High-risk patient

Risk factors and disease indicators [decay] present, low biofilm challenge, approximately 19% of the population. [1]

Amelia

1/21/11: Amelia is a 23-year-old female with little dental history. She has not seen her dentist in 3 years and, 3 years ago, was a new patient who had no cavities or problems at all. She has recently started a job that includes dental insurance and has scheduled a cleaning appointment. During her caries risk assessment, she only self-reported that she sipped drinks other than water more than 2 times daily, but only on healthy drinks like tea and juice. Her CariScreen score was 622, but she had 4 new cavities visible on her x-rays; and during her examination, the dental professional noted it appeared Amelia had not been regular with her home care. Her dental professional was shocked her CariScreen score was so low. Amelia did not seem very forthcoming with information on her risk factors and said she only wanted what her dental insurance would cover. Her dental professional shared that they were there to help her in any way they could and that their goal was to help her improve her oral health. Amelia chose to decline any professional/prescription therapy products and scheduled the fillings covered by her dental insurance.

2/6/11: Amelia returned for her fillings, and her dentist noted her saliva did not seem normal and was thick and sticky. The dentist inquired regarding her risk factors and CariScreen score and asked her if there was anything else going on in her life that could be affecting her diet or if she felt like she had a dry mouth. Amelia again chose not to share any risk factor information with her dentist.

7/19/11: Amelia returned for her 6-month recall visit, and she did not self report any other risk factors other than her frequent daily drinks of tea and juice. Her CariScreen score was 536, and she had one new cavity that needed restoration, a couple small new lesions forming, and as some recurrent decay around one of her previous fillings. Her hygienist inquired as to why Amelia liked to have liquids to drink so frequently. Amelia informed her hygienist that she kept them close because she felt like her mouth was dry sometimes. At this point, her hygienist pulled out Amelia’s caries risk assessment form and went through the risk factor list, covering each question thoroughly but without judgment, knowing something was missing. Amelia was initially resistant, but as the hygienist continued to ask open-ended questions, Amelia began to share and the dental team discovered that Amelia was actually on 4 different medications for depression, anxiety, and back pain that she took daily. Amelia was initially resistant to share her medications as she didn’t feel they were important to her dentist and felt embarrassed about the medications she was taking. During a visit to a local medical clinic a year ago, she had been treated like a “drug seeker” and was tired of feeling judged. She was working hard and was taking care of her mother and little brother and felt that few medical professionals took her seriously. It took her dental team time to build enough trust for her to share some risk factors that were making her more susceptible to dental decay. After understanding the underlying cause of her susceptibility and the options she had, Amelia had an in-office fluoride varnish and chose to begin using a professional rinse and toothpaste/gel with pH neutralization, xylitol, fluoride, and nanoparticles of hydroxyapatite at home (such as CTx4 Treatment Rinse, CTx3 Rinse, and CTx4 Gel 5000).

10/12/11: Amelia returned for a 3-month recall check to assess how her therapy was working. She was still taking the 4 different medications and experiencing dry mouth. She was also still frequently sipping tea and juice. Thankfully, her early lesions identified at the previous visit were showing signs of remineralization and all of her restorations looked great. Due to her low saliva flow, it was important that she continue with a maintenance program of pH neutralization, xylitol, fluoride, and nanoparticles of hydroxyapatite; and Amelia chose to stick with using the professional rinse and toothpaste/gel with pH neutralization, xylitol, fluoride, and nanoparticles of hydroxyapatite daily. To date, Amelia has shown no new decay.

Jerome

7/12/11: Jerome is a 17-year-old high school athlete. He has had numerous problems with decay in the last 3 years. His first caries risk assessment revealed that he only had one risk factor: drinking liquids other than water more than 2 times daily. He had excellent oral hygiene habits and was brushing with an electric toothbrush twice daily as well as flossing daily. He had a CariScreen score of 989 and 4 new cavities as well as some other early lesions the dentist wanted to keep an eye on. He shared that he very regularly consumed diet sodas as well as diet sports drinks due to his daily sports routine and had basically stopped drinking anything else during the day. His dentist explained how both diet sodas and sports drinks were extremely acidic (pH 2.5–3.3). The regular bathing of Jerome’s teeth in acid and some sugars (in the diet sports drink) were causing even the low level of bacteria on his teeth to cause cavities. He said he would try to limit the diet soda and drink more water during his physical activities. He chose to be conservative with his home care program and replaced his toothpaste with the one the dentist recommended that had 1.1% neutral sodium fluoride, pH neutralization, xylitol, and nanoparticles of hydroxyapatite for remineralization (such as CTx4 Gel 5000).

2/2/12: Jerome returned for a 6-month checkup, and his caries risk assessment revealed the same risk factor of liquids other than water more than 2 times daily. His CariScreen score was 1027, and two of the areas the dentist had chosen to watch previously now had decay that needed restoration. But Jerome had two other spots that appeared to have partially remineralized. He shared that he had cut out most of the diet soda but was still consuming 4–5 diet sports drinks on a daily basis. He had a couple of choices: He could choose to keep his same home care program and sports drink consumption and continue getting cavities; although he had slightly less this time, he was still showing signs of the disease. He could choose to increase his home care regimen, which included both prescription toothpaste/gel and a professional oral rinse with pH neutralization, fluoride, xylitol, and nanoparticles of hydroxyapatite for remineralization, or decrease his sports drink consumption. He chose to up his home care program and said he would try to cut back on the sports drinks. He and his parents were tired of all the new cavities, and he really wanted to look into orthodontics and whitening. But his parents said that they weren’t going to pay for any cosmetic dental work until he stopped getting cavities, and his dentist agreed. Adding orthodontic brackets to his teeth would just increase his risk at this point. Jerome’s dentist wanted him to come back in 3 months when his home care kit was gone and reassess if the new therapy program was enough to get him under control.

5/22/12: Jerome came back in for his 3-month reassessment, and his CariScreen score was 416. His dentist noticed multiple areas of remineralization on his teeth, and he had no new cavities. Jerome explained that he had been extremely vigilant with his home care program of rinsing and then brushing but had actually increased his diet sports drink consumption. He also explained that he had taken the dental hygienist’s advice, and whenever he drank the sports drinks during his athletic events, he drank them quickly and then did a quick rinse and spit with regular water to get the liquid off his teeth. This method had reduced the amount of acidic exposure to his teeth. Combined with the increase in protective factors he had, for the moment, found a balance. His dentist said he should keep up his program, and they would revisit his desire for orthodontics and whitening in 6 months if his balance was maintained. 


  1. Based on a private practice study of 3,125 patients, http://carifree.com/dentist/learn/our-systems/data-study.html