Step 2: Consider Individualized Non-operative Strategies for Caries Control

Cleaning: The dental healthcare provider can start by reiterating simple oral hygiene tips for plaque control in the whole mouth, such as brushing teeth twice a day and flossing in between teeth (interdental cleaning).7

However, showing the patient where the lesions are (whether it is with the use of a radiograph or by showing them the lesion itself with the help of a mirror) has been found to help the patient become more involved in their treatment and more compliant with instructions. Teaching the patient to clean the diseased site before cleaning the rest of the mouth is also very useful, and discussing ways to do that most effectively has been found to ward off caries progression.2 Suggestions might include using a different angle than usual when brushing to reach the diseased area, using a different design of brush, or switching from dental floss to an interdental cleaner with a handle to better reach carious-lesion areas in the back of the mouth.2,8,9

Use of Fluoride: All patients should be encouraged to brush with over-the-counter, fluoride containing toothpaste at least twice per day. Fluoride-containing toothpastes are regulated by the U.S. Food and Drug Administration (FDA) and are required to contain a clinically proven level of fluoride. To comply with this requirement, fluoride toothpastes in the US generally contain between 850 -1150 ppm of fluoride. Fluoridated toothpaste is low-cost, very easy for most patients to use, and is quite effective, being linked with a 24% decrease in caries in permanent dentition.10 Fluoridated toothpaste can also be used therapeutically by asking the patient to apply a dab of paste with a finger or brush directly to a cleaned active lesion immediately before going to bed. This will allow an increased concentration of fluoride in the vicinity of the lesion at a time of day when salivary output is naturally low. For patients with active caries who may not be able to clean their teeth adequately with a fluoride toothpaste, a 0.05% NaF fluoride rinse taken once per day, or a 0.02% NaF rinse taken twice per day should be recommended.2 Fluoride mouthrinses have been credited with providing an average reduction in DMFS of 27%, when compared with a placebo rinse, or no mouthrinse at all.11

For patients with high caries activity, it may be necessary to recommend a high-dose prescription fluoride dentifrice, gel, rinse, or supplement tablet for at-home use. Fluoride can also be professionally applied in the form of a varnish after plaque removal by the dentist. This form of application has been linked to a 43% reduction, on average, in caries in the permanent dentition.12

Note that acidulated phosphate fluoride is contraindicated in patients with porcelain or composite restorations, as it can cause pitting and etching. Instead, a neutral sodium fluoride should be recommended to these patients.2

Diet Modification: In a patient with no active caries, the dental professional should review the role of risk factors in dental caries and remind the patient of how any changes in diet might cause them to get caries. The dentist or hygienist can counsel the patient to watch out for times in life when their diet can change to one that may increase caries risk, such as pregnancy, unemployment, divorce, retirement, and bereavement. A simple check regarding any significant changes in status can then be made at subsequent visits.

In a patient with active lesions, an analysis of the diet will help uncover possible caries culprits. One method is to ask a patient to recall all they have consumed, such as food, drinks, and medication, in the last 24 hours; another method is for a patient to record all they consume over a 3-day period. The data collected can help the dental professional work with the patient to devise some practical strategies for reducing the intake or frequency of sugary foods and drinks. One word of caution: Because these methods of collecting data on dietary habits rely on full patient cooperation and honesty, and may not reflect the diet consumed over a much longer period, data should be interpreted with caution.2

Recalling the Patient: Recalls should be scheduled according to the patient’s individual needs. For patients without active caries, recalling the patient once or twice annually typically suffices. However, in higher-risk patients who for some reason may not master plaque control themselves or who have decreased salivary secretion due to certain medical conditions, medications, or deleterious habits, it is recommended that a dentist encourage the patient to return more often for professional tooth cleaning. The interval at the beginning should be short, such as every 2 to 3 weeks, until the patient has reached an acceptable level of plaque control. The interval between appointments may then be extended as the dentist sees fit: a patient with dry mouth should return every 2 to 3 months, while a patient without dry mouth whose caries activity appears under control may only need to be seen every 6 or 12 months.2 During recalls, the mouth should be examined for signs of patient compliance, plaque control, and caries arrest or progression. New radiographs may also need to be taken. Depending on what the dentist finds, he or she may feel the need to remind the patient about oral hygiene instruction and diet, discuss possible changes to current non-operative strategies, or apply a sealant to active non-cavitated lesions.