1.4 Modifying Factors
White Spots/Incipient lesions
White spots are non-cavitated carious lesions in enamel. White spot lesions, like other incipient lesions, may be actively demineralizing, remineralizing, or arrested. The dentist should evaluate white spot and other incipient lesions carefully, record them in the patient’s record, and watch their progress for cavitation or healing. The presence of demineralizing white spot and other incipient lesions may cause the dentist to place the patient in a higher-risk category, set a shorter recall interval, or both. On the other hand, the presence of remineralized or arrested white spot lesions is not a risk factor for dental caries.
Deep and/or uncoalesced enamel pits and fissures are virtually impossible to clean, owing to tooth anatomy, and they place tooth surfaces at increased risk for decay. Bacteria in infected plaque can colonize these surfaces and remain relatively undisturbed. Therefore, the presence of deep and/or uncoalesced pits and fissures is a risk factor for dental caries, while their absence is a protective factor.
Optimal fluoride exposures confer significant protective effects against dental caries. Systemic fluoride from fluoridated water and topical application from toothpaste and professionally applied fluoride decrease caries risk. Patients with little to no exposure to fluorides are at increased risk for caries. Patients with moderate and severe fluorosis seem to be at increased risk as well, perhaps owing to poor enamel formation and, in cases of severe fluorosis, pitting. Many brands of bottled water do not contain fluoride, so systemic fluoride exposure can be difficult to determine, even in a fluoridated community, if the patient often drinks bottled water or is fed infant formula reconstituted with bottled water.
Caries progression is usually more rapid in primary teeth than in permanent teeth. In permanent teeth, carious lesions usually take 3 to 4 years to progress through the enamel, sometimes taking more than 6 years to reach the dentin.44,45 In some patients, however, this progression can be rapid, with progression almost to the pulp within a year.45 Patients with a history of rapidly progressing lesions in permanent teeth are at high risk. Conversely, children ages 5 or older who have very slow caries progression in primary teeth may have an oral environment that places them at lower risk.