the full text of this article, please go to http://jada.ada.org/cgi/reprint/137/8/1151.
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prohibited without the prior written consent of the ADA