Preventive and/or non-invasive dentistry: remineralization technique and cavity approach
1-Introduction:
Prevention and management based on risk analysis are considered the cornerstones of minimal intervention, a modern approach to caries disease.
In daily practice, caries risk assessment helps to determine which patients will develop caries lesions in the near future or who are at risk of worsening caries lesions.
2-Reminder:
Preventive and/or non-invasive dentistry: remineralization technique and cavity approach
As for the evolutionary stages of the lesion, there are 5 of them:
– stage 0: initial lesion without cavitation, strictly enamel or reaching the enamel-dentin junction, but not requiring surgical intervention.
– stage 1: lesions with surface microcavitations having progressed to the external 1/3 of the dentin and requiring restorative intervention.
– stage 2: moderately sized cavitary lesions having progressed into the middle 1/3 of the dentin and requiring restorative intervention.
Stage 3: extensive cavitary lesions having progressed into the inner 1/3 of the dentin and requiring restorative intervention.
Stage 4: Cavity lesions reaching the parapulpal dentinal areas and requiring restorative intervention
3-Early diagnosis:
Radiology:
Radiological examination (retroalveolar X-ray or bite-wing) is a diagnostic tool that has proven to be very reliable for the detection of proximal lesions (even early ones) and for the demonstration of moderate to severe dentin lesions. According to some, retroalveolar X-ray should be performed in all patients before management.
New diagnostic support tools:
Preventive and/or non-invasive dentistry: remineralization technique and cavity approach
4-Definition of individual caries risk:
RCI is defined as the probability of an individual developing carious lesions reaching a given stage of the disease during a certain period of time with constant exposure to risk factors during this period.
Interest in evaluating the RCI:
Calculating the RCI is an important tool for adapting prevention actions
The objectives of the RCI assessment: To guide the practitioner in making choices adapted to his patients; diagnostic, prescription, therapeutic methods (preventive or curative)
To set up patient education and monitoring.
RCI assessment is an integral part of the medical approach to caries disease.
| Factors Low risk High risk | |||||
| General environment | Socio-economic | Favorable. | Unfavorable. | ||
| Family dental health. | Absence of family oral history. | Presence of family history of caries. | |||
| Food. | Regular and balanced meals. Carbohydrate intake mainly during meals. | Snacking, irregular, unbalanced meals. Frequency of carbohydrate intake and sugary drinks outside of meals. | |||
| General conditions of the child | General condition. | Absence of personal general medical history | Presence of personal general medical history reducing salivary secretion. | ||
| Patient behavior. | Confident, cooperative. Responding to prevention actions. | Passive or reluctant. Fear, anxiety or phobia of the dentist. | |||
| Clinical conditions specific to the child | Oral hygiene. | Regular. Brushing supervised by parents. Toothbrush renewed | Irregular, uncontrolled. Last toothbrush purchase > 6 months. | ||
| Oral and dental history. | regularly, of suitable size. Regular visits. Low rate of care and lesions. No carious lesions for one year. | Irregular visits. Carious lesion(s) for the past year. High rate of lesions. History of polycaries in young children. | |||
| Saliva test. | Salivary flow rate ≥ 1 ml/min. Normal buffer capacity. Low SM level < 105/ml. Low Lactobacilli level < 105/ml. | Salivary flow rate < 1 ml/min. Low average buffer capacity. High SM rate > 105/ml High Lactobacilli rate > 105/ml. | Or | ||
| Assessment of fluoride intake. | Regular intake of topical fluorides during childhood. | Fluoride deficiency. | |||
| Anatomical and histological risk. | Tooth of normal size. Non-anfracted grooves. | Large tooth. Anfractured grooves (occlusal, lingual or vestibular). Presence of hypoplasia or hypomineralization. | |||
| ODF | No or no more treatment. Aligned teeth. | Multi-bracket treatment course. Misaligned teeth (rotation, | in | ||
Prevention also aims to prevent the onset of the disease by acting on the known risk factors specific to the etiology of dental caries:
5- Risk factors:
1-Bacteria: the presence of plaque is associated with the development of carious lesions in adults. The principle of microbial testing (plaque-revealing dye) is based on the idea that subjects with a significant number of cariogenic bacteria have a greater risk of developing a carious lesion.
2-Diets:
A diet high in sugar is one of the main drivers of caries activity, and identification of risky dietary habits is necessary for the prevention and management of the disease
3-Brushing teeth:
Toothbrushing is the most commonly used technique for plaque control. However, the toothbrush has limited access to certain dental surfaces.
4-Dental anatomy:
Some morphological variations can also predispose to caries. The morphology of the cusps and the depth of the grooves must be taken into consideration, they are individual risk factors. The quality of the enamel must also be taken into account. There are malformations of the enamel (dysplasia) which make it very fragile to acid attacks.
5-Saliva:
Saliva is made up of immune and non-immune factors that help protect teeth from possible caries. Salivary flow influences the concentration of sugars in the oral cavity and their elimination as well as that of plaque acids.
6-Socio-economic and cultural status: influence eating habits, the quality of oral hygiene and therefore the aggressiveness of the biofilm against dental surfaces
6-Preventive dentistry: remineralization technique
Fluorine:
Fluorides are certainly the most used, because they limit demineralization and promote remineralization.
Their significant anteriority compared to other techniques described explains that their effectiveness has a much higher level of proof. They therefore remain the cornerstone of our treatments.
They also have an impact on cariogenic bacteria because they increase their sensitivity to the acidic environment they create.
Means of application of fluoride:
Fluoride toothpastes:
It contains either Sodium Fluoride (NaF, toothpaste between 250 and 1500ppm), or mono Fluoro Phosphate often in the form of “high contents”
Fluoride varnishes: allow a very effective and very targeted action of fluoride and tend to replace the applications of gel or mouthwashes. The latter are no less effective.
Fluoride gel:
The application of fluoride gel will be reserved for patients with a very high caries risk. Their effectiveness is linked to the fluoride concentration, the application time, the area concerned. They are a good complement to the daily use of fluoride toothpastes.
They contain 0.5% fluoride. There are gels with both fluoride and chlorhexidine. It is advisable to apply it for at least 4 minutes using a mouth guard.
New remineralization products :
The CPP-ACP and CPP-AFCP:
More recently, specialties based on CPP and ACP (casein phosphopeptide –amorphous calcium phosphate) and CPP –AFCP (casein phosphopeptide –amorphous fluoride calcium phosphate) have been introduced. These molecules prove to be promising in the non-invasive management of carious lesions by promoting phosphocalcic remineralization.
7-Non-invasive care technique:
Preventive sealing of furrows:
Groove sealants provide a physical barrier
The lifespan of the resin depends on the materials used (2/3 of the resin remains in place for 5 to 7 years on average)
The materials used for sealing the grooves are: composite sealing resin, CVI (high viscosity) CVI MAR, compomer.
8-Cavity approach:
In the presence of a cavitary and active carious lesion:
Restore while respecting the principles of dentistry at a minimum
Supplement with topical fluoridation at the end of restorative treatment.
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.