Last Friday’s post looked at the concept of caries management by risk assessment ( CaMBRA) and it’s use to identify patients at risk for developing cavities. Identification of people with an elevated caries risk would be pointless unless we use that information to help them understand how to decrease their risk. One of the primary way sin which we assist patients is simply completing the assessment and creating awareness of the factors that combine to create their individual experience with getting cavities. Beyond simple awareness comes the addition of antimicrobials, topical fluoride application and behavior modification to try and balance out the risk factors present. I think about it as a scale or balance between the risk factors and the protective factors. the more risk a patient has, the more preventive measures we want to add to try and cancel out the risk. With that said, we also need to be realistic about what patients will and will not do routinely. We have an assortment of options for our patients so that they can help us understand what works and what doesn’t based on their personality and lifestyle.
Prescription Toothpaste: Products like Clinpro 5000 (3M) are easy to add as it simply replaces the existing toothpaste the patient uses. I am a strong advocate of dispensing it from your office so we do not add a barrier to use by the patient having to go to the pharmacy. If we can get it on the bathroom counter my experience is patient’s will use it. For moderate risk the recommendation is to use it at night before bed, and for high risk both morning and night.
Fluoride Varnish: The application of fluoride varnish at hygiene visits is a very effective way to decrease caries risk. Patients who are clear that they have an elevated risk of developing a cavity are open to the idea of adding fluoride, even being responsible for the fee, as again they do not have to add anything to their home care routine at home.
Chlorhexidine: The recommendation for caries management is to rinse with Chlorhexidine everyday for the first week of the month and then take the rest of the month off for patient’s at high risk. We are all familiar with the challenges of Chlorhexidine, and because of these I am a fan of Chlorhexidine Varnish instead of the rinse. If I am adding fluoride in a prescription toothpaste and seeing high risk patients four times a year we will substitute the chlorhexidine varnish ( Cervitec Plus by Ivoclar) for the fluoride varnish at hygiene visits.
Xylitol Mints: The addition of Xylitol mints is part of the recommendation for both moderate and high risk patients. Patients who already chew gum or use mints or hard candy are the first people I target to swap those out for something that contains Xylitol.
Lastly patients at high risk benefit from having a hygiene visit every 3-4 months instead of the standard 6 months frequency.