How to better managed root caries in older populations

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Using phased personalised care plans to manage root caries, especially among older people

Each decision in the process of minimum intervention caries treatment is dependent upon the variables of the individual case. (Image: SeventyFour/Shutterstock)

Fri. 7 June 2024


As restorative dentistry shifts focus from core operative procedures to individual patient needs and values, the demand for holistic patient care for long-term oral health is increasing. A recent book, A Clinical Guide to Advanced Minimum Intervention Restorative Dentistry, provides clinicians with guidance on navigating the entire clinical journey of minimum intervention oral healthcare, prioritising long-term, prevention-based care aligned with patient risk profiles. With the ageing population in mind, we interviewed the author, Prof. Avijit Banerjee, to discuss the latest evidence-based insights on root caries management.

Prof. Avijit Banerjee. (Image: GC International)

Prof. Avijit Banerjee. (Image: GC International)

Prof. Banerjee, what are some of the challenges of treating older adults?
Firstly, the overall medical condition of older patients needs to be considered, as many older patients are on multiple medications, which can reduce saliva production and cause dry mouth, increasing susceptibility to caries. Secondly, the social aspect is crucial, especially regarding how well older adults are cared for and their ability to maintain oral hygiene. Thirdly, the attitudes and expectations of older adults, such as the adherence to oral healthcare advice and willingness to invest in oral health, are important considerations. Managing these medical, social and personal aspects is key in root caries management, especially considering additional potential clinical issues like failing restorations or the use of dentures.

Do you think the prevalence and incidence of root caries are increasing?
Indeed, data from the UK indicates a rising trend in caries as patients get older. While root caries can occur in younger patients, it’s less common. However, as patients age, factors such as periodontal issues lead to increased gingival recession and exposed surfaces, which often go uncleaned, allowing biofilm to develop undisturbed and lesions to form more rapidly. Factors like dry mouth and dietary habits, effecting nutritional concerns, further contribute to the prevalence of root caries within an ageing population.

While the rate of increase may be slowing compared with previous data, it remains a concern. Recent health economics studies, including a white paper commissioned by the European Federation of Periodontology, have highlighted the global burden of caries and its significant link to the incidence of root caries, indicating a continuing upward trend.

“Ensuring patients maintain oral hygiene remains a challenge for many oral healthcare teams.”

What is the role of preventive measures, and what procedures and materials should be used for preventing, arresting and reversing root caries lesions?
This question is pivotal to managing the caries process, emphasising the importance of prevention. Once these lesions form, they become challenging to treat, underscoring the need to prevent their development. Additionally, the distinction between preventing, arresting and reversing is crucial. We’ve also addressed this in guideline papers developed in collaboration with the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD).

Our mouths are in a state of demineralisation and remineralisation owing to the presence of biofilm and consumption of carbohydrates. To prevent the caries process from becoming active, we must disrupt or modulate the biofilm through non-operative interventions, such as oral hygiene and dietary control.

While societal shifts towards health consciousness are helping people become more aware of the importance of adhering to healthy oral health behaviours, ensuring patients maintain oral hygiene remains a challenge for many oral healthcare teams. By approaching oral care positively and leveraging positive motivational messaging from professionals to the wider public, we can encourage better oral health habits. Products such as GC Tri Plaque ID Gel and GC’s Saliva-Check BUFFER are very helpful in targeted and personalised communications and shared-decision making between the oral healthcare practitioner and the patient, and of course, remineralising agents and varnishes (e.g. GC’s MI Paste Plus and MI Varnish) are great aids to restore the mineral balance at the susceptible tooth surfaces.

In the clinical decision-making process, all factors need to be balanced. (Image: GC International)

In the clinical decision-making process, all factors need to be balanced. (Image: GC International)

Determining the end point of excavation in performing selective caries removal is difficult for many clinicians. Could you recommend guidelines in this regard?
Selective caries removal involves removing infected dentine while retaining deeper caries-affected (demineralised) dentine and preserving sound enamel and dentine. However, within deep lesions, particularly in root caries, where preserving the pulp sensibility is crucial, excavation must prioritise not exposing the pulp. The depth of excavation depends on the lesion’s proximity to the pulp and the restoration’s volume.

In cases of shallower lesions, for which successful restoration is more important owing to limited cavity volume, selective caries removal may not be as relevant, and the priority shifts to ensuring the restoration’s retention and durability. This principle applies to both root and coronal caries, where the lesion’s natural configuration affects the approach.

Although guidelines exist, they are not rigid rules, as each case requires individual assessment and decision-making by the clinician. It is essential for clinicians to trust their expertise and document their rationale for phased personalised care plans.

Crafting a rigid guideline for operative root caries interventions proves difficult owing to the multitude of factors involved. Nonetheless, the selective caries removal guidelines from the EFCD and ORCA offer a reliable foundation. These guidelines stress the importance of understanding and appreciating the histology of the carious tissue (infected and affected enamel and dentine), considering material chemistry and honing clinical skills for effective moisture control and sealing—the golden triangle of minimally invasive operative success! Finding the right balance between these factors is vital, particularly given the common clinical hurdles in root caries treatment.

“While some materials may exhibit longer-lasting results, all materials can be effective when applied correctly. ”

What is the best material for restoring root caries after selective caries removal?
It is challenging to pinpoint one material. However, glass ionomers have emerged as a group that tends to be highly effective, supported by numerous clinical trials. Resin composites can also be effective under optimal conditions, but their use is limited owing to challenges related to moisture control and the nature of the substrate in root caries lesions. Attempting to layer multiple materials in such lesions is clinically challenging and may weaken the restoration’s interface. High-viscosity glass ionomers, resin-modified glass ionomers and glass hybrids are often preferred choices, based on clinical evidence from the past decade.

Ultimately, no trial will definitively prove one material’s superiority over another, as success relies heavily on operator technique and patient adherence to effective biofilm control measures. While some materials may exhibit longer-lasting results, all materials can be effective when applied correctly.Nevertheless, practical considerations and clinical judgement are of great importance here. Over the years, I’ve observed that there are instances where clinicians may not fully adhere to the instructions for use for certain materials. These instructions are based on years of intensive research and are heavily regulated for good reason. While flexibility can be beneficial in some cases, it’s essential to strike a balance and to follow the manufacturer’s instructions closely to ensure optimal outcomes. A good example would be GC’s EQUIA Forte HT system. If the clinician used EQUIA Forte HT Fil without EQUIA Forte Coat, he or she would not be making use of the full benefits of the material. In turn, this would have an impact on the quality of the clinical result. Again, these same factors come into play: knowledge of how the material works and clinical judgement.

In cases where resin composite is used for restoration of root caries, how can the best adhesion be achieved?
Again, having good judgement is crucial. Knowledge of the material highlights the significance of moisture control, which is essential for successful outcomes. Ideally, enamel would be present for proper adhesion. When encountering sclerotic dentine with higher mineral content, it’s important to consider the best etching system for optimal results. It’s based on an intricate decision-making process that includes all variables of the specific case, so putting forward just one approach seems inappropriate.

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