Social and demographic factors
3.7.6 Social and demographic factors
These factors, although not directly involved in the carious process, can have an overriding influence 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. Nevertheless 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.
3 . 8 C A T E G O R I Z I N G C A R I E S A C T I V I T Y S T A T U S6
Following history, clinical, and radiographic examination the dentist should categorize the patient as:
• caries inactive—no active lesions or history of recent restorations
• caries active—active lesions and or an annual increment of two or more new, progressing or filled lesions.
In the caries active patient it is sensible to try to list the factors that seem to be responsible. Some of these may be amenable to change, e.g. improving oral hygiene or diet. Others may be difficult to modify, e.g. an essential medi- cation that also reduces salivary flow. Some factors may seem impossible to alter. Social factors such as poverty and education cannot be altered by the dentist. Behavioural factors may be very difficult to change, and these are discussed further in Chapter 8.
Further reading
1. Fejerskov, O. and Kidd, E. A. M. (eds) (2003) Dental caries. Ch.6: Caries diagnosis:
‘a mental resting place on the way to intervention’? Blackwell Munksgaard, Oxford.
2. Fejerskov, O. and Kidd, E. A. M. (eds) (2003) Dental caries.Ch.7: Clinical and radio- graphic diagnosis. Blackwell Munksgaard, Oxford.
E S S E N T I A L S O F D E N TA L C A R I E S 6 4
3. Fejerskov, O. and Kidd, E. A. M. (eds) (2003) Dental caries.Ch.9: Caries epidemiology with special emphasis on diagnostic standards. Blackwell Munksgaard, Oxford.
4. Fejerskov, O. and Kidd, E.A.M. (eds) (2003) Dental caries. Ch.8: Advanced methods of caries diagnosis and quantification. Blackwell Munksgaard, Oxford.
5. Fejerskov, O. and Kidd, E. A. M. (eds) (2003) Dental caries. Ch.22: Caries prediction.
Blackwell Munksgaard, Oxford.
6. Fejerskov, O. and Kidd, E. A. M. (eds) (2003) Dental caries. Ch.20: Caries control for the individual patient. Blackwell Munksgaard, Oxford.
C A R I E S D I A G N O S I S 6 5
This page intentionally left blank
Prevention of caries by plaque control
4.1 Introduction 68
4.2 Evidence of the importance of tooth cleaning 68
4.2.1 The individual site 69
4.2.2 The individual patient 69
4.2.3 The community 70
4.2.4 Professional tooth cleaning 70
4.3 Mechanical removal of plaque 71
4.3.1 Seeing plaque: disclosing agents and mirrors 71
4.3.2 Toothbrushes 72
4.3.3 Methods of toothbrushing 73
4.3.4 Interdental cleaning 74
4.3.5 Toothpastes 77
4.3.6 Professional plaque control 80
4.3.7 Advice to patients 81
4.4 Chlorhexidine: a chemical agent for plaque control 82
4.4.1 Mechanism of action, dosage, and delivery 83
4.4.2 Side effects 84
4.4.3 The use of chlorhexidine in the control of caries 85
4
4 . 1 I N T R O D U C T I O N
The carious process is the metabolic activity in the plaque (the biofilm). The result may be nothing to see or there may be a net loss of mineral resulting in a carious lesion that can be seen. Plaque is the cause of caries, and a tooth which is completely free of plaque will not decay.
However, it is not always possible to demonstrate a strong association between the presence of dental plaque and caries, and there are some obvious reasons for this. For one thing, people are not able to completely remove plaque themselves, even with supervision. In addition, although the bacterial biofilm is the cause of caries, there are other factors involved. This is why caries is described as a multifactorial disease. These factors may increase or decrease the rate of demineralization.
To give examples, increased sugar intake and decreased salivary flow speed up the carious process. On the other hand, fluoride tends to decrease the rate of mineral loss. Thus it is not only amount of plaque that matters but the combined effect of all the factors, and the combination of factors, which will vary from patient to patient.
Brushing twice daily with a fluoride toothpaste has been advocated by the profession for many years, and this behaviour is a routine part of many people’s behaviour. This daily brushing with a fluoride toothpaste is believed to be the primary reason for the decline of caries observed in many populations since the 1970s. The behaviour should not be taken for granted. Patients should always be asked whether, and how often, they brush their teeth and what toothpaste they use. Most toothpastes contain fluoride, but not all, and it is important to check this. In UK a well-known brand of toothpaste for sensitive teeth is pro- duced in a number of flavours, and at the time of writing, not all these products contain fluoride. Since cavities in teeth can be sensitive to hot and cold, it is not unusual for patients with caries to select a toothpaste for sensitive teeth. Thus the very person who most needs a fluoride toothpaste is sometimes not using it.
Some herbal toothpastes are also formulated in a fluoride-free form.
4 . 2 E V I D E N C E O F T H E I M P O R T A N C E O F T O O T H C L E A N I N G1
The designs of clinical studies to assess the caries preventive effect of tooth- brushing vary greatly. Some will indicate whether the procedure canwork, given full compliance by all concerned. Others are more pragmatic in design, trying to find out whether the procedure doeswork in a real-world com- munity setting when some individuals comply and other do not. It is helpful to consider the evidence at different levels:
• an individual site
• individual patients
• the community.
E S S E N T I A L S O F D E N TA L C A R I E S 6 8