5.3 Treatment of Population Groups

Patients at High Risk

Patients who are at high risk for dental caries either (1) have an active, uncontrolled carious infection in which decay has cavitated smooth surfaces of two to five teeth or (2) are showing signs of re-infection, with two or more new carious lesions (of any type) and a history of smooth-surface lesions in permanent teeth. In addition to the preventive strategies recommended for patients at moderate risk, those at high risk may require dietary counseling, chlorhexidine rinse (for patients ages 12 or older), and perhaps prescription fluoride toothpaste and gum containing xylitol. Surgical restoration should be completed in no more than 2 months so that the margins of new restorations do not have a chance to become infected with odontopathic bacteria from untreated active lesions.

Since multiple appointments will be needed to finish treatment, every appointment should be used as an opportunity to check the patient’s compliance with preventive strategies and provide education and reinforcement. Patients at high risk will need to make significant lifestyle changes to improve their oral health. Children and adolescents will need considerable help and support from their parents to make these changes.

Preventive strategies and the process of providing education about the carious process are more complex for patients at high risk compared with those at lower risk. Therefore, extra time should be allowed during each appointment to check the patient’s compliance with preventive strategies and provide education and reinforcement. When providing education and reinforcement for children and adolescents, parents should always be included.

The recall interval is 3 to 12 months and depends on the rate of caries progression and modifying factors present. If after several recall visits the infection is under control and there are no new lesions, reclassifying the patient to the moderate- or low-risk category and extending the recall interval is appropriate.

Patients at Very High Risk

Like patients at high risk for dental caries, those at very high risk have an active, uncontrolled carious infection. The difference between patients at high and very high risk is the number of active cavitated lesions present at examination.

In addition to implementing the preventive strategies described for patients at high risk, for those at very high risk, the dentist should plan to quickly eliminate active cavitated lesions. If active lesions cannot be eliminated within two appointments in 2 months, dental caries control should be planned. (For more information about dental caries control, see “Sequence of Treatment.”)

The recall interval for this group is 3 to 6 months. The objective at the recall appointment is to determine whether the infection is under control. If the infection is under control, the patient may be moved to the high-risk category. Preventive strategies are continued, and needed restorations are placed. If the infection is not under control at the recall appointment, preventive strategies such as re-prescribing chlorhexidine rinse (for patients ages 12 and older) should be implemented.

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