Moderate risk patient: Caries active

Moderate risk patient: Caries inactive

This patient has several white spot lesions, none of which are cavitated.  These lesions are caries active (enamel surface rough and not shiny).

Bacterial exam is not required. Caries activity is assessed through the texture and appearance of the white spot lesion. The appearance of the enamel surface indicates that ms infection is present. Remember that the ms infectious stage alone, without any enamel surface damage, is the first phase of the dental caries process. Therefore, bacterial control (treating the infection) is the first procedure indicated before proceeding.

Caries progression from the enamel surface to the DE junction takes approximately 3-4 years in adults.
It takes approximately 2-2 1/2 years in primary teeth (1).

Once the infection control is initialted, a remineralization protocol is statred (see below).  Pit and fissures are treated best with the use of fluoride releasing sealants.

On smooth surfaces, if x-rays indicate that penetration is >25% through the dentin and there is no cavitation, the incipient lesions should be restored.  If penetration into the dentin is less and the enamel calcifying matrix is intact (no cavitation), this lesion should treated with a remineralization protocol and watched.  Six month or yearly x-rays should be taken of this area to monitor the status of the lesions.  If the patient has the ms population controlled, lesions should not progress.  Studies(2) have demonstrated that most incipient lesions (with limited dentin penetration) may remain dormant or even regress and heal with treatment.

Research has shown that bonded or sealed restorations placed over frank cavitated lesions arrested their clinical progress.

When undertaking a remineralization treatment the following considerations are important:

1. Host factors
  • Salivary flow status maintained.
2. The diet must be monitored.
3. Bacterial levels should now be low since caries is not active.

Remineralization protocol of caries active white spot lesions (no cavitation).

-Enamel healing--background

Methods to enhance remineralization:

1: Daily home fluoride rinse (.05%) or apply fluoride varnish. (various types of fluoride preperations and more on remineralization).
2: Stress diet compliance.
   -Use of Xylitol gum. 2 sticks, 5 x/day, chew 5 minutes.
   -Use dairy products such as cheese and milk since human studies (3) suggest that the phosphoprotein, casein, and calcium phosphate may be anticariogenic (present in Trident Advantage gum--Recaldent). chewing this gum provides calcium phosphate on the tooth surface for remineralization.
3: Maintain normal salivary flow.
4: Maintain oral hygiene.  
After the office and home care treatment are completed:
-Home fluoride rinse (.05%) during the first year after therapy is completed.
-Stress diet compliance.
-Stress use of Xylitol gum especially after meals and snacks. 2 sticks 5x/day for 5 minutes.
-Recall every 3-4 months to monitor white spot lesions and preventive maintenance for 1 year. By the end of this time period the patient should be able to be classified into the low caries risk category.  If not, the patient will be reassessed.

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1. Pitts F, Lond, FR, Current Methods and and Criteria for Caries Diagnosis in Europe. 53:409-24, 1993
2.Anusavice KJ, Efficacy of nonsurgical management of the initial caries lesion. J Dent Educ, 1997,61:895-905.
3. Reynolds EC. Remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. J.Dent.Res 1997;76:1587-1595..

Copyright-Dr. Arnold D. Steinberg, 2001.