Oral Sedation Dentistry

Oral sedation allows you to relax both your mind and body, and focus on feeling peaceful rather than anxious

By Dr. Michael D. Silverman

Anxiety Just Melts Away

When you are afraid, your threshold for pain is much lower, you become hypersensitive to every sensation, prick, and noise. Fear and anxiety trigger the release of certain chemicals like adrenalin which put your “fight or flight” instincts on high alert. You anticipate that something is going to hurt and so you tense your muscles, even if it is subconsciously. In this heightened state of anxiety you experience more pain during and even after treatment. However this response can virtually be eliminated with oral sedation dentistry!

The whole purpose of oral sedation is to make you as comfortable and relaxed as possible. It allows you to let your guard down, relax both your mind and body, and focus on feeling peaceful rather than anxious. Your apprehension and hypersensitivity to pain melt away, yet you remain awake and in control.

Sometimes referred to as “comfortable” or “relaxation” dentistry, these terms are used to describe the feelings most people perceive during their dental visits, which are produced by oral sedation.

Safety and Effectiveness

Oral Sedation dentistry allows you the confidence and peace of mind to experience dental procedures in a whole new way. Hours seem to pass like mere minutes so that necessary dental treatment can be performed comfortably. When you are relaxed you allow your dentist to be able to work more efficiently by focusing on the work at hand, with the confidence that you are comfortable.

A variety of oral sedative and anxiolytic medications have been developed especially for these purposes. They have been subjected to rigorous research and testing and have a long safety record after decades of use. In addition several have “amnesic” properties, meaning that you remember little to nothing after treatment.

The safety of sedation medications is measured by pharmacists and health professionals on a scale called the “therapeutic index.” The larger the number is on the scale, the safer the drug. Oral sedatives and anxiolytics used in dentistry have the highest numbers possible on the therapeutic index, making them the least likely to cause an adverse reaction.

How to Ensure Safety — What to Let Your Dentist Know

It is critical to provide your dentist with a complete health history including:

• Medical conditions for which you are being treated
• Any and all medications prescribed by a doctor
• Over-the-counter medications, remedies and vitamins (including aspirin)
• Alternative or herbal supplements: Many people seek relief from depression and anxiety symptoms with natural remedies like St. John’s Wort and Kava Kava. These may have a mild interaction with oral sedatives, so it’s critical that you tell your dentist if you are taking them. The medications and dosages for your oral sedation treatment can be adjusted to compensate for any interactions.
• Certain foods: Even something as seemingly insignificant as drinking grapefruit juice can have an effect on sedation. The enzymes in grapefruit interfere with the systems that metabolize (break down) certain oral sedation medications in your body, so you should not consume grapefruit 72 hours prior to or immediately after a sedation procedure.
• Also be sure to tell your doctor about factors like smoking and alcohol consumption, since these can influence the effectiveness of sedation medications.

Administer the Medication Yourself

Oral sedation is a popular treatment option for many people because it does not require injection, so if you’re afraid of “needles,” you needn’t worry. In fact, once you’re comfortable with oral sedatives, it may even be easier to have local anesthesia (numbing shots in the mouth) to further facilitate the ease of dental procedures. Oral sedation is a popular treatment option for many people because it does not require injection, so if you’re afraid of “needles,” you needn’t worry. Medications are given orally (by mouth). They are either placed and dissolved under the tongue, or they can just be swallowed whole.

Many dentists prefer the sublingual (under the tongue) route which works even more quickly. Taken this way they are absorbed into the bloodstream more rapidly. Both methods are safe and effective and work in a matter of minutes. You can even try the medication the night before to see how it affects you and also ensure a good night’s sleep.

Planning for Your Appointment

Once you and your dentist decide to use oral sedation for your next appointment, you will need to make some preparations:

• Your health history can affect your before-and-aftercare plans, especially for diabetics and smokers, so make sure your dentist knows about any medical conditions that you may have.
• You may be instructed to take oral sedation medication the night before your appointment to make sure you get a good night’s sleep.
• You should not eat or drink anything six hours prior to your appointment unless directed by your dentist.
• Be prepared to take time off from work following your appointment. For short appointments, only half a day may be necessary. If a longer appointment is planned, make arrangements to take the remainder of the day off.
• You will need a companion to drive you to and from your appointment; you should not drive or operate heavy machinery until the medication has worn off; this will vary depending upon what drug has been prescribed — follow the directions exactly.
• Be sure to stay hydrated and drink lots of fluids following your appointment.

Which Medication is Right for You?

While your dentist will decide which medications are appropriate for your treatment, being familiar with the different drugs available can be helpful for you. Knowledge about oral sedation is not only powerful — it is empowering.

There are several commonly prescribed medications, including, but not limited to Valium®, Halcion®, Sonata®, Ativan®, Vistaril® and Versed®. With the exception of Vistaril® and Sonata® they all belong to a class of medications called benzodiazepines. Benzodiazepines are prescribed for the treatment of anxiety, insomnia, agitation, seizures, and muscle spasms. Taken in small doses, they are highly effective at relieving the above mentioned conditions.

Each medication has a different duration of action (how long it affects you) and different half-life (how long it remains in your body). Dosages can vary greatly depending on whether swallowed whole or placed under the tongue in addition to the treatment protocols for which the sedation is being used. The drugs take effect anywhere from 20 minutes to an hour. Some varieties of the medication have “amnesic” properties, meaning that you remember little or nothing of your time in the dental chair after the procedure is completed.

Other Forms of Sedation Dentistry

• Inhalation Conscious Sedation is also known as “Nitrous Oxide/Oxygen Sedation.” Nitrous oxide, commonly and inappropriately called laughing gas, has been used by dentists for nearly 100 years. It is an excellent analgesic (pain reliever), but a less effective anxiolytic (anti-anxiety) medication. It is administered through a nasal hood, which is similar to a small cup placed over your nose. Nitrous oxide is extremely safe because it is mixed directly with oxygen to provide you with a feeling of euphoria or light-headedness. All bodily functions remain essentially normal. You may experience a tingling sensation from the use of nitrous oxide. However, its effects wear off almost immediately so there is no “hangover effect.”

In combination with an oral sedative, nitrous oxide allows your dentist to fine-tune the exact amount of sedation needed to provide you with the best possible experience.

• Intravenous (IV) Conscious Sedation also known as “Deep Conscious Sedation” is used by some dentists, and surgical specialists like oral surgeons and periodontists who must undertake specialized training and certification in IV use. With this type of sedation, medications are administered directly into the blood stream intravenously (intra-within, venous-vein). The main advantage of this method is that it works immediately and the level of sedation can be adjusted quickly and easily. There is a higher degree of risk associated with IV sedation since normal bodily functions especially heart rate, blood pressure and breathing can be altered necessitating specialized monitoring equipment. The drugs used for IV Sedation are more potent when given this way than when taken orally and amnesia may be more profound.

Finding the Right Dentist

Like any informed consumer, you will want to make sure that your dentist is qualified to provide sedation dentistry. It is a good idea to request information on your dentist’s training, credentials, and the techniques that may be used prior to an appointment.

You Are Not Alone

Talk to your dentist about your fears and concerns so that together you can decide on the best treatment for you. It’s important to remember that dentistry has come a long way. Years of research have been dedicated to studying and finding methods to alleviate pain and anxiety. There are safe and time-tested options available to ensure that you have a positive and painless experience. Step out from under the shadow of fear and into the calm of sedation dentistry. You are not alone and you don’t have to be afraid anymore.

Age One Dental Visit

By Dr. Joel H. Berg

When parents or caregivers mistakenly say, “They are only baby teeth, they are going to fall out anyway” they have the wrong impression. The Age One Dental Visit sets the tone for lifelong dental health. The fact is, primary teeth serve as the guides for the permanent teeth and are critically important to the health and function of their adult successors. What’s more, primary teeth are the child’s teeth for most of childhood — children don’t usually begin losing them until about age six, and the last primary teeth aren’t lost until around age twelve. It’s just as important to care for them as for the permanent teeth that come later.

An Ounce of Prevention

What really is prevention anyway? Prevention in the truest sense of the word means stopping an anticipated problem before it even starts. The importance of primary teeth and preparing for a lifetime of good oral health are the main reasons why parents should bring their children to see a dentist or pediatric dentist (children’s specialist), preferably before their first birthday. It’s more than just a casual visit: even a one-year old needs a comprehensive examination and even some preventive applications. Parents will benefit from the guidance of “Family Oral Health Education” including: risk assessment for decay; training (hands on) in teeth cleaning; nutritional counseling and use of cups for drinking; fluoride recommendations based on individual needs and important follow-up appointments for monitoring based on the level of risk determined by your dentist.

A baby’s first visit to the dentist sets the stage for lifelong oral health.

The Age One Visit may also reveal underlying conditions that may indicate future problems, and determine how often follow-up visits might be needed. Children with low risk for oral or dental disease might only be seen annually or semi-annually until the primary (baby) teeth are all fully erupted in the mouth and in occlusion (biting function). Children assessed at high risk might be seen as often as every two to three months.

Diagnosing and Treating Tooth Decay

One of the prime purposes for an Age One Visit is to examine the child for a number of forms of tooth decay that can affect babies and small children. For many years, health and childcare professionals have recognized a specific pattern of such decay, known as Baby Bottle Tooth Decay (BBTD). BBTD was believed to be primarily associated with the use of a sleep-time bottle that contains a liquid with natural or added sugars such as formula, juice or Kool-Aid. It generally occurs between the ages of twelve to eighteen months.

In recent years, similar cases of early and severe tooth decay have been found in children who do not fit the classic BBTD pattern of bottle use. The term Early Childhood Caries (ECC) is now being used to reflect a broader concept of the problem of tooth decay in infants and young children. ECC includes cavities associated with many causative factors, mostly sugars. These include continuous use of a “Sippy-cup,” at-will breast-feeding throughout the night, use of a sweetened pacifier or the regular use of sugar-based oral medicine to treat chronic illness.

For many years, health and childcare professionals have recognized a specific pattern of decay, known as Baby Bottle Tooth Decay (BBTD).

ECC develops rapidly — the progression from the hard, outer enamel layer of the tooth into the softer, inner dentin can occur in six months or less. It first affects the upper front baby teeth, which usually erupt at around eight months of age, followed by the primary molars (back teeth), which begin to erupt at about twelve months of age. At its most severe stage, ECC may then affect the lower front teeth.

The extent and severity of ECC can vary depending on culture, the child’s genetic makeup and socio-economic factors. On the other hand, ECC is really much like any other type of tooth decay, dependent on the presence of three conditions: specific bacteria in dental plaque on the teeth, unprotected teeth and the right mix of carbohydrates from food and drinks, such as natural or refined sugars.

“Here We Go Round and Round” — Breaking the Cycle of Decay

These conditions form a cycle of events, even in babies, that slowly unravel oral health: decay causing bacteria interact with the carbohydrates (sugars) to produce acid; the acid in continual contact with the teeth slowly demineralizes (dissolves) the tooth enamel; as demineralization continues, cavities form.

Because all three of these conditions must be present for a cavity to form, there are at least three opportunities for intervention: (1) eliminate or reduce the bacteria through oral hygiene; (2) reduce the presence and frequency of carbohydrates by dietary changes; and/or (3) make the tooth more resistant through the use of fluoride.

Until a child is about seven years old, an adult needs to brush the child’s teeth for them.

Age One Visits provide insight into these three opportunities for both the child and parents. For example, Age One Visits can help parents or caregivers learn the proper techniques for cleaning their children’s teeth. Until a child is about seven years old, an adult needs to brush the child’s teeth for them. Parents can allow the child to brush his or her own teeth, but at least once a day, preferably at bedtime, an adult should carefully and thoroughly brush the child’s teeth.

The child’s dentist can demonstrate the proper way to clean a child’s teeth, a procedure that usually takes less than two minutes with a very small child’s toothbrush or by simply wiping the teeth off with a wet cloth.

Dental professionals can also provide important information on the types of food and their frequency that promote a child’s oral health. At first glance, many foods like cereals, granola bars, and similar snacks may seem healthy and good for a child to have throughout the day. They aren’t — and neither are foods like raisins or fruit juices, even though they contain natural sugars and are full of vitamins and minerals. Carbohydrates in cereals, crackers, and granola bars will stick to the teeth where bacteria can easily interact with them over extended periods of time. And, regardless of whether the food contains processed or naturally-occurring sugars, bacteria metabolize both and form acid. Parents are advised to avoid giving their children sugary foods, especially in high frequency, that have any form of sugar listed as the first or second ingredient.

It’s not just baby drool; frequent snacking also inhibits one of the mouth’s most important cavity-fighters — saliva. Saliva neutralizes acid and supplies calcium and fluoride to protect and even reverse early decay. But it takes time — about two hours to neutralize the effects of acid. So, a snack every hour — which promotes the continual presence of acid in the mouth — won’t give saliva the opportunity to work effectively.

Breast Feeding, Baby Bottles and Other Practices

• Generally, breast-feeding is highly recommended for babies and doesn’t necessarily inhibit good oral health in young children. Breast milk by itself does not promote tooth decay any more than other forms of fermentable carbohydrates. On the other hand, once a child begins to consume foods or liquids in addition to breast milk, the combination of breast milk and other sugar-rich foods may potentially put the child at risk of developing ECC. Babies should be removed from the breast when they are finished feeding and children should not be allowed to nurse at will throughout the night.

• Baby bottles are frequently used by parents or caregivers to modify the child’s behavior by giving it during sleep time to stop fussing or crying. Other methods of improper bottle-feeding include propping the bottle or round-the-clock feeding. All these practices promote the constant production of acid in the mouth, so the use of baby bottles should be limited to meal-times.
• Pacifiers dipped throughout the day in a variety of different sweeteners, including jam, corn syrup or sugar, results in frequent exposure of the teeth to fermentable carbohydrates and promote higher acid levels in the mouth.

• Children with chronic illnesses or special health care needs may also be at increased risk of ECC if their medication contains sugar. Also, certain medications such as antihistamines may cause decreased saliva production causing mouth dryness and diminishing the protective effects of saliva. Daily oral hygiene care for these children is critically important.

• Every time bacteria are exposed to sugars, either refined or “natural,” they produce acid — so the more frequently a child eats sugar, the more frequently the teeth are exposed to acid. Frequent sugar exposures equals frequent acid exposures. Parents can therefore reduce the chances of their child developing cavities by limiting the frequency and amount of sugar their child consumes and not snacking on sugary products especially between meals.

Opportunity for Promoting the Entire Family’s Health

• A child’s oral health is closely related to the family’s overall dental health and hygiene practices. The Age One Visit can educate parents or caregivers on the importance of their own good oral hygiene.

• Children are not born with high levels of cavity-causing bacteria in their mouths. They acquire the bacteria from their caregiver, usually their mother, through close contact. These bacteria are transmitted through kissing, sharing eating utensils like a spoon or a glass, sharing food, or cleaning off a pacifier by mouth. The period when a child is most susceptible to acquiring the decay-causing bacteria is quite short, beginning as early as six months of age and continuing through approximately thirty-one months.

• There is mounting evidence that a child’s oral health is closely tied to his or her mother’s. This is why it is important that caregivers of young children promote their own oral health through regular dental visits and proper hygiene habits. The Age One Visit is a good reminder — and a learning opportunity — for proper hygiene and care.

• Diagnosis, prevention, education and treatment — the Age One Visit can cover a lot of ground for your baby’s first visit to the dentist. Most importantly, the immediate diagnosis and treatment of emerging dental problems, as well as the long-term attention to good oral hygiene, can help build a foundation of good dental health for your child — and your entire family — that will last a lifetime.

By Dr. Dennis J. Wells

The notion of adding materials to teeth in order to change the way they look is nothing new to dentistry. Traditionally, teeth are prepared in some way or fashion in order to place and retain a restorative material — typically a filling, porcelain veneer or crown. Not only is tooth reduction generally necessary to restore lost or damaged natural enamel as a result of the ravages of tooth decay or trauma, but it is also necessary to create room to place an aesthetic and functional “restoration.”

The purpose of this article is to introduce and provide a clear understanding of an alternative cosmetic treatment option, the “no-prep” or “prepless veneer,” whereby no drilling is required to enhance a smile. It also endeavors to bring clarity and understanding to the numerous areas of confusion regarding this treatment modality. Most importantly, it examines the case selection process; when prepless dentistry will work and when it won’t. As with almost all dental and medical procedures, there are risks, benefits and alternatives. It is with the help of a dental professional experienced in these advanced techniques, together with your own goals and understanding, that you can make decisions that are right for you.

No-Drilling: Reality Or Ridiculous?

“Prepless veneers” is a concept that elicits various reactions and opinions among dentists, ranging from absolute disbelief that they can facilitate effective restorations, to appreciation for these conservative and advanced works of art! This range of opinion about a novel approach to cosmetic dentistry is vast and with good reason. The concept of “additive only” restorations intuitively causes the experienced clinician reason for concern as visions of bulky, over-contoured teeth quickly come to mind. Unfortunately, some prepless techniques and products circulated heavily in the media have shown thick, bulky looking restorations, causing skepticism among some dentists and consumers alike.

And yet, despite these concerns, an undeniable trend is emerging among many esteemed cosmetic dentists to incorporate not only minimal prep, but also “no-prep” restorations into their compendium of viable treatment options and alternatives. In recent years, new developments in techniques and materials have resulted in a fresh look at the aesthetic possibilities for the no-prep veneer option. Cases done by talented dentists and lab technicians have produced results which would meet the highest standards in cosmetic dentistry [Figures 1 and 2]. Part of the advanced level of training for prepless veneers includes the important aspect of proper case selection. Not every situation lends itself to a no-prep approach, but when it does, the results can be not only beautiful, but also stable and reversible!

Paradigms and Beliefs — A Shift

The promotion and endorsement of “prepless” veneers is predicated on the following paradigms and beliefs:

• It is not necessary to prepare a tooth to create a border (known in dental terms as a “margin”). Highly skilled dental technicians can design a custom-fit veneer that feathers into the tooth just short of the gumline.
• Aside from the other obvious benefits of prepless veneers, they are not placed under the gum tissue. This eliminates the risk of the restorations having a negative impact on the periodontal (gum tissue) health.
• In many cases it is possible to use an additive-only approach to create aesthetically pleasing and natural-looking restorations without reducing the underlying tooth structure.
• Consumers who are looking for a way to enhance their smiles are more likely to seek out and accept a no-prep approach with a highly-skilled dentist in situations in which they don’t need aggressive enamel removal.

Potential Cases for No-Prep Veneers

• There are a significant number of patients who have relatively small teeth for a variety of reasons:, e.g. external causes such as acid erosion; genetic factors resulting in naturally small teeth and in spacing between the teeth; discrepancies between jaw size and teeth size — to name a few. These instances all provide potential candidates for “prep-less” restorations [Figures 3 and 4].
• Orthodontic cases that involved the extraction of teeth to solve a crowding problem typically result in narrow arch forms with the teeth that sometimes tilt inwards.
• Short, worn teeth — creating a smile with more visible tooth length can sometimes “turn back the clock” for someone who has worn their teeth down by grinding.
• Narrow smiles — Many times, the teeth in the sides of the smile are positioned inward and do not show from a frontal view.
• Teeth that need to be more visually present, e.g. when big lips may overpower them, or the teeth are too small in relation to the overall smile.
• Teeth that are genetically misshapen; “Peg laterals” is a fairly common condition in which one or both of the teeth directly next to the two upper front teeth are very small and peg-shaped.

When No-Prep Veneers Won’t Work

While no-prep veneers can make many positive changes, there are some situations that no-prep veneers can’t correct. In cases that involve improper tooth position, large discrepancies in root position, poor bite relations or a poor facial profile, some form of orthodontic treatment will be required to mechanically move the teeth. If orthodontic treatment is declined, some amount of tooth preparation may be required to create the illusion of proper alignment. When veneers are used to “camouflage” improper tooth positions, it must be with an understanding of the degree of limitations and risks.

Not every smile can be enhanced with prepless veneers. Teeth that are already relatively large or positioned forward in the smile do not typically lend themselves to adding another layer of thickness. In these situations, careful decision-making in partnership with your dentist will be necessary to explore other options that might involve tooth preparation or orthodontics.

There is no substitute for an expert dentist’s talent and expertise in the various cosmetic techniques. These skills — combined with a clear understanding of an individual’s goals and determination of the clinical needs obtained by a thorough diagnostic evaluation — are critical to ensuring a successful and beautiful smile.

Test-Drive Your Smile: Another Benefit of Prepless Veneers

Committing to porcelain veneers can take a great deal of faith on the part of a patient because once the teeth are permanently reduced, there is no reversing the decision to have veneers designed. With no-prep veneers, the process is reversible (though removing them is not an easy task and best accomplished using a laser) and practically risk-free.

If a patient qualifies for prepless veneers, a highly-skilled dentist can artistically design hand-sculpted prototypes in order to allow both a preview and “test-drive” of a new smile. In this prototype phase, changes can easily be made to the tooth-colored materials and to capture them as a blueprint for the laboratory technician who fabricates the final veneers.

While this same approach can also be used for traditional veneers, the difference with no-prep veneers lies in the fact that the prototypes can be easily removed and the patient’s original smile is unaltered.

A Preview of Coming Attractions

After a discussion about the goals and anticipated outcomes of the smile enhancement, detailed diagnostic records are gathered prior to beginning any dental restorations.

A comprehensive smile analysis is completed in order to compile information about the function and health of all the dental structures including the surrounding lips and facial features. Sometimes, a simple “mock up” can be made as a rough sketch in an effort to determine the feasibility of a prepless approach. The prototypes allow evaluation of the results in temporary materials before even making the final veneers. This is where an understanding of natural tooth shapes and contours allows an experienced cosmetic dentist to create the changes necessary for creating a natural looking smile.

The prototype stage allows individuals the exciting prospect of being involved in their smile design process. They can interact with their dentists providing feedback on shapes, sizes, and even colors of the new teeth. The prototypes can be test driven for several weeks while they are duplicated in the final porcelain veneers.

Once the laboratory technician has fabricated the custom porcelain restorations, the prototypes are removed and the final veneers are bonded directly to the enamel on the front surface of the teeth. The porcelain is then carefully contoured and polished to exactly mimic the natural teeth.

Questions to ask your dentist

• Am I a candidate for prepless or drill-free veneers?
• Can you create prototype veneers for me to test drive what my new smile will look like?
• How much will the prepless or drill-free veneers cost?

Conclusion

Though additive-only techniques cannot be used in every case, prepless veneers should be considered for their benefits in cases where they may apply in whole or in part. A prepless approach requires specific skills and training together with a keen sensitivity to natural tooth contours. Those who want to explore this as an option should consult with a dentist whose credentials and experience demonstrate an understanding of this technique-sensitive option.

More and more, dentistry, like medicine, is finding ways to be as conservative as possible while providing the best possible results. No-prep or prepless veneers are one way to improve and enhance smiles without the downside of drilling away healthy tooth enamel.

Don’t wait for cavities to occur and then have them fixed — Stop them before they start

By Dr. V. Kim Kutsch and Dr. Douglas A. Young

Modern dentistry is moving towards an approach to tooth decay management that is evidence-based — meaning it is based on years of systematic, accumulated, and valid scientific research. In other words, using current science, your dental treatment is tailored to your actual risk rather than a “one size fits all” approach. The previous method of “drilling and filling” to treat decay does not change the conditions that lead to the disease in the first place, so that the risk for further infection still remains. What follows below are facts you should know to change the conditions that lead to decay!

A New Look At Dental Decay — A Dynamic Infectious Disease Process

To help you understand, think of the mouth as an ecosystem, where living organisms continually interact with every other element within their environment. The teeth are composed of an outer covering of enamel, a highly mineralized and crystalline structure composed mainly of calcium and phosphate. The teeth are bathed in remarkable fluid— saliva. While it has many functions, one of the most important is its role in maintaining a neutral pH environment or balance between the acids and bases found in your mouth. Acidity is measured scientifically by the pH scale, which ranges from 1 – 14. A pH value of 1 is extremely acidic while a pH value of 14 is extremely basic. The pH of the mouth is generally 7 – neutral.

The oral environment is loaded with bacteria with some of them having the potential to cause decay. Specific acidogenic (acid producing) bacteria attach themselves to dental plaque, the whitish sticky biofilm that collects and forms on the teeth. When you eat sugars or carbohydrates, these acidogenic bacteria break down the sugars and produce acid as a by-product, which in turn drops the salivary pH. At about pH 5.5, the minerals just below the enamel surfaces of the teeth begin to dissolve in a process known as de-mineralization. During this process, more calcium and phosphate leave the surface of the teeth than enter it — the first step in the decay process leading toward cavity formation. And because a tooth’s roots are made of dentin, which is softer than enamel, they are more susceptible to decay. For example, the roots of an exposed tooth will de-mineralize quickly and easily with even weak acids at pH 6.0 – 6.7, which is much closer to neutral.

Why Me? How To Assess Your Risk

Given similar habits, you might wonder why some people get cavities and others don’t. Dr. John Featherstone, an imminent researcher studying the effects of all these different factors, introduced the concept of the Caries Balance in 2002, in which he demonstrated that both the disease, dental caries, and dental health are a delicate balance between pathologic (disease causing) and protective (health promoting) factors. This dilemma can be further explained by understanding that individuals have their own unique balance, similar to a playground’s seesaw that is constantly changing. The challenges are to identify what is out of balance and how to tip it towards health and protection.

It’s Sort Of Like…

A great analogy is likening caries risk assessment to how a physician assesses risk for cardiovascular (“cardio” – heart; “vascular” – blood vessel) disease. The physician reviews your health history, takes your blood pressure, monitors your heart, and provides a treatment plan that may include prescription medications to reduce or manage risk. If your blood pressure is high, it doesn’t indicate that you have had a heart attack or stroke or that you definitely will one day. However, it does mean that you are at higher risk for having a heart attack or stroke and that it would be wise for you to take preventive actions! Some of these include: changing your life-style in terms of diet, exercise, and perhaps medication for lowering your risk.

This same process is precisely what we are doing in dentistry today with the CAMBRA approach. We are providing individualized dental care so that we can minimize your caries risk. In fact, modern dentistry can now evaluate risk factors for dental caries disease and use them to make preventive recommendations with the goal of lowering the risk of tooth decay. And as a result, create more predictable, longer-lasting results for any cosmetic or restorative dental procedures.

New Tools Of The Trade

As we’ve already said, not everyone has the same risk level for developing dental caries. This is further complicated by the fact that risk is dynamic and changes daily, as well as over longer periods of time. Therefore, assessing the degree of risk is crucial. And let’s not forget that prevention includes determining both pathogenic and protective factors — both sides of the balance.

Simply put, there are factors that tip the balance. Some of these include: Disease Indicators and Risk Factors that lead to imbalance, which underscores the risk of disease. Protective Factors shift the balance toward health. These entities are measurable and quantifiable; but importantly, they are modifiable thus leading to predictable preventive and treatment outcomes.

From Research to Practice

By profiling individuals’ degree of risk and implementing preventive strategies to keep their teeth decay-free for life, today’s dental professionals are using a more proactive approach. We’ve summarized these points in the illustrations of the caries balance and imbalance to show you how to identify your own risks. Not only do these illustrations show you what is out of balance, but they also show you what is required to correct it. Mastering the skills necessary to determine risk accurately is greatly aided when your dental professional uses a caries risk assessment form to ask you specific, scientifically validated questions to help pinpoint imbalances. And once an imbalance is identified, corrective action should be taken.

Your dentist may use two types of forms to help assess and manage your risks. One is for children between the ages of 0 – 5 and the other is for everyone (including adults) over the age of 6. The simple form we’ve included shows how easy it is to access and record your Disease Indicators and Risk Factors.

Disease Indicators

Psychologists tell us that the best predictor of future behavior is past behavior. That’s sort of how Disease Indicators work; they are clear signs of what could happen based on what has happened. Identifying them includes the use of modern dentistry’s most sophisticated tools for early diagnosis of decay. This topic will be discussed at length in the next article in this series, “Minimally Invasive Dentistry.”

Here are a few highlights:

Visible cavitations: Decay that is visible in teeth ranging from very early (microscopic) detection using, for example, innovative laser technology, to cavities that are visible to the naked eye.

Radiographic lesions: Early decay that is visible by using today’s highly sensitive yet low dosage x-rays (pictures).

White spot lesions: The first sign of decay in the contacting surfaces of the tooth’s enamel that is often reversible with fluorides.

Cavity within the last 3 years: Any previous cavities add to your risk of further disease.

Risk Factors

A Risk Factor is a variable associated with an increased chance of disease or infection. Risk factors may be linked with a disease, but they do not necessarily cause the disease. For example, it is inaccurate to say, “being young causes tooth decay” just because young people are at a higher risk due to the fact that young enamel is less resistant to decay.

Visible plaque: Dental bacterial plaque, now known as biofilm, is the whitish film that collects on teeth in the absence of effective oral hygiene. When it is clearly visible, it means there is a very high quantity of it. And if the pH of the mouth is low (acidic), the biofilm are especially prone to contain decay producing (acidogenic) bacteria.

Inadequate saliva flow: As we stated earlier, your saliva is critical for protecting your teeth against decay. If you have poor salivary flow (dry mouth), or if its ability to neutralize acid is diminished, protection against decay is seriously compromised. This is considered an extreme caries risk.

Medications that cause dry mouth: Many medications can cause hypo-salivation (“hypo” – below or under; “salivation” – saliva production) leading to dry mouth, which significantly increases the risk of decay. This is also considered an extreme caries risk.

Frequent snacking: Eating sugars, refined carbohydrates, and acidic foods actually promote acid producing “BAD” bacteria, as discussed earlier. Eating a healthy diet will help, but so will reducing how often and how long you expose your teeth to them.

Appliances: Retainers, orthodontic appliances, and bite or night guards all tend to restrict saliva flow over the teeth causing stagnation and promotion of dental bacterial plaque.

Deep pits and fissures: The shapes of teeth vary from person to person thanks to your genetic make-up — another thing you can blame or give credit to your parents for! In other words, your genetics control how deep the tiny grooves (fissures) and pits are on your tooth surfaces. And the deeper they are, the more likely they are to harbor bacteria you just can’t reach or remove with a toothbrush.

Acidic beverages or foods: Not only do acidic beverages and foods increase your risk of tooth decay by promoting the growth of aciduric (acid loving) bacteria, but they also can also directly cause erosion of the whole enamel tooth surface in addition to the areas that usually decay.

Other: Conditions like bulimia and anorexia (psychological conditions in which individuals induce vomiting), and GERD (Gastro-Esophageal Reflux Disease) can create highly acidic conditions in the mouth causing severe erosive damage to teeth.

Testing

Why wait for disease to start with early white spots or cavities when today it is possible to test for the acid-producing bacteria by taking a sample of the biofilm and testing it for acid producing bacteria? For example, if an acid producing biofilm is detected early, you can avoid passing these germs to others as parents and caregivers do unintentionally to infants. Or why not try to eradicate these bacteria by changing the conditions (pH balance) of the mouth? Testing meters can now give estimates of acid producing bacteria in 15 seconds. A reading from 0 – 1500 correlates with low risk and a reading of 1501-9999 correlates with higher risk. This simple and inexpensive test can also be repeated after treatment and is a great motivational tool for both patient and dental professional alike as everyone likes to know if change is working!

Diagnosis and Prognosis

A diagnosis can now be made based on your individual risk from the facts collected on your caries risk assessment form. This is important for three basic reasons: firstly, it is based on identifiable evidence; secondly, the risk can be modified based on recommendations and actions; and thirdly, repeating the procedure can objectively measure change to reduce your risk and improve your health. This affects your prognosis or the ability to predict the probable course and positive outcome from taking action.

Prescribe

In addition to the traditional things you’ve always been told to do like brush, floss, pay attention to your diet, and see your dentist regularly, treatment and preventive strategies are now based on your individual risk rather than treating everybody with the same approach.

If your risk is high, your dental professional may prescribe a program to reduce it. Some of the newer and more specific agents include:

• Rinses containing a safe dilution of sodium hypochlorite solution that can kill bacteria and raise pH (lower acidity) in those individuals found to have high acid producing bacteria levels. Other products are available that are designed to balance an acidic mouth and keep the pH neutral and encourage more normal bacteria.
• Rinses containing chlorhexidine, an antibacterial agent that has been used for eons to reduce bacteria, to disrupt their influence, and to lower the counts of those causing disease.
• Fluoride containing rinses to strengthen enamel surfaces making them more resistant to decay while encouraging re-mineralization.
• Xylitol, a natural sugar alcohol used for years as a sweetener and alternative to sucrose (table sugar), is known to disrupt the ability of acid-producing bacteria to thrive and attach to teeth. Xylitol is available in a rinse, spray, chewing gum, as well a breath-mint.

Once your risk has been modified and reduced, the level of prevention and treatment can be matched to it. For example, you can move from a treatment strategy to more of a preventive one.

Partnership

Finally, it’s about partnership. Your relationship with your dental office team is based on both a scientific approach as well as caring health professionals who have your best interest at heart. Working together, they will ensure that dental decay is a disease of your past so that you can enjoy a lifetime of good oral and dental health.