Reassessing Caries Risk Post-pandemic

As we have learned during the COVID-19 pandemic, a lot can change in two years — including your patients’ oral health! Since practices reopened, you may have seen the impact of COVID-19 reflected in your patients, including increased risk for dental caries. When it comes to oral health, the pandemic created a “perfect storm” of factors that can increase the risk of dental caries. Here, we discuss what may have changed and why assessing caries risk is now more important than ever. 

Reduced access to care and dental visits 

After the pandemic was declared in March 2020, dental practices were forced to close their doors to all but urgent cases. Hygienists were unable to provide routine caries screening, prophylaxis, coaching, topical fluoride therapies and other preventive measures. Vulnerable patients, such as elderly individuals in residential care, were already at increased risk of caries and experiencing difficulty accessing care. Even now, since offices fully reopened, some patients remain reluctant to attend for routine care. Inevitably, we expect to see cases of dental caries that could have been prevented or arrested under normal conditions. 

Oral hygiene and dietary habits 

Many people were furloughed, made redundant, or have worked/studied at home during the pandemic. Without the structure of their usual daily routines, some individuals found it more difficult to maintain positive habits like twice-daily oral hygiene. Meanwhile, demand for snacks and soft drinks has been solid, as shown by data from soft drinks companies. 

Anxiety and depression

The sheer scale of disruption caused by the COVID-19 pandemic has affected every area of our day-to-day lives. In a survey conducted shortly after the pandemic began, clinically significant anxiety and depression were reported by 42% and 38% of participants respectively. Higher levels of anxiety and depression are also found currently compared to pre-pandemic and this impact is expected to be sustained.   

Anxiety and depression can contribute to caries risk by making people:

• Less likely to engage in positive behaviors like oral hygiene and healthy nutrition;

• More likely to consume foods and drinks that are high in fermentable carbohydrates and to snack more;

• More likely to drink excessive amounts of alcohol or use recreational drugs, both of which can cause dry mouth. 

Dry mouth, COVID-19 and medications 

Dry mouth increases caries risk by impairing the buffering and remineralization capacities of saliva. There are many causes of dry mouth, including medications that list dry mouth as a side effect such as antidepressants and anxiolytics. Dry mouth is also known to be one of the earliest symptoms that may occur with COVID-19, and can outlast the infection. Further, some of the antiviral medications used to treat COVID-19 also list dry mouth as a side effect, as do some over-the-counter medications that may be used to treat symptoms, such as decongestants and painkillers.

Conduct an updated caries risk assessment

Regular caries risk assessments have always been important to determine risk level for the individual patient. However, in light of the disruptions many patients will have experienced during the pandemic, an updated risk assessment for each patient is now more important than ever.  The American Dental Association (ADA) and the American Academy of Pediatric Dentistry (AAPD) provide the following resources, guidance and caries risk assessment frameworks for patients of all ages.  

• ADA Caries Risk Assessment and Management

• ADA Caries Risk Assessment Form (Age 0-6)

• ADA Caries Risk Assessment Form (Age >6)

• AAPD Caries Risk Assessment and Management for Infants, Children, and Adolescents

Topical fluoride interventions 

For patients age 6 years and older at increased risk of dental caries, the ADA supports the use of prescription-strength fluoride gels or pastes containing 5,000 ppm fluoride (1.1% NaF) for caries prevention. Options include Colgate PreviDent 5000 Booster Plus and, for patients with dry mouth, consider Colgate PreviDent 5000 Dry Mouth which is specially formulated to minimize dryness. For patients of all ages, the ADA recommends the use of 5% sodium fluoride varnish (22,600 ppm fluoride). For this purpose, Colgate PreviDent Varnish is an option to consider. 

To arrest or reverse non-cavitated and cavitated caries lesions on root surfaces, the ADA recommends prioritizing the use of 5,000 ppm fluoride (1.1% NaF) toothpaste or gel. For cavitated lesions on coronal surfaces, the use of 38% sodium diamine fluoride is prioritized for both primary and permanent teeth. For the arrestment/reversal of non-cavitated coronal caries lesions in both primary and permanent teeth, the ADA recommends that dental professionals should prioritize the use of: 

• Sealants plus 5% NaF varnish on occlusal surfaces;

• 5% NaF varnish on approximal surfaces; and 

• 1.23% APF gel or 5% NaF varnish on facial or lingual surfaces.

Reinforce the importance of positive habits. 

We can also help patients get back on track by reinforcing the importance of positive dietary, behavioral and oral health habits. Sensitively inquire if they have had any difficulty maintaining routines or habits during the pandemic and gauge where you may be able to offer support. One way to help patients is to recommend a smart toothbrush, like the Colgate hum which coaches users while they are brushing, including showing where extra attention is needed.