ABSTRACT

The decreasing trend of edentulism amongst the elderly dentate

population is concomitant with an increase in the number of
remaining teeth. The prevalence of elderly dentate subjects
experiencing moderate to severe periodontitis, gingival recession,
impaired or limited manual dexterity, polypharmacia, full and
partial dentures increases their susceptibility to root caries.
The exact nature of this disease has yet to be understood,
therefore intervention has primarily constituted prevention.
Oral microbial conditions often experienced by these
subjects are high concentrations of salivary mutans streptococci,
lactobacilli and yeasts. Nevertheless, the importance of
identifying risk indicators remains essential in preventing
patient discomfort caused by the sequelae of this disease:
periapical lesions. Due to the poor prognosis of teeth once
diagnosed with root caries- treatment strategies should
encompass a multi-focused preventive approach incorporating
adjunctive antimicrobial agents such as, chlorhexidine.

INTRODUCTION
Demographic and epidemiological evidence show a decreasing trend of edentulism amongst elderly

subjects1'2. Despite various preventative measures case studies have shown that root caries are

concomitant in subjects 50 years and older, often developing as multiple lesions1>2. Several studies

have associated the acidic bacteria mutans streptococci (MS) and lactobacilli (L) and the acidic organism

yeast to the development of dental caries 1'3-5'14'10'15i |n addition other studies have related

these cariogenic microorganisms as risk indicators in the development of root caries in the elderly 1>3>5'7'8.

The prevalence of moderate to severe periodontal conditions, gingival recession, polypharmacia, full and

partial dentures inhibit and promote the retention of plaque thereby increasing salivary concentrations of

MS, L and yeasts 1>3~6. These conditions create an increased need for treatment and preventive care by

placing the remaining dentition at risk through the exposure of root surfaces and the harbouring of

bacteria around vital and healthy abutments 6 Billings et al, findings indicate that there are no conclusive

evidence to suggest any differences between the formation and disease process of coronal and root

caries lesions 1>7. Indeed, continual research has significantly altered and improved the clinicians

understanding of this disease process. Despite this prevention remains a primary treatment modality9'22.

The current basis of prevention constitutes plaque removal from root surfaces and dietary education9

Unfortunately the clinical diagnosis, treatment and management of primary root caries has proven to be
difficult due to continual uncertainty behind its aetiology and pathogenesis therefore education on the

process and formation of primary root caries remains a barrier1>5>7. Joshi et al, performed an analysis of

the diagnosis, treatment and filling of root caries lesions and noted that lesions identified by the dental

professional did not meet the epidemiological criteria requiring them to be filled2. It was also noted that

the filling may exceed the actual surfaces occupied by the lesion2. Hence, the accurate identification of

these lesions continues to be problematic. Consequently, the improvement in diagnostic aids for primary

root caries requires refinement to ensure a clear and concise understanding.

Other studies have found that the effectiveness of antimicrobial agents and fluoride rely on their ability to

inhibit bacterial metabolism therefore, the employment of these chemotherapeutic agents has shown

promise towards the further prevention of root caries5>7'9-11. For example, chlorhexidine (CHX) has been

demonstrated to decrease salivary concentrations of MS, L and yeasts8>10>12'16. Nonetheless, the primary

goal of the dental professional still remains prevention and/or intervention in the formation of primary root

caries. Although antimicrobial agents have been available and prescribed for many years their potential

therapeutic benefits have not yet been fully appreciated and dental professionals continue to strictly

employ the use of fluoride at regular maintenance intervals. The purpose of this paper is to establish a

comprehensive model for the clinician in the assessment and identification of risk indicators in the

development of primary root caries. In addition, promote the efficacy of antimicrobial agents, specifically

chlorhexidine in the prevention and intervention of primary root caries in geriatric clients.

PREVENTION

TABLE 1 Risk Assessment of the Geriatric Client

Examination of the geriatric client allows the clinician to access the clients dentition for exposed root surfaces and carious lesions.
1. Assess diet
2. Assess oral hygiene self-care
3. Assess current chemotherapeutic agents
4. Assess need for chemotherapeutic agents.
5. If necessary, provide or refer client for preventative, intervention or restorative services.
TABLE 2 Risk Indicators
Poor dental history -history of root/coronal caries experience
-susceptible sites - crowns, overhanging margins.

Poor oral hygiene -frequency of brushing

-frequency of professional debridement
-history of plaque deposits
-presence of yeasts

Poor dietary habits -sugar consumption

-fermentable carbohydrates

History of periodontal disease -gingival recession

Presence of partial plates with

clasps -client with limited education on plaque control

Polypharmacia -xerostomic medicines

Morphology of root surfaces -erosion

-abrasion
-access to interproximal surfaces
Concentrations of acidic
Salivary bacterial -mutans streptococci and lactobacilli

Neurological dysfunctions -limited/impaired manual dexterity

Research groups have currently used salivary levels of mutans streptococci (MS) and lactobacilli (L) to

identify at risk dentate geriatric subjects3. A common bacteria found in root caries lesions are MS 1<7'10>14.

This may be associated with their various biochemical factors enabling them to metabolize sucrose to

produce extracellular water- insoluble polysaccharides and use carbohydrates to synthesize intracellular

polysaccharides 1. Without effective removal of bacteria their by-products adhere and accumulate on

exposed smooth surfaces making teeth vulnerable to primary root caries and after it is diagnosed the

prognosis of infected teeth declines as this disease progresses rapidly 1. Additional findings suggest that

the incorporation of chlorhexidine (CHX) into various treatment modalities and methods of delivery may

further suppress salivary levels of MS, L, and yeasts 1>3'9'16 For example, various case studies have

shown that supervised daily or weekly rinsing with CHX, and/or CHX/xylitol gum may control root caries in

the dentate elderly by decreasing salivary concentrations of MS, L and yeasts 10l13> 15~17> 19'21'23-24. other

studies, involving a 1% CHX gel or CHX gel coupled with stannous fluoride gel suggest that it may be

effective in suppressing primary and recurrent root caries in the margins of restorations by inhibiting the

presence of MS1'3'8'9'11'12'18.
 CONCLUSIONS

Table 2 presents risk indicators associated with root caries they can be seen to have biological,

physiological, behavioural and social determinants, hence root caries can be viewed as a lifestyle

disease2>5'6. The inadequate removal of cariogenic microorganisms and their production of cariogenic

substrates leads to the continual presence of plaque on gingivally recessed and abutment teeth of partial

dentures. However, exposure to potential pathogenic risk indicators does not necessarily predict the

occurrence or recurrence of this disease. We must bear in mind that the formation of primary root caries

is multi-factorial by nature and the sequelae of this disease is periapical lesion therefore, it is

essential to utilize a multi-focused approach towards its treatment and prevention. Billings & Bantings

state that once the disease process of root caries is understood it will provide clinicians with a greater

opportunity towards successful prevention and therapeutic outcomes, until then the development of

strict diagnostic guidelines is confounded by the incomplete understanding of root caries.

Socio-economic factors may preventing access to the services a dental professional is capable of

providing therefore, a simplistic approach to prevention should be sought. The first approach to

prevention should be a risk assessment of the geriatric client (Table 1) followed by education on their diet.

For example, xerostomia may relate to an increase in the consumption of fluids such as, soft drinks and

fruit juices - increasing exposure to sugar-containing substances. The second approach should be the

habitual use of oral hygiene aids to ensure the adequate removal of retained plaque from root surfaces.

Unfortunately, the effective removal of plaque may be compromised due to elderly subjects experiencing

limited dexterity or diminished neurological capabilities.

In closing, it is a well-documented fact that chlorhexidine is successful in reducing dental plaque, caries

and gingivitis in humans the reasons for this are its bactericidal action against gram-positive and gram-

negative bacteria and yeasts9. It is therefore likely that the supplemental use of chlorhexidine in the form

of rinses, gels, varnishes and gums may be either specifically or synergistically employed as a part of a

multi-focused approach in the prevention of root caries in the elderly dentate population.
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