What are the treatment options for dental caries?

Dental Caries Treatment

All patients should receive frequent exposure to fluoride through drinking fluoridated water and brushing twice daily with fluoride toothpaste, which forms the foundation of caries prevention and control by inhibiting demineralization and enhancing remineralization of tooth enamel. 1

Risk-Stratified Treatment Approach

For All Patients (Universal Measures)

• Brush twice daily with fluoride toothpaste (1,000-1,100 ppm fluoride) to provide continuous topical fluoride exposure that inhibits acid demineralization and promotes remineralization 2
• Know the fluoride concentration in your primary drinking water source - this is the basis for all decisions regarding additional fluoride modalities 1
• Limit frequent consumption of refined carbohydrates and sugars, particularly between-meal snacking, as cariogenic bacteria metabolize these substrates to produce acid that dissolves enamel 1, 3

For High-Risk Patients (Additional Interventions Required)

High-risk patients include those with low socioeconomic status, limited dental care access, history of high caries activity, reduced salivary flow, poor oral hygiene, or low salivary buffering capacity 2, 3

• Apply professionally-applied high-concentration fluoride products (gel, foam, or varnish) every 3-6 months - routine use provides little benefit to low-risk patients but plays an important role for high-risk groups 1, 3
• Prescribe high-concentration fluoride toothpaste (5,000 ppm prescription strength) for daily home use 3
• Use daily fluoride mouthrinse to provide additional topical fluoride exposure 3
• Consider fluoride supplements for children at high risk whose primary drinking water has low fluoride concentration, prescribed as chewable tablets or lozenges to maximize topical effects 1
• Increase frequency of dental examinations to every 3-4 months for monitoring and early intervention 3
• Recommend sugar-free chewing gum and xylitol-containing products to stimulate salivary flow and provide antimicrobial effects against cariogenic bacteria 3

Special Considerations for Children Under 6 Years

• Supervise all fluoride toothpaste use - parents should place no more than a pea-sized amount (0.25 g) on the toothbrush and supervise brushing to minimize swallowing 1, 2
• Consult a dentist before introducing fluoride toothpaste to children under 2 years to balance caries prevention against enamel fluorosis risk 1
• Do not use fluoride mouthrinse without dental consultation as repeated swallowing can cause enamel fluorosis 1
• Weigh the risk of caries without supplements against the potential for enamel fluorosis when considering fluoride supplements, taking into account all other fluoride sources 1

Mechanism of Action

Fluoride works through multiple complementary mechanisms rather than a single pathway:

• Inhibits demineralization of sound enamel when acid is produced by bacteria 1
• Enhances remineralization of demineralized enamel, creating a more acid-resistant crystal structure with higher fluoride and lower carbonate content 1
• Inhibits bacterial metabolism by affecting how cariogenic bacteria metabolize carbohydrates to produce acid and adhesive polysaccharides 1
• Concentrates in dental plaque and is released in response to lowered pH at the tooth-plaque interface, providing protection exactly when needed 1

Emergency Department Management

• Assess for signs of spreading infection including facial swelling, lymphadenopathy, fever, and trismus 2
• Reserve antibiotics only for systemic infection or significant local spread - not for uncomplicated caries 2
• Arrange definitive dental follow-up within 24-48 hours 2
• Provide oral and written education on proper oral hygiene and caries complications 2

Critical Safety Warnings

• Do not swallow fluoride products - harmful if swallowed and must be kept out of reach of children 4
• Treatment frequency with professional fluoride applications should not exceed 4 treatments per year 4
• Be aware of fluoride toxicity risk, especially in young children - the probably toxic dose for a 70 kg adult is 5.0 mg/kg body weight 2
• Repeated use of acidulated phosphate fluoride (APF) may dull porcelain, composite restorations, and sealants - use neutral pH sodium fluoride (NaF) for patients with ceramic or composite restorations 4

Common Pitfalls to Avoid

• Do not assume normal saliva quantity equals low caries risk - buffering capacity is an independent risk factor requiring specific fluoride intervention even when salivary flow is normal 3
• Do not routinely apply professional fluoride to low-risk patients drinking fluoridated water and brushing with fluoride toothpaste - this provides little incremental benefit 1
• Do not prescribe muscarinic agonists for isolated low buffering capacity - these are indicated only for reduced salivary flow and would expose patients to unnecessary side effects 3