Original Articles

Non-invasive management of superficial root caries

lesions in disabled and infirm patients
G. Johnson1 and H. Almqvist2
1

Department of Cariology, Institute of Odontology, Karolinska Institutet, Stockholm, Sweden; 2OraMed Pty Ltd, Stockholm, Sweden

Abstract
In disabled and infirm patients with limited, if any, capacity for independent oral self-care, it is difficult to
control progression of root caries lesions. Objective: To evaluate the effect of non-restorative cariostatic
treatment on progression of active superficial root caries lesions (n =56). Design: Pilot study. Setting:
Department of Cariology, Institute of Odontology, Karolinska Institutet, Huddinge. Subjects: 15 physicallydependent patients. Intervention: The patients were allotted to one of the following groups. Group 1,
professional tooth cleaning and application of tap water flavoured with eucalyptus oil; Group 2, professional
tooth cleaning and application of Cervitec, (1% chlorhexidine in thymol-containing varnish), Group 3,
professional tooth cleaning and application of Cervitec and Fluor Protector (varnish containing 0.1%
fluoride). Every three months for 18 months, each subject received the treatment twice within a 10-day
interval. Measurements: The status of the 56 root caries lesions was evaluated every six months using a
root caries index based on visual and tactile criteria. The examiners were blind to which treatment group
the patients belonged. Results: In most subjects (14 out of 15), progression of root caries lesions was
arrested. No statistically significant differences could be demonstrated between the three treatment groups.
However, regardless of treatment regimen, there was a statistically significant difference between the
greater number of subjects exhibiting no progression of root caries lesions and those with lesion progression,
at 6 (p=0.022), 12 (p=0.006) and 18 months (p<0.001). Conclusion: This pilot study suggests that in
disabled and infirm patients regular professional tooth cleaning with a fluoride containing paste, with or
without supplementary varnishing with chlorhexidine-thymol and/or fluoride can prevent further
progression of existing superficial root caries lesions.

Key words: adult, professional tooth cleaning, root caries treatment, non-cavitated caries, varnish,
Cervitec, chlorhexidine, Fluor Protector, fluoride

Introduction
Restorative treatment of root caries lesions is not
infrequently a source of frustration for both
clinician and patient. In highly caries active
patients, root caries lesions can extend over the
entire exposed root surface1, making them difficult
to access and technically difficult to restore.
Clinically it is recognised that a root caries lesion,
cavitated or non-cavitated, may revert to an

inactive phase2-4. It is therefore most important to

diagnose the presence of caries disease very early
and institute disease management procedures
designed to prevent lesion progression to the stage
at which there is no alternative to restorative
treatment.
Demographic development in the industrialised
countries shows pronounced increases in the

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10 G. Johnson and H. Almqvist

proportion of elderly people5,6. With increasing age

there is an increase in both caries incidence and
activity7-13. This is probably associated with an
increasing incidence of disease and disability,
which indirectly influences caries-inducing and
caries-resistance factors14
In Sweden, 200,000 residents are currently
entitled to community-subsidised dental care15.
These patients often experience high root caries
activity, which requires special care14. For this
category of patient it would be of great benefit to
establish treatment strategies which are not
dependent on high patient compliance. Such
strategies could be based on plaque-reducing and
remineralising measures, provided in a clinical
setting.
In modern dentistry, the use of fluoride and
chlorhexidine is self-evident. Fluoride exerts its
cariostatic effect by its presence, preferably
constantly, in the oral fluids bathing the dental hard
tissues. The main action of fluoride is to retard
demineralisation and promote remineralisation of
both enamel and dentine16. Although in vitro studies
have demonstrated that fluoride has some
antibacterial effect, the importance of this property
in vivo has yet to be established17.
Chlorhexidine has a broad antibacterial effect18.
Because mutans streptococci are particularly
sensitive to chlorhexidine, it inhibits both plaque
formation and acid production by plaque 19.
Chlorhexidine, in a variety of preparations, has
been shown to have a caries-inhibiting effect, not
only on enamel, but also on dentine and root
surfaces20-24.
Adequate and optimal treatment of caries disease
is causally directed, with treatment measures based
on cariological assessment of the individual patient.
The treatment programme comprises measures to
minimise caries-inducing factors (caries-inducing
microorganisms, bacterial substrate) and to
maximise caries resistance factors (salivary
variables, exposure to fluoride, dental hard tissues).
Such programmes are, however, most successful
in patients capable of independent oral self-care.
The aim of the present pilot study was to evaluate
three non-invasive treatment strategies, on existing,
active, clinically visible root caries lesions in a
clientele with limited, if any, capacity for oral selfcare. The treatments comprised professional
mechanical tooth cleaning and the application of a
varnish containing 1% thymol and 1%
chlorhexidine (Cervitec) or a combination of
Cervitec and 0.1% fluoride varnish (Fluor
Protector).

The Gerodontology Association 2003

Materials and Methods

Subjects
Patients attending a day care centre at a hospital in
suburban Stockholm were invited to participate in
the study. The inclusion criteria were the presence
of superficial active primary root caries lesions
accessible for visual inspection and photography.
Fifteen patients, 10 women and five men, met the
criteria and consented to participation in the study.
In all, 56 superficial active root caries lesions were
monitored. Three patients died prior to the 12
month review. There were also intermittent gaps
in observations during the study due to logistical
difficulties. The average age was 67.514.1 (SD)
years, and the range was 45 to 89 years (median
value 69 years). The subjects and their relatives,
the nursing staff and the subjects regular dentists
were given verbal and written information about
the study and its aim. The study was approved by
the Ethics Committee of Huddinge University
Hospital (Registration No. 21/99).
Clinical registration
Fifty-six superficial root caries lesions were chosen
as indicators of the caries development of the 15
patients. All registrations and assessments were
conducted by the authors in joint session, at
baseline and at 6, 12 and 18 months.
After cleaning and drying with a blast of air, the
root caries lesions were inspected under normal
operation lighting. The lesions were then spotprobed using new, sharp examination probes (SSW
no.5, Nordenta AB, Enkping, Sweden). The root
caries lesions were denoted as active or inactive
on the basis of the following visual and tactile
criteria: Grade 1 = hard lesion with a highly
polished surface (inactive lesion); Grade 2 =
somewhat softened lesion with a dull surface
(active lesion); Grade 3 = soft lesion with a dull,
rough surface (active lesion). Initially, the activity
of all 56 lesions was denoted as Grade 2. At the
final compilation of data, the root surfaces with
Grade 1 and 2 activity were denoted as surfaces
without caries progression (no progression) and
those with Grade 3 activity as surfaces with caries
progression (progression).
The presence of plaque was registered according
to the Plaque Index25, with the following grading:
Grade 0 = surface free of plaque; Grade 1 = the
surface appears clean, but plaque can be scraped
from the gingival third; Grade 2 = visible plaque;
and Grade 3 = the tooth surface is covered with
thick plaque.
The presence of saliva was assessed by a dental
mirror sliding test26. The back of a mouth mirror

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Non-invasive management of superficial root caries lesions in disabled and infirm patients 11

was drawn along the mucous membrane of the

inside of the right and left cheeks and friction was
registered as follows: Grade 1 = no obvious
friction, i.e. the mirror glides readily over the
mucous membrane; Grade 2 = some friction, i.e.
the mirror tends to stick to the mucous membrane
and Grade 3 = high friction, i.e. the mirror sticks
to the mucous membrane.
Clinical procedures
Treatment was carried out by the same dental
hygienist, on two occasions within a 10-day period,
at three-monthly intervals for 18 months
(maximum of 16 sessions/subject).
Without the knowledge of the examiners, the
hygienist randomly allotted the subjects to one of
the following groups: Group I: Professional tooth
cleaning and application of tap-water flavoured
with eucalyptus oil (n=5), Group II: Professional
tooth cleaning and application of 1%
chlorhexidine/thymol varnish (Cervitec, Vivadent,
Schaan, Liechtenstein) (n=6), Group III:
Professional tooth cleaning and application of
Cervitec followed by application of a varnish
containing 0.1% fluoride (Fluor Protector,
Vivadent, Schaan, Liechtenstein) (n=4).
Professional tooth cleaning included use of
prophylaxis paste containing 0.2% NaF (RDA 170,
Dental AB, Upplands-Vsby, Sweden) and
interproximal cleaning with an appropriate
interdental brush The varnishes were applied in
accordance with the manufacturers instructions.
Scheduling two applications 10 days apart
is in accordance with the manufacturer s
recommendation for Cervitec.
Statistical methods
The percentage of the root caries lesions which
had improved or not changed at 6, 12 and 18
months was calculated for each subject. In order
to relate the number of improved and unchanged
surfaces (%) to treatment group, the Kruskal-Wallis
one way analysis of variance was used.
The sign-test was used to test the effect of the
treatment strategies, i.e. whether the patient had
been kept free of root caries progression. If the
patient had one or more root caries lesions with
progression, the treatment outcome was denoted
as negative, in other cases as positive.

be kept free of root caries progression (Table 1).

No statistically significant differences could be
demonstrated among the three treatment groups.
However, the sample sizes were too small for any
definite conclusions to be drawn about the
difference in treatment effect among the groups.
On the other hand, regardless of treatment
programme, there was a statistically significant
difference between the greater number of subjects
who exhibited no progression of root caries lesions
(Grade 1 and 2) and those with lesion progression
(Grade 3), at 6 (p=0.02), 12 (p=0.006) and 18
months (p<0.001) (Table 1).
Discussion
The present pilot study suggests that regular, noninvasive treatment based on professional tooth
cleaning with fluoride prophylaxis paste (0.2%
NaF), with or without supplementary varnishing
with chlorhexidine-thymol and/or fluoride, can
control superficial caries lesion progression on root
surfaces. Of the 15 patients included in this study
only one patient showed progression of existing
lesions.
Clinicians increasingly seek non-invasive
approaches to the treatment of caries disease,
particularly for disabled and infirm patients at high
risk of developing root caries27. These patients
frequently exhibit high caries activity, lack
motivation and are unable to comply i.e. they
cannot adequately manage oral hygiene procedures
based on independent self-care. It is assumed that
over a period of 18 months, caries would progress
in the absence of professional caries preventive
measures. There are, however, no longitudinal
studies to support this assumption, because it would
be unethical to conduct long-term studies in such
high risk subjects without providing treatment for
the control group.
Regular prophylaxis with fluoride prophylaxis
paste has previously been shown to have a

Table 1. Number of subjects with and without

caries progression on root surfaces initially
registered with superficial, active caries lesions.
Clinical registration of caries at baseline, and at 6,
12 and 18 months.

Results
All 56 root surfaces under observation exhibited
plaque of Grade 2 or 3, throughout the
experimental period. In all subjects, friction from
the oral mucous membranes was registered as low
(Grade 1).
The results show that most of the patients could

6 months 12 months
No progression
Progression
Missing observation
Sign-test

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11
2
2
p=0.02

11
1
3
p=0.006

18 months
10
0
5
p<0.001

12 G. Johnson and H. Almqvist

cariostatic effect on coronal caries28. Vigild et al.29

have shown that an oral health care programme
including dental hygienist treatment every three
months improved oral health indicators. The
literature also supports non-invasive treatment of
root caries. Nyvad and Fejerskov3 showed that over
a period of 18 months, brushing with 0.1% fluoride
toothpaste and intermittent treatment with 0.2%
NaF solution converted active root caries lesions
to inactive. Billings et al.2 showed that daily
application of 1% F-gel in soft plastic trays could
convert active root caries lesions to inactive, with
a success rate of 20 to 70%, depending on the depth
of cavitation. Johansen et al.30 also demonstrated
that root caries development could be arrested by
oral hygiene measures combined with fluoride gel
applications and mouthrinses. In 1993, Emilson31
showed that a self-care programme using fluoride
toothpaste and fluoride tablets, combined with
professional tooth cleaning and application of
fluoride varnish, markedly reduced the number of
active root caries lesions.
Application of chlorhexidine varnish (40%) and
Duraphat varnish (5% NaF) at three monthly
intervals over 12 months has been shown to reduce
the development of root caries21. There are no
reports of studies of the effect of treatment with
Cervitec varnish on the development of root caries.
There are, however, studies, which demonstrate a
prophylactic effect on enamel caries in children32,22-24.
There are no uniform diagnostic criteria, which
address the dynamics of the development of root
caries. Different registration criteria have been
applied in different studies and there is an absence
of objective methods of measurement. However,
in a recently published study, an instrument based
on electrical resistance was used to evaluate root
caries progression 4 . The earliest clinically
discernible stage of root caries is surface softening.
In cases of high root caries activity the initial lesion
has not undergone any discernible colour change
at this stage. Therefore, the condition of the surface
has emerged as a more reliable indicator of disease
activity than the colour of the lesions33. Beighton
et al.33 classified primary root caries lesions in five
categories based on treatment needs. They found
that decreasing treatment needs corresponded to
decreasing numbers of cariogenic microorganisms,
and that the lesion softness and texture was a
reliable indicator of these findings. The grading of
root caries on a scale of 1 to 3 used in the present
study is based on the above observations and on
clinical experience. Grade 1 lesions would be
comparable to the hard lesions in the work of
Beighton et al. 33 , grade 2 lesions could be

The Gerodontology Association 2003

comparable to the leathery lesions deemed to

require a pharmaceutical approach and grade 3
lesions could be comparable to the soft, most severe
lesions. A similar caries index has been presented
for coronal caries34 and has proved reliable for
differentiating between active and inactive caries
lesions.
The index used in the present pilot study is simple
to apply and allows early identification of patients
at risk. This is most important, because the ensuing
treatment and management strategies are based on
the diagnosis of severity of disease activity.
In this pilot study, the dynamics of existing root
caries lesions on buccal and lingual surfaces have
been used as an indicator of the severity of an
individual patients caries disease. It is probable
that these observations reflect quite accurately the
caries development in the various subjects, insofar
as a persistently high plaque index was a common
factor for the whole group. Nor was any subject
totally lacking in saliva.
Because of the limited sample sizes, this pilot
study failed to demonstrate any additional benefit
of applications of the chlorhexidine and thymol
containing varnish, with or without fluoride. This
does not, of course, exclude the possibility that
supplementary varnishing with fluoride and
chlorhexidine is a valuable adjunct in the control
of root caries progression.
Conclusion
This pilot study suggests that in disabled and infirm
patients regular professional tooth cleaning with a
fluoride containing paste, with or without
supplementary varnishing with chlorhexidinethymol and/or fluoride, may prevent further
progression of existing superficial root caries
lesions and warrants further investigation.
Acknowledgement
This study was supported by The Swedish Patent
Revenue Fund for Research in Preventive
Dentistry.

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The Gerodontology Association 2003

Address for correspondence:

Assoc Professor Gunilla Johnson
Department of Cariology
Institute of Odontology
Karolinska Institute
Box 4064
S-141 04 Huddinge
Sweden
Tel:
+46 8 728 82 98
Fax: +46 8 711 09 88
e-mail: Gunilla.Johnson@ofa.ki.se

Gerodontology