How long does treatment take?
There are many confounding factors that influence caries risk treatment time and the potential results a patient and practitioner can expect. Each patient’s oral biofilm is as uniquely specific to them as their fingerprint, and no two patients will respond exactly alike to therapy and remineralization agents. It is important to remember that high-risk patients may require therapy modification throughout the treatment phase to reach a state of balance. Many patients may require ongoing therapy agent usage during the maintenance phase. Perhaps for life, if risk factors are unmodifiable or still present. The good news is that professional/prescription dental products have also improved at treating both the pH imbalance and the bacterial condition that may be present. Professional/prescription products are also capable of remineralization under the right conditions. Take-home professional therapy should be recommended in 3- to 6-month increments, and reassessment should take place as soon as the prescribed therapy is finished.
Factors Influencing Treatment Time and Results
Time. The length of time a patient has been experiencing issues with dental decay should be considered when setting therapy expectations. A patient who has experienced symptoms of the imbalance (cavities) for years is probably going to require more therapy over a longer period of time than a patient with their first cavity. This is why caries risk assessment is vital. The earlier a patient can be identified at risk, and the sooner intervention can be initiated, the shorter the duration of treatment will likely be.
Number of risk factors. The number of risk factors plays an important role in treatment time and effort. Patients with multiple risk factors will likely face a greater challenge to lower their risk and reduce the incidence of signs/symptoms than patients with one risk factor. Many risk factors, when combined, can cause a compounding effect on a patient’s risk. For example, frequent snacking combined with low saliva flow can make the acid challenges a patient experiences longer and more intense, placing a greater challenge on the effectiveness of therapeutic agents and strategies. The more risk factors a patient has, the more therapy may be required.
Modifiable versus unmodifiable risk factors. If the risk factors driving the disease progression for a patient are unmodifiable, such as life requiring prescription medications that cause reduced salivary flow, it will increase the length of time a patient will require therapy. If the risk factors driving the patient’s disease are behavioral habits, and the patient is not yet ready to change those behaviors, more therapy and time may be required. Modifying and eliminating risk factors is the most cost-effective method of therapy, and an essential part of reducing a patient’s caries risk.
Risk factor severity. Patients may need to rely on their dental professionals’ expertise to define the severity of specific risk factors, such as salivary flow or biofilm challenge. As an example, a patient taking a single medication daily (while it is an important risk factor to consider) is probably not as severe as a patient taking ten different types of medications daily. For some patients, the severity of their risk factors can create a dramatic barrier to reaching a state of oral health balance.
Risk factor frequency. The frequency a patient is being exposed to risk factors should be analyzed when considering treatment time and expectations. If a patient is consuming one snack per day, the frequency may not be of as much concern as a patient who snacks 3 or more times per day between meals. Patients who are experiencing a higher frequency of exposure to risk factors will require more time and effort to reach a state of oral health balance.
Presence of symptoms. If a patient’s disease has progressed to the point of experiencing signs/symptoms of the oral imbalance such as visible cavitations, white spot lesions, or cavities identified on x-rays, they have reached a later stage of the disease and have a longer treatment time than a patient who has yet to express signs/symptoms.
Severity of signs/symptoms. The severity of the signs/symptoms should also be an indicator of the amount of time and effort required to reach a state of oral health balance. A patient with one new cavity is not in as severe a condition as a patient with several new cavities.
Timely restorations. The capability of therapy products to modify a biofilm and help move a patient toward health will be hindered by unrestored sites of disease. While remineralization is possible for early lesions that have not progressed beyond the DEJ (dentin-enamel junction), or E2 lesions, once the lesion depth has penetrated the DEJ and is a D1 or D2 lesion, the enamel surface is cavitated and the tooth requires surgical removal of the lesion followed by restoration. Cavitations that have reached a depth requiring restoration must be restored in a timely manner, and potential sources of the infection must be removed, if an oral health balance is to be achieved.
Level of therapy. Patients have choices when moving forward with prescription/professional therapy, and the level of therapy they choose partially dictates the length and expectations of therapy. For example, if the recommended therapy for a high/extreme-risk patient is a professional home care kit for 3 months, and the patient chooses an over-the-counter preparation, the patient’s expectations need to be appropriately adjusted. The patient may experience no change or only experience a slowing progression of signs/symptoms or biofilm challenge rather than a meaningful reduction or reversal. However, choosing to do something rather than doing nothing is always a smarter move toward health.
Patient therapy compliance/adherence/participation. While it may seem fundamental, lack of patient follow-through with medical recommendations is one of the primary reasons diagnosed medical conditions continue to progress. The majority of prescriptions written in the United States never even make it to the pharmacy to get filled, much less get taken on a regular basis as prescribed. It is essential that patients continue to use the therapy they have been prescribed, as prescribed, for the duration of the therapy time recommended. If the patient has been prescribed 3 months of therapy product but reassessment with their dentist has not been scheduled for 6 months, the patient should get another 3-month supply as directed after the initial therapy product has been used, or risk regression of their disease risk status.
Therapy Milestones and What to Do
Assuming a patient has chosen to move forward with some form of therapy or preventive product with pH neutralization, 0.2% sodium hypochlorite, 0.5% or 1.1% fluoride, xylitol, and nanoparticles of hydroxyapatite and the therapy has been supplied in 3-month increments (such as CTx Kits), it is advisable to reperform a full caries risk assessment and each subsequent reassessment appointment at 3-month intervals. The number, frequency, and severity of risk factors can change substantially between appointments.
Three months. Depending on the level and severity of the patient’s risk, some practitioners may wish to reassess the patients risk and therapy level at 3 months, while most have the patient continue the therapy for 6 months. Many patients (if compliant) show some form of progress at the 3-month appointment (See Figure 18). Although it may not be enough to lower the patient’s therapy requirements yet, the progress can encourage both the patient and the practitioner that the patient is on the right therapy program. Some examples of progress might be remineralization of early white spot lesions or areas of demineralization, improved visual soft tissue health and appearance, decrease in bleeding gums when flossing or probing, reduction in sensitivity, decreased incidence of halitosis (bad breath), a feeling of “cleaner” teeth, reduced noticeable plaque buildup, “hardening” of tooth enamel, improved tooth luster, etc. Some patients with a high biofilm challenge at the initial appointment may see a reduction in their biofilm challenge at the 3-month reassessment. The patients likely to see a reduction in their biofilm challenge at this point are patients that initially presented with limited risk factors, no severe risk factors, and no disease indicators and who were compliant with professional recommendations.
A practitioner’s goal at the 3-month reassessment should be to identify any kind of progress and verify patient participation or compliance. If progress is identified, it is recommended that the patient continue with the current level of therapy. If no progress is identified, it is recommended that the patient either increase their level of therapy, continue with the current level of therapy with modified expectations, or continue with the current level of therapy and modify one risk factor.
Six months. Most patients (if compliant) will show progress at the 6-month appointment, and the progress may be adequate to lower the patient’s therapy level. Some examples of progress might be remineralization of early areas of demineralization, improved soft tissue health on inspection, decrease in bleeding gums when flossing or probing, reduction in sensitivity, decreased incidence of halitosis (bad breath), feeling of “cleaner” teeth, reduced plaque buildup, “hardening” of tooth enamel, improved tooth luster, and/or reduced incidence of cavities. Some patients with a high biofilm challenge at the initial appointment may see a reduction in their biofilm challenge at the 6-month reassessment. The patients most likely to see a reduction in their biofilm challenge at this point are patients that initially presented with limited risk factors, no severe risk factors, and no disease indicators or limited disease indicators. A practitioner’s goal at the 6-month reassessment should be to identify progress of any kind, verify adherence, and if the practitioner or patient is not satisfied with the progress, recommend an increase in the patient’s level of therapy. If the patient assesses at a lower level of risk, suggest the recommended level of therapy for that new risk level and caution the patient that relapse is a possible outcome until multiple healthy appointments have been established. Therapy recommendations should be made for the next 6 months. Keep in mind during these reassessment appointments the factors influencing treatment time and results such as the amount of time the patient has had the issue; the number, frequency, and severity of risk factors; the presence and severity of symptoms; the restorative treatment plan; and the level of compliance.
Twelve months. Approximately 80–90% of compliant patients will see substantial progress by the 12-month appointment. Examples of progress would be reduced progression of biofilm challenge or decay, lower incidence of decay, lower biofilm challenge (See Figure 19), improved soft tissue health on inspection, decrease in bleeding gums when flossing or probing, improved enamel luster, reduced plaque buildup, etc. Patients who may have yet to see substantial progress are patients with severe or unmodifiable risk factors, patients who were not successfully adherent or have gaps in their treatment regimen, and patients with a long history of severe decay.
Again, the practitioner’s goal at the 12-month reassessment should be to identify progress of any kind and verify adherence to the recommended therapeutic regimen. If the practitioner or patient is not satisfied with the progress, there should be a recommendation to increase the patient’s level of therapy. If the patient has been assessed at a lower level of risk, suggest the recommended level of therapy for that new risk level and caution the patient that relapse is a possible outcome until multiple healthy appointments have been established. Therapy recommendations should be made for the next 6 months. Keep in mind during these reassessment appointments the factors influencing treatment time and results such as the amount of time the patient has had the issue; the number, frequency, and severity of risk factors; the presence and severity of symptoms; the restorative treatment plan; and the level of participation or adherence.
It is important to note that the 3-, 6-, and 12-month appointments are very critical tipping points for patients looking to improve their level of health and reduce their risk. The practitioner must work with the patient to determine realistic expectations based on the choices the patient makes and how that corresponds with the patient’s disease condition and long-term goals. Historically, many patients and practitioners have the impression that treatment of medical conditions is one of quick fixes with a simple pill, and the expectation of immediate results. But the oral imbalance/infection that causes dental decay is one that often begins in the patient’s first months of life and may take long periods of time to manifest and consequently can take significant time and effort to reverse. Many patients and practitioners have expectations that prescription/professional oral care products can work similarly to antibiotics given to a patient with a minor infection such as an ear infection, and if the patient is compliant with the prescription, the problem will clear up in 10–14 days. This is not the case with dental caries, a complex, multifactorial biofilm and pH specific disease.
The reality of therapy expectations for dental disease should be closer in comparison to weight loss. While it can take only a few months to put on an unhealthy amount of weight, the work and time required to lose the weight may be longer and require more time and effort. Similarly, the longer a patient has had a weight problem, the longer it may take them to reach their goals and relapse is common. Many patients and practitioners choose to wait until there are serious signs/symptoms of the problem, such as cavities, prior to making changes to behavioral risk factors or prescribing targeted oral care therapy products. The sooner patients can be identified with risk factors or a biofilm challenge prior to cavities developing, the less time and effort it will take to get the patient back into balance.
For patients looking to begin a weight loss program, there are generally three ways they can choose to move forward. They can begin an exercise program while making no dietary changes. They can make dietary changes while making no changes to their activity level. Or they can increase their level of exercise and make dietary changes. Each and every patient is different, and how they choose to attack the issue will be based on their individual issues and goals. But patients that make consistent changes over time on both sides of the equation will experience the most success.
Patients with high caries risk have the same variety of options when the goal is achieving a healthy oral balance. On one side of the equation, they can choose to make behavioral changes and reduce their risk factors while continuing their current oral care product and hygiene regimen. Another option is to make no changes to their behavioral risk factors and make changes to their hygiene regimen with prescription/professional oral care products. Ideally, patients at risk would choose to alter their oral care product and hygiene regimen as well as the modifiable behavioral risk factors associated with the disease. But behavioral studies have shown that the most successful patients choose to make one lifestyle change at a time; and it is recommended that at each stage of the 3-, 6-, and 12-month appointments, patients and practitioners choose only one area at a time to modify. During the process, based on each reassessment, they can additionally decide if more changes are necessary based on the progress made. When there are several different behaviors that should be changed, it is advisable to offer the options to the patient and let them pick the behavior they want to focus on.
Finally, patients and practitioners must be looking not only for obvious signs of progress but also for a reduction in the progression of the disease. Just as a patient who is beginning a weight loss program and has a history of gaining additional weight every month and with diet modification may at first see only a slowing of the additional weight gain, a dental patient who has had a history of high biofilm challenge may only experience a slight decrease in the elevation path of the biofilm challenge at first, or only experience a reduction in the number of new cavities they develop. Instead of developing 2 or 3 new cavities every year, they may only develop 1 new cavity. Although these patients are continuing to see progression of the disease, they are making progress and should be encouraged to continue making changes to reach their goals.
Eighteen to thirty-six months. 90+% of compliant patients see substantial progress if they continue with therapy for 36 months. Examples of progress would be reduced progression of biofilm challenge, lower decay rate or eliminated incidence of decay, lower biofilm challenge, improved soft tissue health on inspection, decrease in bleeding gums when flossing or probing, improved enamel luster, reduced plaque buildup, etc.
Again, the practitioner’s goal at the 18- to 36-month reassessments should be to identify progress of any kind, verify compliance, and if the practitioner or patient is not satisfied with the progress, increase the patient’s level of therapy. If the patient assessed is at a lower level of risk, suggest the recommended level of therapy for that new risk level and caution the patient that relapse is a possible outcome until multiple healthy appointments have been established. Therapy recommendations should be made for the next 6 months. Keep in mind during these reassessment appointments the factors influencing treatment time and results such as the amount of time the patient has had the issue; the number, frequency, and severity of risk factors; the presence and severity of symptoms; the restorative treatment plan; and the level of compliance.
Patients who, by the 36-month appointment, are still experiencing dental decay are those that were noncompliant with therapy, noncompliant with behavioral risk factor changes, patients who have gaps in their treatment regimen, or patients with a long history of severe decay or have severe and unmodifiable risk factors. Many of these patients can and will reach a level of balance with their oral health, but for some, that level of balance may be one with a reduced but still occurring level of decay or a plateaued but elevated biofilm challenge.