From Volume 40, Issue 10, December 2013 | Pages 814-820
This article seeks to bring together the preventive messages given in Paper 1 and apply them to specific individual patients. The key elements are the appropriate advice on fluorides, fissure sealants, diet and formulating advice in terms of an individual's educational background.
The previous paper1 considered the scientific evidence for the advice the dental team can give to individual patients on caries prevention. In addition, the major impact of the ‘diagnostic threshold’ of individual clinicians on preventive interventions was highlighted. In this paper, case studies are presented which bring the preventive messages together. Experienced clinicians will no doubt have gathered much of this evidence together through practical experience. The main caveat is that in dentistry, as in many branches of medicine, there are a number of ways for experienced clinicians to achieve a set goal, so that the case studies and the suggested answers are not definitive, but do have a practical clarity and simplicity.
A mother brings her 3½-year-old daughter to your dental practice. She has noticed that the upper primary anterior teeth have become brown in colour and pieces of them are breaking off (Figure 1).
She has also noticed what she refers to as holes in some of the back teeth. The family live in a middle class suburb. The father is a headmaster and mother a senior executive with a credit card company.
Nothing of relevance except the child does seem somewhat overweight.
The child has never complained of pain and mother missed an appointment for a check-up a year ago because of a business meeting abroad.
Mother had been away for six weeks with her work and now has a three week break and has noticed the dental problem. Most of the childcare is undertaken by an au pair from Italy. Father is involved in a reorganization of the education facilities in his school so has been working late, and not participating in ‘bath time’.
A quiet child who allows a full dental examination. There are no problems noted on the extra-oral examination.
The following teeth are charted as present:
The teeth are clean, but there are approximal and buccal carious lesions on the upper primary incisors and lesions involving the four first primary molars (Ds).
Radiographs are not taken as the mother is most concerned about radiation. On a practical note, the child appears ready to cry, so pushing the parent to agree bitewing radiographs seems counterproductive at this initial visit.
The child is suffering from early childhood caries, but is not in pain.
The presentation of considerable dental caries in a child from a middle class, high income family warrants careful investigation before deciding how best to proceed. It must be stressed that restorative care in such a mouth will not prevent further carious lesions.
The first task would be to undertake a detailed dietary assessment which, in this case, is likely to be difficult as the mother is not directly involved in childcare and spends a considerable time away from the family home. Although the father is said to be late home because of short-term work commitments, it would seem more appropriate to seek information from him about the child's diet as he is not ‘routinely’ absent. It is essential to tread carefully and avoid apportioning blame, which could create a source of family tension. The practice hygienist, talking to the father, discovers the key problem is the diet. He reports that his daughter is always reluctant to go to sleep at night and the au pair has found that a bottle, containing warm diluted juice, to which she added sugar, helps to induce sleep.
The action point here must be to cut out this sugary-filled bottle at night. This, however, is likely to be a difficult task, given the initial reason for providing it was as a comforter. The option chosen is to weaken the dilution of the juice over a 10-day period until only warm water is given. This works, but only because the parents refuse to give in to some fairly violent tantrums! Two months after the water only regime is introduced the child gives up the night-time bottle altogether.
As there is active caries it is suggested that the au pair or parent should brush the teeth twice a day, last thing at night and on one other occasion, with a pea size amount of toothpaste containing 1450 ppm F. The child is encouraged to spit out any excess.
Fluoride varnish is applied by a dental hygienist to the posterior primary molars and upper primary anteriors. A short recall (2 months) is used to review progress. After 4 months, fluoride varnish is re-applied and restorative care is initiated by a dental therapist in collaboration with a specialist in paediatric dentistry.
Diagnosis and investigating reasons for extensive dental caries is at the heart of dental practice. If the sugary night-time bottle had not been identified and remedial action taken the future of the primary dentition would have been bleak.
A six-year-old boy, who is a regular patient, is brought to see you because of oral pain and discomfort on eating.
Nothing of relevance reported.
Has been seen regularly in your practice since he was 3 years old. Fluoride varnish has been applied at approximately 6-monthly intervals and there have been no reported oral health problems.
Pain and discomfort from lower right quadrant, particularly when eating.
Extra-oral, no swelling evident. The following teeth are charted as present:
The lower right 6 is partially erupted with an inflamed flap of gum tissue overlying the distal portion of the tooth; all other first permanent molars fully erupted.
Bitewing radiographs were taken when he was five years of age. The perceived clinical problem did not warrant further exposure to ionizing radiation.
Pericoronitis: there is an inflamed flap of gum which is being subjected to occlusal trauma (Figure 2).
The partially erupted lower right 6 is clearly the source of the pain and discomfort. Both the parent and patient are reassured and advised to use analgesics and rinse the mouth with warm water. It is recommended that the patient is reviewed in one week's time, when advice on brushing the teeth and simple diet advice would be given. Fluoride varnish is applied by the dental hygienist to the four permanent molars.
Reassurance is the key, as the problems of pericoronitis in young children are usually self limiting. The dental health advice and the use of fluoride varnish fits in with the philosophy of ensuring teeth remain free of caries.2
A 14-year-old girl, new to the practice, presents requesting a check-up, and an appointment is given. She attends that appointment with her father.
No relevant medical history.
Has been a fairly regular attender, but stopped visiting for ‘routine check-ups’ approximately two years ago when her family dentist retired.
Parents are concerned that the pattern of regular dental monitoring was interrupted by closure of the dental practice, and wish to ensure continuing dental care.
Extra-oral, nothing relevant noted.
The following teeth are charted as present:
Early caries involving occlusal fissures of all second molars is evident and they appear to be enamel lesions with no involvement of dentine (Figure 3).
As this is a new patient to the practice, and there are early enamel lesions visible clinically on the occlusal surfaces of the lower second molars, bitewing radiographs are taken (Figure 4).
Caries into dentine involving the distal surface of the UR4 and an early lesion on the mesial surface of the UR5. There is no radiographic evidence that the early carious lesions clinically visible in the second lower permanent molars have penetrated into dentine.
The presence of early carious lesions is an important sign that preventive care is extremely important. With the appropriate help the mouth can stabilize, but there is a danger that the risk of further carious lesions could accelerate without specific preventive advice.
The preventive care plan is as follows:
The patient should be offered a 6-month recall for new bitewing radiographs to be taken to monitor the early lesions on the upper premolars.
Preventive care at this time will ensure that the teeth remain in a healthy condition to allow early lesions to remineralize.
A 15-year-old boy, who has been having orthodontic treatment at another practice, presents for a routine examination. He has not visited his general dental practitioner for over two years.
No relevant medical history.
The patient had upper and lower fixed appliances placed 1½ years ago. Despite advice regarding his diet and the need to brush twice daily with an adult fluoride toothpaste, he has chosen to ignore it and the orthodontist terminated treatment and the bands were removed (Figure 5).
Mother is concerned that the orthodontic treatment was terminated and the front teeth look decayed.
Early carious lesions are evident around the margins of the sites where the orthodontic brackets were attached.
Both the patient and his mother were concerned that the orthodontist had taken a large number of radiographs, so preferred not to have bitewings taken.
Active carious lesions evident where orthodontic brackets had been removed.
Further advice regarding reducing the frequency of sugar-containing foods and drinks is given by the dental hygienist who also applies fluoride varnish to all affected surfaces. The patient is prescribed a toothpaste containing 2800 ppm F and advised to brush twice a day, last thing at night and on one other occasion. The hygienist gives him three appointments to ensure that he understands the information and he is encouraged to take a greater interest in his teeth. Review appointments are made at 3-monthly intervals when fluoride varnish will be re-applied. A full diagnostic examination is scheduled for 12 months’ time.
A preventive programme utilizing fluoride, together with intensive advice, is chosen because of the early lesions and the history of non compliance with previous advice on oral health care. Clearly, early lesions may also be present on the mesial and distal aspects of molars and premolars but, as no radiographs were taken, we can only act on the basis that this is a high caries risk patient.
A 21-year-old male student in his third year at University has returned home on vacation. He has noticed some holes in his front teeth and decides that a dental ‘checkup’ might be appropriate, mainly because of pressure from his girlfriend.
He is a poorly-controlled, insulin-dependent diabetic. His glucose level fluctuates and he admits that he has been failing to adhere to a strict dietary regime.
He has received care in the past but this has lapsed whilst he has been away. His dental records show that he was last in the practice over 4 years ago.
His girlfriend is worried that his front teeth are spoiling his smile and that he may need false teeth.
Large carious lesions involving the approximal surfaces of all upper incisor and canine teeth (Figure 6).
Bitewing radiographs also confirm lesions involving the distal surface of the LL6, mesial surface of the LL7, distal surface of UL5 and occlusal surface of UL6 (Figure 6).
Active caries in a medically compromised patient.
It is important to encourage this young man to visit his general medical practitioner regarding the control of the diabetes. A referral letter is written to the family GP to emphasize the importance of seeking professional help. The practice hygienist gives him advice on reducing the frequency of drinking sugar-containing liquids. Appointments are made for restorative care and twice daily brushing with a toothpaste containing 5000 ppmF is advised.
He is reviewed in one month to check whether he has seen his GP and to reinforce the dietary and oral hygiene advice. At this visit he is given a daily fluoride rinse as an adjunct to brushing with fluoride toothpaste.
A short recall is essential to monitor progress and determine whether there has been compliance with the advice offered.
This patient is a 65-year-old male, who retired from work 9 months ago. His wife died in a road traffic accident two years ago. He has three grown-up children who he sees infrequently.
He has suffered from depression since the loss of his wife and is taking anti-depressive medication [Fluoxetine (Prozac)].
He smoked 25+ cigarettes a day until 8 months ago but is now using nicotine patches.
There is a history of reduced salivary flow, which is a common side-effect of the selective serotonin re-uptake inhibitors (SSRIs) such as Prozac. This is probably the reason why he is sucking mints to help lubricate his mouth. He has also been prescribed the ACE inhibitor, Ramipril, for the control of his high blood pressure.
Regular attender until five years ago when his dentist retired. He has had routine restorative care and extractions under local anaesthesia.
His molars are very sensitive to both hot and cold stimuli and this is the main reason for the consultation. He has stopped cleaning his teeth because they are so sensitive.
This shows that the following teeth are present:
There is gingival recession around all teeth, and many have carious lesions that are relatively hard on gentle probing (Figure 7).
The patient is suffering from root caries and sensitivity on brushing.
There are a number of aspects to this case which imply a need for immediate and longer term care plans.
This patient has suffered from depression and hypertension and is in the process of giving up cigarette smoking. The root caries is very likely to be related to the frequent use of the sugary mints. The main difficulty will be to reduce the cariogenic challenge and also to assist in the remineralization of the root caries. A preventive care programme can be planned, which assists remineralization, namely:
If there are positive outcomes to the oral hygiene and diet advice, further clinical care can be planned, which would include:
Excess sugar consumption is overwhelming the oral defences and encouraging demineralization, hence the need for dietary advice. Sugar-free mints, as a substitute for sugary ones, should be helpful. Toothbrushing advice will assist in the control of the plaque and distribute fluoride round the mouth.
All too often, the dental team does not have a clear understanding of the key preventive messages for caries control.4 The following age-specific messages taken from the English Department of Health Prevention Toolkit (website) may aid the reader when preventive care plans are being developed for specific patients.5
The practice of dentistry requires dental professionals to be reflective and spend time carefully diagnosing a clinical problem prior to action. Once the diagnosis has been made there are two key themes which must be part of care plans:
The majority of the dental profession will work as general practitioners with a defined group of patients who will be offered care over a long period of time. These patients require the dual preventive and restorative approach. It is up to us as dental professionals, not only to be fine clinicians, but to achieve sustainability in our preventive care. This means repetition and reinforcement are crucial to ensuring that preventive advice is accepted and becomes part of a patient's everyday behaviour.
For many patients a lack of knowledge about the aetiology of the common dental diseases is a frequent reason for suffering dental ill-health. The dental profession has the preventive agents and the scientific information to help, but all too often we fail to help our patients and ignore our responsibilities as healthcare advisors. Now is the time to change and become a diagnostician, not just someone who removes infected tissue in a vain attempt to control a bacterial disease.
