Selecting the proper treatment strategy

The primary goal when selecting the proper treatment strategy is to provide enough protective agents to outweigh any risk factors or biofilm challenge present and reverse the balance back toward health. This involves choosing specific treatment agents targeted to offset specific issues. For example, if a patient is screened and a high biofilm challenge (bacterial infection) is identified, a broad-spectrum oxidizing antibacterial agent capable of penetrating a biofilm (0.2% sodium hypochlorite) should be part of the treatment strategy (such as CTx4 Treatment Rinse). Based on each patient’s specific level of risk, the patient will be offered three different choices with regard to initial therapy. A “recommended therapy,” which is designed to provide enough protective factors to outweigh each patient’s specific risk level and move them toward an oral health balance. A “provisional therapy,” which is a lower-cost alternative to the recommended therapy and designed to provide enough protective factors to simply keep a patient from getting worse assuming no increase in risk factors. The “provisional therapy” will likely not outweigh the patient’s risk. As a third option, the patient can choose to decline any recommended changes. With each option, the patient can be informed of the likelihood that they will experience new decay in the next 12 months if they continue with their current behavioral/diet/home care habits (e.g., high/extreme-risk patients have an 88% chance of experiencing new decay in the next 12 months without a change in care). The Caries Management Guide (See Figure 17) provides the general guidelines for managing caries risk based on each patient’s specific risk assessment. Here are some more specific recommendations based on different types of risk factors or issues a patient may face.

Risk Factors

“I notice plaque buildup on my teeth between brushings.” Rapid growth of the bacterial biofilm between brushings may be a sign of inadequate homecare, inadequate oral care product selection, low saliva flow, or frequent consumption of food and drink providing additional nutrients to the biofilm, stimulating growth. Elevated pH (8.0+) dental products (gels, sprays, rinses) should be considered to offset the potential acidic side effects of the excessive plaque biofilm. Broad-spectrum oxidizing antibacterial rinses (0.2% sodium hypochlorite) should also be considered to lower the total bacterial load (such as CTx4 Treatment Rinse).

“Do you take medications daily? If so, how many?” Taking just one medication daily can affect saliva flow, and most people may not even notice. Taking multiple medications can compound the salivary flow issue. Elevated pH (8.0+) dental products with xylitol in the form of gels or sprays should be considered after meals and snacks to quickly elevate the pH after an acid challenge. Depending on the patient’s caries risk, prescription/professional home care products for brushing and rinsing should be considered.

“Do you feel you have a dry mouth at any time of the day or night?” If you are noticing a dry mouth at any time, the problem of saliva flow should be a serious concern. By the time the patient notices a saliva flow problem, the problem is likely severe. Elevated pH (8.0+) dental products with xylitol in the form of gels or sprays are essential after meals and snacks to quickly elevate the pH after an acid challenge. Elevated pH gels with xylitol and nanohydroxyapatite (such as CTx4 Gel 1100) can be worn in whitening trays at night if nighttime oral dryness is an issue. Depending on the patient’s caries risk, prescription/professional products with pH neutralization, xylitol, fluoride, and nanohydroxyapatite for morning and night home care should be prescribed.

“Do you drink liquids other than water more than 2 times daily between meals?” Every time a patient drinks something other than water between meals, they are adding an additional daily acid attack on their teeth. This acid attack can increase cavity-causing bacterial growth as well as supply the current biofilm with additional nutrients, creating acids that demineralize the teeth. If the patient is not willing to change this dietary habit or move their beverage consumption to meal times, elevated pH (8.0+) dental products with xylitol in the form of gels or sprays should be considered after meals and drinks to quickly elevate the pH after an acid challenge. Depending on the patient’s caries risk, prescription/professional home care products for brushing and rinsing should be considered.

“Do you snack daily between meals?” Every time a patient eats something (yes, even nuts, fruits, and vegetables), they are adding an additional daily acid attack on their teeth. This acid attack can increase cavity-causing bacterial growth as well as supply the current biofilm with additional nutrients, creating acids that demineralize the teeth. If the patient is not willing to change this dietary habit or it is something necessary for their health, elevated pH (8.0+) dental products with xylitol in the form of gels or sprays should be considered after snacks to quickly elevate the pH after an acid challenge. Depending on the patient’s caries risk, prescription/professional home care products for brushing and rinsing should be considered.

“Do you have an oral appliance present?” Oral appliances create artificial areas on the teeth that can not only be hard to clean but also allow a biofilm to mature and potentially demineralize teeth. Patients with oral appliances should be aware of other risk factors and consider using a broad-spectrum oxidizing antibacterial agent capable of penetrating a biofilm to help reduce biofilm in areas that are hard to reach with brushing and flossing (such as CTx4 Treatment Rinse). Elevated pH (8.0+) dental care products with 1.1% neutral sodium fluoride, xylitol, and nanoparticles of hydroxyapatite should also be considered to support remineralization (such as CTx4 Gel 1100).

“Other health concerns.” Other health concerns such as tobacco use, acid reflux, and diabetes are important as, often, patients with these concerns experience increased acid attacks and/or reduced salivary flow. Elevated pH (8.0+) dental products with xylitol in the form of gels or sprays are essential to quickly elevate the pH after an acid challenge. Elevated pH gels with xylitol and nanohydroxyapatite can be worn in whitening trays at night if oral dryness or excessive acid attacks are an issue. Depending on the patient’s caries risk, prescription/professional products with pH neutralization, xylitol, fluoride, and nanohydroxyapatite for morning and night home care should be prescribed (such as CTx4 Gel 1100).

Disease Indicators

Disease indicators such as new or progressing cavitations, new or progressing white spot lesions, etc., are signs/symptoms of the disease. Patients with signs or symptoms are advised to make changes to their home care product regimen and consider behavioral changes to modify risk factors whenever possible. Put simply, if the patient’s current home care product regimen was working and keeping the patient in healthy balance, it would have worked and no changes would be necessary.

Biofilm Challenge

Patients with a high biofilm challenge identified by ATP (CariScreen) testing or by bacterial culture are at increased risk for decay. For this reason, a broad-spectrum oxidizing antibacterial agent capable of penetrating a biofilm, such as 0.2% sodium hypochlorite oral rinse, should be considered as part of a treatment strategy (such as CTx4 Treatment Rinse).