July 1st, 2009 by admin

Once a dentist has assessed a patient’s caries activity status as high, an
attempt should be made to identify the relevant risk factors because it may be
possible to modify these and thus slow down disease progression. Some of
these risk factors are listed in the box opposite.
3.7.1 Medical history
All patients should have their medical history taken, and this will include
noting all medications. Some medications have sugar in their formulation,
and if these are consumed frequently they can cause caries. In addition,
some medications may decrease salivary  ow. A low salivary  ow rate pre-
disposes to caries; the many reasons for this are discussed in more detail in
Chapter 7. Each medication should be looked up in the British National For-
mular y because this lists the contents of the medication (including sugar)
and whether the drug is known to cause a dry mouth.
Other diseases and treatments directly affect the salivary glands, such as
Sjögren’s syndrome and radiotherapy in the region of the salivary glands for
head and neck malignancies.
Medications containing sugar
Medications known to cause a dry mouth
Radiotherapy for head and neck malignancy
Sjögren’s syndrome
Disability
Dental history
History of multiple restorations
Frequent replacement of restorations
Sudden need for multiple restorations
Oral hygiene
Low frequency of tooth cleaning
Toothpaste that does not contain  uoride
Paste vigorously rinsed from the mouth?
Appliance worn e.g. orthodontic appliance; partial denture
Diet
Frequent sugary snacks or drinks
Fluoride
No  uoride supplementation e.g. no  uoride in toothpaste
Teeth rarely brushed
Saliva
Stimulated and unstimulated salivary  ow is low
Social and demographic factors
Poverty
Low educational status
Unemployed
Religion and ethnicity may be relevant
Absence of  uoride in water
3.7.2 Dental history
A history of multiple restorations and a need for frequent replacement of
restorations is always relevant. These patients have proved themselves to be
at high risk to caries, and dentist and patient need to work together to identify
why this is. A sudden need for multiple restorations indicates something has
changed. Perhaps it is salivary  ow, perhaps diet, but again detective work is
needed to try to identify the cause.
3.7.3 Oral hygiene
Since the carious process occurs in the plaque, questions about oral hygiene
are very important. How often does the patient clean? How is the paste
cleared from the mouth, by rinsing or spiting? Does the toothpaste contain
uoride? Is a mouthwash used? Does the patient use an appliance, such as an
orthodontic appliance or a par tial denture? These make cleaning more
difficult and may increase caries risk (Figure 3.22). Plaque control and caries
are considered further in Chapter 4.
3.7.4 Diet
Questions about diet are obligatory when a patient presents with active
carious lesions or a history of multiple restorations that are frequently
replaced. Dentist and patient are searching for an inappropriate dietary habit
3.7.5 Saliva
Saliva is a protective  uid as far as the mouth is concerned. A low secretion
rate leads to reduced elimination of microorganisms and food remnants,
impaired neutralization of acids, and a reduced ability to repair minor
demineralizations. Increased caries activity is often seen in persons with
a reduced rate of salivary secretion. However, although some patients are
aware of a dry mouth (this is called
xerostomia
), others with reduced saliv-
ary  ow (
hyposalivation
) do not realize they have a dry mouth. Dentists
can sometimes detect a lack of saliva during the course of a clinical examina-
tion because the mouth mirror tends to stick to the mucosal surfaces or the
saliva appears frothy.
Where a dry mouth is suspected, or in cases where a high caries incidence
cannot be explained, stimulated and resting salivary  ow rates should be
measured. The normal secretion rates in adults are 1–2 ml/min for stimu-
lated secretion and 0.3–0.5 ml/min for unstimulated secretion
Unstimulated salivary secretion rate.
The patient sits quietly in the
dental chair for 10 minutes, without chewing or swallowing but spitting
into a disposable cup.
• Normal unstimulated secretion rate in adults: 0.3–0.5 ml/min
• Normal stimulated secretion rate in adults: 1–2 ml/min
• Low stimulated secretion rate in adults: <0.7 ml/min
• Severely dry mouth: <0.1 ml/min
Saliva is considered fur ther in Chapter 7.
3.7.6 Social and demographic factors
These factors, although not directly involved in the carious process, can have
an overriding in uence in health and disease and on the changes in lifestyle
a patient is able to make. It is not easy to assess these important issues,
particularly when the patient is not in their home environment but on
the dentist’s territory, the dental surgery. Never theless the dentist will
notice such things as cleanliness, age, dress, demeanour, disability, ethnicity,
speech, educational status, and employment status. However, it is unwise
to jump to conclusions, and relevant factors may only emerge after dentist
and patient come to know each other better