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hygiene the international C.E. magazine of dental hygiene

14 I IC.E. article_ caries management hygiene 1_2013 contributingbehaviorsandhabitstopreventcarious lesions.In1999,Dr.JohnFeatherstonedevelopedthe “caries balance” (Fig. 1), a multifactorial process that balances protective factors and pathological factors (Featherstone, 2000). Any imbalance of either side increases the risk for thedevelopmentofdentalcaries.ACAMBRAclinical study is used to confirm the caries balance. The idea behindtheCAMBRAistopreventortreatthecauseof dentalcariesattheearlieststageratherthanwaiting for irreversible damage to the teeth. An assessment is done and the patient’s medi- cal, dental and social histories are considered. The resultsareplacedintoalow-,moderate-orhigh-risk category. The CAMBRA clinical study confirms that fluoride alone cannot overcome a high bacterial challenge and that restorative treatment does not reduce bacterial count in the rest of the oral cavity. Moreover, one or more frank lesions indicate high bacterial challenge and high risk for future decay. And the use of chemical therapies can significantly reduce the level of new caries. Research shows that 20 to 46 percent of the total population is affected by dry mouth, also known as xerostomia(Kutsch&Bowers,2012).Thenaturalpro- tective function of saliva is to balance the ecological environment in the oral cavity. It helps maintain the pH, bathes and maintains the teeth for mechanical cleansing and clears ingested carbohydrates. There are many reasons a person can experience xerosto- mia; however, medications and systemic diseases seem to be at the top of the list. To assess the quantity and quality of saliva, it is important to establish a base line through testing. The saliva test should include the assessment of stimulated and unstimulated pH, consistency, the quantityofflowproductionandthebufferingcapac- ity. A person produces about 1 to 1.5 liters of saliva per day. Anything less than this is considered low salivaryfunction,andsuchpatientsshouldbeplaced in a moderate- or high-risk category, depending on other factors. Adjunctive technologies are available and are an additional assessment tool to clinical findings. These technologies do not take the place of clinical exami- nation, lab findings or radiographs; they augment the assessment phase to discover incipient lesions. Adjunctive technology options include: • Loupes — magnification to enhance detection of demineralized areas. • Digital fiber optic transillumination — a high intensity light that distinguishes demineralization through transillumination. It detects occlusal, inter- proximal, smooth surface and recurrent decay. • Quantitative light fluorescence (QLF) — detects and monitors the progression of a lesion on occlusal and smooth surfaces. Although it is a good research instrument, it does not detect interproximal lesions. • Infrared fluorescence — measures the fluores- cenceofcariogenicmicrobialontheocclusalsurface and is translated into a numerical value. Calibration is necessary for each tooth. • Light fluorescence — is much like the infrared fluorescence; however, this is an imaging software that gives quantified results of the occlusal surface. • Red-infrared reflectance — one of the few in- terproximaldevicesonthemarket,itdetectsocclusal and interproximal lesions, emitting sound and light to signify when further investigation of demineral- ized areas is necessary. • AC Impedance spectroscopy — a low voltage current evaluates the mineral density and rates it on a 0.0 to 100 scale with color to reflect the demin- eralized area. No calibration is necessary; however, software is needed to display and tabulate. _Behavior modifications Once the assessment stage is complete, what is done with the information is an important piece of the puzzle. Modifications, corrective actions, therapies and product recommendations should include extensive home care instructions, pH neu- tralization, fluoride treatments, diet modifications, xylitol, chemical therapies and sealants. Educa- tion is a vital part of behavior modification, thus educationalhome-careinstructionsarenecessaryto communicate why it is critical to disrupt the biofilm withbrushing,flossingandsupplementalaids.These instructions, along with demonstration and interac- tion, will help educate the patient and reduce the amount of deposits and carious lesions. DietaffectsthepHthroughfermentablecarbohy- drates, which begin to break down in the oral cavity. Fig. 1_The ‘Caries Balance,’ developed by Dr. John Featherstone in 1999, is a caries risk assessment processbasedonmaintaining balance between protective and pathological factors. (Charts/By DTI) Fig. 1