Management Of Dental Caries

A seminal study showed that for individuals who have compromised salivary function, excellent oral hygiene alone is insufficient to prevent rapidly progressive dental decay.12 The use of topical fluoride and diet counseling was critical for caries prevention.

Box1

Protocol for determination of unstimulated whole salivary flow rate

Unstimulated whole saliva collection measures saliva production under resting or basal conditions. The subject should not have had anything to eat or drink for 90 minutes before the procedure. The use of a parasympathomimetic should be discontinued for 12 hours before the procedure, and the use of artificial salivas should be stopped 3 hours prior. During the collection procedure, the subject is instructed to minimize actions that can stimulate saliva (talking, increased orofacial movement) and should not swallow. At time "0," any saliva present in the mouth is cleared by swallowing. For the subsequent 5 minutes, any saliva collected in the mouth is emptied into a preweighed tube every minute (ie, five times). This collecting tube then is weighed to determine a postcollection weight. The difference between the pre- and postcollection weight is determined, and this represents the unstimulated whole saliva production for 5 minutes. To convert to a volume of saliva from the weight of saliva, an assumption is made that saliva is similarto water, where 1 g of water/saliva at 4°C equals 1 mL of saliva/water. Less than 0.100 mL/min is considered a reduced unstimulated salivary flow rate.6 Adapted from Protocols developed for the Sjogren's International Collaborative Clinical Alliance (http://sicca.ucsf.edu); with permission.

Box 2

Protocol for determination of a stimulated whole salivary flow rate

A stimulated whole salivary flow rate may be determined by using a preweighed tube and small piece of paraffin or unflavored chewing gum. The patient chews on the preweighed paraffin in a precise, timed manner for 5 minutes, and the saliva is emptied into the preweighed graduated tube. At the end of the collection period, the saliva-soaked paraffin is placed into the preweighed tube containing the collected saliva. The weight of saliva + paraffin is divided by total minutes collected to determine the salivary flow (mL/min).

A reduced stimulated whole salivary flow rate would be less than 0.5 mL/min to 0.7 mL/min.7

Caries is an oral disease that can be exacerbated by salivary dysfunction. Therefore, treatment of this oral disease should address prevention and management. Important to this process are:

Caries risk assessment

Diet assessment

Early detection and prevention of caries

Chemoprophylaxis to decrease the bacteria thought to contribute to the decay process

Use of new dental procedures allowing the practice of minimally invasive dentistry

Increasing the amount of saliva in the mouth

Managing oral mucosal infections

Caries risk assessment can be determined from the oral examination looking for clinical signs of hyposalivation, measurement of salivary production, presence and number of active caries lesions, amount of plaque, quality of diet, frequency of ingestion and duration of exposure to sugar and fermentable carbohydrates, use of xeros-tomic medication, and clinical judgment. Specific protocols have been developed for caries risk assessment (Caries Management by Risk Assessment, CAMBRA),13,14 where an individual may be triaged into low-, moderate-, high-, and extremely high-risk categories.

There are some very limited clinical data showing that individuals who have salivary dysfunction are not be able to raise intraoral pH back into the neutral range after an acidic challenge as quickly as those individuals who can produce saliva.2,3 A critical pH has been defined at 4.5 to 5.5 for the enamel tooth surface and at 6.2 to 6.4 for the exposed root surface. Below this critical pH, oral conditions favor demineralization or promotion of the caries process on the tooth surface. Progression of dental decay may be faster on the root surface in an oral environment that tends toward acidity. Saliva is the oral buffering agent, so the inability to produce saliva under resting/basal conditions or the inability to increase production under stimulated conditions may result in a compromised ability to buffer acid from plaque and exogenous sources. The management goal is therefore to shift the intraoral pH away from conditions that favor demineralization toward an environment that favors remineralization of the tooth surface. Carbonated beverages, juices, or waters (with additives) are examples of an exogenous acid that can have a pH ranging from 2.5 to 4.15-18 A baking soda rinse (2 teaspoons in a small 12 to 16 oz bottle of water) has been proposed for use several times of day to neutralize intraoral pH.14,19 Baking soda gums are also available.20,21 Clinical evidence supporting the use of bicarbonate to directly interfere with the caries process in those who have normal or reduced ability to salivate is lacking. Salivary buffering capacity may be assessed using commercially available kits (Dentobuff Strips, Orion Diagnostics, Esposo, Finland; GC Saliva Check, GC America).

The use of sugar-free gum and candies has been recommended to increase salivary flow. Again, this technique is most effective for those individuals who have some stimulated salivary function. Xylitol is thought to have an indirect role in reducing the population of bacteria that cause decay, inhibiting demineralization and promoting remineralization, and inhibiting plaque formation.22,23 Xylitol is taken up by oral bacteria and either metabolized slowly or not at all, and it can result in a shift in the intraoral bacterial population to one that is less cariogenic. The clinical evidence for xylitol having a direct cariostatic effect is mixed.24,25 The precise amount of xylitol to prevent caries in vivo has not been defined precisely.22 The adjunctive use of a xylitol- containing gum or candy four to five times per day for 5 minutes after meals and snacks is recommended.14,25 The use of chewing gum should be judicious or avoided in those who have pathology of the temporomandibular joint.

Commercial kits are available to monitor levels of caries causing bacteria in the mouth (Dentocult strips, Orion Diagnostics). To assist in management of these bacteria and their effects, the use of chemoprophlyactics is becoming more common. Short-term consumption of xylitol is associated with a decrease in the caries-causing bacteria Streptococcus mutans levels, and long-term consumption is associated with a shift in the bacterial population to one that is less adherent to the tooth surface. Baking soda has antibacterial properties and has the ability to neutralize acid (Arm and Hammer Dental Care Toothpaste and Baking Soda Gum). A 0.12% chlorhexidine gluconate mouth rinse may be used for 1 minute daily at bedtime for 1 week each month. Individuals who have severe dry mouth may be sensitive to the alcohol in this rinse. An alcohol-free version of the chlorhexidine rinse is available but limited in its distribution. Chlorhexidine gels and varnishes are not available In the United States. Chlorhexidine can bind to fluoride, so they should not be used concurrently; alternatively, it may be used at a separate time.

Diet assessment should address eating habits beyond the role of sugar in caries promotion.24 The frequency of ingestion of fermentable carbohydrates and exogenous acids (ie, carbonated beverages, wine, citrus) and the duration of exposure can play a role in caries promotion. Strategies to minimize the intraoral effects of these foods and beverages may be initiated.

Early detection of caries is critical in that it is known that an early, noncavitated (white spot, Fig. 1) lesion can be reversed or arrested from progressing by chemical means (fluoride) rather than by restorative means. Thus early detection equals prevention.

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