Taking care of white lesions

March 31, 2006
Five everyday tips that can prevent bacteria from working overtime.

By Kristine A. Hodsdon, RDH, BS

1. Licensed dental hygienists should assess the disease process/ active lesion at the earliest possible time. The goal in caries management is to identify a potential active (white) lesion when it can still benefit from remineralization treatment and products vs. restorative treatment. This can be easily achieved by using caries detection technology and proper armamentarium.

The following products should be considered for a caries management protocol:

• Risk assessment (see Tip 3 below)

• Properly fitted magnification loupes

• KaVo DIAGNOdent laser caries detection system (KaVo Dental Corporation)

• Qualitative Light-induced Fluorescence (QLF) incorporated in the Inspecktor Pro System (OMNII Oral Pharmaceuticals)

• Caries indicator dye

• Salivary culture, Mutans/ Bacterial assessments/ test

2. With the emergence of new products and claims, dental hygienists should ask lots of questions and make sure they completely understand all the distinctions in the realm of chemotherapeutics. Chemotherapeutics should be applied to noncavitated lesions to remineralize the areas. Yet before prescribing such medicaments, clinicians need to make sure they comprehend of all the modes of action and delivery methods, efficacy statements, FDA legal usage vs. off label usage, clinical relevance, and research.

Examples of such agents that should be further investigated for your caries protocol include:

• Fluoride

• Fluoride varnish

• Chlorhexidine

• Xylitol (sugar alcohol)

• Non-ionic agents (triclasn, phenols, "anti-plaque" substances)

• Calcium phosphate (learn the modes of action of its various forms)

• Enzymes (antimicrobial agents found added to toothpastes/mouthrinses)

• Fluoride releasing sealant treatments/glass ionomers

3. All preventive dental hygienists should become familiar with — and consider consistently implementing — a caries management risk assessment in their practices. Such assessments are defined as protocols that identify the cause of the disease and provide guidelines that the patient and clinician can follow to modify and or change caries initiating habits.

One example is the CAT, a caries-risk assessment tool as described by the American Academy of Pediatric Dentistry. It is used to assess the level of risk for caries (cavity) development in infants, children, and adolescents based on a set of clinical, environmental, and general health factors.

Many hygiene-friendly preventive manufacturers have pre-fab caries assessment guidelines and/or tools that can help the clinician. Why re-invent the wheel when these resources are readily available.

Whichever assessment standard your office collectively decides to use, the following host risk factors are of importance (dental caries should be documented/tracked) since they can indirectly influence the caries process:

• Medical history
o Intake of medicines (by their content of fermentable carbohydrates, low pH, or by affecting the saliva).
o Diseases in early child-hood influencing the formation of the enamel
o Radiation towards the head-neck-region leading to a destruction of the salivary glands

• Dental caries status
o Tooth surface activity assessment

• Fluoride use

• Salivary assessment
o Changes in saliva formation and composition

• Diet Assessment
o A shift to a caries-inducing dietary pattern

4. Dental caries is a multifactorial process involving substrate, specific bacteria, host factors, and time. One factor by itself will not initiate caries. So developing caries protocols that incorporate long-term followup schedules and products are essential.

The following are some steps your office can follow in regard to long-term successes:

• Increase office continuing care appointments:
o BW's and other x-rays PRN
o Continue with 1.2% APF office treatment.
o Apply fluoride varnish.
o Continue with CHX rinses-combined use of fluoride and CHX.

• If risk assessment and or activity remain high, monitor with tests in three weeks.
o Recall the patient every three to four months for one year to monitor.
o Continue to evaluate activity levels (white spots, soft tooth structure) and risk levels via caries risk assessment questionnaires/ surveys)

• At home:
o Daily home Fluoride rinse (0.5%)
o Xylitol gum/mints (Use of xylitol gum. two sticks, five times a day, chew five minutes)
o Stress diet compliance (decrease high sugar snacks/meals/drinks) (use dairy products such as cheese and milk since human studies suggest that the phosphoprotein, casein, and calcium phosphate may be anticariogenic chewing this gum provides calcium phosphate on the tooth surface for remineralization)
o Maintain normal salivary flow.
o Maintain oral hygiene.

5. Quick, take-back-to-the-office factoids about dental caries. A national health and nutrition examination survey reveals the following about the status of dental caries in the United States:

• Dental caries has decreased since 1960.
• In the United States, 20 to 30 percent of the population has 70 percent of the coronal lesions.
• 50 percent of the younger than 21 year olds have been caries free. However, in a variety of ethnic populations caries has increased. Early childhood caries has also been increasing.
• Beginning to see more rampant caries.
• Pit and fissure caries are more prevalent than smooth surface caries.
• There is a slower progression of all lesions.
• In 21-45 year olds, caries appears to increase and level off with increased age.
• Above the age of 60, root caries becomes more prominent.
• Less than 20 percent of individuals above the age of 65 are currently edentulous.
• Other industrialized nations have a similar caries status.

Kristine A. Hodsdon, RDH BS is the Director for RDH eVillage an online newsletter from the PennWell Corporation. She is a hygiene marketing consultant and speaker who frequently contributes to industry publications. Kristine has presented over 200 lectures both nationally and internationally on topics such as dental hygiene marketing, the future of dental hygiene, and communication skills. Kristine is scheduling for her newest program: "Age-Defying Benefits: Discover the Mouth-Beauty Connection." She can be reached at Kristine Hodsdon