PreventiveDentistry

Anthony S Blinkhorn

Robin M Davies

Preventing Dental Caries: Part 2.

Case Studies in Prevention
Abstract: This article seeks to bring together the preventive messages given in Paper 1 and apply them to specific individual patients.
The key elements are the appropriate advice on fluorides, fissure sealants, diet and formulating advice in terms of an individual’s
educational background.
Clinical Relevance: This article offers practical advice on the prevention of dental caries using individual patient-based scenarios.
Dent Update 2013; 40: 814–820

The previous paper1 considered the Case study 1 education facilities in his school so has been
scientific evidence for the advice the working late, and not participating in
A mother brings her 3½-year-
dental team can give to individual ‘bath time’.
old daughter to your dental practice. She
patients on caries prevention. In addition,
has noticed that the upper primary anterior
the major impact of the ‘diagnostic
teeth have become brown in colour and Clinical examination
threshold’ of individual clinicians on
pieces of them are breaking off (Figure 1). A quiet child who allows a full
preventive interventions was highlighted.
She has also noticed what she dental examination. There are no problems
In this paper, case studies are presented
refers to as holes in some of the back teeth. noted on the extra-oral examination.
which bring the preventive messages
The family live in a middle class suburb. The The following teeth are charted
together. Experienced clinicians will
father is a headmaster and mother a senior as present:
no doubt have gathered much of this
executive with a credit card company.
evidence together through practical
experience. The main caveat is that E D C B A A B C D E
in dentistry, as in many branches of Medical history E D C B A A B C D E
medicine, there are a number of ways Nothing of relevance
for experienced clinicians to achieve a except the child does seem somewhat The teeth are clean, but there
set goal, so that the case studies and the overweight. are approximal and buccal carious lesions
suggested answers are not definitive, but on the upper primary incisors and lesions
do have a practical clarity and simplicity. involving the four first primary molars (Ds).
Dental history
The child has never
complained of pain and mother missed Radiographic examination
an appointment for a check-up a year ago Radiographs are not taken
Anthony S Blinkhorn, PhD, MSc, FDS, because of a business meeting abroad. as the mother is most concerned about
BDS, Professor and NSW Health Chair radiation. On a practical note, the child
− Population Oral Health, Faculty of appears ready to cry, so pushing the parent
Dentistry, University of Sydney, 1 Mons Reason for attendance
to agree bitewing radiographs seems
Road, Westmead NSW 2145, Australia Mother had been away for
counterproductive at this initial visit.
and Robin M Davies, PhD, FDS, BDS, six weeks with her work and now has a
Dental School, Coupland III, Manchester three week break and has noticed the
University, Higher Cambridge Street, dental problem. Most of the childcare is Diagnosis
Manchester M15 6FH, UK. undertaken by an au pair from Italy. Father The child is suffering from early
is involved in a reorganization of the childhood caries, but is not in pain.
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 PreventiveDentistry

Oral care programme the heart of dental practice. If the sugary right 6 is clearly the source of the pain and
The presentation of considerable night-time bottle had not been identified discomfort. Both the parent and patient are
dental caries in a child from a middle and remedial action taken the future of the reassured and advised to use analgesics
class, high income family warrants careful primary dentition would have been bleak. and rinse the mouth with warm water.
investigation before deciding how best to It is recommended that the patient is
proceed. It must be stressed that restorative reviewed in one week’s time, when advice
care in such a mouth will not prevent further Case study 2 on brushing the teeth and simple diet
carious lesions. advice would be given. Fluoride varnish is
A six-year-old boy, who is a
The first task would be to applied by the dental hygienist to the four
regular patient, is brought to see you
undertake a detailed dietary assessment permanent molars.
because of oral pain and discomfort
which, in this case, is likely to be difficult as
on eating.
the mother is not directly involved in childcare
and spends a considerable time away from Conclusion
the family home. Although the father is Medical history Reassurance is the key, as the
said to be late home because of short-term Nothing of relevance reported. problems of pericoronitis in young children
work commitments, it would seem more are usually self limiting. The dental health
Dental history
appropriate to seek information from him advice and the use of fluoride varnish fits
Has been seen regularly in your
about the child’s diet as he is not ‘routinely’ in with the philosophy of ensuring teeth
practice since he was 3 years old. Fluoride
absent. It is essential to tread carefully and remain free of caries.2
varnish has been applied at approximately
avoid apportioning blame, which could 6-monthly intervals and there have been
create a source of family tension. The practice
hygienist, talking to the father, discovers the
no reported oral health problems. Case study 3
key problem is the diet. He reports that his A 14-year-old girl, new to the
daughter is always reluctant to go to sleep at Reason for attendance practice, presents requesting a check-up,
night and the au pair has found that a bottle, Pain and discomfort from lower and an appointment is given. She attends
containing warm diluted juice, to which she right quadrant, particularly when eating. that appointment with her father.
added sugar, helps to induce sleep.
The action point here must be to
cut out this sugary-filled bottle at night. This, Clinical examination
however, is likely to be a difficult task, given Extra-oral, no swelling evident.
the initial reason for providing it was as a The following teeth are charted
comforter. The option chosen is to weaken the as present:
dilution of the juice over a 10-day period until
only warm water is given. This works, but only 6 E DC 2 1 1 2 CD E 6
because the parents refuse to give in to some 6 E DC 2 1 1 2 CD E 6
fairly violent tantrums! Two months after the
water only regime is introduced the child The lower right 6 is partially
gives up the night-time bottle altogether. erupted with an inflamed flap of gum Figure 1. Case study 1: Active caries in the
As there is active caries it is tissue overlying the distal portion of the primary dentition.
suggested that the au pair or parent should tooth; all other first permanent molars
brush the teeth twice a day, last thing at night fully erupted.
and on one other occasion, with a pea size
amount of toothpaste containing 1450 ppm F.
Radiographic examination
The child is encouraged to spit out any excess.
Bitewing radiographs were
Fluoride varnish is applied by
taken when he was five years of age. The
a dental hygienist to the posterior primary
perceived clinical problem did not warrant
molars and upper primary anteriors. A short
further exposure to ionizing radiation.
recall (2 months) is used to review progress.
After 4 months, fluoride varnish is re-applied
and restorative care is initiated by a dental Diagnosis
therapist in collaboration with a specialist in Pericoronitis: there is an
paediatric dentistry. inflamed flap of gum which is being
subjected to occlusal trauma (Figure 2).

Conclusion
Diagnosis and investigating Oral care programme
reasons for extensive dental caries is at The partially erupted lower Figure 2. Case study 2: Inflamed gum flap.

December 2013 DentalUpdate 815

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 PreventiveDentistry

The following teeth are Conclusion

charted as present: Preventive care at this time will
ensure that the teeth remain in a healthy
7 6 5 4 3 2 1 1 2 3 4 5 6 7 condition to allow early lesions to
7 6 5 4 3 2 1 1 2 3 4 5 6 7 remineralize.

Early caries involving occlusal

fissures of all second molars is evident
Case study 4
and they appear to be enamel lesions A 15-year-old boy, who has been
with no involvement of dentine (Figure 3). having orthodontic treatment at another
Figure 3. Case study 3: Early caries in second practice, presents for a routine examination.
adult molars. He has not visited his general dental
Radiographic examination
practitioner for over two years.
As this is a new patient to the
a
practice, and there are early enamel lesions
visible clinically on the occlusal surfaces Medical history
of the lower second molars, bitewing No relevant medical history.
radiographs are taken (Figure 4).
Dental history
Diagnosis The patient had upper and
Caries into dentine involving lower fixed appliances placed 1½ years
the distal surface of the UR4 and an early ago. Despite advice regarding his diet
lesion on the mesial surface of the UR5. and the need to brush twice daily with an
There is no radiographic evidence that adult fluoride toothpaste, he has chosen to
b the early carious lesions clinically visible ignore it and the orthodontist terminated
in the second lower permanent molars treatment and the bands were removed
have penetrated into dentine. (Figure 5).

Oral care programme Reason for attendance

The presence of early Mother is concerned that the
carious lesions is an important sign that orthodontic treatment was terminated and
preventive care is extremely important. the front teeth look decayed.
With the appropriate help the mouth
can stabilize, but there is a danger that
the risk of further carious lesions could Clinical examination
Figure 4. Case study 3: Bitewing radiographs. accelerate without specific preventive Early carious lesions are evident
advice. around the margins of the sites where the
The preventive care plan is as orthodontic brackets were attached.
Medical history follows:
No relevant medical history.  Give advice on diet, particularly
Radiographic examination
controlling the frequency of intake of
Both the patient and his mother
sugary snacks;
Dental history were concerned that the orthodontist had
 Advice on oral hygiene and the use of
Has been a fairly regular attender, taken a large number of radiographs, so
adult fluoride toothpaste;
but stopped visiting for ‘routine check-ups’ preferred not to have bitewings taken.
 A daily fluoride rinse to aid the
approximately two years ago when her remineralization of the early lesions on
family dentist retired. the smooth surfaces would be helpful. Diagnosis
Rinse should be used at a different time Active carious lesions evident
from brushing. In this case, the rinse to be where orthodontic brackets had been
Reason for attendance
used when the patient returns home removed.
Parents are concerned that the
from school;
pattern of regular dental monitoring was
 Fissure seal all the second permanent
interrupted by closure of the dental practice, Oral care programme
molars.
and wish to ensure continuing dental care. Further advice regarding
The patient should be offered
a 6-month recall for new bitewing reducing the frequency of sugar-containing
Clinical examination radiographs to be taken to monitor the foods and drinks is given by the dental
Extra-oral, nothing relevant noted. early lesions on the upper premolars. hygienist who also applies fluoride

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 PreventiveDentistry

a history of non compliance with previous advice GP to emphasize the importance of seeking
on oral health care. Clearly, early lesions may professional help. The practice hygienist
also be present on the mesial and distal aspects gives him advice on reducing the frequency
of molars and premolars but, as no radiographs of drinking sugar-containing liquids.
were taken, we can only act on the basis that Appointments are made for restorative care
this is a high caries risk patient. and twice daily brushing with a toothpaste
containing 5000 ppmF is advised.
He is reviewed in one month
Case study 5 to check whether he has seen his GP and
b A 21-year-old male student in his to reinforce the dietary and oral hygiene
third year at University has returned home advice. At this visit he is given a daily fluoride
on vacation. He has noticed some holes in his rinse as an adjunct to brushing with fluoride
front teeth and decides that a dental ‘check- toothpaste.
up’ might be appropriate, mainly because of
pressure from his girlfriend.
Figure 5. Case study 4: (a) Orthodontic bands Conclusion
in place and (b) appearance of anterior teeth A short recall is essential to
on their removal. Medical history monitor progress and determine whether
He is a poorly-controlled, insulin- there has been compliance with the advice
a
dependent diabetic. His glucose level offered.
fluctuates and he admits that he has been
failing to adhere to a strict dietary regime.
Case study 6
Dental history This patient is a 65-year-old male,
He has received care in the past who retired from work 9 months ago. His
but this has lapsed whilst he has been away. wife died in a road traffic accident two years
His dental records show that he was last in the ago. He has three grown-up children who he
practice over 4 years ago. sees infrequently.
b

Reason for attendance Medical history

His girlfriend is worried that his He has suffered from
front teeth are spoiling his smile and that he depression since the loss of his wife and
may need false teeth. is taking anti-depressive medication
[Fluoxetine (Prozac)].
He smoked 25+ cigarettes a day
Clinical examination
until 8 months ago but is now using nicotine
Large carious lesions involving the
Figure 6. Case study 5: (a) Carious anterior teeth patches.
approximal surfaces of all upper incisor and
and (b) left bitewing radiograph. There is a history of reduced
canine teeth (Figure 6).
salivary flow, which is a common side-effect
of the selective serotonin re-uptake inhibitors
Radiographic examination (SSRIs) such as Prozac. This is probably the
varnish to all affected surfaces. The patient
Bitewing radiographs also confirm reason why he is sucking mints to help
is prescribed a toothpaste containing 2800
lesions involving the distal surface of the LL6, lubricate his mouth. He has also been
ppm F and advised to brush twice a day, last
mesial surface of the LL7, distal surface of UL5 prescribed the ACE inhibitor, Ramipril, for the
thing at night and on one other occasion. The
and occlusal surface of UL6 (Figure 6). control of his high blood pressure.
hygienist gives him three appointments to
ensure that he understands the information
and he is encouraged to take a greater interest Diagnosis Dental history
in his teeth. Review appointments are made at Active caries in a medically Regular attender until five years
3-monthly intervals when fluoride varnish will compromised patient. ago when his dentist retired. He has had
be re-applied. A full diagnostic examination is routine restorative care and extractions under
scheduled for 12 months’ time. local anaesthesia.
Oral care programme
Conclusion It is important to encourage
A preventive programme utilizing this young man to visit his general medical Reason for attendance
fluoride, together with intensive advice, is practitioner regarding the control of the His molars are very sensitive to
chosen because of the early lesions and the diabetes. A referral letter is written to the family both hot and cold stimuli and this is the main
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 PreventiveDentistry

 Encouraging effective oral hygiene is also times only;

an important part of the plan, not only to  Doctors and dentists should only prescribe
reduce the bacterial challenge to the tooth sugar-free medicines.
tissue but as part of the therapy to maintain
his general health status.3
Children 3−7 years
 Place on short 2-month recall and
 Brush teeth twice a day, last thing at night
re-apply fluoride varnish on the root surfaces
and on one other occasion;
and check whether he has managed to
 Brushing should be supervised, and a
implement the dietary advice.
pea-sized amount placed on the brush. In
Figure 7. Case study 6: Root caries and gingival If there are positive outcomes
many countries a ‘garden pea’ is not in common
recession. to the oral hygiene and diet advice, further
usage so pick an appropriate analogy, ie
clinical care can be planned, which would
peanut or betel nut;
include:
 Use a 1450 ppm fluoride toothpaste. (This
reason for the consultation. He has stopped  Restorative care; and
depends on local legislation in USA and
cleaning his teeth because they are so sensitive.  Thorough scaling.
Australia);
 Tell the child to spit out after brushing but
Clinical examination not to rinse with a large volume of water;
Conclusion
This shows that the following teeth  Make sure that sugary foods and drinks are
Excess sugar consumption
are present: confined to meal times only;
is overwhelming the oral defences and
 Prescribe sugar-free medicines.
encouraging demineralization, hence the
76 4321 123 567 need for dietary advice. Sugar-free mints, as a
7 54321 123 456 substitute for sugary ones, should be helpful. Children 7−15 years
Toothbrushing advice will assist in the control  Brush twice daily, including just before bed-
There is gingival recession around of the plaque and distribute fluoride round the time;
all teeth, and many have carious lesions that mouth.  Use 1450 ppm fluoride toothpaste;
are relatively hard on gentle probing (Figure 7).
 Spit out paste, do not rinse with a large
volume of water;
Diagnosis Key dental health education  Restrict the consumption of sugary drinks
The patient is suffering from root messages for individual and foods to meal times only;
caries and sensitivity on brushing. patients to aid the prevention  A fluoride mouthrinse 0.05% NaF will be
of dental caries helpful to individuals with caries problems. Use
All too often, the dental team when child returns home from school.
Oral care programme does not have a clear understanding of the
There are a number of aspects to key preventive messages for caries control.4
this case which imply a need for immediate The following age-specific messages taken Adults
and longer term care plans. from the English Department of Health  Brush twice daily with a fluoride toothpaste.
This patient has suffered from Prevention Toolkit (website) may aid the Use a paste of at least 1450 ppm F;
depression and hypertension and is in the reader when preventive care plans are being  Consider prescribing a toothpaste containing
process of giving up cigarette smoking. developed for specific patients.5 2800 or 5000 ppm F in caries active individuals;
The root caries is very likely to be related  Always brush just prior to going to bed and
to the frequent use of the sugary mints. on one other occasion;
The main difficulty will be to reduce the Children 0−3 years  Do not rinse mouth after brushing;
cariogenic challenge and also to assist in the  From 6 months of age children should be  Limit sugary foods and drinks to meal times
remineralization of the root caries. A preventive introduced to drinking from a cup; only;
care programme can be planned, which assists  At 12 months taking any liquids from  An oscillating/rotating power toothbrush
remineralization, namely: a feeding bottle should be discouraged, could be helpful in improving plaque control;
 Place Duraphat varnish on the carious lesions especially at night;  A fluoride mouthrinse 0.05% NaF, used at
and other sensitive root surfaces.  Sugar should not be added to foods or a different time from toothbrushing, will be
 Prescribe a 5000 ppm fluoride toothpaste drinks; helpful to individuals with a caries problem.
to be used twice a day to assist further with  Parents should begin brushing twice a day
remineralization. when teeth erupt;
 Give a 3-day diet diary. Examine the diet  A smear of fluoride toothpaste containing Preventive interventions
diary and give advice on reducing frequency no less than 1000 ppm F should be used; available to the dental team
of sugary intakes. Suggest use of sugar-free  Frequency of sugar snacks should be  Fluoride varnish (2.2% F) offers a benefit in
mints/sugar-free gum if patient can’t do controlled; terms of caries prevention to all ages.
without sweets.  Sweet foods should be consumed at meal  Apply at least three times per year;
December 2013 DentalUpdate 819
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 PreventiveDentistry

 Reduce recall intervals for patients with profession will work as general practitioners References
caries problems to monitor changes in with a defined group of patients who will be 1. Davies RM, Blinkhorn AS. Preventing
behaviour and caries progression; offered care over a long period of time. These dental caries: Part 1. The scientific rationale
 Children (10+), adolescents and adults patients require the dual preventive and for preventive advice. Dental Update 2013;
with coronal and/or smooth surface caries restorative approach. It is up to us as dental 40: 719−726.
prescribe 2800 ppm fluoride toothpaste; professionals, not only to be fine clinicians, 2. Tickle M, Threlfall AG, Hunt CM, Milsom
 5000 ppm fluoride toothpaste can be but to achieve sustainability in our preventive KM, Blinkhorn AS. Exploring the factors
prescribed for those patients 16+ years with care. This means repetition and reinforcement that influence general dental practitioners
active dental caries; are crucial to ensuring that preventive advice when providing advice to help prevent
 Monitor diet through a 3-day diet record. is accepted and becomes part of a patient’s caries in children. Br Dent J 2007; 202: E10.
everyday behaviour. 3. De Oliveira C, Watt R, Hamer M.
For many patients a lack of Toothbrushing inflammation and risk of
Conclusion knowledge about the aetiology of the cardiovascular disease: results of a Scottish
The practice of dentistry requires common dental diseases is a frequent reason Health Survey. Br Med J 2010; 340: C2451
dental professionals to be reflective and spend for suffering dental ill-health. The dental doi: 10.1136/bmj.c2451.
time carefully diagnosing a clinical problem profession has the preventive agents and 4. Levine RS, Stillman-Lowe CR. The Scientific
prior to action. Once the diagnosis has been the scientific information to help, but all too Basis of Oral Health Education 6th
made there are two key themes which must often we fail to help our patients and ignore edn. London: British Dental Journal
be part of care plans: our responsibilities as healthcare advisors. Books, 2009.
 To consider why there are problems and Now is the time to change and become a 5. Department of Health/British Association
what can be done to prevent and control them; diagnostician, not just someone who removes for the Study of Community Dentistry.
 To implement appropriate clinical care. infected tissue in a vain attempt to control a Delivering Better Oral Health: An Evidence-
The majority of the dental bacterial disease. based Toolkit for Prevention 2nd edn, 2009.

Book Review Chapter 3 deals with exposure, ‘Documentation’, does a good job of
and although it includes ISO and, briefly, suggesting documentation for orthodontic,
Photography in Dentistry. Pasquale Loiacono colour settings, it doesn’t cover the association periodontal and prosthetic disciplines.
and Luca Pascoletti. New Malden: Quintessence between the main elements of exposure. This I think most practitioners will want
Publishing Co Ltd, 2012 (336pp, £110 h/b). ISBN comes later in an interesting chapter but which to skip chunks of some of the chapters, but
978-88-7492-169-0. could be skipped. this is easy to navigate. Having said that, the
The first part of Chapter 4 can be majority of chapters are very useful for
This is a quality, well produced book consisting skipped, however, later it covers file formats the novice and experienced dental
of over 300 pages illustrated with over 800 which gives good information on the RAW photographer alike.
excellent quality images and graphics. I format and its implementation in clinical Mike Sharland
was impressed with the easy layout, which photography, and also image transfer University of Birmingham
facilitated ‘skipping’ some chapters. for storage. School of Dentistry
The first chapter covers general Chapters 5, 6 and 7 cover the role/
principles of photography, with the first few use of photography in clinical practice, such as
paragraphs enthusing on the indispensible a diagnostic instrument, communication aid
benefits of image capture. There is to my and medico-legal use. Camera settings and
mind a little too much detail for most, but to techniques are also well covered.
the enthusiast the detail is interesting. A brief Flash units are covered in Chapter
description of aperture and shutter speed in 8, with good descriptions of some flash options
general photography terms follow. This chapter and the results obtainable. Photography of
also covers correct handling and choice radiographs is covered in Chapter 9.
of camera. The first chapter under the
Chapter 2 gives more ‘in depth’ heading ‘Techniques’ is Chapter 10 and covers
descriptions of optical systems I suspect many equipment and accessories, cameras, flash,
will want to skip, that is until the detail on retractors, etc.
‘magnifications’, which is good, is reached. Extra-oral and intra-oral
The authors have a good knowledge of the photography techniques are covered in
main aspects of optical reproduction and the Chapters 11 and 12, giving good practical advice
information is accurate. Mastering magnification on positioning and camera settings, and good
combined with the camera settings, covered in hints and tips for positioning of the operator,
Chapters 6 and 10, is paramount to achieving camera and patient.
consistent reproducible images. Chapter 13, entitled

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