Root Caries Prevention

Tooth decay can occur at any age—not just in children. Coronal caries begins in the pit and fissures of the occlusal surfaces or the interproximal surfaces of posterior teeth. As patients age, they may become at risk for root caries, which is one of the most significant dental problems among older adults today.¹ Dental hygienists need to be well prepared to address root caries in light of a rapid growth in the United States’ population of older adults. The number of Americans age 65 and older increased from 35 million in 2000 to 40 million in 2010. This number is expected to grow to 55 million in 2020. By 2030, the number of older adults in the US will most likely reach 72.1 million.² The number of Americans age 85 and older has also been rapidly increasing from 5.6 million in 2009, to 5.8 million in 2010, to a projected 6.6 million in 2020.²

Root caries is one of the most common causes of tooth loss among older adults, and tooth loss significantly impacts quality of life for this population.³ Today, more older people retain their natural teeth than ever before.¹ Prevention and management of root caries are key to preserving and sustaining optimum oral health throughout life.

CLINICAL SIGNS OF ROOT CARIES

Root caries is most frequently detected through a visual and tactile examination. Oral health care providers initially look for visual changes within the color and contour of the area at the cementoenamel junction (CEJ). Tactilely, clinicians may notice a leathery notch in the CEJ area of the tooth. Any color changes within the root surface of the tooth may indicate active root caries (Figure 1). The most important clinical sign of root caries is a patient complaining of pain in this area.

Incipient root caries may begin as a slight discoloration at the CEJ and cause dentinal hypersensitivity. Recurrent root caries may first appear as a discoloration present at or under existing restorations, causing pain. Cementum is more susceptible than enamel because it has less mineral content and is more soluble, therefore, more susceptible to root caries.⁴

RISK FACTORS FOR ROOT CARIES

Xerostomia is a significant risk factor for root caries because it creates an oral environment conducive to bacteria proliferation, and reduced salivary flow leaves supporting structures of the oral cavity without protection. Many medications reduce salivary flow and may cause xerostomia.

Patients who have undergone radiation treatment for head and neck cancer are at greater risk of root caries because their normal salivary functions are inhibited.⁴ Xerostomia signs and symptoms include dry, burning mouth and throat, and dry, cracking lips, especially in the corners (eg, angular cheilitis). The cracks may be tender and/or bleed.⁵ Saliva is essential in neutralizing the acidic environment, thus inhibiting bacteria growth. Any decrease in saliva increases the risk of root caries.¹  The presence of exposed root surfaces due to periodontal diseases or previous loss of gingival tissue attachment is another risk factor. Exposed root surfaces leave the CEJ and cementum vulnerable to bacteria and demineralization. Gingival recession caused by normal aging, forceful toothbrushing, and/or periodontitis also raises the risk of root caries.

Physical limitations in the ability to perform effective oral hygiene result in plaque and calculus build-up. Diminished manual dexterity caused by stroke, arthritis, or Parkinson’s disease, as well as cognitive deficits due to mental illness, depression, Alzheimer’s disease, or dementia, are risk factors for root caries among older adults. The purpose of oral hygiene is to diminish, eliminate, and prevent the formation of plaque and inhibit bacteria production, which are essential to reducing root caries risk.

PREVENTION OF ROOT CARIES

Root caries prevention requires a thorough examination and caries risk assessment for each patient. Prevention methods, such as plaque removal, nutritional counseling, patient education, and the use of chemotherapeutic aids, should be implemented. In-office fluoride application, as well as prescription fluoride products (containing 5,000 ppm), should be considered for those at risk. A prescription for a chlorhexidine mouthrinse, spray, gel, or varnish, or other antiseptic may be indicated. Sequeira-Byron and Lussi conducted a randomized controlled trial of 306 older adults that investigated the effects of chlorhexidine varnish, fluoride varnish, diammine silver fluoride solution (not available in the US), and oral hygiene instruction alone on the risk of developing root caries. They found that those participants who received the chlorhexidine varnish, fluoride varnish, or diammine silver fluoride solution developed fewer root caries surfaces than those who were only given oral hygiene instruction.⁶

The addition of remineralizing products that contain calcium phosphate technologies to patients’ daily oral health care regimens may also keep root caries at bay.⁷ For patients with xerostomia, clinicians should offer strategies to help stimulate salivary flow, such as chewing gum with or without active ingredients (eg, chlorhexidine, xylitol, casein phosphopeptide-amorphous calcium phosphate); sugarless candies; buffered citric/fruit acid tablets; and systemic cholinergic medications (eg, pilocarpine/cimeviline). Applying saliva substitutes, such as gels, sprays, and liquids, around dentures, as well as on teeth and oral soft tissues, will aid in lubricating the oral tissues while diminishing xerostomia.⁷

Oral health care providers should assess patients’ risk factors for root caries at each visit and schedule appropriate treatment based on the results.

CONCLUSION

Oral health care providers are treating more older adults who have maintained their natural dentition, and this trend is projected to continue. While limited research is available on preventing root caries in older adults, traditional caries recommendations can be used, implementing shorter intervals for those patients at high risk. No one intervention will be ideal for all patients so dental hygiene treatment should be modified based on individual patient needs and caries risk assessment. Patient education regarding professional fluoride application, appropriate oral hygiene instruction techniques, proper nutrition, and routine dental hygiene treatment can delay the progression of current root caries, as well as the development of new lesions.

REFERENCES

1. Gati D, Vieira AR. Elderly at greater risk for root caries: a look at themultifactorial risks with emphasis on genetics susceptibility. Int J Dent. 2011;2011:647168.
2. Administration on Aging. A Profile of Older Americans: 2010.Available at: www.aoa.gov/aoaroot/aging_statistics/Profile/2010/4.aspx.Accessed February 20, 2013.
3. Saunders RH Jr, Meyerowitz C. Dental caries in older adults. Dent Clin North Am. 2005;49:293–308.
4. Bowen DM. Prevention of root caries. J Dent Hyg. 2011;85:78–82.
5. Mohammed A. Caries later in life: diagnosis and assessment of root caries in older patients. Dimensions of Dental Hygiene. 2009;7(11):24–30.
6. Sequeira-Byron P, Lussi A. Prevention of root caries. Evid Based Dent.2011;12:70–71.
7. Gupta B, Marya CM, Juneja V, Dahiya V. Root caries: an aging problem. Available at: www.ispub.com/journal/the-internet-journal-ofdental-science/volume-5-number-1/root-caries-an-agingproblem.html#sthash.diP9EJoT.dpbs. Accessed February 20, 2013.

From Dimensions of Dental Hygiene. March 2013; 11(3): 36, 38.