Do you have a strategy to prevent Dental Caries (Tooth Decay)?

Dental caries (tooth decay) is a highly infectious, transmissible bacterial disease. The disease may be transmitted from a mother to a child. Oral pathogens enter the bloodstream of the mother by periodontal infection and pass from mother to child (Madianos et al. 2001). The disease is unfortunately on the rise among toddlers. It is the most common chronic disease in children ages 6-11 and adolescents ages 12-19. What is your strategy for preventing dental caries?

Dr.’s Hackmyer and Triplett discuss the basic premises and strategy they have adopted in their practice and at the University of Tennessee to prevent and manage dental caries: CAMBRA or caries management by risk assessment (Hackmyer and Triplett 2017).. They find that CAMBRA can help to prevent, reverse and treat caries before the disease causes irreversible damage to tooth structure (e.g. cavities). Following CAMBRA, the dental professional “evaluates the presence of disease indicators and assesses the patient’s risk based on biological, behavioral and medical history factors” (Hackmyer and Triplett, p. 53). CAMBRA’s gives focus to prevention and early intervention.

Step 1: Assessment

CAMBRA begins with caries risk assessment. The patient’s risk factors are tallied to determine whether the patient is at low, medium or high risk of dental caries. Factors are regarded either as biological or clinical. Biological factors include: susceptible host, diet and microflora levels. Clinical factors include: plaque accumulation, white spot lesions, precavitated lesions and caries. Additionally, the assessment includes whether or not the patient had caries in the first three years of life. Socioeconomic status of the patient may also be contributing factor as persons with less education and less financial resources may be less aware or less able to secure good preventive care.

Using CAMBRA, saliva is tested for bacterial levels and for the extent of presence of Streptococcus mutans, a key bacterium in the caries disease progression. S. mutans is considered the primary bacterium involved in plaque formation and the initiation of dental caries and the most cariogenic of all oral Streptococci species (Banas, 2004; Loesche, 1986). As S. mutans is a normal inhabitant of the oral cavity, a realistic objective may be the control of S. mutans within the oral ecology rather than its complete elimination. Saliva samples can serve as an indicator as to whether S. mutans has a significant presence or has overgrown the oral ecology. It should be noted oral rinses containing stabilized chlorine dioxide have proven effective in controlling the growth S. mutans (Botha and Molobela, 2006)[i].

             Next, the CAMBRA protocol focuses on the evaluation of the frequency and type of food and liquid intake. “The consumption of fermentable carbohydrates significantly contributes to the caries process, because bacteria produce acids that feed on fermentable carbohydrates, which leads to enamel breakdown” (Hackmyer and Triplett, p. 53).

In particular, S. mutans degrades sugars (sucrose) into fructose and glucose in the formation of dental plaque. It is worth noting that the human body has no way of clearing biofilms and dental plaque; that is why regular professional visits to the dentist go hand in hand with premium home oral care aimed at halting and reducing plaque and biofilms.

CAMBRA calls for the clinician to assess the patient’s self-care including; type of toothbrush used, type and amount of toothpaste used, frequency of brushing and flossing and whether or not the patient uses irrigation devices or fluoride supplements or rinses. Biofilm can begin to rebuild in less than 48 hours after a dental exam, so how the patients manage their own home oral care becomes critical to effective caries management and prevention. Also, the risk of caries is heightened when the patient, siblings and caregivers have histories of dental caries as such history is also a strong indicator of future risk.

 Step 2: Prevention

The next step of the CAMBRA protocol is the use of tools and treatments to inhibit or prevent the occurrence of caries. Preventative methods include; professional prophylaxis, topical fluoride treatment or fluoride varnish, sealants on non-cavitated primary teeth and permanent posterior teeth and on early non-cavitated lesions on permanent posterior teeth. The use of sealants over early minimal caries lesions can inhibit pathogens and arrest the lesions progression. Preventative methods are the key to avoiding restorative care. 

             Both the American Academy of Pediatric Dentistry (AAPD) and International Caries Detection and Assessment System Foundation (ICDAS) have published caries management protocols that embrace CAMBRA (Hackmyer and Triplett, p.54).  They encourage treatment plans to be developed and customized for each patient. The AAPD divides their protocols based on patient age and the ICDAS known as International Caries Classification and Management System (ICCMS) has separate protocols for primary and permanent teeth. The use of these protocols supports the case for minimally invasive dentistry through preventative maintenance and individualized treatment plans.

              Other methods of preventative treatments discussed by Dr.’s Hackmyer and Triplett include the use of gum, hard candies or lozenges that contain polyols for children over 5 years of age. Products such as Xylitol can help keep a neutral pH level in the mouth and they also prevent bacteria from sticking to teeth. For those patients in communities without fluoridated water, fluoride supplementation should be considered and for those high risk patients, a high-dose-fluoride prescription paste may be added to self-care routines. 

              Dr.’s Hackmyer and Triplett have proved a clear and useful review of the CAMBRA protocol, noting that it has improved the effective management of patients’ oral health through its use of assessment and preventative maintenance and minimally invasive treatments rather than through treatment of conditions alone. They strongly believe that use of the CAMBRA protocol by more dental practices will improve overall patient oral health.

 References:

Banas, J.A. Virulence properties of Streptococcus mutans. Front. Biosci. 2004, 19, 1267–1277.

Botha SJ and Molobela IP. Effective Inhibition of Oral Organisms by Chlorine Dioxide (ClO2). The Preliminary Program for Scientific Meeting of the South African Division of IADR. Sept. 6-7, 2006.

Hackmyer, S. P., DDS, & Triplett, O. L. (2017). Caries Prevention Protocols. Decisions in Dentistry, 3(Number 7), 52-55. Retrieved August 3, 2017, from https://decisionsindentistry.com/article/caries-prevention-protocols/

Loesche, W.J. Role of Streptococcus mutans in human dental decay. Microbiol. Rev. 1986, 50, 353–380.

Madianos, P.N. et al. Maternal periodontitis and prematurity. Part II: Maternal infection and fetal exposure. Annals of Periodontology, 6(1) 2001: 175-182.

[i][i] CloSYS Oral Rinses have been shown to kill Streptococcus, including S. mutans and S. sanguinis. Research on file at Rowpar Pharmaceuticals, Inc. See U.S. Patent 5,348,734, U.S. Patent 8,926,951. For more information, please visit: www.CloSYS.com/support materials