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© Borgis - Nowa Stomatologia 2/2017, s. 89-96
*Agnieszka Mielczarek1, Elżbieta Bołtacz-Rzepkowska2, Joanna Bagińska3, Renata Chałas4, Anna Kwiatkowska1, Aleksandra Hajdo1, Milena Marcinkowska-Ziemak1
Dental caries – preventive and therapeutic recommendations. A position statement of the working group of the Polish Branch of Alliance for a Cavity-Free Future (ACFF) for caries prevention in adults
Próchnica zębów – zalecenia profilaktyczne i terapeutyczne. Stanowisko grupy roboczej Polskiego Oddziału Sojuszu dla Przyszłości Wolnej od Próchnicy (ACFF) ds. zapobiegania próchnicy w populacji osób dorosłych
1Department of Conservative Dentistry, Medical University of Warsaw
Head of Department: Agnieszka Mielczarek, MD, PhD
2Department of Conservative Dentistry and Endodontics, Medical University of Łódź
Head of Department: Elżbieta Bołtacz-Rzepkowska, MD, PhD
3Department of Propaedeutics Dentistry, Medical University of Białystok
Head of Department: Anna Kierklo, MD, PhD
4Department of Conservative Dentistry and Endodontics, Medical University of Lublin
Head of Department: Barbara Tymczyna, MD, PhD
Streszczenie
Próchnica w populacji osób dorosłych w Polsce stanowi poważny problem zdrowotny. Ze względu na stale wydłużającą się średnią długość życia, wzrasta trend zachowania naturalnego uzębienia do późnej starości. Wraz z wiekiem tracimy zdolności manualne, co utrudnia prawidłową higienę, przyjmujemy więcej leków, które mogą modyfikować skład i ilość śliny, a istniejące często złe nawyki dietetyczne modyfikują przebieg choroby próchnicowej. Osoby starsze powinny być objęte szczególną opieką stomatologiczną i promocją zdrowia. Częstym problemem w tej grupie populacyjnej jest próchnica korzenia. Jej skuteczne leczenie uwarunkowane jest wczesną diagnostyką i wdrożeniem prawidłowych metod leczenia, zgodnych ze standardami stomatologii małoinwazyjnej (MID) oraz stosowaniem procedur hamujących progresję choroby. Działania profilaktyczne powinny skupiać się na zachowaniu aktywnej równowagi pomiędzy czynnikami próchnicotwórczymi a tymi, które hamują demineralizację tkanek zęba i wzmagają procesy naprawcze. Ponadto, istotnym etapem leczenia, umożliwiającym wdrożenie najskuteczniejszej terapii, jest diagnostyka aktywności zmian próchnicowych, jak również ocena ich zasięgu, do której obecnie zaleca się stosowanie systemu ICDAS II.
Summary
Nowadays, dental caries has grown to become a major oral problem in the Polish population. Owing to the constantly growing life expectancy, a trend for preserving one’s natural dentition well into old age flourishes. While ageing, people acquire some physical disabilities that limit good oral hygiene, use more medications that elicit salivary hypofunction, and prefer diet rich in carbohydrates, which only aggravates the progression of hard tissues demineralisation. Older people are at a higher risk for developing caries, thus management of this dentate population should address their special needs. Root caries has become an existent problem among the elderly. In order to treat it successfully, the dentist needs to diagnose the primary stage early, implement appropriate treatment corresponding to the MID standards, and stop the progression of the disease. Professional dental care and prophylaxis should be focused on managing the active balance between the existing cariogenic factors and the ones that promote remineralisation. Furthermore, the crucial stage of treatment is the time when the dentist diagnoses the activity of a given lesion, and determines its depth and future treatment plan according to the ICDAS II system.
Caries denotes a disease related to the person’s lifestyle, which may develop in patients at every age and stage of life. Its creation is favoured by poor oral hygiene and frequent consumption of products rich in carbohydrates. Microorganisms present in the dental plaque make use of sugar to produce acids. Their presence in the oral cavity results in acidification of the environment and is conducive to initiating damage to the enamel and dentine. Early symptoms of caries, initially white decalcification, are of a reversible nature and may be treated or their development may be halted with the use of non-invasive remineralisation methods, e.g. the application of fluoride varnish or gel (1). No control over the progression of caries leads to cavitation. At this stage of the disease, tissue preparation and dental restoration are necessary. The reconstruction of dental tissues does not ensure final resolution of the problem. The key role in controlling the carious process is played by maintaining in the oral cavity a dynamic balance between caries-creating factors and the ones halting demineralisation of dental tissues and supporting the recovery (2).
Among adult Poles, caries still constitutes a serious health issue – affecting nearly 100% of the population. Along with the more and more popular trend of preserving natural teeth until very old age, promoting the health of the oral cavity focused on the population of the elderly is very important. The elderly are particularly exposed to the development of caries, including both the coronal and root caries (3). The reasons for the creation of caries foci within the cementum and root dentine are similar to the ones initiating lesions within the enamel. The specific nature and the course of the root caries are different. Carious lesions are multi-foci and often combine into widespread, circular strips surrounding the teeth roots. Owing to a lower level of minerals in the cementum and the dentine than in the enamel, these tissues are subject to destruction quicker. The course of caries in adults is influenced by any concomitant general diseases and medications used during the therapy, which modify the composition and reduce the amount of the saliva excreted. The decreasing motor skills in the elderly additionally limit the efficiency of good hygiene within the oral cavity (4).
The risk of caries development in adults is related to:
– a history of caries,
– active caries foci within the crown,
– poor oral cavity hygiene,
– carbohydrate-rich diet,
– periodontal diseases,
– gingival recession and crown surface exposure to the operation of oral cavity environment factors,
– multiple dental restorations,
– the use of removable dental plates,
– taking saliva-excretion inhibiting drugs,
– radiotherapy within the head and neck.
To effectively prevent the development of caries, one should rigorously abide by recommendations concerning the prophylaxis taking into account proper dietary and hygiene habits. It is recommended to limit the frequency of consuming sugar-containing products, including extrinsic sugar present in products usually not associated with sweet taste, e.g. ketchup, crisps or mustard.
Recommendations concerning home-based oral cavity hygiene in the case of adults with the risk of caries include:
– brushing teeth twice a day with a toothpaste containing 1450 ppm of fluoride,
– if possible, using an electric toothbrush which is more efficient in the elimination of dental plaque than a regular one,
– everyday use of dental floss and/or interdental brushes,
– performing twice a day hygiene procedures of prosthetic restorations,
– cleaning the tongue twice a day using appropriate accessories, e.g. special tongue cleaner,
– rinsing the oral cavity twice a day with a mouthwash containing 0.12% CHX for 2 weeks (excluding people with xerostomia),
– application of preparations based on CPP-ACP, or other containing non-fluoride remineralisation agents, which facilitate the course of regeneration of dental hard tissues – once a day in the evening. Where risk factors for root caries are present, additional recommendations that should be followed include:
– brushing teeth twice a day with a toothpaste with increased fluoride content (5000 ppm F),
– using artificial saliva preparations and other solutions for everyday oral hygiene in the case of dysfunction of salivary glands and deficits of antibacterial and buffering systems (5-7).
The following prophylaxis is recommended under a professional dentist’s care:
– oral health check-ups – 4 times a year,
– application of fluoride varnish containing 5% NaF – 4 times a year,
– application of varnish containing 1% CHX – 4 times a year,
– bitewing X-ray every 6-12 months (8).
Full diagnostics of caries includes:
– evaluation of carious lesion advancement with the use of the ICDAS II system,
– carious lesions activity evaluation,
– oral hygiene indicators assessment,
– saliva excretion pace assessment,
– cariogenic bacteria level assessment in the saliva,
– dietary habits analysis,
– systemic diseases and medications taken (the impact of medications on the level and quality of saliva).
The use of ICDAS II system is recommended when assessing the level of progression of carious lesions. The diagnostics of coronal caries is based on a 6-level scale. The surface of the teeth is assessed under humid conditions and following drying out. Particular codes mean:
– code 0: enamel normal,
– code 1: matt stain, white or brown – lesion visible when the surface dries out,
– code 2: matt stain, white or brown – lesion visible on a wet surface,
– code 3: local loss of enamel integrity, no lesions within the dentine,
– code 4: subsurface shade within the dentine, with or without local loss of enamel integrity,
– code 5: minor cavity exposing the dentine,
– code 6: widespread cavity exposing the dentine.
When assessing root caries, the following codes are suggested:
– code E: no access to the root surface – assessment impossible,
– code 0: no discoloration on the root surface, no loss of tissue integrity or loss of anatomical outline within the enamel-cementum junction and within the root surface caused by carious demineralisation,
– code 1: expressly visible area of discoloration (yellow or pale brown) on the root surface or within the area of enamel-cementum junction with no express tissue loss, loss of anatomical outline < 0.5 mm,
– code 2: expressly visible area of discoloration (yellow, dark brown or black) on the root surface or within the area of enamel-cementum junction with express tissue loss, loss of anatomical outline ≥ 0.5 mm (9).
A significant element of the diagnostics is testing the activity of carious lesions. The testing is based on visual assessment of the colour and gloss of the tissues and their texture using a dental probe. Four types of lesions may be distinguished on that basis:
– hard – inactive, arrested, dark brown or black,
– leathery – active or inactive, yellow or brown,
– soft – active, yellow or pale brown.
The nature of the lesions and their advancement determine the prophylaxis and therapy (10). Caries prevention and management in the populations of adults requires taking into consideration many aspects, including the aspects related to the patient’s overall health. Cooperation with the patient must be preceded by a detailed interview and physical examination. In the case of using complex pharmacotherapy, it is recommended to consult a physician for possible modification and limitation of the impact on the level of saliva excretion (11).
The first stage of intervention is development of an initial treatment plan taking into account procedures aimed at pain elimination, dental plaque removal, instruction on oral hygiene and education concerning the implementation of correct dietary habits and hygiene. An element of the initial treatment plan is also the restoration of the integrity of dental tissue, which limits the accumulation of dental plaque and the level of the infectious factor.
Recommendations concerning treatment in the case of caries located both within the tooth crown and root take into consideration non-invasive procedures or invasive ones, depending on the degree of progression and the activity of carious lesions (12, 13).

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Piśmiennictwo
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otrzymano: 2017-04-12
zaakceptowano do druku: 2017-05-04

Adres do korespondencji:
*Agnieszka Mielczarek
Zakład Stomatologii Zachowawczej Warszawski Uniwersytet Medyczny
ul. Miodowa 18, 00-246 Warszawa
tel. +48 (22) 502-20-32
agnieszka.mielczarek@wum.edu.pl

Nowa Stomatologia 2/2017
Strona internetowa czasopisma Nowa Stomatologia