The Caries Management System: an evidence‐based preventive strategy for dental practitioners. Application for children and adolescents

The application of the Caries Management System (CMS) for children and adolescents follows the rationale underlying the application of the CMS for adults. Briefly, the CMS is a 10‐step, risk‐based, non‐invasive strategy to arrest and remineralize early lesions and to enhance caries primary prevention. The method for assessing each patient’s diet, plaque distribution, and signs of caries as shown in bitewing radiograph images, follows the protocols for adults. Protocols presented here relating to caries risk assessment, lesion diagnosis and management, and patient recall are specific for children and adolescents. Fundamentally, non‐cavitated lesions in primary and especially permanent teeth are managed: (1) professionally by preservative non‐invasive means, including fluoride varnish and sealants; and (2) daily home toothbrushing using fluoride toothpaste where the aim is to arrest lesion progression so that restorations will not be necessary. Monitoring of lesions through the review of clinical signs and bitewing images is the means for assessing caries activity. For those who fail to respond to advice to reduce cariogenic exposures and continue to develop new lesions at a steady or increased rate, a more intensified programme is required; their higher risk status is confirmed and treatment follows the corresponding protocol.     

State-level differences in the oral health of Australian preschool and early primary school-age children

Background: This study compares oral health outcomes and behaviours for young Australian children by residential state or territory to determine whether state differences arise from individual exposures to risk factors. Methods: Cross‐sectional data for 4606 2–3 year olds and 4464 6–7 year olds were obtained from the Longitudinal Study of Australian Children. Outcome measures were parent‐reports of children’s caries experience, frequency of toothbrushing and dental services use. Results: For 2–3 year olds, children from the Australian Capital Territory were less likely to have parent‐reported caries than children from other states, and more likely to brush their teeth twice daily and to have used dental services. For 6–7 year olds, optimal outcomes were observed in New South Wales for lowest caries experience, Western Australia for highest toothbrushing, and South Australia for highest dental services use. Adjustments for socio‐demographic predictors did not eliminate state differences in oral health. Conclusions: Large state differences in the oral health of young children persisted after adjustment for individual socio‐demographic determinants, suggesting these arise from variations in the systems to promote and care for children’s oral health. Several states would benefit from a stronger emphasis on oral health promotion in young children, and disparities from a young age suggest the need for better engagement of early childhood professionals in oral health promotion.     

Prevalence of early childhood caries among 5‐year‐old children: A systematic review

The aim of the present review was to describe the updated prevalence of early childhood caries (ECC) among 5‐year‐old children globally. Two independent reviewers performed a systematic literature search to identify English publications from January 2013 to December 2017 using MEDLINE, ISI Web of Science, and Scopus. Search MeSH key words were “dental caries” and “child, preschool”. The inclusion criteria were epidemiological surveys reporting the caries status of 5‐year‐old children with the decayed, missing, and filled primary teeth (dmft) index. The quality of the publications was evaluated with the modified Newcastle‐Ottawa Scale. Among the 2410 identified publications, 37 articles of moderate or good quality were included. Twenty of the included studies were conducted in Asia (China, India, Indonesia, Korea, Nepal, and Thailand), seven in Europe (Greece, Germany, Great Britain, and Italy), six in South America (Brazil), two in the Middle East (Saudi Arabia and Turkey), one in Oceania (Australia), and one in Africa (Sudan). The prevalence of ECC ranged from 23% to 90%, and most of them (26/37) were higher than 50%. The mean dmft score varied from 0.9 to 7.5. Based on the included studies published in the recent 5 years, there is a wide variation of ECC prevalence across countries, and ECC remains prevalent in most countries worldwide.     

Supplemental fluoride use for moderate and high caries risk adults: a systematic review

Objectives: Multiple systematic reviews have evaluated fluorides for caries prevention in children, but a need to review the literature regarding supplemental fluoride use in adults still remains. The purpose of this systematic review is to evaluate the research regarding professional and/or supplemental self‐applied fluoride for preventing and remineralizing caries in moderate and high caries risk adults. Methods: Utilizing multiple databases, a comprehensive search was undertaken in both foreign and English languages. Studies included were randomized control trials (RCT) or clinical trials conducted in moderate or high caries risk adult populations, evaluating self‐ or professionally applied fluoride with the outcomes of caries reduction/remineralization. Studies were excluded if they were in situ, in vitro, split mouth design, or with unclear outcomes specific to fluorides. A quality evaluation of the studies used a checklist of critical domains and elements for an RCT. Results: Seventeen studies were included in the systematic review. Findings were categorized into the following groups: sodium fluoride (NaF) and amine/potassium fluoride mouthrinses of varying strengths, NaF gels and pastes, NaF varnish, and stannous fluoride. Quality evaluation scores varied from 50.2 percent to 88.9 percent. Conclusions: The strongest studies demonstrated the following modalities as moderately effective in higher caries risk adults: low strength NaF rinses [relative risk reduction (RRR) for carious lesions: 50‐148 percent]; 1.1 percent NaF pastes/gels (RRR for root lesion remineralization: 35‐122 percent); fluoride varnishes [RRR for RC remineralization: 63 percent; RRR for decrease in decayed, missing, and filled surfaces: 50 percent]. Evidence regarding 1.1 percent NaF and 5 percent NaF varnishes related primarily to root caries and older adults.     

Salivary proteins as a biomarker for dental caries—A systematic review

AimTo develop a systematic review based on the relation between salivary proteins and dental caries by comparing subjects with and without caries experience and to evaluate whether salivary proteins can be considered biomarkers for dental caries or not.MethodsAn electronic search was performed in the PubMed Medline, Ovid Medline, ISI Web of Science, Medline, Cochrane Library, Lilacs, Scielo, BBO, Paho and Wholis databases applying the following MeSH terms: “dental caries” OR “tooth demineralization” OR “dental caries susceptibility” OR “dental enamel solubility” AND “salivary proteins and peptides” OR “saliva” AND “proteins”. To be eligible for the systematic review, the observational controlled studies had to have groups with and without caries experience. Studies with high risk of bias were excluded.ResultsFrom a total of 188 identified studies, only seven were included in this systematic review. Four studies were classified as “low risk of bias” and three as “moderate risk of bias”. Three studies reported a relation between salivary proteins and dental caries.ConclusionThere was not sufficient evidence to establish salivary proteins as a biomarker for this disease although three of the seven studies showed a relation between salivary proteins and dental caries in terms of protein phenotypes, total protein concentration and protein molecular weight.     

Is the consumption of fruit cariogenic?

Aim: The aim of this study was to investigate possible risk factors for dental caries in primary school children. Methods: Children aged 10–12 years (n = 257) residing in Lithgow, a non‐fluoridated community in New South Wales, Australia, were examined for caries experience in the permanent dentition. Information on dental practices, diet, residential movements, and socioeconomic status were obtained from self‐completed questionnaires. Results: Caries risk in the permanent teeth was associated with social disadvantage and diet. Among the dietary factors, the frequency of fruit consumption was associated with higher odds of caries experience (odds ratio: 1.52, 95% confidence intervals: 1.05, 2.21). Conclusions: Exposure to a high level of fruit consumption was suggestive of increased caries risk. Longitudinal studies are required to investigate the relationship between fruit consumption and dental caries.     

The Monitor Practice Programme: is non‐invasive management of dental caries in private practice cost‐effective?

Background: The objective of this research was to assess the efficacy and cost‐effectiveness of a non‐invasive approach to dental caries management in private dental practice. Methods: Private dental practices from a variety of locations in New South Wales were randomly allocated to either non‐invasive management of caries, or continue with usual care. Patients were followed for three years and caries incidence assessed. A patient‐level decision analytic model was constructed to assess the cost‐effectiveness of the intervention at two years, three years, and hypothetical lifetime. Results: Twenty‐two dental practices and 920 patients were recruited. Within the clinical trial there was a significant difference in caries increment favouring non‐invasive therapy at both two and three years. Efficacy was independent of age, gender, medical concerns, fluoride history, or previous history of dental caries, in a population of patients attending for treatment in private dental practices, in a variety of locations both urban and rural. Cost per DMFT avoided estimate was A$1287.07 (two years), A$1148.91 (three years) decreasing to A$702.52 in (medium) and A$545.93 (high) risk patients (three years). Conclusions: A joint preventive and non‐invasive therapeutic approach appears to be cost‐effective in patients at medium and high risk of developing dental caries when compared to the standard care provided by private dental practice.     

Caries Risk Assessment and Management for the Prosthodontic Patient

Prosthodontic patients are often at a high risk for caries, and assessing that risk prior to treatment is important. Historically, the nature of dental education and clinical practice has oriented clinicians toward recognizing and correcting the damaging effects of caries, rather than actively assessing and managing caries risk potential. New developments have led to better diagnostics and protocols for caries management, although one adapted to the specific needs of the prosthodontic patient has not been proposed. Our purpose is to outline caries risk assessment and management for the prosthodontic patient.     

Enamel defects and dental caries in 9-year-old children living in fluoridated and nonfluoridated areas of Auckland, New Zealand

Abstract – Objectives: This epidemiological study aims to investigate the developmental enamel defects and dental caries among 9‐year‐old children resident in fluoridated and nonfluoridated regions in Auckland, New Zealand. Methods: A stratified, two‐stage random selection design where strata were defined by fluoridation status, school size, and school decile. After informed consent was obtained, parents completed oral health questionnaires and children underwent dental examinations at school clinics. Results: 612 children from 38 schools participated in the study. Overall, 175 (29%) children had lived continuously in fluoridated areas, 149 (24%) had lived continuously in nonfluoridated areas, and 288 (47%) had resided intermittently in fluoridated areas. Diffuse opacities were present in 117 (19%) children and deciduous teeth dental caries was seen in 370 (60%) children. After adjustment for covariates, a strong dose–response relationship between diffuse opacity and fluoridation status was found, with children who lived continuously in fluoridated areas being 4.17 times as likely to have diffuse opacities as children who lived continuously in nonfluoridated areas (P < 0.001). Conversely, a strong protective dose–response relationship between caries experience and fluoridation status was seen, with children who lived continuously in fluoridated areas being 0.42 times as likely to have dental caries as children who lived continuously in nonfluoridated areas (P < 0.001). Conclusions: Reticulated water fluoridation in Auckland reduces the risk of dental caries but increases the risk of diffuse opacities in 9‐year‐old children. Guidelines and health‐promotion strategies that enable children to minimize their risk to diffuse opacities yet reduce their risk of dental caries should be reviewed.     

Status and progress of treatment methods for root caries in the last decade: a literature review

The aim of this literature review is to explore the treatment methods for root caries in laboratory and clinical research in the last decade. A systematic search of publications in PubMed and Web of Science databases was performed. The timespan was limited to the last 10 years and English language. Further retrieval was conducted using the search terms of specific therapies or treatments. Eighty‐two articles were included in this systematic review and full texts were retrieved. Types of studies included laboratory studies and clinical trials. Therapeutic approaches for root caries without risk of pulp exposure can be categorized into non‐invasive and restorative treatment. Non‐invasive treatments which targeted different causative factors of root caries have been developed in the last decade. Accordingly, several artificial caries model systems have been proposed for the study of root caries in the laboratory. Carious tissue excavation techniques and restorative materials and procedures have been modified to improve the prognosis of invasive treatment. It is of importance to determine the most appropriate therapy for root caries and further clinical trials are needed to draw firm conclusions concerning the efficacy and consistency of the various treatment methods proposed.     

Cost‐effectiveness of an experimental caries‐control regimen in a 3.4‐yr randomized clinical trial among 11–12‐yr‐old Finnish schoolchildren

The aim of this study was to assess the cost‐effectiveness of an experimental caries‐control regimen in a randomized clinical trial (RCT) conducted in Pori, Finland, in 2001–2005. Children (n = 497) who were 11–12 yr of age and had at least one active initial caries lesion at baseline were studied. The children in the experimental group (n = 250) were offered an individually designed patient‐centered regimen for caries control. The children in the control group (n = 247) received standard dental care. Furthermore, the whole population was exposed to continuous community‐level oral health promotion. Individual costs of treatment procedures and outcomes (DMFS increment score) for the follow‐up period of 3.4 yr were calculated for each child in both groups. The incremental cost‐effectiveness ratio was €34.07 per averted DMF surface. The experimental regimen was more effective, and also more costly. However, the total costs decreased year after year, and for the last 2 yr the experimental regimen was less expensive than the standard dental care. The experimental regimen would probably have been more cost‐effective than standard dental care if the follow‐up period had been longer, the regimen less comprehensive, and/or if dental nurses had conducted the preventive procedures.     

Dental caries experience in older people over time: what can the large cohort studies tell us?

BACKGROUND: Little was known of the natural history of dental caries among older adults until recently, but reports from a number of large cohort studies have now enabled better understanding of the nature and determinants of dental caries in older people. The aim of this review is to examine and compare findings from established population-based longitudinal studies of older adults in order to determine their preventive implications. METHODS: The dental literature was reviewed in order to identify reports on dental caries incidence from large, population-based dental longitudinal studies of older adults (age 50+) with at least 3 years of follow-up. RESULTS: Reports were identified from four studies (in Iowa, North Carolina, Ontario and South Australia) which met the criteria; four reports dealt with coronal caries, and five with root surface caries. When annualised, coronal and root surface caries increments were combined and compared with those reported for adolescents, the caries experience of older people over time (between 0.8 and 1.2 new surfaces affected per year) exceeded that reported from cohort studies of adolescents (between 0.4 and 1.2 surfaces per year). The only caries risk factor common to all four studies was the wearing of a partial denture (for root surface caries only). CONCLUSIONS: Older people are a caries-active group, experiencing new disease at a rate which is at least as great as that of adolescents. PRACTICE IMPLICATIONS: Dentate older people should be the target of intensive monitoring and preventive efforts at both the clinical practice and public health levels. There is no easily identifiable 'magic bullet' for preventing caries in that age group, but the use of evidence-based preventive interventions (such as fluoride) should suffice.     

Dentist reliability in classifying disease risk and reason for treatment

OBJECTIVES: The reliability of practicing dentists' classifications of patients' caries risk and periodontal disease risk and reason for treatment for individual teeth were determined. The risk classification protocols had been in use in a group practice for more than a year, and the reason-for-treatment protocol had been introduced six months previously. METHODS: Eight dentists' classifications for caries (n = 66) and periodontal disease risk (n = 66), and six dentists' classifications for reason for treatment (n = 73) were compared to those of a nominal standard examiner. Reliability was expressed as percent agreement and kappa values. RESULTS: Percent agreement was 76 percent, 83 percent, and 74 percent for caries, periodontal disease, and reason for treatment, respectively, with kappa values of 0.56, 0.70, and 0.69. CONCLUSIONS: Dentists can attain reasonable levels of reliability using simple classification protocols with little formal training, although misclassification may be problematic for specific administrative or research-related purposes.     

Assessing caries risk in children

With the dramatic improvements in the oral health of children in Australia that have occurred over the past two decades, the option of, and the need for, targeted prevention of dental caries for those at high risk has become apparent. Since caries is of multifactorial aetiology, the clinical outcome varies depending on which factor, or combination of factors, is prominent in a particular individual; this may be related to both age and stage of life. Tests for caries risk can assist in prediction, but clinical signs and history are as important in assessing the main cause(s) of caries in an individual. In studies involving several factors, past caries experience (especially of the first permanent molar) continues to be the best predictor of future caries in children. Despite their ready availability, tests in the form of commercial kits are still expensive; no one test is an adequate predictor of caries risk, and the specificity and sensitivity of the tests are not reliably diagnostic for an individual. There is a need for regional longitudinal risk assessment studies in which potential risk factors are identified before the onset of caries in order to maximize predictive power and then validated against subsequent caries. Caries activity may not be able to be predicted in a population with low disease prevalence. Any risk assessment strategy must be followed by appropriate preventive interventions.     

Pit and fissure sealants in high-caries-risk individuals.

This paper examines the evidence demonstrating the effectiveness of sealants in high-caries-risk children and discusses the Research Triangle Institute/University of North Carolina's (RTI/UNC) systematic review. The strict RTI/UNC protocol limited the number of sealant studies that could be included. This analysis expanded their criteria to permit additional methods of determining caries risk (for example, past caries experience, less than two pairs of sound first permanent molars available/child in half-mouth designs) and outcome measures in addition to DMFS (that is, percent sealant retention, survival rates, cost-effectiveness, changes in salivary S. mutans levels). Nine clinical studies with a randomized, half-mouth, clinical trial design and seven studies with observational study designs were included. There is good evidence that sealants can be used efficaciously and effectively in high-risk children as long as the sealant is retained. Sealants are more effective in preventing further caries and providing cost savings in a shorter time span if placed in children who have high rather than low caries risk.     

A view from both sides

This letter to the editor is from one of the key figures in caries management by risk assessment. Dr. Featherstone brings a unique perspective to the access issue. He grew up in New Zealand and experienced care under the dental therapist provider model. His letter is included here because it complements the other articles by providing his views on CAMBRA in the context of addressing barriers to care.     

Caries prevalence,severity, and 3‐year increment,and their impact upon New Zealand adolescents' oral‐health‐related quality of life

Objective: To examine dental caries experience among New Zealand adolescents and determine the nature of caries‐associated differences in oral‐health‐related quality of life (OHRQoL) among adolescents. Method: Follow‐up was conducted of a random sample of 430 children first examined in 2003 at age 13, when they completed the Child Perceptions Questionnaire (CPQ_11‐14). At age 16, 255 (59.3% of the baseline sample) were re‐examined and again completed the CPQ_11‐14. Results: Caries prevalence (1 + DMFS) rose from 68% to 79.2%; mean DMFS rose from 2.9 (SD 4.7) to 3.6 (SD 4.8), and the prevalence of high caries experience (5 + DMFS) rose from 20.0% to 40.8%. The 3‐year mean net caries increment of 0.5 surfaces (SD 2.6) was dominated by occlusal surfaces. At both ages, overall CPQ_11‐14 scores, as well as emotional well‐being subscale scores, were significantly higher for those with DMFS values of 5 or more. Conclusion: Caries experience increased over the three years; this age group is caries‐active. Dental caries affects adolescents' OHRQoL, although not as strongly as maybe expected.     

龋易感人群健康美学管理的策略与实践

针对龋易感人群,提出一种全新的诊疗体系--健康美学管理。健康美学管理旨在恢复牙体美观的同时,考虑牙体、牙髓的保存,兼顾健康与美学,并达到个性化诊疗效果。健康美学管理的策略主要包括5个方面的内容：1）龋病风险评估;2）早期龋探测;3）数字化微笑设计;4）微创技术;5）龋病行为管理及医患沟通平台。本文结合临床实践,对健康美学管理的流程和方案进行阐释。     

Clinical decision-making for coronal caries management in the permanent dentition.

Optimal conservative treatment decisions to prevent, arrest, and reverse tooth demineralization caused by caries require probability estimates on caries risk and treatment outcomes. This review is focused on the use of the best scientific evidence to recommend treatment strategies for management of coronal caries in permanent teeth as a function of caries risk. Evidence suggests that assigning therapeutic regimens to individuals according to their risk levels should yield a significantly greater probability of success and better cost effectiveness than applying identical treatments to all patients independent of risk. Depending on caries risk levels, treatment decisions based on risk can minimize unnecessary surgical intervention by incorporating the best evidence to prescribe treatment regimens for the use of fluoride-releasing agents, sealants, chlorhexidine, or combinations of these products.     

Childhood obesity and dental caries among paediatric dental clinic attenders

International Journal of Paediatric Dentistry 2011; 21: 217–222 Background. More than one‐quarter of New Zealand children are overweight or obese. Research on the causes of obesity has found associations with high consumption of sweetened foods and beverages, which have also been shown to be risk factors for dental caries, but studies investigating a possible association between dental caries and obesity have had conflicting findings. Aim. The aim of this study was to determine whether deciduous dental caries experience was associated with BMI among paediatric dental clinic attenders. Design. This was a cross‐sectional study of clinical records of 200 children aged eight and under (70% European) treated in the University of Otago undergraduate paediatric dentistry clinic between 2004 and 2006. Height and weight were measured and used to calculate BMI. Deciduous dental caries experience was recorded. Results. The overall mean BMI was 16.0 (SD = 2.0). Pacific Island children had a higher mean BMI (at 17.0) than NZ European, Maori, and Asian/Other children (15.7, 16.8, and 15.9 respectively; P < 0.05). The dmft ranged from 0 to 15, with a mean of 6.1 (SD = 3.8); 24% had dmft <3, and 38% had dmft >8. No significant association was found between the BMI and caries experience (P‐value = 0.932). Conclusions. There was no association between BMI and dental caries experience in this convenient sample.