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Caries Risk Assessment and Management
Key Points Dental caries is defined as a “biofilm-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues.” The formerly practiced paradigm of “drill and fill,” that is drilling out pits and fissures or surgically removing decayed and diseased tissue and placing permanent restorations, does not address the full continuum of the caries disease process, including microbial activity and the balance between enamel remineralization and demineralization. Systematic methods of caries detection, classification, and risk assessment, as well as prevention/risk management strategies, can help to reduce patient risk of developing advanced disease and may even arrest the disease process. INTRODUCTION Dental caries, or tooth decay, is one of the most prevalent diseases in humans, affecting 97% of the population worldwide during their lifetimes.1 The term “dental caries” can be used to describe both the disease process and the lesion (noncavitated or cavitated) that is formed as a result of the disease process.2 One definition of caries is “a biofilm-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues.”
The process of caries is multifactorial and, over time, can culminate in localized destruction of hard dental tissues by the weak acids produced by bacterial carbohydrate fermentation.2 Microbiological shifts within the oral biofilm upset the balance of the tooth enamel remineralization/demineralization process; this balance is also affected by salivary flow and composition, fluoride exposure, consumption of dietary sugars, and preventive behaviors (e.g., brushing teeth).2 Whether dental caries progresses, is halted, or reverses depends on a balance between protective and pathogenic factors. Caries is a continuum of disease states of increasing severity and tooth destruction, ranging from subclinical changes at the molecular level to lesions involving the dentin, either with an intact surface or obvious cavitation.2 The formerly practiced paradigm of “drill and fill,” drilling out pits and fissures or surgically removing decayed and diseased tissue and placing permanent restorations, does not address the full continuum of the caries disease process.2, 5 Arresting or preventing the caries process from resulting in cavitated lesions requires careful and systematic methods for documenting and monitoring disease at early stages and intervening prior to the development of advanced lesions. Detection of Caries/Caries Classification and Risk Assessment Systems Caries Detection
detect caries lesions, such as fluorescence-based techniques or other light-based caries diagnostic tools, are “emerging and, as they are developed, clinically tested and validated, they may contribute to a more precise placement of caries lesions within the ADA CCS categories.” Classification and Risk Assessment Systems Risk assessment is a valuable tool for the prevention and management of dental caries. Dentistry has entered an era of personalized care in which targeting care to individuals or groups based on their risk has been advocated. There are many risk tools and models in the literature. Some examples are provided in the following section. The International Caries Detection and Assessment System is an evidence-based, preventively oriented strategy that classifies the visual appearance of a lesion (i.e., detection, whether or not disease is present), characterization/monitoring of the lesion once detected (i.e., assessment), and culminates in diagnosis.10 The system is scored on clean, dry teeth and cautions against using sharp explorers or probes in order to prevent iatrogenic damage to the tooth.
The classification criteria, and associated estimates of caries activity, are based upon the histological extension of lesions spreading into tooth tissue.11 The scores are on a 7-point rating scale, as follows: The International Caries Classification and Management System™ (ICCMS™) takes the results of the ICDAS classification and translates them into a risk-assessed caries management system individualized for the patient. 11 The key elements of ICCMS 11 are: Initial patient assessments (collecting personal and risk-based information through histories and systematic data collection); Lesion detection, activity, and appropriate risk assessment (detection and staging of lesions, assessment of caries activity, and caries risk assessment); Synthesis and decision making (integrating patient-level and lesion- level information); and Clinical treatments (surgical and nonsurgical) with prevention (ensuring that the treatment planning options available are 0 Clinically sound 1 to 2 Clinically detected “intact” enamel lesions (initial stage decay) 3 to 4 Clinically detectable early, shallow, or microcavitations (moderate decay) 5 to 6 Clinically detectable late or deep cavitations (extensive decay)
Caries Experience of Mother, Caregiver and/or other Siblings: Carious lesions in the last 6 months (ages 0 to 14 years) Special Health Care Needs: developmental, physical, medical or mental disabilities that prevent or limit performance of adequate oral health care by themselves or caregivers (ages 0 to 14 years) Chemo/Radiation Therapy (ages >6 years) Visual or Radiographically Evident Restorations/Cavitated Carious Lesions: Carious lesions or restorations in last 24 months (ages 0 to 6 years) Noncavitated (incipient) Carious Lesions: New lesions in the last 24 months (ages 0 to 6 years) Cavitated or Noncavitated (incipient) Carious Lesions or Restorations (visually or radiographically evident): 3 or more carious lesions or restorations in last 36 months (ages >6 years) Teeth Missing Due to Caries: Any (ages 0 to 6 years) or in the past 36 months (ages >6 years) Severe Dry Mouth (Xerostomia; ages >6 years) or Visually Inadequate Salivary Flow (ages 0 to 6 years) Caries Prevention and Risk Management Strategies Behavioral Modification: Oral Hygiene and Diet Patients, especially those at high risk of caries development, should be instructed to reduce the amount and frequency of carbohydrate consumption.14 Patients should limit sugary snacks between meals15 and eat a healthy diet that limits added sugars and high-acid foods that can affect mineralization of enamel.15 Encourage patients to chew sugar-free gum with xylitol, which can promote salivary flow,
remineralization, and cannot be metabolized by cariogenic bacteria.16 All patients should be educated in optimal oral hygiene practices, including brushing with fluoride toothpaste twice a day and cleaning between teeth daily. Although some caries prevention recommendations5 include use of topical antimicrobials (e.g., chlorhexidine rinse) in patients 6 years of age and older who are at high risk of caries, a 2015 Cochrane systematic review found no trials for the use of antimicrobial chlorhexidine mouth rinses, sprays, gels, or chewing gums to prevent caries in children and adolescents. Topical Fluoride Application for Caries Prevention or Arrest A 2013 systematic review18 from the ADA CSA Expert Panel on Topical Fluoride Caries Preventive Agents provided evidence-based clinical recommendations regarding professionally applied and prescription- strength, home-use topical fluoride agents for caries prevention. Evidence was sought from clinical trials of professionally applied and prescription-strength topical fluoride agents—including mouthrinses, varnishes, gels, foams and pastes—reporting on caries increment outcomes. Clinical recommendations included the following for people at risk of developing dental caries: The panel recommends the following for people at risk of developing dental caries: 2.26% fluoride varnish or 1.23% fluoride (acidulated phosphate fluoride) gel, or a prescription- strength, home-use 0.5% fluoride gel or paste or 0.09% fluoride mouthrinse for patients 6 years or older. Only 2.26% fluoride varnish is recommended for children younger than 6 years. The strengths of the recommendations for the recommended products varied from “in favor” to “expert opinion for.” As part
came to the following evidence-based clinical recommendations for the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars in children and adolescents.24, 25 sealants are effective in preventing and arresting pit-and-fissure occlusal caries lesions of primary and permanent molars in children and adolescents compared to the non-use of sealants or use of fluoride varnishes; and sealants can minimize the progression of non-cavitated occlusal caries lesions (also referred to as initial lesions) that receive a sealant. Based on available limited evidence, the panel was unable to provide specific recommendations on the relative merits of one type of sealant material over the others, so the choice of sealant type used depends on provider preference and experience. The report defined pit-and- fissure sealant materials as follows: 1) resin-based sealants, 2) glass ionomer cements or sealants, 3) polyacid-modified resin sealants, and
- resin-modified glass ionomer sealants. 2018 ADA Clinical Practice Guideline on Nonrestorative Treatments for Carious Lesions In 2018, the ADA Center for Evidence-Based Dentistry conducted a systematic review and network meta-analysis 26 informing a clinical practice guideline 27 on nonrestorative treatments for carious lesions. The expert panel formulated 11 clinical recommendations, each specific to lesion type (i.e., cavitated, noncavitated), tooth surface (i.e., coronal, root surface [in adults]) and dentition (i.e., primary or permanent), each recommendation with an associated strength or certainty of the evidence (please refer to the clinical practice guideline for specific recommendations, strength of those recommendations,
and the certainty of the evidence associated with them). The panel provided recommendations for the use of the most effective treatment options, including 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide–amorphous calcium phosphate. The chairside guides for primary; and permanent dentition are available for download, and clinicians may also consult the online tool for personalized clinical recommendations based on the clinical parameters of the lesion. This guideline is the first in a series of four guidelines that will focus on caries management from the ADA Center for Evidence-Based Dentistry.28 The other guidelines are scheduled to be developed and published in the coming years and will focus on caries prevention, restorative treatments for carious lesions, and carious lesion detection and diagnosis. ADA Position on Early Childhood Caries PREVENTION AND CONTROL OF EARLY CHILDHOOD CARIES (Trans.2014:507) The American Dental Association recognizes Early Childhood Caries (ECC) as the presence of one or more decayed, noncavitated or cavitated lesions, missing due to caries, or filled tooth surfaces in any primary tooth in a child under the age of six. In children younger
Dental Home before age one, provide them with oral health education based on the child's developmental needs and explain methods for reducing the risk for ECC, including specific details of how to reduce risk factors and promote protective factors. The Association recommends state and local dental societies act as a resource for the medical community and public health programs (e.g., Women, Infants and Children [WIC] and Head Start). Dentistry can be instrumental in educating other health professionals and the public about risk factors for ECC and the importance of the establishment of a Dental Home before age one. The Association recognizes that the unique characteristics of ECC should be considered in selecting treatment protocols that are based on a child’s individual risk. The Association, recognizing that the science surrounding ECC continues to evolve, encourages research activities to study risk factors, preventive practices, disease management strategies and new technologies to address the challenges posed by this multifactorial disease. References
- Berg JH. The marketplace for new caries management products: dental caries detection and caries management by risk assessment. BMC Oral Health 2006;6 Suppl 1:S6.
- Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369(9555):51-9.
- Pitts NB, Zero DT, Marsh PD, et al. Dental caries. Nat Rev Dis Primers 2017;3:17030.
- Featherstone JD. Caries prevention and reversal based on the caries balance. Pediatr Dent 2006;28(2):128-32; discussion 92-8.
- Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc 2000;131(7):887-99.
- Pitts NB. Diagnostic tools and measurements--impact on appropriate care. Community Dent Oral Epidemiol 1997;25(1):24-35.
- Bader JD, Shugars DA, Bonito AJ. A systematic review of the performance of methods for identifying carious lesions. J Public Health Dent 2002;62(4):201-13.
- American Dental Association. ADA News: Committee adds 11 new codes to CDT. March 15, 2016. Accessed May 27, 2021.
- Young DA, Novy BB, Zeller GG, et al. The American Dental Association Caries Classification System for clinical practice: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(2):79-86.
- Young DA, Featherstone JD, Roth JR. Curing the silent epidemic: caries management in the 21st century and beyond. J Calif Dent Assoc 2007;35(10):681-5.
- Pitts NB, Ekstrand KR. International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) - methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 2013;41(1):e41-52.
- American Dental Association. Caries Risk Assessment Form (Age 0-6). Accessed May 27, 2021.
- American Dental Association. Caries Risk Assessment Form (Age >6). Accessed May 27, 2021.
- Wright JT, Tampi MP, Graham L, et al. Sealants for preventing and arresting pit-and-fissure occlusal caries in primary and permanent molars: A systematic review of randomized controlled trials-a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc 2016;147(8):631-45 e18.
- Wright JT, Crall JJ, Fontana M, et al. Evidence-based clinical practice guideline for the use of pit-and-fissure sealants: A report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc 2016;147(8):672-82 e12.
- Urquhart O, Tampi MP, Pilcher L, et al. Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis. J Dent Res 2018:22034518800014.
- Slayton RL, Urquhart O, Araujo MWB, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. J Am Dent Assoc 2018;149(10):837-49.e19.
- Fontana M, Pilcher L, Tampi MP, et al. Caries management for the modern age: improving practice one guideline at a time. JADA 2018;149(11):935-
