The patient perspective
Having finalised a mutually-agreed care plan in the ‘decide’ phase, the ‘DO’ phase involves both the planning and implementation of that care plan. Planning is good for both the practitioners and patients; making an explicit plan has repeatedly been shown to ensure adherence to health care recommendations. The do stage is not only about professional treatment but also working with the patient to ensure that they have a clear plan of action to support their own oral health (Fig. 6).
What it is
Appropriate tooth-preserving and patient-level prevention and control is the fourth essential step in the cycle that delivers the personalised comprehensive CariesCare plan built on the outcomes of the first three Ds. This fourth ‘D’ consists of two elements:
• Managing the patient’s caries risk, tailored at the individual level with actions to improve the risk status where possible
• Managing individual caries lesions according to their severity and activity. Caries care options may differ between the primary and permanent dentition.
How to conduct appropriate tooth-preserving and patient-level prevention and control
Managing the patient’s caries risk
• The caries risk factor management plan can involve two levels:
1. Homecare approach: activities to be conducted at home by the patient or their parent/guardian/carer, as instructed by a member of the dental team, which takes into account the patient’s needs, opportunities and preferences. Activities include fluoridated toothpaste use, fluoride rinse/gel, toothbrushing, interproximal cleaning and behaviours related to oral health including diet and other oral hygiene advice
2. Clinical interventions: activities conducted at the practice, including discussing personalised ways of improving oral health-related behaviour, topical fluoride application at a frequency appropriate to the patient’s risk classification, sealant application, one-to-one dietary advice (with emphasis on sugars), and, if required, managing hyposalivation or other specific risk factors.
• There is strong evidence for the use of topical fluoride both professionally applied and for home use in the prevention of dental caries
• Based on the available evidence, concentrate on delivering advice on brushing twice a day with a fluoridated toothpaste that is appropriate to the age of the patient and their risk factors
• Advice should include basic details of when brushing is most effective and how to maintain the fluoridated toothpaste in contact with the teeth (spit, don’t rinse)
• Emphasis should be placed on improving oral hygiene and delivery of topical fluoride in plaque stagnation areas where caries commonly occurs
• Given the understanding of the disease process, dietary advice should be directed at identifying sugars in the diet (including hidden sugars), reducing the amount/frequency of sugar intake and suggesting safe alternatives
• Organise and agree with the patient or their carer a risk-based recall (re-care) interval depending on risk classification.
Managing tooth-level caries lesions
• Care options for caries lesions include:
1. Non-operative care (NOC); this is non-surgical preventive care to control caries
2. Tooth-preserving operative care (TPOC); this is minimally-interventive surgical treatment.
• The severity status of the caries lesion will inform and dictate preventive (non-operative) or operative management, but lesion activity should also be considered:
1. Initial caries lesions should be managed with non-operative care when active and when inactive should be reviewed at recall appointments for any change in status
2. Moderate caries lesions (ICDAS 3 and 4) management depends on a number of factors including patient-level risk status, radiographic appearance, lesion activity, and whether or not there is surface breakdown; if the lesion radiographically extends up to the outer dentine third (mainly in ICDAS 3 or microcavity) it is feasible to manage with non-operative care if inactive, and in some cases in the absence of other risk factors and if the patient is compliant
3. Extensive caries lesions (ICDAS 5 and 6) should generally be managed with tooth-preserving operative care according to lesion severity and pulp involvement.
• Take into account patient-level strategies for therapeutic control of initial lesions and:
1. In children there is strong evidence for the use of fissure sealants for the caries management of pit and fissure caries, but there is a trend for strict indications for preventive sealants on sound teeth in high caries risk children and an increased focus on therapeutic sealants for initial caries lesions which cannot be controlled by non-operative caries measures
2. Where operative intervention is required, tooth-preserving operative care should be provided according to the patient’s needs (age, setting, environment). There is evidence that more conservative caries removal techniques are effective in preserving tooth tissue and avoiding pulpal complications
3. In restored teeth consideration should be given to repair of a restoration rather than re-restoration, where possible, to avoid further loss of tooth tissue by unnecessary removal of sound sections of the old restoration.
Good practice points
• Wherever possible, caries should be managed with prevention (non-operative interventions) to avoid unnecessary surgical intervention
• Where surgical intervention is required, tooth-preserving operative care should be considered
• Management options are dependent on patient- and tooth-level assessment (risk, caries lesions, restorative status and patient compliance)
• In some cases, moderate or extensive inactive caries lesions may require TPOC due to local factors such as the presence of a removable prosthesis or a clasp contacting the lesion
• Recall interval should be based upon a combination of risk assessment and management as well as clinical procedures carried out
• Erosive tooth wear, developmental defects of enamel and periodontal status should be considered for comprehensive care
• Most evidence is based on children, adolescents and young adults but good clinical practice would suggest this is applicable for older adults
• Note: local adaptations may be required, for example according to varying levels of systemic fluoride concentration
• The intensity of the risk-based intervention is cumulative, so for patients with higher risk all preventive interventions prescribed for patients with lower caries risk should also be considered
• Clinicians and their teams should be familiar with evidence-based prevention guidance applicable locally to them
• Dentists should keep up to date with both changes in cavity preparation philosophy and the requirements and opportunities given by new developments in dental materials
• Successful use of direct adhesive restorative techniques and materials that require effective moisture control and rubber dam isolation should be considered over relative isolation with cotton rolls
• As the Minamata treaty is implemented internationally, there is both an opportunity for prevention and a need for caution when dental amalgam is replaced by more technique-sensitive materials.
Guidance references: 1,2,3,4,5,6,7,8,9,10,37,38,39,40,41,42, 43,44,45,46,47,48,49,50,51,52,53,54
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3rd D: DECIDE: Personalised care plan: Patient and tooth levels
2nd D: DETECT & ASSESS – Caries staging and activity
1st D: DETERMINE Caries Risk