Several times during my career, various dental leaders have prognosticated the demise of dental caries. Each time the predictions were premature, and dental caries has continued to be a challenge for patients and dental practitioners. However, as observed by practicing clinicians, the incidence of dental caries in the conventional areas described by G.V. Black—Class I through Class V—has changed, and there has been an overall reduction in caries frequency.
G.V. Black originally described and classified dental caries according to the frequency of occurrence. Class I was the most commonly observed; however, there is an expanded presence of caries in Class V locations evident to practitioners. This increased dental caries incidence in Class V areas undoubtedly is related to the increased human life expectancy; gingival recession, exposing dentinal root surfaces to fluids and debris; and the decreased ability of many mature patients to practice adequate oral hygiene.1–3
In this article, I discuss and compare the several preventive and restorative options for Class V lesions in caries-active mature patients.
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PREVENTION OF CARIES
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Mature patients who have retained their natural teeth have had a genetic predisposition toward reduced dental caries, a noncariogenic diet, good oral hygiene, or all of these characteristics. As patients become older and less capable physically and less alert mentally, oral hygiene usually suffers. Caries-active mature patients should be encouraged to use high-fluoride–containing (5,000 parts per million) prescription toothpastes for routine daily use. Examples of products are the following: PreviDent 5000 (Colgate, Canton, Mass.), ControlRX (OMNII Oral Pharmaceuticals, West Palm Beach, Fla.) and Fluoridex (Discus Dental, Culver City, Calif.). If caries involvement is extreme, the following additional preventive procedures should be offered to caries-active patients of any age, but especially to mature patients.
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TECHNIQUE FOR DELIVERING HIGH-CONCENTRATION FLUORIDE GEL AND REMINERALIZING PASTES
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Practitioners should follow these steps to deliver fluoride gel and remineralizing pastes:
- – Make an alginate impression and pour a cast for each arch.
- – Make a rigid "suck-down" shell for each arch, trimming it to produce an extension of about 1 millimeter apical to the gingival crest. The same tray can be used on separate occasions for both fluoride application and remineralizing pastes.
- – Instruct the patient to place several equally spaced drops of whichever 5,000-ppm fluoride gel is preferred in the trays and keep them in the mouth for at least five minutes per day, preferably just before bedtime. If the patient drinks fluoridated water, he or she should rinse the excess fluoride gel from the mouth, but seldom do I find that patients drink tap water. Most patients drink bottled water, various juices, coffee, tea or carbonated beverages, all of which contain minimal or no fluoride.
Oral hygiene instruction and dietary counseling are desirable to reduce caries, but changing the long-practiced hygiene and dietary habits of a mature person is difficult. Continue to instruct patients in oral hygiene and diet, but, in my opinion, high-level fluoride therapy and remineralizing pastes can be more effective.
Use of calcium/phosphate remineralizing pastes, such as PROSPEC MI Paste (GC America, Alsip, Ill.), is desirable, either as a brush-on paste or in the trays (as described above) for three minutes. A simple daily procedure is the application of remineralizing paste in trays and the continuing use of regular toothpastes containing 1,000-ppm fluoride or higher-level fluoride materials (5,000 ppm), either as a brush-on paste or in trays. The preceding procedures provide an excellent potential for reducing caries progression.
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TOOTH RESTORATIONS FOR THE MATURE PATIENT
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About 32 percent of practitioners do not use silver amalgam.4 Amalgam use has been reduced in the United States, presumably because of the gray tooth discoloration caused by amalgam, the color of the material itself and the health allegations concerning its use. High-fluoride–releasing restorative materials are the logical choices for simple Class V restorations in caries-active mature adults. Numerous methods can be used to place these restorations, some of which are described below.
Class V lesions in relatively unrestored teeth.
If the restorations are in nonesthetic areas, resin-modified glass ionomer is the preferred restorative material. Popular and effective materials are Fuji II LC (GC America) and Vitremer Restorative Material (3M ESPE, St. Paul, Minn.). Either product provides an adequate, but not excellent, esthetic result; acceptable longevity; and release of significant quantities of fluoride.5–23
A significant percentage of mature people become physically and psychologically incapable in their last years of life, and these years are when preventive care and caries-preventive restorations are most needed.
Class V lesions in areas of esthetic concern.
If the lesions are in esthetic areas, resin-modified glass ionomer restorative material may be placed on the internal aspect of the tooth preparation, followed by a layer of resin-based composite on the surface of the restoration. This technique provides an excellent esthetic result and the potential for caries reduction.
Restorations on the margins of previously placed crowns or fixed prostheses.
Resin-modified glass ionomer is my choice for restorations placed where the esthetic result is not a major consideration. At this time, no good technique exists for highly esthetic repair of crown margins.
Mature patients with severe caries.
Mature patients who have severe caries or are unable to physically tolerate typical restorative care can be served well for a few years by placement of reinforced conventional glass ionomer (Fuji IX GP, GC America). This product has been used in both pediatric and geriatric situations and has shown acceptable service and preventive ability.5–23
Human life expectancy is one of the great unknowns. Although the current average life expectancy is approximately 77.6 years,24 we should plan for the service life of tooth restorations to be longer than the expected average remaining years of life. A significant percentage of mature people become physically and psychologically incapable in their last years of life, and these years are when preventive care and caries-preventive restorations are most needed.
When oral conditions involve difficult-to-clean materials, such as fixed prostheses, implant-supported restorations, removable partial dentures and degenerating crowns or restorations, adjunctive oral hygiene devices such as water lavage units, mechanical toothbrushes and oral rinses should be prescribed.
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SUMMARY
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During the past few decades, life expectancy has increased significantly. As a result, mature patients often have receding gingival tissues, physical and mental debilitation, less energy and motivation, and the resultant Class V carious lesions. In this article, I suggest the use of high-level fluoride in tooth-pastes, remineralizing pastes and high-level fluoride gels for topical application in trays to reduce the progression of caries. To accompany fluoride therapy, high-fluoride–releasing restorative materials are indicated for Class V carious lesions. Adequate caries-preventive and restorative concepts for mature patients require planning, patient education and close patient supervision.
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PREVENTION OF CARIES
TECHNIQUE FOR DELIVERING HIGH...
