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Profile in Oral Health: Technologies for Caries Risk Assessment and Prevention by Tim Ives, RDH

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Technologies for Caries Risk Assessment and Prevention
by Tim Ives, RDH

The implementation of caries risk assessment (CRA) and caries risk management (CRM) is more than simply filling out a risk assessment form. The challenge now is to discover the agents, materials and technologies that best complement both CRA and caries prevention. Interventions are based on the concept of altering the caries balance in favor of health by identifying and treating pathological (risk) factors such as pathogenic bacteria, unhealthy saliva and poor dietary habits (i.e. frequent ingestion of fermentable carbohydrates) and promoting protective factors including saliva, sealants, antimicrobials, fluoride, oral probiotics and a healthy diet.

Technologies for Caries Risk Assessment
Screening systems or “caries activity tests” are available today and should be simple, inexpensive, rapid and accurate. They complement the risk assessment and assist the clinician in determining treatment management priorities. These tests are also helpful in patient education and motivation. Current tests provide information about saliva and bacteria present. Saliva tests measure hydration, flow, viscosity, pH and buffering capacity. Bacterial testing measures the presence of significant numbers of S. mutans or levels of bacteria that would put a patient at risk for caries.
  1. Saliva hydration, flow and viscosity
  2. Saliva pH
  3. Saliva buffering
  4. Specific bacterial quantity and activity

Saliva Testing
Caries is basically a pH disease, so the level of acid in the saliva is critical. Saliva plays a significant role in maintaining a healthy oral environment by neutralizing acids and flushing away food and bacteria. Saliva acts as a lubricant and delivers calcium, phosphate and fluoride to tooth surfaces. When saliva pH flow and buffering capacity are not within normal limits, demineralization occurs. Understanding these aspects of a patient’s saliva provides the clinician valuable information needed to determine treatment choices and preventive strategies.

The Saliva-Check Buffer test kit from GC America provides instruction to the clinician for evaluating hydration, salivary consistency, resting saliva pH, stimulated saliva flow, stimulated saliva pH and saliva buffering capacity. These six tests can be completed within 10 minutes.

Hydration is measured visually by watching saliva flow from minor salivary ducts on the inside of the lower lip. Beginning with a dry inner lip surface, droplets of saliva will appear in less than 60 seconds for a normal flow rate. Taking longer than 60 seconds for droplets to appear indicates a low flow rate.

Saliva consistency is determined by observing resting saliva in the mouth. Normal viscosity of saliva is clear and watery. Frothy bubbly saliva indicates increased viscosity and viscosity increases more as it becomes sticky.

Testing for pH is easily done with a piece of litmus paper or a specific pH testing strip. The patient expectorates any pooled saliva into a small collection cup and the strip is placed in the saliva for 10 seconds. Comparing the color change of the strip to the testing color chart will determine pH.

Saliva quantity is tested over a period of five minutes as the patient chews a piece of wax and expectorates all saliva into a small collection cup with markings. Normal salivary flow varies between 1ml and 1.6ml per minute. After five minutes the quantity of saliva collected should be 5ml or more. Less than 3.5ml collected over five minutes is considered very low.

Buffering capacity is tested with a buffer test strip. A small plastic pipette is used to draw saliva from the collection cup and dispense one drop onto each of three test pads on the buffer test strip. The test strip colors begin to change immediately and after two minutes the final colors will be variations of green, blue and red, with greens and blues indicating greater buffering capacity and blues and reds, less buffering capacity.

Bacterial Testing
Estimates now suggest the number of bacterial species identified in the mouth is as high as 800. Other researchers studying DNA implications suggest the numbers are actually 3,600 to 6,800, while still other researchers suggest the number of different oral bacteria is as high as 19,000. No matter the number, only a few hundred can actually be cultured in the laboratory. The new genetic variations of oral bacteria recently reported cannot be measured in clinical practice. Despite these new findings, the primary species associated with cavitated lesions is Streptococcus mutans. In-office testing of S. mutans is available and easy to do. GC America sells Saliva-Check-Mutans, a 15- minute test to identify or monitor the presence of S. mutans.

The patient is given a piece of wax to chew that stimulates salivary flow. Saliva is expectorated into a small receptacle to which a drop of Reagent 1 is added, the container is tapped 15 times and then four drops of Reagent 2 are added. Shaking the container disperses the reagent and the color changes to green. A sample of the saliva is then dispensed onto the window on the testing card and 15 minutes later, if the bacterial count for S. mutans is over a threshold level, a red line appears under the T for test, next to the red line of the control or C.

Another chairside test for oral bacteria measures the production of ATP by bacteria, giving an indication of the number of bacteria present. The CariScreen Caries Susceptibility Test by CariFree uses a swab, a reagent and a meter for reading the outcome. The swab comes in a protective tube that becomes the test device. The cotton swab is removed from the protective tube and used to collect a sample of bacterial biofilm from the lingual surface of the lower anterior teeth, careful not to touch lips, tongue or gingiva. The swab is returned to the protective tube and the reagent is released from a bulb on the end of the swab case. A reaction is created that is then measured using the meter. Scores given by the meter range from 0 to 9,999. A score under 1,500 is considered healthy, while scores above that are considered at risk for caries.

Plaque pH Testing
GC America provides a plaque indicator kit, which is a simple plaque pH test. Plaque is collected from maxillary and mandibular teeth on two small plastic probes. These probes are then dipped for one second into a solution and allowed to stand for five minutes at room temperature. Acidic strains of bacteria will cause a color change on the probe that can be measured against a supplied color chart.

Developing a Preventive Protocol
Results from the various screening tests and additional information regarding dental history, medical history, lifestyle, age and socio-economic status will be taken into account when designing an individualized preventive protocol. The overall preventive protocol includes four specific areas: reparative, therapeutic, behavioral and non-modifiable aspects.

Reparative interventions include both restorative treatments and remineralization protocols. Lesions through the enamel and into the dentin will need to be repaired with a dental restoration. Demineralized lesions that have not yet broken though the enamel can often be remineralized by products that stimulate salivary flow or provide minerals necessary for remineralization. Many products containing amorphous calcium phosphate, tricalcium phosphate, xylitol or fluoride are now available for remineralization therapy.

Therapeutic interventions target the bacteria, the salivary pH and support remineralization. Products include antimicrobial rinses and xylitol containing products. For those with high levels of oral S mutans and/or an acidic resting pH, antimicrobial mouthrinses containing stabilized chlorine dioxide can be used in combination with a xylitol rinse twice daily for three months prior to re-testing. Professional topical iodine treatments every three months will also address high bacterial counts. Use of xylitol products will interfere with bacterial communication and acid production leading to a decrease in the number of bacteria in the mouth. Xylitol will also stimulate salivary flow and elevate the pH. To be most effective, these products should be sweetened with 100 percent xylitol. The Spry Dental Defense products fit this criteria and are available in toothpaste, gel, mouthrinse, chewing gum, candy, mints and a dry mouth spray. Xylitol has a slight cooling sensation that is responsible for stimulation of salivary flow. Low salivary pH levels can be elevated quickly with a rinse made with a teaspoon of baking soda in a glass of water. Patients should be encouraged to drink more water. A professional rinse is available from CariFree to elevate the oral pH.

Behavioral interventions focus on counseling with the patient for both oral hygiene needs and dietary modifications. Many options are available today to control bacterial biofilm, so limiting oral hygiene instructions to brushing and flossing is a thing of the past. Dietary modifications take into account the frequency of sugar and fermentable carbohydrate ingestion, limiting soda, juice and sugars to mealtime. Motivational interviewing focuses on communication between patient and clinician to decide a plan of action that the patient can and wants to accomplish.

Non-modifiable issues that need to be addressed include special needs, xerostomia, medicines being taken and general health issues. While these cannot easily be changes, the preventive plan can be adapted to take these conditions into consideration.

Summary
A variety of products are now available to complement the risk assessment process, providing the clinician with valuable information. Each positive or negative result within the testing sequence will guide the clinician into altering the patient’s oral balance in favor of health. With the right combination of products, instructions and guidance, caries can be prevented and eradicated.

Curing Caries – The Book!
These two articles really only scratch at the surface of caries management and provide a taster for a book, Curing Caries, which is being launched this Spring. This will provide the essential scientific theory but more importantly act as a pictorial step-by-step guide to the process of risk assessment including saliva and bacterial testing within the dental office. There will be a section on product options recommend for each specific testing result. These recommendations are based on several years of clinical experience in which many patients have successfully been cured of caries. In addition, there will be advice and guidance on incorporating a caries management system into your current practice setting. Don’t miss the 2012 Townie Meeting, featuring Tim Ives presenting a lecture/handson program in the Hygiene Track.

Caries Management Consulting
During July and August 2012 Tim Ives and Dave Bridges, co-author of Curing Caries, will be visiting the U.S. providing one-day, in-office caries management training sessions. Brochure and scheduling information is available in the message board titled: Curing Caries – The Book at: www.dentalvillage.co.uk.

Author Bio
Timothy Ives, RDH, spent 22 years in the Royal Air Force, much of that time providing dental hygiene services. His tours of duty included Hong Kong, Cyprus, Germany, New Zealand, Holland and the U.K. Besides clinical practice, he also has a certificate in appraisal of dental practices. He has a passion for minimally invasive dentistry (MID) and co-runs an MID-based Web site with his friend, Dave Bridges, RDH: www.dentalvillage.co.uk. Tim is an active Townie, member of the Hygienetown.com Advisory Board and available for in-office CAMBRA training.
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