Caries Risk Assessment Clinical Case #1

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Question 1 of 3

1. Question
In addition to the preventive measures described in the previous question, you decide to apply fluoride varnish to José’s teeth while he is in your office.

Which of the following steps will best maximize the benefit of the fluoride varnish applied to José’s teeth?
- Apply fluoride varnish only to wet teeth. The teeth should be as dry as possible while applying fluoride varnish as this promotes good adhesion of the varnish. However, do not worry about keeping the teeth completely dry. Once applied to the teeth, fluoride varnish will set on contact with saliva. Avoid brushing the teeth after applying varnish until the next morning.
- Discontinue any supplemental fluoride after applying fluoride varnish. Only if José’s well water contains fluoride levels of greater than 0.3PPM should systemic fluoride be discontinued. Since José is high risk for future caries, he should receive topical fluoride (tooth paste and varnish) as well as dietary fluoride supplements.
- Apply fluoride varnish every 3 months, since José is at high risk for caries.
- Apply fluoride varnish only twice per year since José is at risk for fluorosis if the varnish is applied more often. Fluoride varnish can be safely applied to the teeth of an at-risk child every 3 months. The risk of fluorosis, a condition characterized by discoloration of permanent teeth due to chronic excessive exposure to fluoride while the teeth are developing, is not concern with fluoride varnish used at that frequency.
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Question 2 of 3

2. Question
José is a 15 month old male brought to you for a well child exam. Mom reports that he uses a sippy cup during the day and drink 2-3 cups of fruit juice each day. Mom lets him brush his own teeth once a day in the mornings. Your oral exam reveals the following:

Joanna Douglass, BDS, DDS

Which of the following options should be the best next step for home management of his dental findings?
- Recommend José follow up in 3 months for his 18 month well child exam with no change in management. José has white spots on both central incisors and left lateral incisor indicating demineralization, and a brown spot on his right lateral incisor consistent with an early cavitated carious lesion. These lesions should prompt you to refer José to a dentist as soon as possible, and implement other preventive measures such as dietary advice, oral hygiene instruction, and consideration of fluoride supplementation.
- Advise his mom to discontinue use of the sippy cup. José does not need to stop using his sippy cup but the contents and how he uses the cup should be changed. His mom should be counseled to avoid giving José sugary drinks between meals because this increases his risk of caries. Between meal drinks should consistent of plain white milk or water. Mom should also be counseled to avoid letting José brush his own teeth until he is 6 years old. Instead, she or another adult should brush José’s teeth twice per day with a smear size amount of fluoridated tooth paste on the tooth brush.
- Prescribe supplemental fluoride drops if the family’s drinking water comes from a well. Fluoride is a naturally occurring mineral present. Hence, the fluoride content of well water can vary significantly. Dietary fluoride supplementation should only be considered after the well water has been tested and the amount of fluoride found to be inadequate.
- Assess the level of fluoride in the family water supply.
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Question 3 of 3

3. Question
José returns to your office for his 18 month check up. Mom learned that the amount of fluoride present in her family’s well water is less than 0.1 ppm. On examining José’s teeth you identify additional cavitated carious lesions.

Joanna Douglass, BDS, DDS

Which of the following is the best treatment option at this point?
- Immediate referral to a dental office for intensive prevention and possible restorations.
- Prescribe dietary fluoride supplements and educate José’s mom about making a dental appointment with a dentist when he is 3 years old. Dietary fluoride supplements should be prescribed but dental care should begin now. The American Academy of Pediatric Dentistry and the American Academy of Pediatrics recommend that patients establish a dental home by the child’s 1st birthday, especially if evidence of clinical decay is present.
- Tell José’s mom to apply additional fluoride toothpaste to the toothbrush when brushing his teeth. Applying additional toothpaste to his toothbrush might increase José’s risk of fluorosis and is unlikely to further decrease caries risk. Current guidelines recommend applying a smear (grain of rice) of fluoridated toothpaste under the age of three and a pea size amount above the age of three.
- Provide additional dietary counseling aimed at reducing snacks and sweetened liquids between meals. While additional dietary counseling would probably be of benefit to José and should be provided, it is not a substitute for immediate dental referral given his active decay.
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Caries Risk Assessment, Fluoride Varnish, and Counseling

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