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Treatment Solutions for a Complex High-Risk Caries Patient
Planning for long-term success in a case of poor compliance
Joyce Bassett, DDS, FAACD, FAGD
Offering high quality dentistry is the goal of every dentist. Our responsibility is to evaluate the condition and gain a thorough understanding of the patient’s history, circumstances, and expectations, while assessing the risk, longevity, and liability of the proposed treatment modality. It may be difficult for the dentist to determine if an identified condition is progressing, regressing, or stable. Uncertainty is problematic because appropriate treatment often depends on an accurate understanding of oral conditions.
A 14-year-old male patient presented for a structural and esthetic assessment of his dental condition (Figure 1). He reported that his orthodontist decided that early debanding was required, leaving the buccal corridor undeveloped. He had been noncompliant with wearing elastics and had missed many appointments. The enamel exhibited many decalcified areas and plaque control was poor. The patient’s mother sought a conservative approach to his current situation. He was displeased with his appearance and stated that he detested all visits to the dentist.
The patient received a comprehensive exam, full-mouth series of radiographs, a panoramic x-ray, diagnostic photos, records, and a periodontal evaluation. Periodontal sulcus depths of 2 to 3 mm were noted. Plaque was rampant and his hypertrophied gingiva exhibited bleeding on probing. The panoramic x-ray revealed bone support within 2 mm of the cementoenamel junction. A clinical evaluation revealed white spot lesions and carious lesions on multiple surfaces of his dentition.
The patient exhibited a dental Class I malocclusion. The musculature and joints were not painful to loading or palpation. On a full smile, he demonstrated high lip dynamics on the maxillary arch and low lip dynamics on the mandibular arch (Figure 2).
The patient’s esthetic vision could not be addressed until caries control, caries removal, and hygiene compliance was attained.
Topical anesthetic was placed, and scaling and curettage was performed. The patient was given plaque management and oral hygiene instructions, along with reinforcing future monitoring of home care. The re-evaluation of the hyperplastic tissue 60 days after the initial periodontal therapy revealed the necessity to perform a gingivectomy and gingivoplasty on the maxillary incisors.
To ensure that the biologic width was respected, sounding to bone was performed after anesthetizing1 and before any tissue was removed to safeguard the health of the dentogingival complex. The NV® microlaser 810 Nm diode (DenMat, www.denmat.com) was used because the zone of necrosis is 3 to 5 cells thick and the healing was quick and painless.2
Caries is a disease of susceptibility. Bacterial plaque accumulation called biofilm creates an acid environment that allows caries disease to spread. Risk factors for developing caries include active orthodontics, a cariogenic diet, presence of biofilm, poor oral hygiene, and acquired enamel defects.
White spot lesions are caused by the demineralization of the subsurface enamel, either by the malformation of the enamel during tooth development or breakdown of the enamel due to acids and poor oral hygiene. Since the surface of the enamel is porous, phosphates can move out of the tooth.3
To offer the most conservative treatment, the Icon system was considered (DMG America, www.dmg-america.com), as MI Paste™ (GC America, www.gcamerica.com) and Icon have been successfully used in the early stages of white spot lesions. The Icon system involves microabrasion with hydrochloric acid, simultaneously eroding and abrading the enamel while saturating the enamel with hydrochloric acid and infusing it with liquid resin. The challenge for the dentist is diagnosing the lesion stage and its degree of activity. Visual assessment cannot determine the depth or activity of the lesion. It must be determined if anterior lesions are progressing, regressing, or remaining the same. After this HCl-infused microabrasion, the remaining enamel is dense and aprismatic and more resistant to acid challenges and plaque retention.4
A multifaceted intervention approach combining fluoride, xylitol, remineralization, resin infiltration, MI Paste, and antimicrobials was investigated.
A pediatric dental specialist expert and an initial tester for the Icon resin infusion system was employed to perform a diagnostic evaluation to see if the Icon product would repair this situation in a conservative manner. He reported that the penetration and destruction was so advanced, the minimally invasive resin infiltration was not a possible solution. Therefore, the treatment with the best long-term predictable outcome was removal of the damaged enamel and affected dentin. The carious lesions were so widely distributed that full-mouth reconstruction was necessary.
A 5000-ppm toothpaste, a fluoride rinse, and MI Paste were prescribed in the interim.
Bleaching and Caries Removal
Since this patient was only 14 years old at the initial visit and nervous about dental treatment, it was important to arrest the disease while gaining his confidence and keeping appointments as short and pain free as possible. At-home bleaching trays had been fabricated during initial periodontal therapy, but he was not satisfied with the home tray protocol and admitted he was noncompliant. He desired the quickest solution to attain the whitest smile, so in-office power bleaching (Philips Zoom WhiteSpeed, Philips Oral Healthcare, www.philipsoralhealtcare.com) was chosen (Figure 3 and Figure 4).