Patient Case Study: Extreme Risk

by Dr. V Kim Kutsch


I am often asked exactly how I treat my patients. This patient is a true case of success and I wanted to share how we went about getting her healthy. Notice: it is a process. This doesn’t happen over-night. However, the time spent is well worth the outcome in my opinion.



extreme risk patientThe patient is a 38 year old female who presents with extensive active decay. Her health history indicates that she takes Ibuprofen as needed for dental pain. She has no other contraindications to treatment. The patient’s primary concern is the esthetic appearance of her teeth, but states that she had given up on dentistry because she has always had decay and continued to get new decay every time she had her teeth restored. She was considering dentures, but wanted to know what her options were. While she may or may not be a candidate for esthetic restorative care, certainly the biomechanical condition and the appearance of her smile is a valid concern. Certainly, just providing esthetic restorations for this patient is not a viable choice for a predictable outcome.



Extreme Risk 2The patient has multiple visible restorations and multiple visible cavitations, although she does not have severe visible plaque build-up on her teeth. The first step in the caries risk assessment process is to evaluate a standardized caries risk assessment form, to determine the possible risks for this patient’s responsible for her condition.

Extreme Risk 3



The caries lesions are extensive, this is a high/extreme risk caries patient requiring thorough diagnostic management. The patient’s periodontal condition is Type II, generalized gingivitis and isolated periodontitis. There is adequate alveolar bone radiographically and generalized 2-4 mm pocket depths with isolated 5 and 6 mm measurements in the molar regions. Her occlusion demonstrates acceptable function.

The bitewing radiographs reveal a history of extensive decay and restorations and new/progressing multiple radiolucencies, indicative of caries lesions on the teeth. She has high caries and biomechanical risk to her teeth. Tooth number 15 is non-restorable and indicated for extraction.

Caries Risk Assessment Form: The patient is open and engaged in the caries diagnostic process and interested in discussing her condition and options for therapy. Her specific risk factor is that she snacks frequently throughout the day. Snacking frequently contributes to the prolonged periods of low pH, the selection pressure for cariogenic bacteria in her biofilm. Her disease indicators include: new/progressing cavitations, active whitespot lesions, and approximal radiographic radiolucencies. She has had numerous cavities in the previous three years. Her biofilm load/activity is tested with the Carifree Cariscreen meter and swab, and measures high. In applying critical thinking to her risk assessment summary, her Risk Factors, Disease Indicators and Biofilm Challenge are a present concern, and she is identified as a High/Extreme Risk patient.

He recommended treatment/management for this patient is to have required extractions performed, and all lesions restored with GIC while her biofilm disease is being corrected. From the Carifree Caries Management Guide, this patient should have recommended therapy that includes antimicrobial rinse, fluoride, xylitol, pH strategies, and nano-HA strategies for 3 month intervals until she stops developing new lesions and her biofilm challenge tests normal. Upon examining her options, the patient elected to have the extraction, the GIC restorations placed and to also pursue the recommended therapy. During this period of time the patient is coached on wellness, and effective options to modify her dietary behaviors.


The patient has had all of her caries lesions restored with GIC, and following multiple treatments with antimicrobial rinses, Carifree CTx 4 Treatment Rinse, has maintained a healthy mouth for a period of two years. She has had no new lesions and her Biofilm Challenge repeatedly tests low or normal. This patient has maintained this condition of health by modifying her diet and using the Carifree CTx 4 Gel 5000 for two years. She is now at a point where she may have her teeth restored with esthetic restorations with greater predictability of a successful restorative outcome and favorable long-term prognosis.


Case originally published in Dental Product Shopper


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