#54680: Caries-Prone Patients: Prevention, Assessment, and Intervention

Untreated dental caries among deciduous ("baby/milk") teeth is the most prevalent childhood ailment, affecting 514 million children globally. Overall, dental caries affects 97% of the global population at some point in their lives [3,4]. The accepted theory of caries formation is related to the acids produced by oral bacteria removing tooth surface minerals, eventually causing a cavitation. Streptococcus mutans (S. mutans), S. sobrinus, Bifidobacterium species, and Lactobacillus micro-organisms have all been found to aid in caries progression [5,6]. These same bacteria are associated with root caries, as are the micro-organisms Actinomyces viscosus and A. naeslundii, which are notably present in active lesions [7].

Infants are not born with pathogenic oral bacteria but can acquire them from the skin or vaginal area during delivery or from family members with whom they are in close contact [8]. It has been determined that these bacteria can be transmitted between individuals through kissing, sharing eating utensils or cups, and other interactions. Studies have demonstrated that the mouth of the neonate is colonized by bacteria that resemble those from the oral cavity of the mother [9]. Women of childbearing age, parents, and caregivers of young children should be educated about the potential to transmit the bacteria contributing to dental caries.

All erupted teeth have the potential to develop caries lesions. However, teeth with optimal fluoride content are more resistant to caries lesion development than are teeth lacking in fluoride, as fluoride has an essential role in protecting enamel from demineralization [10]. Patients with recession (exposed root surfaces) are at increased risk for dental caries because roots do not have enamel, the extremely hard and most caries-resistant material surrounding the crown of the tooth.

A diet high in sugar, including fermentable carbohydrates, increases the likelihood of developing dental caries. Included are foods that are innately sugary (e.g., juices), those with sugar added (e.g., soda and candy), and starchy foods that break down into sugars in the mouth (e.g., breads and crackers).

When fermentable carbohydrates are introduced into the mouth, the sugars begin to be broken down to acid by oral bacteria. This acid lowers the pH of the saliva and oral plaque biofilm and may increase the rate of demineralization of tooth surfaces. Tooth enamel begins to demineralize at a pH of 5.5, and root surface demineralization occurs at an even milder pH of 6.2 [11]. Once the pH dips into these ranges, the outer layer of the tooth loses minerals. This causes a loss in surface hardness and increases the possibility of caries lesion progression.

Time is a contributing factor in the caries process because the probability of caries increases as the frequency of acid formation from fermentable carbohydrate–rich food sources increases [6]. Simply stated, the more often fermentable carbohydrates are ingested, the more often salivary pH will decrease, and the greater the likelihood that teeth will experience demineralization. The extent of demineralization depends on the length of time the acidic biofilm is in contact with the tooth surface and the frequency of this contact. Caries lesions are the result of repeated or extended periods of demineralization.

To prevent tooth decay, the American Dental Association recommends the following oral hygiene behaviors [16]:

Since the average patient brushes for less than one minute and few adults floss daily, it is important to review the ADA guidelines with patients at dental visits. To increase patient acceptance and understanding of oral hygiene instructions, it is advantageous for the dental professional to give patients the opportunity to demonstrate oral hygiene techniques. This allows the patient to receive feedback and gain confidence.

Power toothbrushes may be advisable for some patients because they are better than manual toothbrushes at reducing dental plaque levels and can be an exceptional oral hygiene tool for orthodontic patients and those with limited manual dexterity [16]. Timers may also be recommended to ensure that patients are brushing for a full two to three minutes.

Snacking is a common habit in the United States, with 90% of U.S. adults reporting one or more snacks per day—which accounts for approximately 22% of their daily energy intake [18]. Snacking promotes caries for a number of reasons. First, patients do not often brush or floss after eating snacks, leaving food debris and dental plaque biofilm in the mouth for extended periods. Second, most snack foods either have elevated sugar content or—like potato chips and crackers—are high in fermentable carbohydrates, allowing for acid formation from oral bacteria. Third, snacks are usually eaten throughout the day, permitting oral bacteria to produce acid and lower the salivary and plaque biofilm pH multiple times in a relatively short period.

Snacking habits have changed over the years, making it important for dental professionals to stay abreast of healthy options and nutritional evaluation techniques. Over a span of 35 years—between 1977 and 2012—there was a significant increase in per capita energy intake from snacking. The snack foods and beverages consumed were typically sugar-sweetened beverages, desserts, sweets, and salty snacks, the consistent consumption of which is not ideal for oral or systemic health [18]. The consumption of such snacks between meals or at a time that is typically not conducive to tooth brushing leads to a cumulative effect of an increased potential for the development of carious lesions. It is estimated that in the United States, approximately 22% of the daily caloric intake is from snacks that are sweet, salty, or desserts despite dietary guidelines that these items should comprise a limited portion of the daily caloric intake [18]. Even patients trying to eat healthfully may fall prey to ingesting excessive sugar because many snack foods marketed as "low-fat" have increased sugar per serving to improve taste once the fat is removed.

The average American consumes approximately 20 teaspoons of sugar every day via ingredients in foods and beverages such as fructose, dextrose, and high-fructose corn syrup [19]. The amount of sugar in the typical American diet not only promotes caries but also underlies the increase in obesity, heart disease, and diabetes in the general population. The American Heart Association recommends that men consume no more than 9 teaspoons (36 grams or 150 calories) of added sugar per day and that women consume no more than 6 teaspoons (25 grams or 100 calories per day) of added sugar per day [20].

The Nutritional Questionnaire and Food Log shown in Table 1 is an example of a dietary questionnaire that clinicians can use to gather nutritional information that is pertinent to oral health. A food log can help the dental professional guide patients to modify snacking habits and include fewer fermentable carbohydrates and sugars. Some dental providers ask their patients each question, and the questions can be customized depending on previous knowledge. Other dental providers send questionnaires home with patients and assess them at a subsequent appointment.

NUTRITIONAL QUESTIONNAIRE AND FOOD LOG

Table 1

Source: Author

The technique used would depend on the caries risk of the individual and the suspicion that diet plays a role. See the Resources section for websites that contain valuable information and interactive programs to help patients improve their diets.

To decrease caries risk, dental professionals should encourage patients to make changes in the composition and frequency of snacks—moving toward more healthy choices. Even minor changes, such as limiting snacks to a period of 10 to 15 minutes once a day and brushing teeth or chewing sugar-free gum after snacks, may decrease this common habit's negative effects on patients' teeth.

The American population's consumption of fast food has been growing steadily for many years. Data from the National Health and Nutrition Examination Survey of 2017–2018 indicated that on an average day, 36.5% of American adults consume fast food, which accounted for 13.8% of their daily calories [21]. Children and adolescents vary in their daily caloric intake from fast food consumption. Each day, approximately 36.3% of children and adolescents consume fast food, with 11.4% of children and adolescents obtaining more than 45% of their daily caloric intake from fast food; 13.8% obtaining 25% to 40% of their caloric intake from fast food; and 11.1% obtaining less than 25% of their caloric intake from fast food [22]. Clearly, millions of Americans consume fast food on a regular basis, and this is associated with a high caloric intake and poor diet quality. Patients who eat fast food meals or snacks laden with carbohydrates are at increased risk for caries due to the high amounts of sugar and fermentable carbohydrates present in fast food items [23]. Being armed with knowledge of the statistical relationships between fast food and caries may help the dental professional counsel patients on making healthier fast food choices.

In addition, there is a correlation between eating fast food on a regular basis and developing insulin resistance, which is a risk factor for type 2 diabetes [24]. To guide patients with diabetes and the general public toward healthier fast food options, the practitioner can refer patients to the American Diabetes Association website (http://www.diabetes.org), their physician, or a nutritionist for guidance specific to the patient's health condition, keeping in mind that as a dental professional, oral health should remain a focus.

Within the United States, the median annual per capita consumption of sugar-sweetened beverages (SSB) in 2021 was 37.1 gallons, with the annual per capita consumption of SSB the lowest in Hawaii (23.5 gallons) and the highest in Missouri (51.8 gallons) [25]. Most people are unaware of the sugar content of their favorite sugar-sweetened beverage or soda, and they are not aware of the daily recommended maximum amount of sugar. The World Health Organization has recommended that for children the maximum daily consumption of sugar is 3 teaspoons. A 20-ounce bottle of soda contains about 16 teaspoons of sugar, while a 12-ounce can contains about 10 teaspoons of sugar [26]. Many nutritional experts and health organizations believe that soda and SSB in general are a major contributing factor to the escalation of childhood and adult obesity [27]. The consumption of soda doubles the risk of the development of carious lesions in children and increases the potential for the development of carious lesions in adults [26].

The patient education pamphlet "Sip All Day, Get Decay!" produced by the Minnesota Dental Association (available at http://www.sipallday.org) states that the average 12-ounce can of soda has 10 teaspoons of sugar and a pH just over 3. The low pH of soft drinks results from the ingredient phosphoric acid. Sodas also contain carbonic acid, and many contain citric acid. Therefore, even diet sodas are detrimental to oral health due to their acidic pH levels.

Patients who sip soda throughout the day cause their oral pH to plunge due to the acidity of the soda and the acid formed from oral bacteria metabolizing the sugars with this extended exposure a source of an increased risk for the development of dental caries [28].

Sports drinks and fruit juices also tend to be acidic and contain high amounts of sugar [29,30]. The use of these products should be limited. Milk and water remain the best drink options for healthy teeth. The development of flavored, unsweetened water gives patients another drink option that is not detrimental to their teeth.

It is important for dental professionals to study the factors influencing patients' diet choices to understand the motivations behind them and to offer healthy alternatives. Factors influencing diet include food availability, family structure, convenience, parental influence, habit, cost, and media [31,32].

Because all teeth, once erupted, are susceptible to dental caries, even very young children are vulnerable. Early childhood caries (ECC) is defined as the presence of one or more decayed, missing (due to caries), or filled tooth surfaces in the primary dentition of a preschool-age child [49]. This condition is seen throughout the general population but is more common in the poor and near-poor preschool children. In the United States, it is estimated that between 3% and 6% of children have early childhood caries [50]. The National Institute of Dental and Craniofacial Research (NIDCR) has indicated that between the years of 2011–2016 that 23% of children between the ages of 2 and 5 years had carious lesions in their primary teeth and that children from lower-income families were twice as likely to have decay in their primary teeth compared to children from higher-income families [51]. Among children ages 6 to 11 years, 17% had decay in their permanent teeth [51].

To prevent ECC development, the American Academy of Pediatric Dentistry (AAPD) recommends that children have their first dental appointment soon after their first tooth erupts and no later than their first birthday [49]. Educating the child's primary caregiver about oral hygiene care for the child and proper use of bottles is one of the main objectives of this appointment. Sodas, juices, and other sugared drinks should not be given to children, or they should be given very sparingly, and they should never be dispensed through a bottle. Children using bottles should not be allowed to go to sleep with them unless the bottle contains water. The AAPD also advises eliminating the use of a baby bottle by age 12 months and avoiding foods and drinks that contain sugar for children under 2 years of age [49].

Parents and primary caregivers need to be reminded about the eruption pattern of teeth and the fact that children have new teeth exposed to the oral environment from age 6 months to approximately age 12 years. The enamel of primary teeth is thinner and less organized compared to the enamel of permanent teeth, so the former is more susceptible to demineralization and the formation of carious lesions compared to the latter [50]. Therefore, soda, sugar, and fermentable carbohydrate exposure is more detrimental in youth than in adults.

The incidence of caries continues to rise as children grow into teenagers. According to the NIDCR, approximately 57% of adolescents between ages 12 and 19 have had carious lesions in their permanent teeth [52]. Adolescence is a time of increased caries risk because teenagers consume diets that are higher in fermentable carbohydrates and sugars, and they often practice poor oral hygiene.

Research shows that this age group responds to health behavior change requests through motivational interviewing (MI) techniques, rather than the traditional dissemination of information and dispensing of advice [53]. Motivational interviewing, a collaborative, goal-oriented form of communicating behavior change, has been shown to positively affect adolescents' change in diet, exercise, and compliance with medications. MI techniques that will help professionals better communicate oral healthcare principles with this age group and the mechanisms by which MI works to instill behavioral changes in adolescents is an area of continued research [54]. Among high school students between 2019–2021, approximately 16.5% of boys and 12.7% of girls had consumed one or more sugar-sweetened soda beverages each day [55,88]. Soda is included with other sugary products and those made with solid fats in the category of empty calories. Empty calories account for 30.2% to 34.4% of 9- to 13-year-olds' daily caloric intake and 30.5% to 35.5% of that of 14- to 18-year-olds [56]. Utilizing the principles of MI, the dental professional can work with each teenager to find easily accessible and tasty alternatives to sugar-laden foods. The Resources section contains links to websites that can be shared with young patients and their parents.

Many adolescents have braces or other orthodontic appliances that complicate oral hygiene. The combination of susceptible tooth surfaces, a high-sugar diet, and poor oral hygiene is the perfect recipe for caries formation.

To decrease caries risk in the adolescent population, medical and dental professionals should inform teenagers about the impact of diet choices on teeth and educate them about healthy eating. Minor changes such as limiting soda consumption to mealtimes and brushing after meals can have a large impact on caries development. In addition, the use of fluoride and sealants is extremely beneficial in preventing caries in the adolescent population.

Adolescents are forming habits that will be a foundation for their adult life. Healthy eating, limiting snacks and sugars, and good oral hygiene will be invaluable practices that will help protect their teeth from caries.

Older adults are at increased risk for caries as a result of gingival recession, reduced saliva flow, inadequate oral hygiene, physical and sensory limitations, and cognitive limitations [57]. In the United States alone, the elderly population (i.e., those age 65 and older) will grow to 20% (72 million) by 2030 [57,58]. Aging baby boomers who have retained more of their teeth and have undergone more complex dental procedures will have a greater exposure to dental caries and periodontal concerns, as well as greater expectations of their dental care providers [57,59]. Many studies have found root surface caries to be most prevalent in the elderly population [60].

Ideal oral hygiene may be difficult to achieve, as manual dexterity often becomes limited in elderly patients. The presence of partial dentures also complicates oral hygiene, as food and plaque frequently accumulate where the dentures rest against the natural tooth structure. Educating elderly patients who wear partial dentures, and their caregivers when applicable, concerning proper oral hygiene is essential to protect the teeth adjacent to partials from caries. Practices such as cleaning the mouth after meals with fluoridated toothpastes and rinses, removing partials when performing oral hygiene, removing partial dentures before going to bed, paying attention to dietary intake, and using prescription-strength fluoride gels or toothpastes should be encouraged in these patients [59,61].

Elderly patients also consume an elevated amount of fermentable carbohydrates and sugars, further increasing their caries risk. Missing teeth, poorly fitting prosthetics, and tooth mobility due to periodontal disease may make eating fresh fruits, vegetables, and high-fiber foods difficult. To replace these items in their diet, elderly patients are more likely to consume breads, cakes, pies, and food replacement drinks, as these substances are easy to prepare and eat [59]. In addition, elderly patients may suck on hard candies and eat sugary snacks throughout the day to combat the symptoms of xerostomia.

Special considerations need to be taken into account when recommending dietary changes to elderly patients. Food cost, level of difficulty of preparation, and ease of mastication are factors that must be taken into account when advising dietary changes. Replacing candies with a sugar-free variety, limiting snacks, and adding calcium-rich foods such as cheese to their diet are a few of the measures that older adults can take to reduce caries risk. The use of power toothbrushes and fluoride may also be helpful in reducing caries incidence in this population.

Xerostomia is the subjective description of dry mouth, which can be caused by any number of events [62]. Dry mouth can be a transient reduction or loss of saliva as a result of salivary gland dysfunction. It places patients at a higher risk for caries because saliva contains buffers to neutralize acids in the mouth. Adequate saliva is important for several reasons. The presence of calcium and phosphate in the saliva aids in the remineralization of tooth surfaces [63]. Saliva also helps to naturally cleanse teeth, protects the oral mucosa from mechanical injury, facilitates chewing and swallowing, and inhibits bacterial growth [64,65].

Saliva production can decrease with age [59,66]. Moreover, some medications are commonly associated with xerostomia. More than 500 medications have reduced saliva as a side effect [62,67]. The main medication classes associated with xerostomia include antidepressants, antihypertensives, antihistamines, antipsychotics, sedatives, anorexiants, antiparkinsonism agents, opioids, muscle relaxants, and diuretics [65]. Head and neck radiation therapy and the autoimmune disease Sjögren syndrome are other common causes of salivary gland dysfunction that results in dry mouth [62,68].

Remedies for reducing the effects of xerostomia vary, and recommendations should be patient specific. Depending on a patient's age and cognitive ability, dental professionals should encourage them to chew sugar-free gum, use sugar-free candies, or sip water to reduce the exposure to sugars. The use of over-the-counter saliva substitutes for oral lubrication also helps to increase patients' comfort. Prescription medications designed to stimulate saliva flow may also be recommended for patients who have undergone radiation treatment and for those with Sjögren syndrome. However, efficacy, side effects, and compliance must be weighed against the benefits of using these medications [67,69]. Patients experiencing xerostomia need to demonstrate excellent oral hygiene and may benefit from fluoride and other caries prevention treatments such as the application of in-office fluoride varnish or in-office fluoride treatments [70].

Fluoride has been used for more than 80 years to prevent dental caries [70]. Demineralization and remineralization are natural processes, as minerals are lost and returned to the tooth surface during the day [71]. Fluoride strengthens enamel, making it more resistant to the acids that promote demineralization and facilitate the development of carious lesions. It also enhances the remineralization of impaired tooth surfaces [72]. Erupted teeth accrue the most benefit from fluoride when its salivary concentration is incorporated into the biofilm that adheres to the teeth [72]. Although it is a bit controversial, water fluoridation is one method of achieving these conditions [70,72]. Approximately 72.7 of U.S. communities have fluoridated water as of 2020 [55]. Bottled water does not contain enough fluoride to prevent dental caries, so patients who drink only bottled water must be educated about the benefits of the topical fluoride found in toothpaste, oral rinses, and prescription-strength fluoride supplements [70,73]. Parents of young children should be aware that multiple forms of fluoride ingestion can lead to fluorosis, that is, detectable changes in the tooth surface that can discolor the tooth but that do not adversely affect tooth strength [72].

Fluoridated water, toothpastes, and mouth rinses are advisable for the general population and especially for caries-prone patients because the use of a fluoride mouth rinse in conjunction with the use of a fluoridated toothpaste enhances enamel fluoridation and remineralization [72]. The use of prescription-strength fluoride toothpaste (1.1% neutral sodium fluoride) may be advantageous to and is usually well tolerated by patients consuming caries-promoting foods, orthodontic patients, patients with xerostomia, and those demonstrating substandard oral hygiene [72].

In-office fluoride treatments may help patients reduce dental caries. Treatments come in a variety of forms, including foams, gels, rinses, and varnishes. The application of 5% sodium fluoride varnish twice a year on the primary and permanent teeth of children ages 6 months through 15 years is beneficial in preventing caries in this age group as well as for the permanent teeth of adult patients [10,70]. The use of in-office professionally applied fluoride gel or foam at 3- to 12-month intervals provides the most preventive benefit for those do not consume fluoridated water and/or whose at-home oral hygiene is substandard [74].

Xylitol, a sugar alcohol (polyol), is a sugar substitute that helps to prevent dental caries because oral bacteria are unable to break it down to an acid [49,75]. Xylitol also inhibits plaque formation, especially that of mutans streptococci, and has been shown to contribute to remineralization [76,77].

Nutritionally, xylitol has fewer calories than sugar—2.4 calories per gram versus approximately 4.0 calories per gram of sugar [76]. It is also safe for diabetic patients to consume, making it a wise choice for replacing sugar in patients' diets for reasons beyond caries control because xylitol lowers the insulin response compared to foods sweetened with sorbitol or ordinary sugar [78]. Replacing sugar with xylitol has been shown to cause a statistically significant reduction in S. mutans, which is the primary cariogenic bacterial species [79].

New studies are seeking to determine the efficacy and optimal dosage of erythritol, another polyol, for caries prevention. The efficacy of polyols to prevent caries when used to sweeten gum, candy, and food may be confounded by the presence of natural and added fluoride in the diets of the study participants. Some studies have revealed that the combination of xylitol and fluoride can reduce the biofilm in which the cariogenic bacteria reside [80].

Dosage recommendations for xylitol as an anticaries agent include several small exposures during the day, with a plateau effect for the reduction of the cariogenic bacterium S. mutans noted between 6.88 grams per day and 10.32 grams per day [76]. This can be accomplished by using toothpastes, gums, and mints that contain xylitol and using xylitol as a sugar replacement to sweeten foods and drinks. Xylitol can also be used in place of sugar in baking, but patients should be cautioned that consuming large quantities of xylitol may cause gastrointestinal upset.

The pits and fissures of teeth can be especially caries prone, and applying sealants here is a component of a comprehensive approach to caries management [4]. Pits and fissures in the occlusal, buccal, and lingual surfaces retain food particles and plaque, thus complicating oral hygiene efforts. Consequently, these surfaces are the predominant areas of dental caries. Pit and fissure sealants have been employed to prevent pit and fissure dental caries since the 1960s and remain an excellent method of reducing risk for dental caries. A 2016 systematic review suggests that well-placed occlusal sealants protect the pits and fissures from caries development better than fluoride varnish application does [4]. The review in no way recommends forgoing fluoride application to protect occlusal surfaces from caries. Rather, it states that the available evidence supports the use of both preventive measures where appropriate. Clinicians need to use a combination of assessment and diagnostic tools to determine the best treatment plan for preventing decay and preserving tooth structure in individual patients.

In order to identify pits and fissures that are suitable for the application of preventive sealants or other minimally invasive procedures, dental examinations should include the clinical evaluation of tooth surfaces visually and with the use of a blunt explorer; laser detecting device; compressed air; and the newest addition to caries classification, the International Caries Detection and Assessment System [81]. The ICDAS system is an evidence-based process for identifying and classifying dental caries lesions using visual cues [82]. This method of classifying carious lesions allows clinicians to apply appropriate evidence-based preventive and minimally invasive treatment methods to affected tooth surfaces. Using a scale of 0 (sound) to 6 (extremely decayed) to classify each pit and fissure, clinicians can safely determine the best practice for treating the surface, which can include no treatment, fluoride application, sealants, or restorative procedures [82].

Patients with a moderate- to high-risk level of caries may benefit from a separate nutritional counseling appointment. The appointment length is individualized based on the patient's dental knowledge, dietary habits, and motivation level. During this appointment, the dental professional and patient have an opportunity to evaluate the patient's current diet, discuss preventive treatments, and set goals to improve the diet and reduce caries incidence.

To gain information concerning dietary habits, the dental professional may have patients complete a diet questionnaire and food log [87]. An example of a dietary questionnaire and food log was previously shown in Table 1. Alternatively, the dental professional may choose to interview patients concerning dietary habits, using questions such as:

Follow-up to the nutritional counseling appointment should take place in order to encourage the patient's goals and reinforce habit changes. This follow-up may consist of a phone call to check in with the patient, or it may be a short appointment a few weeks after the counseling appointment. The patient's progress can be reevaluated at subsequent dental appointments.

Establishing and routinely reassessing a patient's caries risk level allows the dental professional to provide proactive care and recommend preventive measures to minimize the patient's risk of dental decay.

Occasionally, a patient may benefit from a referral to a dietician, nutritionist, or primary care physician. This is especially true if a condition such as acid reflux, an eating disorder, or chemical dependency is suspected or confirmed.

The dental professional should be practical when recommending changes to a patient's diet. Asking patients to forfeit their favorite foods in exchange for increased brushing and flossing will rarely improve patient compliance. It is important to note, however, that relatively minor changes in nutrition and habits can lower a patient's caries risk. By evaluating each patient's individual incentives and motivation level, dental professionals can help patients set goals that are realistic and achievable.

Some examples of these goals are:

As patients set and achieve goals, additional changes can be recommended to further decrease caries risk. Nutritional counseling, like other behavioral modification interventions, is a dynamic process that is emphasized depending on need.

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?

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.