Dyract® eXtra

Information on diagnosis, treatment planning and re-evaluation with patients requiring eXtra care

The following information, which is intended as a guide for correct preventive treatment, is taken from the handbook, “Professional prophylaxis in the dental practice“ (2nd Edition, 2003), German Chamber of Dentists (BZÄK). Handbooks on this and other topics can be obtained from the BZÄK.

We would like to thank the BZÄK for their kind permission to print extracts from the handbook.

1. Anamnesis

A professional anamnesis, family anamnesis as well as medical anamnesis (e.g. general illnesses, long-term medication, injuries, operations, traumata, evaluation of the patient’s general condition), behavioural anamnesis (e.g. dietary and oral hygiene habits, smoking, inability or unwillingness to cooperate) and oral health data (e.g. according to the Oral Health Impact Profile, OHIP) not only provide personal data but also important information about the (medical) history of the patient and are important factors in determining subsequent intervention.

2. Oral cavity records

Existing fillings, carious lesions and factors that affect the risk of caries or periodontitis should be recorded. All these factors have to be assessed before a proper diagnosis can be made.

2.1 Hard tissue records

• Dental records
  Existing teeth affected by caries, differentiated according to the initial lesion (limited to the enamel), cavitations and/ or lesions in the dentine should be recorded. The DMFT index, malocclusion and information about the occlusion are also recorded.
• Restorations
  The extent, position and material of the restoration as well as defects on the restoration should be recorded.

2.2 Soft tissue records

• e.g. oral hygiene and plaque indices
  Various indices can be used: approximal area plaque index, Silness-Löe index, Quigley-Hein index, plaque formation rate index, periodontal screening index.
• Gingival inflammation
  e.g. sulcus bleeding index or papillae bleeding index, bleeding on probing (BOP with periodontal pockets)

2.3 Clinical functional analysis

• In the case of suspected craniomandibular dysfunction (CMD)

2.4 Tooth position and occlusal relationship anomalies – orthodontic records

• Classification according to the degree of severity to assess the need for treatment e.g. according to the KIG model.
• Documentation of Angle classes, deep bite, overcrowding etc.

2.5 Changes to the oral mucosa

2.6 Other records

3. Assessing the risk of oral disease, diagnosis and treatment planning

Risk assessment is based on various factors, e.g. the duration and extent of caries or periodontitis in the patient, the amount of pathogenic bacteria and any other parameters that also affect the disease, e.g. standard of oral hygiene and nutrition.  In a risk assessment these risk factors are used with specific weighting factors, which allow the risk to be assessed as high, medium or low (cf. ADA chart for assessment of a high caries risk). The level of risk determines the extent of preventive measures, some of which can be carried out by the patient as well as professionally in the practice. The ratio between domestic and professional preventive measures depends in part on the cooperation and capability of the patient. Records of existing caries, defects in restorations, lesion activity as well as the level of risk are all assessed by the dentist in making a correct diagnosis specific to the tooth area. This diagnosis is the basis for determining preventive and treatment requirements.

There are different options for preventive and treatment measures depending on the risk of caries or periodontitis and the actual diagnosis. After informing the patient of the options, the dentist has to decide in consultation with the patient on an appropriate strategy for intervention and prevention.

Cooperation on the part of the patient and the patient’s financial circumstances should be taken into account as well as dental and clinical considerations.

4. Appropriate prophylactic intervention

The primary function of preventive measures is to reduce causal and predisposed risk factors and the secondary function is to support the treatment of existing carious, gingival or periodontal lesions.

The type of prophylaxis depends on the results of the risk assessment; in principle, this does not depend on the age of the patient and should in fact be available to patients throughout their life. For children and teenagers up to the age of 16/18 years prophylactic treatment is currently financed within the parameters of the GKV (statutory health insurance). The latter applies to Germany, only.

4.1 Oral hygiene
The main aim of preventive treatment is to provide an effective oral hygiene regime that suits the age of the patient; preventive treatment can be supported by additional measures for showing up plaque (colouring agent) before and after oral hygiene measures to indicate problem areas and achieve improvement. The patient should be given advice on the correct oral hygiene aids (e.g. toothbrush, dental floss, interdental brush, dental sticks, toothpaste) as well as the correct oral hygiene technique. This should be preceded by scaling and polishing.

4.2 Fluoride application
A professional local application of fluoride gel or varnish is recommended if there is an increased risk of caries; in the case of a moderate risk two applications are recommended twice a year and with a high risk two applications are recommended at least every three months or even every week. The importance of fluoride application by brushing the teeth twice a day with fluoride toothpaste, without rinsing thoroughly after brushing, should again be underlined.

4.3 Chemical plaque reduction
Plaque reduction can be effectively supported on the one hand by mechanical oral hygiene using a toothbrush, dental floss and interdental brushes particularly in the approximal area and on the other hand by pharmaceutical solutions.

Chlorhexidine solutions with 0.1 – 0.2 % active substance can be used effectively as a rinse for reducing plaque; these solutions have a high substantivity and are crucial in the treatment of periodontal problems. Any side effects such as brown discoloration, mucosal irritation or impairment of taste should be noted, though these can be controlled with good mechanical oral hygiene.

Rinses containing amine fluoride, tin fluoride or triclosan are also recommended for plaque reduction.

4.4 Nutrition
Individual nutritional advice, if possible based on a diet protocol, can contribute to caries prevention in children and teenagers by highlighting any hidden sugar content and by helping change diet-related exposure frequencies. Even in an adult a sudden change of dietary habits (new drink) can contribute to an increased risk of caries.

There is also a connection between modern dietary habits and greater exposure of the oral cavity to acidic products, which increases the risk of erosion. In the case of illnesses like bulimia, anorexia or alcoholism there is continual etching of the tooth structure by gastric acid.

4.5 Medication
Finally, long-term medication that can lead to reduced salivary flow with increased bacteria count and even candida infection in older patients should be noted during patient consultation and examination.

5. Preventive re-evaluation – Recall

In accordance with systematic, preventive-orientated dental and oral medicine, successful treatment is followed by a preventive re-evaluation to assess the risk of oral disease and to motivate the patient. The risk of oral disease can only be determined by repeated assessment of the oral risk factors.

5.1 Determining caries activity
Caries activity can only be assessed retrospectively following re-evaluation of the extent of the caries and in particular initial carious lesions (white spots on smooth surfaces and discoloured fissures or pits).

During clinical examination it is, however, possible to assess caries activity based on the structure of the lesion. Active carious lesions depend on the standard of oral hygiene and are usually covered with plaque before examination. They have a dull, rough appearance in the enamel, while inactive lesions have more of a shiny appearance and are more frequently plaque-free.

 
ADA chart for assessing a high caries risk*
Age and group classification for recall patients

*Source:
Caries Diagnosis and Risk Assessment.
A Review of Preventive Strategies and Management, JADA, Vol. 126, June 1995 7-S
 – Extract–

5.2 Determining the risk of caries
Causal and predisposed factors, which mainly involve the assessment of caries activity (DMFT and DMFS) and initial caries, are recorded to assess the risk of caries; it is important to assess caries activity as a whole and not just the individual components! Functional saliva parameters (pH, buffer capacity, flow rate) can also be recorded and the bacterial saliva parameters (streptococcus mutans, lactobacilli count) determined. As well as determining the pH of the oral cavity with the saliva test, it is now also possible to determine the amount of lactic acid in the oral cavity produced by plaque.

Source:
BUNDESZAHNÄRZTEKAMMER (Hrsg.) (2003): Qualifizierte Prophylaxe in der Zahnarztpraxis – Leitfaden der Bundeszahnärztekammer, 2nd Edition fully revised and updated; P. 31-34