CASE STUDY 1

Savannah is a 4-year-old girl coming to your office for the first time. She is wearing a pretty dress and sparkly shoes, and she has a pink bow tying her long black hair up in a ponytail. She is obviously frightened. As you escort Savannah and her mother to the treatment room, the only thing Savannah says is that she does not want silver teeth. Savannah has an unremarkable medical history, takes no medications, is current with her vaccinations, and has no allergies. When you ask Savannah if any of her teeth hurt, she quietly nods. Upon being asked whether Savannah has been to the dentist, her mother explains that Savannah lived with her aunt for several months and during that time had been taken to her aunt's dentist. Her aunt's dentist had recommended stainless-steel crowns for Savannah's carious teeth #E and #F, but the aunt did not want to have the crowns placed without Savannah's mother's permission. Savannah is covered by insurance, but the insurance pays only for stainless-steel crowns, and Savannah's mother admits to having been unable to afford the tooth-colored crowns until now.

Establishing a caries risk level for this child should be easy, as her mother admits that she has active carious lesions. What is her caries risk level? One look at Savannah's cute smile reveals severe caries on teeth #E and #F. At this point, you complete the caries risk assessment form, determining the child's fluoride exposure level, oral hygiene routine, and snacking habits. Savannah's mother works full time and has two children, Savannah and her 3-year-old sister, Lillian. Savannah's mother admits that the girls don't brush their teeth regularly, as they commonly fall asleep in front of the television and are carried to bed. A typical breakfast consists of sweetened cereal, milk, and a juice box. They eat lunch at the babysitter's, and their mother tries to make them sit down to have dinner each night. The girls like to eat candy after dinner, frequently not eating all their dinner in order to save room for the candy.

Treating Savannah's oral conditions will be a long process. Because her caries risk is high, each appointment should include a short nutritional counseling session, which can be added to the treatment plan. If Savannah were your patient, what would be your plan for preventing new carious lesions? What would you consider to be a manageable step 1 for this child?

Treatment Plan

Savannah has ECC, with several carious lesions in each quadrant needing extensive restorative intervention. Her mother does not want her sedated, so the restorations will require no fewer than five appointments.

Vision for Preventing New Carious Lesions

Restore all existing cavitated lesions, promote remineralization of the noncavitated lesions, develop excellent oral self-care habits, and perform preventive dental hygiene care every four to six months until no new caries activity has been observed for a period of three years. In other words, the goal is to reduce Savannah's caries risk to low. It is imperative to break the chain of the four elements required for caries activity: Caries-causing micro-organisms, a susceptible tooth surface, fermentable carbohydrates, and time.

What Would You Consider to be a Manageable Step 1?

Initial examination should include simple nutritional counseling and thorough oral hygiene instruction that includes both the mother and child. Poor oral hygiene and eating habits are difficult to change. A good first step may be to give the family the goal of brushing their teeth after each meal. Discuss the bacteria and food that remain on teeth after eating and how they need to be removed after each meal. Comparing this process to the habit of washing hands before each meal to remove bacteria and dirt may help the child make the connection. Have Savannah's mother complete the Nutritional Questionnaire and Food Log and bring it to the next nutritional counseling session.

CASE STUDY 2

Mr. Ribeiro, a 68-year-old male, arrives for his dental hygiene recare appointment. He is a pleasant, retired gentleman. He appears happy, healthy, and quiet, as usual. His medical history is unchanged from his last visit six months ago. He has high blood pressure and prostate malfunction. He takes losartan, finasteride, and terazosin. He has no dental complaints. During your oral health and caries risk assessment, you detect very little plaque biofilm, no bleeding on probing, stable periodontal health, adequate saliva flow, a broken cusp on tooth #31, and what appears to be a recurrent carious lesion under the crown on tooth #8. As you complete your caries risk assessment, your first inquiry goes as follows:

Q: How often do you brush?

A: Three times a day.

Q: How do you clean in between your teeth?

A: I use that flosser thing three times a day.

Q: Do you snack?

A: Not very often.

Q: What do you drink when you're thirsty?

A: Water.

Dental professionals commonly see this scenario. The patient knows all the right answers, and you can't dispute his oral health routine, as his periodontal condition is excellent. However, he does have recurrent decay on tooth #8.

What follow-up questions might you choose to ask to fill in the blanks about the role his nutritional intake may play in this case?

Recalling the four factors necessary for the caries disease progression—susceptible tooth, diet, time, and bacteria—you need to be a bit of a detective. Mr. Ribeiro's history of dental care also includes several crowns and a recent restoration. This tells you that his teeth are susceptible. He maintains a clean mouth, or so he says, so you must consider that he removes the oral bacteria from his teeth regularly. Diet may be the culprit.

A good way to begin with a patient who knows all the right answers and does not want to be lectured might be to go through your caries risk assessment out loud. Begin by telling him why you are asking these questions. Tooth decay is preventable, and you want to help him prevent the need for more costly crowns and fillings in the future. Ask him to tell you what he has eaten in the past 24 hours. Share with him that even though he brushes three times a day, the bacteria and acids on his teeth will eventually begin to demineralize his teeth. Often, letting that fact form a picture in a patient's head can spur questions or even solutions for reducing the risk. Change is most likely to happen when the patient is a partner in the change.