Article

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

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

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.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Over the last decade, new philosophies or systems have been proposed for caries management that have similar focus but different emphasis on the caries-management cycle (7)(8)(9)(10)(11)(12)(13)(14)(15). These new approaches have been developed by a small cadre of committed researchers, educators, cariologists, and dentists. ...
... The CAMBRA coalition defines caries lesion activity (21) The CMS system (12,13) regards all lesions as active at baseline. Lesions are deemed to be arrested when, following treatment, lesion size (or depth) shrinks or ceases to increase. ...
... According to the CMS (12,13), caries risk is determined on the basis of the caries incidence rate. Risk reduction strategies aim to reduce exposures to risk factors and enhance protective factors. ...
Data
Full-text available
In May 2012, cariologists, dentists, representatives of dental organizations, manufacturers, and third party payers from several countries, met in Philadelphia, Pennsylvania, to define a common mission; goals and strategic approaches for caries management in the 21th century. The workshop started with an address by Mr. Stanley Bergman, CEO of Henry Schein Inc. which focused on the imperative for change in academia, clinical practice, and public health. For decades, new scientific evidence on caries and how it should be managed have been discussed among experts in the field. However, there has been some limited change, except in some Scandinavian countries, in the models of caries management and reimbursement which have been heavily skewed toward 'drilling and filling'. There is no overall agreement on a caries' case definition or on when to surgically intervene. The participants in the workshop defined a new mission for all caries management approaches, both conventional and new. The mission of each system should be to preserve the tooth structure, and restore only when necessary. This mission marks a pivotal line for judging when to surgically intervene and when to arrest or remineralize early noncavitated lesions. Even when restorative care is necessary, the removal of hard tissues should be lesion-focused and aim to preserve, as much as possible, sound tooth structure. Continuing management of the etiological factors of caries and the use of science-based preventive regimens also will be required to prevent recurrence and re-restoration. These changes have been debated for over a decade. The Caries Management Pathways includes all systems and philosophies, conventional and new, of caries management that can be used or modified to achieve the new mission. The choice of which system to use to achieve the mission of caries management is left to the users and should be based on the science supporting each approach or philosophy, experience, utility, and ease of use. This document also presents a new 'Caries Management Cycle' that should be followed regardless of which approach is adopted for caries prevention, detection, diagnosis, and treatment. To aid success in the adoption of the new mission, a new reimbursement system that third party payers may utilize is proposed (for use by countries other than Scandinavian countries or other countries where such systems already exist). The new reimbursement/incentive model focuses on the mission of preservation of tooth structure and outcomes of caries management. Also described, is a research agenda to revitalize research on the most important and prevalent world-wide human disease. The alliance of major dental organizations and experts that started in Philadelphia will hopefully propel over the next months and years, a change in how caries is managed by dentists all over the world. A new mission has been defined and it is time for all oral health professionals to focus on the promotion of oral health and preservation
... Currently, the diagnostic strategy for caries lesions detection indicated in most clinical guidelines is the clinical examination simultaneously associated with a radiographic assessment [9,17,[23][24][25][26] Visual inspection must be performed in all patients at the beginning of the treatment, and the method presents high speci city for the detection of caries lesions that need some type of treatment. However, clinical examination tends to overlook several caries lesions requiring operative treatments, mainly at occlusal and proximal surfaces of posterior teeth [26,27]. ...
... Therefore, many lesions requiring operative interventions (at most advanced stages) and missed during clinical examination, could be detected [17,23,26]. Another advantage would be the early detection of caries lesions before a cavitation is present, and therefore, treated them non-operatively, avoiding a more invasive approach [9,17,[24][25][26]. In both situations, a simultaneous diagnostic strategy is advocated. ...
... The current diagnostic strategy for caries detection in children recommended by clinical guidelines is the simultaneous association of a clinical examination with radiographic assessment [9,17,[23][24][25][26]. ...
Preprint
Full-text available
Background: To evaluate the clinical course and interventions required during two years of follow-up of dental surfaces of deciduous molars diagnosed, and consequently treated, by two different strategies: diagnosis made by clinical examination alone or associated with radiographs. Methods: This is a secondary analysis of a two-arm randomized clinical trial with two parallel groups related to the diagnostic strategy for caries detection in preschool children. 216 children (3 to 6 years old) were followed-up for two years. All dental surfaces were diagnosed by visual inspection and later, through radiographic assessment. Baseline treatment was made in accordance with the results obtained by visual inspection performed alone or combined with radiographic method, considering the allocated group. Dental surfaces with no restoration needs, or those restored at the beginning of the study were followed-up for two years. The treatment decision was made according to the allocated group. The outcome was the occurrence of failure (a new caries lesion or a restoration replacement) during the follow-up. Results: 4,383 proximal and occlusal surfaces of deciduous molars in 216 preschool children were diagnosed and treated according to the abovementioned diagnostic strategies and followed-up for 24 months. The assessment of radiographs made change the initial decision reached by visual inspection in about 30% of the surfaces when all types of interventions were considered. However, most disagreements occurred for initial lesions, where radiographs tended to underestimate them. Discordances between methods occurred in less than 5% of all surfaces when considered lesions requiring operative treatment. For discrepancy cases, the placed interventions guided by following the radiographic results did not present less failures against those made following only visual inspection. As a matter of fact, the use of radiographs in the diagnostic strategy for caries detection in children brought more harms than benefits due to the occurrence of false-positives, overdiagnosis and lead-time bias. Conclusions: Simultaneous association of visual inspection and radiographic assessment for caries detection in preschool children causes more harms than benefits, and therefore, visual inspection should be conducted alone in the regular clinical practice. Trial registration: clinicaltrials.gov platform: NCT02078453, registered on 5th March 2014
... The RT should be placed at the stage of a "moderate" carious lesion with a radiolucency deeper than the external third of dentine 1,2 . For primary teeth, the RT has never been clearly defined: some dentists place it at the stage of a moderate lesion with radiolucency within the dentine 3,4 and others in the presence of a cavitation [5][6][7][8][9][10] . ...
... ICDAS stages were used for occlusal lesions because of the abundance of scientific literature on the topic 1,19,23 . On the basis of the CCI TM guide for permanent molars and different publications focusing on caries lesion management in particular cases of primary molars 1,3,5,8,24 , the correct RT was underlying dark shadow from dentine (ICDAS 4) or radiolucency involving the external third of dentine (i.e., radiographically evident carious dentine lesions) for both primary and permanent molars. ...
... 17%) or high-viscosity GIC (HV-GIC: n=58; 29%). 2 Approximal lesions in primary molars were restored with compomer (n=7; 3.5%), RM-GIC (n=38; 19%) or HV-GIC (n=64; 32%). 3 Occlusal lesions in permanent molars were restored with RM-GIC (n=5; 2.5%) or HV-GIC (n=11; 5.5%). 4 Approximal lesions in primary molars were restored with compomer (n=1; 0.5%), RM-GIC (n=3; 1.5%) or HV-GIC (n=8; 4.5%). ...
Article
Background Worldwide, numerous surveys have investigated practices and knowledge about caries management in adults, but few are available for children. Aim The present cross‐sectional survey aimed to assess the restorative thresholds (RTs) in primary and permanent molars in children used by a population of dentists treating children and practicing in France. Design The study population consisted of French dentists treating children who were registered in the French Society of Pediatric Dentistry (n=250). A specific questionnaire was developed. Descriptive and statistical analyses were performed. Results Response rate was 80.4% (n=201). Considering that an appropriate RT is at the stage of a moderate lesion (occlusal: International Caries Detection and Assessment System 4; approximal: lesion involving the external third of dentine), more than 50% of respondents showed a tendency for iatrogenic treatment, except for occlusal carious lesions in primary molars. Inappropriate invasive strategies were more often reported for occlusal lesions in permanent than primary molars. Moreover, for both molar types, these inappropriate RTs were more often chosen for approximal than occlusal lesions. Conclusions The present survey suggested that French dentists treating children tend to overtreat in terms of caries management in both primary and permanent molars.
... Currently, the diagnostic strategy for caries lesions detection indicated in most clinical guidelines is the clinical examination simultaneously associated with a radiographic assessment [9,17,[23][24][25][26]. Visual inspection must be performed in all patients at the beginning of the treatment, and the method presents high specificity for the detection of caries lesions. ...
... Therefore, many lesions requiring operative interventions (at most advanced stages) and missed during clinical examination, could be detected [17,23,26]. Another advantage would be the early detection of caries lesions before a cavitation is present, and therefore, treated them non-operatively, avoiding a more invasive approach [9,17,[24][25][26]. In both situations, a simultaneous diagnostic strategy is advocated. ...
... The current diagnostic strategy for caries detection in children recommended by clinical guidelines is the simultaneous association of a clinical examination with radiographic assessment [9,17,[23][24][25][26]. Nevertheless, such recommendation is based on accuracy studies as an attempt to minimize the problem of the visual inspection´s low sensitivity [27] since by associating both methods there´s a tendency to increase sensitivity [26]. ...
Article
Full-text available
Background To evaluate the clinical course and interventions required during two years of follow-up of dental surfaces of deciduous molars diagnosed, and consequently treated, by two different strategies: diagnosis made by clinical examination alone or associated with radiographs. Methods This is a secondary analysis of a two-arm randomized clinical trial with parallel groups related to the diagnostic strategy for caries detection in preschool children. 216 children (3–6 years old) were followed-up for two years. All dental surfaces were diagnosed by visual inspection and later, through radiographic assessment. Baseline treatment was made in accordance with the results obtained by visual inspection performed alone or combined with radiographic method, considering the allocated group. Dental surfaces with no restoration needs, or those restored at the beginning of the study were followed-up for two years. The treatment decision was made according to the allocated group. The outcome was the occurrence of failure (a new caries lesion or a restoration replacement) during the follow-up. Results 4383 proximal and occlusal surfaces of deciduous molars in 216 preschool children were diagnosed and treated according to the abovementioned diagnostic strategies and followed-up for 24 months. The assessment of radiographs made change the initial decision reached by visual inspection in about 30% of the surfaces when all types of interventions were considered. However, most disagreements occurred for initial lesions, where radiographs tended to underestimate them. Discordances between methods occurred in less than 5% of all surfaces when considered lesions requiring operative treatment. For discrepancy cases, the placed interventions guided by following the radiographic results did not present less failures against those made following only visual inspection. As a matter of fact, the use of radiographs in the diagnostic strategy for caries detection in children brought more harms than benefits due to the occurrence of false-positives, overdiagnosis and lead-time bias. Conclusions Simultaneous association of visual inspection and radiographic assessment for caries detection in preschool children causes more harms than benefits, and therefore, visual inspection should be conducted alone in the regular clinical practice. Trial registration Clinicaltrials.gov platform: NCT02078453, registered on 5th March 2014.
... Although the visual inspection is the most frequently used caries detection method [1][2][3], it has presented low sensitivity, especially on molars' proximal surfaces [3,4]. For this reason, many authors and clinical guidelines advise the dentists to take two bitewing radiographs combined with visual inspection [5][6][7][8][9][10]. ...
... With regard to the detection of proximal caries lesions, most authors have indicated the use of bitewings as an adjunct method for all patients at the beginning of the dental treatment, even when they are asymptomatic [1,[5][6][7][8][9][10]. This recommendation's main reason is that visual inspection performed alone usually overlooks many caries lesions [2,3]. ...
... Besides being a simple, safe, and inexpensive method, visual inspection alone seems to be the best diagnostic strategy to be used in all patients, mainly due to the low prevalence of non-evident cavitated caries lesions in young permanent teeth. Considering the findings from similar studies involving primary teeth [25,14,[20][21][22] and the results of this study, clinical guidelines that recommend the association of visual inspection and radiographic method for all patients at the beginning of the dental treatment, in order to detect proximal lesions in children and adolescents [5][6][7][8][9], should be reviewed. ...
Article
Full-text available
Objective To evaluate the performance of visual inspection alone and associated to radiographic and laser fluorescence (LF) methods in detecting non-evident caries lesions at adolescents’ proximal surfaces.Materials and methodsAdolescents (12 to 17 years old) were assessed for the presence of caries lesions through visual inspection, radiographic examination, and LF method (DIAGNOdent pen), at non-cavitated (NC) and cavitated lesion (CAV) thresholds. Temporary separation with orthodontic rubbers followed by direct visual inspection was the reference standard method. Two examiners conducted the examinations, and the first examiner reassessed around 20% of the sample, to evaluate inter- and intra-examiner reproducibility, respectively. Sensitivity, specificity, accuracy, and utility values were calculated for the methods alone and combined with visual inspection using two different strategies: simultaneous and sequential combination.ResultsA total of 834 proximal surfaces (51 adolescents) were included. Visual inspection presented higher reproducibility values (higher than 0.98). Moreover, visual inspection presented higher sensitivity (around 0.51) than those obtained with other diagnostic strategies (varying from 0.09 to 0.20) at the NC threshold. For CAV, visual inspection presented higher specificity (0.996) than the sequential association with adjunct methods (around 0.97), but with lower sensitivity. Accuracy and utility values for combined strategies were similar or lower than those achieved with the visual inspection performed alone.Conclusion Visual inspection alone performs better for detecting caries lesions in premolars and molars of adolescents than other diagnostic strategies.Clinical relevanceThe best diagnostic strategy for caries detection of proximal caries lesions in adolescents is the visual inspection alone.
... Early Childhood Caries risk is determined on the basis of caries experience and visible plaque level, according to the Caries Management System, 31 and, in addition, to free sugars exposure (Table 1). ...
... (b) plaque level-has this been reduced-yes or no? (c) incidence of new ECC lesions-yes or no? and (d) lesion behaviourdid existing lesions progress, remain static, regress-yes or no? Outcomes are entered on the risk assessment form at monitoring appointments for comparisons with earlier findings. At the same time, ongoing noninvasive treatment of early lesions and collaborative modification of risk factors is required.Monitoring frequency is risk specific: 3 monthly, 6 monthly and yearly, respectively, for high-, medium-, and low-risk children.31 Improved plaque control, lesion arrest rates and a reduction in new lesion incidence provide objective measures of ECC risk reduction.If, after 2 years, lesions have not progressed, they are presumed to have arrested, and, if no new lesions have appeared, the ECC risk status of such children should now be reclassified as defined in ...
Article
Full-text available
The global Early Childhood Caries (ECC) burden is of concern to the World Health Organisation (WHO), but the quantification of this burden and risk is unclear, partly due to difficulties in accessing young children for population surveys and partly due to diagnostic criteria for ECC experience. The WHO criterion for caries diagnosis is the late stage event of dentine cavitation. Earlier stages of the caries lesion are clinically detectable and should be registered earlier in the life of children and arrested/remineralized before lesions progress to the cavitation stage. A protocol for ECC diagnosis is proposed to guide those engaged in clinical dentistry in their characterization of the ECC lesion. As management of early lesions is a critical step to reduce risk of their progression to later stage lesions, a practical method for assessing ECC risk is proposed also. Risk assessment is very important because it determines (a) urgency for interventions aimed to arrest lesion progression; (b) the frequency of such interventions and (c) the need to enhance the primary prevention of ECC. The guidelines are set out separately for ECC diagnosis for ongoing clinical care and for epidemiologic purposes. Similarly, guidelines are set out for ECC risk assessment and ongoing monitoring.
... Unfortunately, there was no comparison with a control group not receiving a programme with tailored recall intervals. Evans and Dennison (2009) proposed a 10-step caries management system. Non-cavitated lesions are managed by home care measures to control plaque, principally by twice daily toothbrushing using fluoride toothpaste, thereby arresting lesion progression. ...
... Recall protocol for children and adolescents used byEvans and Dennison (2009) Caries risk Monitoring lesion activity and patient behaviour Low 12 months after first visit Note: Oral hygiene review and coaching at each visit At-risk… where evidence is: ICDAS II codes [1 3-monthly until lesion progression has arrested, i.e., evidence of (1) no extension of demineralisation or (2) that GIC sealant remains intact Note: Oral hygiene review and coaching at each visit At-risk… where evidence is: Bitewing radiographs [ C2* for primary teeth [ C3** for permanent teeth 3-monthly for (1) F varnish and (2) oral hygiene monitoring until lesion progression has arrested and patient is reclassified as low risk Note: Oral hygiene review and coaching at each visit At-risk… where only evidence is: Sites with Plaque Index = 3 One week following first visit to review and coach tooth brushing competence Then, 1 month later for same * C2 Caries within the inner half of enamel ** C3 Caries involving the enamel dental junction ...
Article
Full-text available
Aim: This was to collect information for the 9th European Academy of Paediatric Dentistry Interim Seminar and Workshops to discuss the state of art on non-invasive caries therapy to be used if possible to formulate clinical guidelines by European experts in paediatric dentistry METHODS: Based on systematic reviews and additional papers were assessed for methods to prevent caries initiation and caries progression both in the state of pre-cavitation and cavitation without invasive technologies. Results: The use of fluoridated water, careful diligent daily use of fluoride toothpaste, fluoride varnishes, pit and fissure sealants and leak-proof restorative materials without excavation of caries are evidence based for caries prevention and for non-invasive treatment of pre-cavitated and cavitated caries. Other technologies are far less evidenced based and would not logically fit in guidelines for the non-invasive treatment of caries. Recent studies on cavitated lesions in the primary dentition demonstrate that thorough oral hygiene practices may arrest progression. This strategy depends heavily on the strategies in the dental surgery to change behaviour of children. An important aspect is for advice to be tailored at recall intervals to ensure compliance and to timely detect unnecessary and unwanted progression of the lesions. Conclusion: Non-invasive therapies have been proven to be effective for caries prevention and the management of pre-cavitated caries lesions. Non-invasive therapies can also be effective to arrest cavitated lesions but the success depends greatly on behavioural changes of patients to brush the lesions.
... The CMS protocol is caries risk-specific. 20,21 Highrisk patients are those who currently have frank cavities, or are recall patients who develop two or more new lesions per year. Medium-risk patients have radiographic signs of caries lesions in the outer third of dentine, or are recall patients who develop one new lesion per year and low-risk patients have less advanced signs of caries lesions or none at all. ...
... The MPP was planned and implemented initially as a 3-year multicentre cluster-randomized controlled clinical trial designed to test the hypotheses that the CMS protocol, tested previously in a hospital setting, would reduce risk of dental caries experience in patients attending privately operated general dental practices. [20][21][22] The trial involved 22 dental practices across New South Wales and the Australian Capital Territory, half of which adopted the CMS treatment protocol while the other half continued their usual mode of care, as control practices. The dentists had volunteered to join the study following presentations at Australian Dental Association meetings. ...
Article
The restorative model of care, known colloquially as drilling and filling, has been challenged on the basis of its inappropriateness. The Caries Management System protocol was developed as an evidence‐based strategy for non‐surgical treatment of caries lesions and the Monitor Practice Program was designed to test the hypothesis that use of the protocol would reduce risk of dental caries experience. After 7 years, patients attending intervention practices, compared with those attending control practices, needed: 30‐50% fewer restorative interventions; 55% fewer first time restorative interventions; 32% fewer repeat restorative interventions; and were only 23% as likely to be classified as high risk. The outcome was cost‐effective and patients attending intervention practices highly valued non‐invasive care, and intervention dentists derived professional satisfaction from non‐surgical caries management. The implications of the program are that the general public will likely embrace the benefits of non‐invasive caries management, as will many current and future dental practitioners. This calls for dental practice reform including: the establishment of a clinical discipline in cariology; cariology curriculum development; revised accreditation regulations for cariology programs in dental schools; advanced training in clinical cariology leading to a specialty; support from the dental profession; and public health advocacy. This article is protected by copyright. All rights reserved.
... Most adolescents accessing NSW Public Oral Health Services are from disadvantaged groups including the working poor. These individuals would benefit greatly from preventive care and advice [10,12,21,31,32] from Therapists. ...
... The use of bitewing radiographs by Therapists as a diagnostic and caries management tool was clearly not a standard procedure. This is clearly insufficient as they provide relevant clinical information prior to the placement of fissure sealants and planning a preventive strategy [26,32,40]. Despite the evidence of the value of fissure sealants as a preventive treatment, most NSW LHDs with high restorative and dental extraction activities reported low fissure sealant placement activity. ...
Article
Full-text available
Dental Therapists and Oral Health Therapists (Therapists) working in the New South Wales (NSW) Public Oral Health Service are charged with providing clinical dental treatment including preventive care for all children under 18 years of age. Adolescents in particular are at risk of dental caries and periodontal disease which may be controlled through health education and clinical preventive interventions. However, there is a dearth of evidence about the type or the proportion of clinical time allocated to preventive care.The aim of this study is to record the proportion and type of preventive care and clinical treatment activities provided by Therapists to adolescents accessing the NSW Public Oral Health Service. Clinical dental activity data for adolescents was obtained from the NSW Health electronic Information System for Oral Health (ISOH) for the year 2011. Clinical activities of Therapists were examined in relation to the provision of different types of preventive care for adolescents by interrogating state-wide public oral health data stored on ISOH. Therapists were responsible for 79.7 percent of the preventive care and 83.0 percent of the restorative treatment offered to adolescents accessing Public Oral Health Services over the one year period. Preventive care provided by Therapists for adolescents varied across Local Health Districts ranging from 32.0 percent to 55.8 percent of their clinical activity. Therapists provided the majority of clinical care to adolescents accessing NSW Public Oral Health Services. The proportion of time spent undertaking prevention varied widely between Local Health Districts. The reasons for this variation require further investigation.
... The concept of a non-operative caries treatment and prevention (NOCTP) program has been the subject of several studies. Although results to the contrary have been found [Arrow, 2000], most studies investigating a form of NOCTP report good efficacy and effectiveness [Carvalho et al., 1992;Ekstrand et al., 2000;Ekstrand and Christiansen, 2005;Hausen et al., 2007;Evans and Dennison, 2009]. Most studies on caries prevention strategies with NOCTP are performed in high-risk populations, but also for populations with relatively low caries prevalence rates, it is important to identify the feasibility of these strategies and to determine which strategy is most effective in preventing caries. ...
Article
A parallel-randomized controlled trial on caries-preventive strategies was conducted in a general dental practice with a mixed socioeconomic background patient population. The aim of this study was to test the hypothesis that, compared to regular care consisting of check-ups twice a year with professional fluoride applications and pit and fissure sealants in all permanent molars, a larger caries-preventive effect can be achieved by following a non-operative caries treatment and prevention (NOCTP) strategy or by following, in addition to regular care, an increased number of professional topical fluoride applications (IPFA). A total of 230 children (6.0 years ± 3 months of age) were randomly assigned to the two experimental groups or the control group. After 3 years, 179 participants remained in the study (54 NOCTP, 62 IPFA and 63 control). The children were examined at baseline and at 3 years by the same experienced examiner, who was blinded for the allocation of the children. Caries was scored clinically at the D3 level. Per protocol analysis revealed a mean DMFS increment after 3 years of 0.15 (95% CI -0.05 to 0.35) for NOCTP, 0.34 (95% CI 0.11 to 0.54) for IPFA and 0.47 (95% CI 0.26 to 0.68) for the control group. To account for missing data, multiple imputation was used, after which the mean DMFS increment was 0.11 (95% CI -0.05 to 0.27) for NOCTP, 0.29 (95% CI 0.11 to 0.46) for IPFA and 0.40 (95% CI 0.21 to 0.55) for the control group. Testing the differences with independent samples t test revealed a lower caries increment in the NOCTP group compared to the control group. ANCOVA was used to correct for differences in baseline dmfs, socioeconomic status and perceived dental hygiene burden. The ΔDMFS effect size between the NOCTP and the control group dropped, losing statistical significance (p = 0.06). Although the results in this study are promising, it has yet to be established in a larger study whether NOCTP has the ability to be effective in regular dental practice with a mixed socioeconomic status population. © 2014 S. Karger AG, Basel.
... My patient S.W had extracted tooth # B due to caries one year ago which shows that he had early childhood caries. According to the article "The Caries Management System" by Evans R, the main determinants of ECC are oral hygiene status, night feeding with sweetened beverage, bacterial infection, enamel defects, tooth morphology and unfavorable exposure to potential caries risk factors namely plaque and frequency of sucrose intake (4). For this patient the reason of tooth # B getting carious to an extent that had led to extraction was night feeding with sweetened beverage and lack of toothbrushing prior to two years old that exposed him to one of the potential caries risk factors for ECC such as plaque. ...
... The CMS comprises a set of protocols (covering risk assessment, diagnosis, risk management, monitoring, and recall) that bring together evidencebased caries preventive methods in a systematic framework (7,8). It specifies how they should be delivered to patients who are at different levels of caries risk. ...
Conference Paper
Full-text available
Objective: The Monitor Practice Program (MPP) is a multicentre clustered randomised controlled trial of preventive intervention according to the Caries Management System (CMS). The CMS is a risk-specific non-surgical intervention designed to arrest and remineralise non-cavitated carious lesions and prevent new incident lesions. At three years, the mean DMFS increment was 34% less among patients attending intervention practices compared with those attending control practices (p<0.001). The aim was to determine whether the outcome achieved at three years would be sustained. This presentation reports on outcomes at five and seven years. Method: Following publicity about the MPP, 22 dental practices were recruited and randomly assigned to the control group where patients received usual care or the intervention group. During the first three years, investigators established frequent contacts with practices to monitor diagnostic standards at all practices and to facilitate the implementation of the CMS protocols at the intervention practices. Contacts with practices during years 4-7 were much less frequent. Result: The distribution of DMFS increment at seven years ranged from a mean of 9.1–21.5 in control practices and 7.6-45.8 in intervention practices. Excluding two intervention practices at which the protocols were not followed (PNF), the intervention mean DMFS ranged from 7.6-11.4. At five years since baseline, the control and intervention mean DMFS increments were 10.4 and 8.7 respectively (p=0.19) as per intention to treat (ITT) principle. By excluding data from the two PNF practices, the respective control and intervention mean DMFS increments were 10.4 and 6.2 (p=0.009). At seven years since baseline, the control and intervention mean DMFS increments were 15.7 and 13.0 respectively (p=0.09) as per ITT but exclusion of the two PNF practices gave respective control and intervention mean DMFS increments of 15.7 and 9.1 (p=0.008). Conclusion: Decreased caries risk at three years was sustained at seven years.
... Children who began brushing teeth at 18 months or less were seen to have lower caries prevalence but higher fluorosis especially for the 1000 ppm F than 400-550 ppm F toothpaste. [3] Hence, lowfluoride toothpastes were developed for small children who were at a risk of developing fluorosed teeth. [4,5] The low fluoride toothpaste (400-550 ppm F) was not statistically different with standard fluoride toothpaste (1055 ppm F) for caries prevention [6,7] and did not significantly decrease the risk of fluorosis in the permanent maxillary incisor. [8] Hence, there was an interest in other remineralizing agents including calcium phosphate-based remineralization system. ...
Article
Full-text available
Objectives Fluoride toothpaste has been extensively used to prevent dental caries. However, the risk of fluorosis is concerning, especially in young children. Calcium phosphate has been an effective remineralizing agent and is present in commercial dental products, with no risk of fluorosis to users. This in vitro study aimed to compare the effects of different calcium phosphate compounds and fluoride-containing dentifrices on artificial caries in primary teeth. Materials and Methods Fifty sound primary incisors were coated with nail varnish, leaving two 1 mm² windows on the labial surface before immersion in demineralizing solution for 96 hours to produce artificial enamel lesions. Subsequently, one window from each tooth was coated with nail varnish, and all 50 teeth were divided into five groups (n = 10); group A – deionized water; group B – casein phosphopeptide–amorphous calcium phosphate (CPP–ACP) paste (Tooth Mousse); group C – 500 ppm F (Colgate Spiderman®); group D – nonfluoridated toothpaste with triple calcium phosphate (Pureen®); and group E – tricalcium phosphate (TCP). Polarized light microscopy and Image-Pro® Plus software were used to evaluate lesions. Results After a 7-day pH-cycle, mean lesion depths in groups A, B, C, D, and E had increased by 57.52 ± 10.66%, 33.28 ± 10.16%, 17.04 ± 4.76%, 32.51 ± 8.99%, and 21.76 ± 8.15%, respectively. All data were processed by the Statistical Package for the Social Sciences (version 16.0) software package. Comparison of percentage changes using one-way analysis of variance and Fisher's least squares difference tests at a 95% level of confidence demonstrated that group A was significantly different from the other groups (P < 0.001). Lesions in groups B and D had a significant lesion progression when compared with groups C and E. Conclusions All toothpastes in this study had the potential to delay the demineralization progression of artificial enamel caries in primary teeth. The fluoride 500 ppm and TCP toothpastes were equal in the deceleration of enamel caries progression and better than CPP–ACP paste and TCP toothpaste.
... Researchers [22][23][24][25][26][27][28][29][30] These recommendations have been integrated into the NSW Ministry of Health policy for providing preventive care to children under 18 years targeting those most at risk of dental disease [31][32][33]. The Information System for Oral Health (ISOH: Information System for Oral Health: a NSW State-wide Public Oral Health Service centralised repository for patient data information) is used to determine what activity is conducted across the state by clinician's to align with the policy as identi-fied by dental treatment item numbers based on the Australian national dental schedule [34]. ...
Article
Full-text available
Background: Many adolescents are at risk of dental caries and periodontal disease due to poor tooth brushing and dietary behavior. However, these oral health problems can be moderated by providing individuals with preventive care and advice. In New South Wales (NSW) Dental Therapists and Oral Health Therapists (Therapists) working in the public health system can help this vulnerable group by providing free dental care including advice on preventing dental caries and periodontal disease. The aim of this study was to identify factors that influence Therapists in the provision of preventive care to adolescents .
... Our patient was advised to use a high fluoride containing toothpaste (5000 ppm), as per previously published guidelines. 16 Use of CCP-ACP remineralization products was also encouraged, in keeping with previously published recommendations. 3 The symptomatic management of mouth dryness included advice pertaining to the use of sugar-free chewing gum, oral lubricants and maintenance of adequate hydration. ...
Article
Salivary gland aplasia is a rare condition with only a small number of cases reported worldwide. It is more commonly seen in males and can occur either in isolation or association with other defects or syndromes. It may or may not occur with a hereditary background. Scant literature exists detailing the status of sublingual salivary glands in patients with any form of major salivary gland aplasia. This case report describes the clinical and magnetic resonance imaging presentation of a 16-year-old girl with major salivary gland aplasia detailing the status of all six major salivary glands.
... Caries arrest treatment with fluorides in various vehicles (toothpaste, gel, varnish, soluation, mouthrinse) has been shown to be a viable alternative to the traditional restorative approach. Studies showed that daily toothbrushing using fluoridated toothpaste (1000 ppm F) could arrest non-cavitated lesions [8] as well as dentin caries lesions [9]. Toothpaste containing higher fluoride concentration, e.g. ...
Article
Full-text available
Background: Untreated dentin caries in primary teeth is commonly found in preschool children worldwide. Recently, the use of simple non-surgical approaches to manage the situation has been advocated. The aim of the study was to systematically review and evaluate the literature on effectiveness of non-surgical methods in arresting or slowing down the progression of active dentin caries in primary teeth in preschool children. Methods: A systematic search of the main electronic databases (Pubmed, Cochrane Collaboration, EMBASE) was conducted to identify peer reviewed papers published in English in the years 1947-2014. Keywords and MeSH terms used in the search were "dental caries", "primary dentition" and various non-surgical treatments (fluoride, sealant, resin infiltration, xylitol, chlorhexidine, CPP-ACP, ozone, etc.). The inclusion criteria were clinical studies conducted in children under 6 years old, and reported findings on caries arrest or caries progression in primary teeth. Retrieved papers were read by two reviewers independently to assess suitability for inclusion, and the final decision was made by consensus. Quality of the included studies was assessed and data were extracted for analysis. Results: The search identified 323 papers for screening. Among these, 290 papers did not satisfy the study inclusion criteria. Consequently, 33 full papers were retrieved and reviewed. Finally, 4 studies were included. Three studies reported that topical applications of silver diammine fluoride (SDF) solution could arrest dentin caries in preschool children. One study supported that having a daily toothbrushing exercise in kindergarten using toothpaste with 1000 ppm fluoride could stabilize the caries situation in young children. Conclusions: There is limited evidence to support the effectiveness of SDF applications or daily toothbrushing with fluoride toothpaste in arresting or slowing down the progression of active dentin caries in primary teeth in preschool children. More well-designed randomized controlled trials are required to confirm these findings.
... The concept of a non-operative caries treatment and prevention (NOCTP) program has been the subject of several studies. Although results to the contrary have been found [Arrow, 2000], most studies investigating a form of NOCTP report good efficacy and effectiveness [Carvalho et al., 1992;Ekstrand et al., 2000;Ekstrand and Christiansen, 2005;Hausen et al., 2007;Evans and Dennison, 2009]. Most studies on caries prevention strategies with NOCTP are performed in high-risk populations, but also for populations with relatively low caries prevalence rates, it is important to identify the feasibility of these strategies and to determine which strategy is most effective in preventing caries. ...
Article
Een gerandomiseerd gecontroleerd onderzoek naar cariespreventieve strategieen werd uitgevoerd in een grote tandheelkundige praktijk met een patientenpopulatie van gemengde sociaaleconomische status. Een groep kinderen die een ‘non-operative caries treatment program’ (NOCTP) volgde, werd vergeleken met een controlegroep en een groep die in aanvulling op het controleregime (2 keer per jaar periodieke gebitscontrole met professionele fluorideapplicatie en het routinematig sealen van eerste blijvende molaren) nog 2 professionele fluorideapplicaties kregen (IPFA). In totaal werden 230 kinderen van 6,0 jaar oud willekeurig aan een van deze groepen toegewezen. Na 3 jaar werden 179 kinderen opnieuw onderzocht (54 NOCTP, 62 IPFA en 63 controlegroep). In de NOCTP groep werd een DMFS-toename van 0,15 gevonden. In de IPFA-groep en controlegroep was dit respectievelijk 0,34 en 0,47. Hoewel de resultaten in dit onderzoek zeer bemoedigend zijn, moet vervolgonderzoek op grotere schaal uitwijzen of het toepassen van NOCTP effectiever is dan reguliere preventie in de algemene praktijk.
... For example, Evans and Dennison's caries management system (CMS) provides a clinical protocol that presents an evidence-based preventive strategy for children and adolescents. 15 A specific odontogram, using the International Caries Detection and Assessment System (ICDAS) coding, illustrates ten clear steps for clinical actions. 13 Considering CMSs are scientific-based concepts that graduates bring with them into public oral health settings, it is a matter of some concern that NSW Health LHDs have not tested the CMS protocol in the public oral health arena. ...
Article
Full-text available
Many adolescents are at risk of dental caries and periodontal disease, which may be controlled through health education and clinical preventive interventions provided by oral health and dental therapists (therapists). Senior clinicians (SCs) can influence the focus of dental care in the New South Wales (NSW) Public Oral Health Services as their role is to provide clinical support and advice to therapists, advocate for their communities, and inform Local Health District (LHD) managers of areas for clinical quality improvement. The objective of this study was to record facilitating factors and strategies that are used by SCs to encourage therapists to provide preventive care and advice to adolescent patients. In-depth, semistructured interviews were undertaken with 16 SCs from all of the 15 NSW LHDs (nine rural and six metropolitan). A framework matrix was used to systematically code data and enable key themes to be identified for analysis. All SCs from the 15 NSW Health LHDs participated in the study. Factors influencing SCs' ability to integrate preventive care into clinical practice were: 1) clinical leadership and administrative support, 2) professional support network, 3) clinical and educational resources, 4) the clinician's patient management aptitude, and 5) clinical governance processes. Clinical quality improvement and continuing professional development strategies equipped clinicians to manage and enhance adolescents' confidence toward self-care. This study shows that SCs have a clear understanding of strategies to enhance the therapist's offer of scientific-based preventive care to adolescents. The problem they face is that currently, success is measured in terms of relief of pain activities, restorations placed, and extraction of teeth, which is an outdated concept. However, to improve clinical models of care will require the overarching administrative authority, NSW Health, to accept that the scientific evidence relating to dental care has changed and that management monitoring information should be incorporated into NSW Health reforms.
... Despite long-standing consensus supporting minimal intervention and non-operative preventives for caries management in dental practice [1], a preventionoriented strategy is far from reaching universal adoption: for example, many dentists favor restoration placement over non-operative therapy for enamel-confined lesions [2][3][4]. In contrast to traditional reliance on surgical means, a risk-based approach to the clinical management of dental caries stresses individualized treatment decisions based on patients' behavioral and biological characteristics, with an emphasis on caries prevention and preservation of tooth structure [5][6][7][8][9]. ...
Article
Full-text available
Consensus guidelines support non-operative preventives for dental caries management; yet, their use in practice is far from universal. The purpose of this study was to evaluate the effectiveness of non-operative anti-caries agents in caries prevention among high caries risk adults at a university clinic where risk-based caries management is emphasized. This retrospective observational study drew data from the electronic patient records of non-edentulous adult patients deemed to be at high risk for dental caries during baseline oral evaluations that were completed between July 1, 2007 and December 31, 2012 at a dental university in the United States. We calculated and compared adjusted mean estimates for the number of new decayed or restored teeth (DFT increment) from baseline to the next completed oral evaluation (N = 2,724 patients with follow-up) across three categories of delivery of non-operative anti-caries agents (e.g., high-concentration fluoride toothpaste, chlorhexidine rinse, xylitol products): never, at a single appointment, or at ≥2 appointments ≥4 weeks apart. Estimates were adjusted for patient and provider characteristics, baseline dental status, losses-to-follow-up, and follow-up time. Approximately half the patients did not receive any form of non-operative anti-caries agent. Most that received anti-caries agents were given more than one type of product in combination. One-time delivery of anti-caries agents was associated with a similar DFT increment as receiving no such therapy (difference in increment: -0.04; 95 % CI: -0.28, 0.21). However, repeated, spaced delivery of anti-caries agents was associated with approximately one decayed or restored tooth prevented over 18 months for every three patients treated (difference in increment: -0.35; 95 % CI: -0.65, -0.08). These results lend evidence that repeatedly receiving anti-caries agents can reduce tooth decay among high-risk patients engaged in regular dental care.
... An alternative strategy, implementing the concept of non-operative caries treatment and prevention (NOCTP), based on parental homecare, has been the subject of several studies. Although results to the contrary have been found (Arrow, 2000), most studies investigating delivering individualized preventive care report good efficacy and effectiveness (Carvalho et al., 1992;Ekstrand et al., 2000;Ekstrand & Christiansen, 2005;Evans & Dennison, 2009). ...
... The CMS comprises a set of protocols (covering risk assessment, diagnosis, risk management, monitoring, and recall) that bring together evidencebased caries preventive methods in a systematic framework (7,8). It specifies how they should be delivered to patients who are at different levels of caries risk. ...
Article
Full-text available
Objectives: To report, at two and 4 years post-trial, on the potential legacy of a 3-year randomized controlled clinical trial (RCT) of the Caries Management System (CMS) at private general dental practices. The CMS was designed to reduce caries risk and need for restorative care. Methods: Nineteen dental practices located in city, urban, and rural locations in both fluoridated and nonfluoridated communities participated in the RCT. Eight practices were lost to follow-up post-trial; however, baseline mean DMFT balance between CMS and control practices was maintained. At the control practices, caries management following usual practice continued to be delivered. The patient outcome measure was the cumulative increment in the DMFT index score, and the practice outcome measures included the practice-mean and practice-median increments of patient DMFT index scores. In covariable analysis (patient-level unit of analysis), as the patients were clustered by practices, mean DMFT increments were determined through multilevel modeling analysis. Practice-mean DMFT increments (practice-level unit of analysis) and practice-median DMFT increments (also practice level) were determined through general linear modeling analysis of covariance. In addition, a multiple variable logistic regression analysis of caries risk status was conducted. Results: The overall 4-year post-trial result (years 4-7) for CMS patients was a DMFT increment of 2.44 compared with 3.39 for control patients (P < 0.01), a difference equivalent to 28%. From the clinical trial baseline to the end of the post-trial follow-up period, the CMS and control increments were 6.13 and 8.66, respectively, a difference of 29% (P < 0.0001). Over the post-trial period, the CMS and control practice-mean DMFT increments were 2.16 and 3.10 (P = 0.055) and the respective increments from baseline to year 7 were 4.38 and 6.55 (P = 0.029), difference of 33%. The practice-median DMFT increments during the 4-year post-trial period for CMS and control practices were 1.25 and 2.36 (P = 0.039), and the respective increments during the period from baseline to year 7 were 2.87 and 5.36 (P < 0.01), difference of 47%. Minimally elevated odds of being high risk were associated with baseline DMFT (OR = 1.17). Patients attending the CMS practices had lower odds of being high risk than those attending control practices (OR = 0.23, 95% CI = 0.06, 0.88). Conclusion: In practices where adherence to the CMS protocols was maintained during the 4-year post-trial follow-up period, patients continued to benefit from a reduced risk of caries and, therefore, experienced lower needs for restorative treatment.
... In July 2011, Dental Health Services Victoria (DHSV), in consultation with the Head of the Department of Dentistry at the Royal Children's Hospital, developed a CRA tool (adapted from the work undertaken by Featherstone et al. 36 and Evans et al. 37,38 ) that is considered to be simple, accurate and costeffective (See Appendices A and B). However, at this stage this CRA has not been validated. ...
Article
Public dental patients suffer from poorer oral health than the general population. Management of dental caries tends to focus on surgical interventions, such as restorations and extractions, rather than prevention and early intervention of the disease process. The current public dental system struggles to address the lifestyle and broader health issues affecting oral health and although an immediate dental problem can usually be alleviated, it can often be through the unnecessary removal of tooth structure, which invariably leads to other health and quality of life problems. There is widespread recognition by oral health clinicians that the restorative approach to the management of dental caries in the public sector is failing to improve oral health outcomes for many public patients. Oral health experts have recently adopted a national consensus statement on minimum intervention dentistry indicating their intention to work together to develop ways to implement this approach across the public dental sector. It is clear that, despite some significant challenges and required changes, the momentum for minimum intervention dentistry continues to grow across Australia. There is an urgent need to undertake research to assess the cost-effectiveness of this approach in the public sector.
... Dental sealants were introduced in the 1960s as part of the preventive dental programs. Sealing is a method widely described in literature as a simple, safe and effective clinical procedure in terms of cost / benefit and, therefore, it is highly recommended [1] [2] ]3] [4] [5]. The longevity of sealant coverage [i.e. ...
Article
Full-text available
The effectiveness of sealants in preventing pits and fissures decay is currently assessed by retention as principal clinical evaluation criteria. Among the determinants for sealant retention, an incomplete removal of plaque debris can cause lack of adhesion at the sealant-enamel interface. Therefore, in order to optimize the caries prevention outcome, clinical procedures of biofilm detection and cleansing are crucial. Technological aids can help clinicians in these critical phases. A clinical procedure is described of sealant application using VistaCam iX Proof fluorescence camera for quantitative assessment of surface demineralization and Combi air polishing unit for plaque removal. Pre and post air polishing intraoral VistaCam iX Proof images show the effectiveness of glycine airpolish technology in plaque removal. The results encourage technological aided clinical procedures in enhancing sealant application for pit and fissures caries prevention. Further clinical research is needed to validate our preliminary outcomes.
... The depth of initial carious lesion was based on the examination of the pre-operative digital radiographic images utilizing the "Caries Management System." (Evans & Dennison, 2009;Gugnani et al., 2011) Radiographs were standardized for image capture and analysis using a Satelex X-Mind DC unit (with short cone), 70 kVp,8 mA, film speed "D" used with Scan-X phosphor plate digital imaging system at an exposure of 0.125 s. ...
Article
Full-text available
Objectives The aim of this retrospective study was to evaluate the outcome of preformed metallic crowns (PMC) utilizing the HT in carious primary molars for children treated within public dental clinics across the Sydney region. Materials and Methods A retrospective cohort study was designed, whereby two investigators evaluated 113 primary molars treated with HT PMCs involving 71 participants (aged between 5 and 11 years) after a minimum of 6 months post treatment. The mean time elapsed between crown placement (treatment) and the review was 1.42 years (17 months). The outcome of the HT was assessed by clinical and radiographic criteria. Results One hundred thirteen HT PMCs were reviewed from 71 participants. The overall success rate of PMCs placed utilizing the HT was 99%, with only one case presenting with confirmed failure. Conclusions HT PMCs have an overall high success rate as a treatment option in carious primary molars.
... For over 50 years it has been recommended to use products based on fluorine and toothpaste represents by far the most common one [9,10], able to provide higher concentrations of fluorine compared to drinking water. Despite being one of the most effective strategies which led to a drop in caries in industrialized countries [11], it must be taken into account that water fluorination, fluorine supplements in our diet, the use of toothpastes and topical application of fluorine may result in a potential risk of developing dental fluorosis [12]. At an early age, children do not possess full control of the swallowing process and involuntarily ingest toothpaste during the daily oral hygiene practice, resulting in a systematic accumulation of fluorine [13,14]. ...
Article
Full-text available
Background Dental caries is a recognized worldwide public health problem. Despite being one of the most effective strategies against dental caries, the excessive use of fluorine may result in a potential risk of developing dental fluorosis especially in children under age of six. The purpose of this work is to analyze a fluorine-free toothpaste containing Biomimetic Hydroxyapatite to assess enamel re-mineralizing and repairing properties. Results The study was performed in vitro and in vivo, comparing the hydroxyapatite toothpaste with two others toothpaste containing different fluorine concentrations. The coating effect of the micro-structured Hydroxyapatite nanoparticles reintegrates the enamel with a biomimetic film reproducing the structure and the morphology of the biologic Hydroxyapatite of the enamel. As demonstrated, the coating is due to the deposit of a new layer of apatite, which presents fewer particles than the natural enamel, not based on the chemical—physical changes occurring in fluorinated toothpastes. Moreover, it shows resistance to brushing as a consequence of chemical bonds between the synthetic and natural crystals of the enamel. Conclusions The use of Biomimetic Hydroxyapatite toothpastes has proven to be a valuable prevention measure against dental caries in primary dentition since it prevents the risk of fluorosis.
... Dental fillings or restorations are used as a therapeutic option for the management of childhood caries. (23) Considering the high prevalence of carious lesions among children in most countries, noninvasive interventions have been adopted as a new approach. (24)(25)(26)(27) The minimally invasive approaches can arrest caries progression with the aid of therapeutic agents that promote remineralization. ...
Article
Full-text available
Background and aim: Dental caries is one of the most common childhood diseases worldwide. The implementation of strategies that facilitate the prevention of early dental caries and interrupt its progression has been recently advocated. It has been reported that casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) derived from casein reduces tooth demineralization and enhances the remineralization process. The aim of this in-vitro study was to assess the efficacy of two types of CPP-ACP paste in calcium uptake by enamel surfaces. Materials and methods: Forty premolars were longitudinally dissected into experimental and control halves, and were coated with nail varnish, except for an enamel window of 4×4 mm. The samples were subjected to cycling in a demineralizing solution and were divided into two groups of GC Tooth Mousse CPP-ACP paste and Misswake CPP-ACP paste. The calcium contents of each half were examined using the acid etch enamel biopsy technique and were measured by atomic absorption. The values were statistically analyzed using Kolmogorov-Smirnov test and one-way analysis of variance (ANOVA). Results: The enamel surfaces treated with the pastes exhibited higher calcium contents compared to the controls. There was a significant difference between GC Tooth Mousse CPP-ACP paste and Misswake CPP-ACP paste in terms of calcium uptake; a higher calcium uptake was witnessed with GC Tooth Mousse CPP-ACP paste than with Misswake CPP-ACP paste (P
... Many respondents believed risk factors needed to be considered when deciding on the management of a lesion (see Table 4). Although on average, lesion progression from enamel to dentine tends to be slow, an assessment of caries risk is necessary at the outset of dental care and such care needs to follow a risk-specific protocol to arrest and remineralise non-cavitated lesions [30][31][32][33]. This survey suggests that although caries risk assessment is taught and considered in the decision-making of caries lesion management, most Australasian programs are teaching students to restore lesions in the outer third of dentine. ...
Article
Full-text available
Background: The Australian and New Zealand chapter of the Alliance for a Cavity Free Future was launched in 2013 and one of its primary aims was to conduct a survey of the local learning and teaching of cariology in dentistry and oral health therapy programs. Methods: A questionnaire was developed using the framework of the European Organisation for Caries Research (ORCA)/Association of Dental Education in Europe (ADEE) cariology survey conducted in Europe in 2009. The questionnaire was comprised of multiple choice and open-ended questions exploring many aspects of the cariology teaching. The survey was distributed to the cariology curriculum coordinator of each of the 21 programs across Australia and New Zealand via Survey Monkey in January 2015. Simple analysis of results was carried out with frequencies and average numbers of hours collated and open-ended responses collected and compiled into tables. Results: Seventeen responses from a total of 21 programs had been received including 7 Dentistry and 10 Oral Health programs. Key findings from the survey were - one quarter of respondents indicated that cariology was identified as a specific discipline with their course and 41% had a cariology curriculum in written format. With regard to lesion detection and caries diagnosis, all of the program coordinators who responded indicated that visual/tactile methods and radiographic interpretation were recommended with ICDAS also being used by over half them. Despite all respondents teaching early caries lesion management centred on prevention and remineralisation, many taught operative intervention at an earlier stage of lesion depth than current evidence supports. Findings showed over 40% of respondents still teach operative intervention for lesions confined to enamel. Conclusion: Despite modern theoretical concepts of cariology being taught in Australia and New Zealand, they do not appear to be fully translated into clinical teaching at the present time.
... Uma limitação desse estudo é que após a sua conclusão, outros protocolos baseados em risco de cárie para o manejo da CPI foram publicados (24,25,26,27). Nesse sentido, fica a sugestão de estudos futuros de avaliação dos novos protocolos publicados com a mesma metodologia e instrumento AGREE (19), para quem sabe, propor um protocolo adequado e atualizado para equipes de saúde bucal (28). ...
... The fluoride dentifrice used in the study had a low content of fluoride (500 ppm), which was dictated by the local FDA regulations of the country where the study was undertaken. Using dentifrices with a low fluoride content has been suggested as a means of reducing the risk of developing fluorosis (Evans and Dennison 2009). While it was originally believed that the effectiveness of 500 ppm fluoride dentifrices was not greatly less than that of dentifrices with 1000 ppm fluoride (Winter et al. 1989;Holt 1995), more Table 1 Baseline characteristics of study subjects a Data show frequency and percentages of the total, at baseline, for those using the fluoride dentifrice alone, the CPP-ACP topical crème alone, or the combination of both measures b Data for caries show the mean and SD for ICDAS scores. ...
Article
Purpose To compare the effects of a fluoride dentifrice alone, versus a topical CPP–ACP crème used as a dentifrice, versus the combination of both agents (fluoride dentifrice followed by CPP–ACP crème) on early caries lesions (ECL) in primary anterior teeth of children over a 6-month period. Methods In this single blinded randomised clinical trial, children (n = 114, aged 4–5 years) with high caries risk and who had at least one ECL (ICDAS 2) on their primary anterior teeth were allocated to three groups. Subjects used different agents twice daily: fluoride dentifrice (500 ppm F, n = 42), CPP–ACP crème (10% w/v, n = 35), and the fluoride dentifrice followed by CPP–ACP crème (n = 37). Changes in lesions were tracked using QLF, comparing the baseline situation to 3 and 6 months of treatment. Results QLF changes consistent with mineral gain (∆F/fluorescence, lesion area) occurred in all three groups (baseline versus 3 months or 6 months, p ≤ 0.05 for all three groups). Differences between treatment groups were not statistically significant (p > 0.05). Conclusion The topical CPP–ACP crème used alone gave effects similar to the fluoride dentifrice; however, the combination of the two did not give additive benefits over either agent used in isolation.
... Sitthisettapong et al (2012) found more than half of children in their study brushed their teeth unsupervised. A low-fluoride dentifrice has been created for young children to reduce the risk of fluorosis (Evans and Dennison, 2009). Studies have found the benefit of using fluoride dentifrice for caries prevention among children and adolescents compared to placebo, but the con-centration of fluoride should be 1,000 parts per million (ppm) or higher (Walsh et al, 2010). ...
Article
Full-text available
Fluoride dentifrice is effective in preventive dental caries but may cause fluorosis, especially in young children. Reducing the concentration of fluoride from the regular concentration of 1,000 parts per million (ppm) to 500 ppm can reduce the risk for fluorosis but increases the risk of caries. Adding tricalcium phosphate (TCP) to the dentifrices may improve the efficacy of remineralization possibly allowing for a lower concentration of fluoride to reduce the risk of fluorosis. We studied this to inform future caries prevention efforts in children. We immersed 40 sound primary incisors into demineralizing solution (pH=4.4) for 96 hours at 37°C to create demineralized lesions. The 40 teeth were then divided into 4 groups of 10 teeth each. Group A: control (treated with deionized water only); Group B: treated with fluoride dentifrice at a concentration of 1,000 ppm; Group C: treated with fluoride dentifrice at a concentration of 500 ppm and 500 ppm TCP, and Group D: treated with fluoride dentifrice at a concentration of 1,000 ppm and 500 ppm TCP. The teeth were each subjected to 7 days of pH-cycling and the studied dentifrice was applied for one minute, 3 times daily during the 7 day period. After the 7 day period the teeth were each sectioned and examined with polarized light microscopy. The depths of demineralized areas were measured using Image-Pro plus software. A pair t-test was used to compare lesion depths before and after dentifrice treatment. Differences in mean lesion depths within each group were analyzed using the One-way ANOVA and LSD tests; a 95% confidence intervals were calculated. The mean lesion depths in all the groups before dentifrice treatment were not significantly different (p=0.143). The mean demineralized lesion depths after dentifrice treatment were significantly different by group (p=0.00). The mean demineralized lesion depth in Group A significantly deeper than the other groups (p=0.00). Group D had the shallowest depth, significantly shallower than the other groups (p=0.006). There was no significant difference in the mean demineralized lesion depth between Groups B and C (p=0.478). The mean demineralized lesion depth changed significantly after dentifrice treatment in all the groups (p=0.00). Group A was significantly deeper (p=0.00) and groups B, C and D were all significantly shallow. Group D had the greatest reduction in mean demineralized lesion depth (p<0.05). The 1,000 ppm fluoride plus TCP dentifrice gave superior remineralization than the 500 ppm fluoride plus TCP and the 1,000 ppm fluoride dentifrice. The 500 ppm fluoride plus TCP gave the same remineralizing effect as the 1,000 ppm fluoride dentifrice. TCP enhances remineralization on primary enamel when added to fluoride dentifrice. Our results show if TCP is added to fluoride dentifrice a lower concentration of fluoride is needed to provide the same benefit as fluoride dentifrice with a higher concentration of fluoride, reducing the risk of fluorosis in children.
... 6,7 Protocols on non-invasive strategies for caries control and risk assessment are designed to orient clinical care away from surgical approaches. [8][9][10] More recently, new calls for better directions in caries management have been led by the International Dental Federation. 11 In Pennsylvania, USA, cariologists, dentists and other stakeholders from several countries discussed the new direction for caries management. ...
Article
The objective of this review was to investigate rates of caries lesion progression, arrest, and regression in approximal surfaces of deciduous teeth following secondary preventive interventions in order to inform caries management protocols. Studies published in English and other languages from 1960 till February 2017 were searched in electronic databases. Inclusion criteria were: randomized controlled clinical trials and longitudinal studies that involved non‐invasive preventive treatment. We excluded: in‐vivo studies and incidence studies. 805 potential articles were located, of 38 full text reviews, 10 were included. Two types of studies were found; those reporting the mean percentage of lesion progression as progression estimate and those reporting the survival rate of lesions presented as the mean or median survival time in months as survival estimate. Weak evidence suggests it would appear that the most effective secondary preventive intervention was one involving a combination of silver fluoride and stannous fluoride, but this has not been substantiated. To inform treatment protocols better, it is recommended (i) that new well‐designed RCTs are conducted to test the effectiveness of different forms of fluoride to arrest lesion progression in deciduous teeth, and (ii) to continue on‐going research into the caries preventive effects of approximal surface sealants. This article is protected by copyright. All rights reserved.
... Due to these properties of remineralization and desensitization, HA NPs could be an interesting alternative to fluoride toothpaste, which is recommended to prevent caries [256]. Its use led to a decrease in caries in industrialized countries [257], but the daily use of fluoride toothpaste is a potential source of fluorosis [258]. Moreover, Tschoope and colleagues compared fluoride toothpaste and HAP NP toothpaste, and demonstrated, in vitro, that the HAP NP toothpaste displayed higher remineralizing effects on both hard tissues than fluoride toothpaste [259]. ...
Article
Full-text available
Many investigations have pointed out widespread use of medical nanosystems in various domains of dentistry such as prevention, prognosis, care, tissue regeneration, and restoration. The progress of oral medicine nanosystems for individual prophylaxis is significant for ensuring bacterial symbiosis and high-quality oral health. Nanomaterials in oral cosmetics are used in toothpaste and other mouthwash to improve oral healthcare performance. These processes cover nanoparticles and nanoparticle-based materials, especially domains of application related to biofilm management in cariology and periodontology. Likewise, nanoparticles have been integrated in diverse cosmetic produces for the care of enamel remineralization and dental hypersensitivity. This review summarizes the indications and applications of several widely employed nanoparticles in oral cosmetics, and describes the potential clinical implementation of nanoparticles as anti-microbial, anti-inflammatory, and remineralizing agents in the prevention of dental caries, hypersensitivity, and periodontitis.
... It appears to be more convenient for the providers from APF gels on facial or lingual surfaces [50]. A ten-step non-invasive strategy protocol was proposed and adopted for adults [45]. ...
... The thinner enamel and high pulp horns of primary teeth is associated with increased risk of caries progression into dentine, and risk of pulp exposure during operative intervention (Table 1). 2 History, Examination, and Special Tests (radiographs) are key elements in establishing an accurate diagnosis. In this regard, the clinician must question the child and his/her parents/carers re symptoms related to the carious tooth. ...
Article
Various methods, with a variety of materials, exist for restoring carious primary teeth. Successful restoration of primary teeth is dependent on accurate diagnosis, knowledge of the caries process, knowledge of dental materials, and treatment choice. The purpose of this evidence‐based review is to present evidence that will help clinicians to make an appropriate diagnosis, from which the optimum treatment plan can be made; to explore the literature regarding restoration of carious primary teeth; and to try and draw conclusions as to which materials and methods can be recommended. This review will primarily deal with the restoration of carious cavities in primary molars. A short discussion on restoration of primary incisors is included, with presentation of what limited evidence there is relating to this.
... Then, dental radiographs were taken and interpreted. In dental radiographs, an early demineralized lesion was defined as a radiolucent lesion within the enamel (C1) because dental caries is recognized as a radiolucency in a radiograph in daily clinical practice when the lesion becomes C1 or severer [10]. ...
... In two descriptive studies, the proponents of the CMS have described it as a structured evidence-based noninvasive strategy to manage caries risk by arresting and remineralizing non-cavitated lesions. 9,25 They have considered that the patient at risk, the status of each lesion, patient management, clinical management and monitoring are central for caries management in the 10-step strategy of the CMS. After reviewing risk factors for caries such as sugar consumption, fluoride use and dental plaque by means of taking a detailed history, a thorough clinical examination is performed to detect enamel cracks and incipient caries. ...
Article
Objective To identify and map the caries risk management protocols with multiple strategies, which were used in Australia and New Zealand and reported in the existing literature. Methods A scoping review was conducted by electronically searching PubMed, Web of Science, Scopus, Embase and Dentistry and Oral Science. Studies on caries risk management protocols, written in English, limited to Australia and New Zealand and published up to March 2018 were included in the review. There was no restriction on participants’ age. Results Of 257 studies identified, seven were included in the review. These seven studies were reported in Australia and all but six were based on the Caries Management System (CMS). There were two descriptive studies, one 3‐year multicentre cluster randomized controlled trial (RCT), one 2 to 4‐year post‐RCT follow‐up and two cost‐effective evaluations based on Markov decision analytic models. Conclusion While concentrating on assessing individual behavioural risk factors for dental caries, studies indicated that the CMS would be more cost‐effective if its protocol was properly adhered to. Future studies on caries risk management protocols are suggested to consider both the individual characteristics and the social context of different population groups in view of enhancing the effectiveness of oral care. This article is protected by copyright. All rights reserved.
... Reports of such protocols' preventive programs have been published for adults, children, and adolescents. [9][10][11][12] Single preventive measures on incipient caries in the dental literature have been evaluated, such as the application of sealants, [13][14][15][16] fluoride, [17][18][19] and amorphous calcium phosphate-casein phosphopeptide (ACP-CPP). [20][21][22][23] With regard to preventive programs, few studies have evaluated protocols (but not for incipient caries), mainly on special needs patient groups, such as the elderly population, 24,25 patients with xerostomia, [26][27][28] patients who have undergone head and neck radiation and chemotherapy, 24,[29][30][31][32][33] and other studies which have not evaluated incipient caries. ...
Article
The aim of this study was to investigate the management of incipient caries lesions in adults with two preventive protocols. A total of 44 adult patients with high, moderate and low caries risk with 516 incipient caries took part in the study. These patients were assessed for caries with International Caries Detection and Assessment System (ICDAS) criteria and were then divided into three groups depending on their caries risk profile: a high-risk group (group A), a moderate-risk group (group B), and a low-risk group (group C). Participants in each group were further divided randomly into two subgroups. In subgroups A1, B1, and C1, an intensive preventive protocol was applied, while in subgroups A2, B2, and C2, the protocol consisted only of instructions in oral hygiene. The invasive-intensive protocol included the topical application of fluoride, brushing with 5000-ppm fluoride toothpaste, use of amorphous calcium phosphate-casein phosphopeptide, applications of sealants for occlusal lesions (ICDAS code 2), and minimal resin restorations for occlusal lesions (ICDAS code 3). There was no statistically significant difference in the number of lesions (baseline and after one year) in the high-risk and moderate-risk groups that received the intensive protocol (groups A1 and B1), while the control groups were statistically significant different (groups A2 and B2). In the low-risk group, there was no statistically significant difference in the number of lesions (groups C1 and C2). The two different preventive protocols in the high- and moderate-risk groups presented differences in effectiveness, while in the low-risk group, no significant difference was demonstrated.
... Poor oral hygiene increased the chance of keeping enamel lesions active. Daily tooth brushing using fluoridated toothpaste in combination with professionally applied topical fluorides can halt the progression of non-cavitated carious lesions [62]. Oral health education with professional preventive care or with supervised tooth brushing can also reduce caries prevalence in children. ...
Article
Full-text available
Early childhood caries (ECC) is a significant global health problem affecting millions of preschool children worldwide. In general, preschool children from families with 20% of the lowest family incomes suffered about 80% of the ECC. Most, if not all, surveys indicated that the great majority of ECC was left untreated. Untreated caries progresses into the dental pulp, causing pain and infection. It can spread systemically, affecting a child’s growth, development and general health. Fundamental caries management is based on the conventional restorative approach. Because preschool children are too young to cope with lengthy dental treatment, they often receive dental treatment under general anaesthesia from a specialist dentist. However, treatment under general anaesthesia poses a life-threatening risk to young children. Moreover, there are few dentists in rural areas, where ECC is prevalent. Hence, conventional dental care is unaffordable, inaccessible or unavailable in many communities. However, studies showed that the atraumatic restorative treatment had a very good success rate in treating dentine caries in young children. Silver diamine fluoride is considered safe and effective in arresting dentine caries in primary teeth. The aim of this paper is to review and discuss updated evidence of these alternative approaches in order to manage cavitated ECC.
Article
Aim: To determine if the NSW school dental screening program, the School Assessment Program (SAP), achieved its aim of being the key entry point for high risk children to receive care. Methods: A secondary analysis was conducted on epidemiologic data gathered in 16 NSW primary schools (10 SAP and 6 non-SAP) in 2003. The validity of the SAP targeting criteria in identifying high risk schools was determined. Post-screening treatment outcomes were evaluated from the assessment of treatment ratios: ft2003/(dt+ft)2002 [FT2003/(DT+FT)2002]. A treatment ratio of 1.0 indicates whether 2002 restoration needs were fully met by 2003. Results: There was negligible difference in either the caries experience or proportions of high-risk children irrespective of their SAP status. The sensitivity and specificity values were around 60% and 40%, respectively, using various case definitions of high risk applied to both children and schools. The deciduous dentition treatment ratios for SAP and non-SAP children with dmft≥1 ranged from 0.48-0.79 and 0.47-0.73, respectively. The respective permanent dentition ratios for SAP and non-SAP children with DMFT≥1 were 0.49-0.82 and 0.64-1.08. Conclusions: The SAP failed to identify schools with high caries risk children or confer post-screening caries treatment benefits.
Article
Caries risk assessment forms the cornerstone for the successful application of a minimum intervention dentistry philosophy in the management of dental caries. Patients, particularly those with evidence of active dental caries at baseline, require a caries risk assessment to identify those risk factors that will most likely contribute to the progression of the carious disease process. Once identified, these factors should be eliminated or at least moderated to ensure the disease progression is stabilized before conservative and rehabilitative dental procedures are undertaken. Each individual will present with a slightly different caries risk profile and the principles of a patient centred approach to manage each case should be applied to the individual diagnostic and treatment planning phases of dental care. Current chairside technologies such as caries susceptibility and activity tests can be utilized to provide baseline and follow-up data to assist the dental practitioner in this task. However, clinician intuition or 'gut feeling' has been found to be a better prognostic indicator for future dental caries experience than present caries prediction instruments in most cases. As caries risk data are accumulated and refined at a population, community and individual level, the sensitivity and specificity of the caries risk assessment modelling will improve as will the positive predictive power of the final statistical model algorithm. It is likely that online caries predictive tools will be available for general dental practitioners in the not too distant future to help clinicians formulate accurate caries risk profiles for their patients.
Article
Full-text available
Introduction: Caries risk assessment (CRA) is essential as the basis for successful management of dental caries. Of the many published CRA tools, four well-known ones are CAMBRA, Cariogram, American Dental Association (ADA), and American Academy of Pediatric Dentistry (AAPD) CRAs. The predictive accuracy of CAMBRA and Cariogram CRA tools have been examined in clinical outcomes studies in thousands of patients and the tools are widely used all over the world. The purpose of the present paper is three-fold, namely (1) to briefly review, compare and contrast these four CRA methods, (2) to provide a concise method for CRA introducing a quantitative component to the CAMBRA forms (CAMBRA 123), and (3) to guide the choice of CRA methods that will support caries management decisions. Comparison of Caries Risk Assessment Methods: In the present evaluation, the above-mentioned four CRA methods for ages 0–6 years and 6 years-adult were compared using 26 hypothetical patients (13 per age group). Comparison results show that Cariogram and CAMBRA categorized patients into identical risk categories. Each of the ADA and AAPD tools gave different results than CAMBRA and Cariogram in several comparison examples. CAMBRA 123 gave the same caries risk level results as the Cariogram and the CAMBRA methods for all hypothetical patients for both age groups. Conclusions: Both the Cariogram and the CAMBRA CRA methods are equally useful for identifying the future risk of dental caries. CAMBRA 123 shows promise as an easy-to-use quantitative method for CRA in clinical practice. The health care providers will be the ones to decide which CRA method will allow them to establish individualized, successful caries management therapies and how to combine these for the best care of their patients.
Article
The object of this conference paper was to review and discuss caries risk assessment in general practice from the questions i) ‘Why’, ii) ‘When’, and iii) ‘How’. Narrative review. i) Patient caries risk assessment is the basic component in the decision-making process for adequate prevention and management of dental caries and for determination of individual recall intervals. ii) Caries risk assessment should always be performed at a child's first dental visit and then regularly throughout life, and especially when social or medical life events are occurring. iii) There are several risk assessment methods and models available for but the evidence for their validity is limited. Although there is no clearly superior method for predicting future caries, the use of structured protocols combining socioeconomy, behavior, general health, diet, oral hygiene routines, clinical data, and salivary tests or computer-based systems are considered best clinical practice. The accuracy ranges between 60% and 90%, depending on age. Caries risk assessment is more effective in the selection of patients at low risk than those with high caries risk. As evidence suggests that past caries experience is far from ideal but the most important single risk component for more caries at all ages, any clinical sign of likely active demineralization on smooth, occlusal, and proximal tooth surfaces should be taken as a signal for the implementation of individually designed preventive and disease management measures.
Article
Objective: Aim: of this systematic review was to assess the clinical performance of sealants on various teeth in an evidence-based manner. Sources: Five databases were searched from inception to February 2017. Data: Randomized clinical studies on humans. Methods: After duplicate study selection, data extraction, and risk of bias assessment according to the Cochrane guidelines, Paule-Mandel random-effects meta-analyses of Relative Risks (RRs) and their 95% confidence intervals (CIs) were calculated. Results: A total of 16 randomized clinical trials with 2778 patients (male/female 49.1%/50.9%) and an average age of 8.4 years were included. No significant difference in either caries incidence of sealed teeth or sealant retention could be found according to (i) mouth side (right versus left), (ii) jaw (upper versus lower), (iii) and tooth type (1st permanent molar versus 2nd permanent molar/1st permanent molar versus 2nd deciduous molar/1st deciduous molar versus 2nd deciduous molar), based on evidence of very low to low quality. On the other side, compared to 1st permanent molars, sealed premolars were significantly less likely to develop caries (3 trials; RR=0.12; 95% CI=0.03 to 0.44; P=0.001) and less likely to experience loss of the sealant (5 trials; RR=0.33; 95% CI=0.20 to 0.54; P=0.001), both based on low to moderate quality evidence. Conclusions: The performance of pit and fissure sealants does not seem to be negatively affected by mouth side, jaw, and tooth type, apart from the exception of a favorable retention on premolars. Clinical significance: Based on existing evidence, pit and fissure sealants can be effectively applied on any deciduous or permanent posterior teeth without adverse effects on their clinical performance.
Article
Full-text available
Autotrasplantation of impacted wisdom tooth for sostitution of second molar irremediably compromised: case report Summary Dental transplants are a frequently forgotten chapter of dentistry, even though it is a technique validated by literature. The conclusions of all available articles are unanimous in asserting that autotransplantion is a reliable therapy with high long-term success rates. In many clinical cases, dental autotransplantation should be the first therapeutic choice, while implantology should be considered only in the event of transplant failure. Instead, clinicians often plan an implant rehabilitation even where there is a specific indication of transplantation. Obviously, the selection of cases is more selective in dental transplants than implant rehab and it is not always possible to opt for this surgical technique, either due to the lack of a suitable donor element or for an inadequate recipient site. Ideal cases are those where autotrasplantation does not generate significant biological costs for the patient, as in the case of alignement of impacted teeth when the orthodontic therapy is inapplicable or as in the case of substitution of compromised teeht with non-functional element. In the case of this article a second inferior molar had to be extracted, and in order to perform an implant rehabilitation it was also necessary to extract the contiguous wisdom tooth. Therefore, transplantation was the first choice, while implantology would only be considered in the event of transplant failure. The transplanted tooth of this article has a four years follow up with a clinical and radiological condition that makes it indistinguishable from a tooth originated in the recipient socket.
Article
Full-text available
This is a position paper about 'Gewoon Gaaf' ['Just Smooth'], a paradigmatic change in the management of caries in children with a special focus onprevention. Caries is now considered a disease related to behaviour. Behavioural changes are essential in the prevention of caries because only patient's self care can keep caries under control. It is the task of the oral care provider to alert parents and child to their own influence on the development of caries and particularly on how to keep this process under control. Evaluations have revealed that the traditional form of preventive care has hardly improvedoral health. In contrast, various studies have shown the good results of the 'Gewoon Gaaf' approach. Moreover it fits in well with the public debate, which puts more and more attention on efficiency and transparency in the care.
Article
To summarise the findings of recent systematic reviews (SR) covering caries risk assessment in children, updated with recent primary studies. A search for relevant papers published 2012-2014 was conducted in electronic databases. The systematic reviews were quality assessed with the AMSTAR tool and the primary publications according to the Cochrane handbook. The quality was rated as low, moderate, or high risk of bias. The findings were descriptively synthesised and the quality of evidence was graded according to GRADE. For the recommendations of practice, the SIGN scores were used (recommendation levels A-D). Three SR, three guidelines, and five papers, not considered in previous SR, were identified and formed the base for the present summary and recommendations. One of the systematic reviews and three of the primary publications were of moderate risk of bias, while the rest displayed a high risk of bias. Based on the present summary of literature, it may be concluded: (1) a caries risk assessment should be carried out at the child's first dental visit and reassessments should be done during childhood (D); (2) multivariate models display a better accuracy than the use of single predictors and this is especially true for preschool children (C); (3) there is no clearly superior method to predict future caries and no evidence to support the use of one model, program, or technology before the other (C); and (4) the risk category should be linked to appropriate preventive care with recall intervals based on the individual need (C).
Article
Full-text available
A randomized controlled study of caries prevention strategies was conducted on patients with a mixed socioeconomic status in a large general dental practice in the Netherlands. A group of children following a non-operative caries treatment programme (NOCTP) was compared to a control group and a group that also received 2 topical fluoride applications (IPFA) as a supplement to the control programme (receiving a dental check-up twice a year with topical fluoride applications and routinely sealing of the first permanent molars). A total of 230 6-year-old children were randomly assigned to one of these groups. After 3 years, 179 children were studied again (54 NOCTP, 62 IPFA and 63 controls). Caries-increment was lowest in the NOCTP group (0.15 DMFS). In the IPFA group and the control group DMFS-increments were 0.34 and 0.47 respectively. Although the results of this study are very promising, a follow-up study on a larger scale is required to make clear whether the application of NOCTP is more effective than standard prevention in general practice.
Article
Background: An individual risk assessment is essential for effective prevention and management of dental caries and should be carried out at the child's first dental visit and then regularly throughout life. As caries is a multi-factorial disease, the use of risk models with a wide range of factors are more accurate than few or single factors. The use of structured protocols or software combining socio-economy, behavior, diet, oral health routines, clinical findings and saliva tests is considered best clinical practice. The accuracy varies between 60-90 % and is generally higher among preschool children than in schoolchildren and adolescents. Conclusion: There are no clearly superior methods for predicting future caries but any clinical sign of likely active lesions on smooth, occlusal or proximal tooth should be a signal for implementing individually-designed preventive measures.
Chapter
Recent epidemiological analyses showed that caries risk continues throughout all age groups. Moreover, it seems that there are trajectories of oral health. Individuals seem to enter such a trajectory at an early age and it shows to be difficult to escape to another trajectory with better health perspectives. Therefore it is important to start caries prevention even before birth in order to ensure that children start in a favorable trajectory. Also health depends on social, environmental, and economic determinants which are conceptually summarized in the life course theory. For oral health, this implies that primary health-care providers integrate oral health into their routine examinations with oral health screenings, preventive education, and prophylactic fluoride applications. The main message for each age group is the twice daily toothbrushing with a fluoridated toothpaste individually supplemented with other oral hygiene techniques. If the oral hygiene technique fails, improvement can be achieved through composing self-care management goals. This method stimulates patients to formulate self-management goals, action and coping planning, and control. Patient’s adherence to his own goals is strengthened by the oral care provider who alerts the patient (and parents, caregivers, or voluntary aids) continuously about their own decisive influence on the control of caries in his own mouth. This requires tailored recall intervals for monitoring, motivation, and stimulation. The self-management goals are the take-home message towards creating a stronger and healthier dental atmosphere at home and are a vital facet to preventing caries for all age groups.
Article
Full-text available
Toothbrushing may help prevent some oral health diseases considered to be public health problems--in particular, certain presentations of chronic periodontal diseases and dental caries. The authors conducted a study to identify variables associated with frequency of toothbrushing with toothpaste among schoolchildren aged 6 to 12 years. The authors collected data regarding sociodemographic, socioeconomic, oral hygiene and attitudinal variables through a cross-sectional questionnaire administered to 1,373 schoolchildren from Campeche, Mexico. They categorized toothbrushing frequency as "two times a day or fewer" and "three times a day or more." The authors used logistic regression to analyze the data. Multivariate analyses showed that girls (odds ratio [OR]=1.41), older children (OR=1.07) and offspring of mothers with higher levels of schooling (OR=1.07) were more likely to brush more frequently. The results showed an interaction between the attitude of the mother toward oral health and the use of dental care in the previous 12 months. When mothers had a positive attitude, the likelihood of their children's brushing more frequently was higher among those who received dental care in the previous 12 months (OR=2.43; P <or= .001) than among those who did not receive dental care. Mothers' characteristics were associated with more favorable patterns of toothbrushing in children. Thus, targeting the linkages between mothers' characteristics and children's behaviors could lead to more effective health promotion and preventive efforts among this population. Clinicians should take into account that certain characteristics of mothers are associated with more desirable habits in their children. Future research should try to fully characterize these family linkages and determine how to support them.
Article
Full-text available
To conduct a systematic review of the literature on risk factors for dental caries in deciduous teeth of children aged six years and under, to give a scientific framework for the international collaborative studies on inequalities in childhood caries. Accepted guidelines were followed. Studies were identified by electronic searching and reviewed on the basis of key words, title and abstract by two reviewers to assess whether inclusion criteria were met. Copies of all articles were obtained and assessed for quality according to the study design. 1029 papers were identified from the electronic search, 260 met the prima facie inclusion criteria. 183 were excluded once full copies of these papers were obtained. Of the 77 studies included, 43 were cross sectional, 19 cohort studies, 8 case control studies and 7 interventional studies. Few obtained the highest quality scores. 106 risk factors were significantly related to the prevalence or incidence of caries. There is a shortage of high quality studies using the optimum study design, i.e. a longitudinal study. The evidence suggests that children are most likely to develop caries if Streptococcus Muttans is acquired at an early age, although this may be partly compensated by other factors such as good oral hygiene and a non-cariogenic diet. Diet and oral hygiene may interact so that if there is a balance of 'good' habits by way of maintaining good plaque control and 'bad' habits by way of having a cariogenic diet, the development of caries may be controlled.
Article
Full-text available
Claims have been made that the effectiveness of water fluoridation has reduced due to the widespread availability of other sources of fluoride. This study examines the differences in the oral health of children living in fluoridated and non-fluoridated areas of Canterbury and Wellington, New Zealand. The data used in this cross-sectional study had been routinely collected into a computerized data-collection system by the School Dental Services in the two study areas. Records of dental status (dmfs/DMFS), fluoridation status, ethnicity, and socio-economic status for 8030 5-year-olds, and 6916 12-year-olds in 1996 were analysed. Caries prevalence and severity was consistently lower for children in the fluoridated area for both age groups, and within all subgroups. Five-year-olds in the fluoridated area had 2.63 dmfs (sd, 5.88), and those in the non-fluoridated area 3.80 dmfs (sd, 6.79). For 12-year-olds the respective figures were 1.39 DMFS (sd, 2.30) and 2.37 DMFS (sd, 3.46). Multivariable analysis confirmed the independent association between water fluoridation and better dental health. This results of this study show children living in a fluoridated area to have significantly better oral health compared to those not in a fluoridated area. These differences are greater for Maori and Pacific children and children of low socio-economic status.
Article
Full-text available
To determine the efficacy of fluoride varnish (5% NaF, Duraphat, Colgate) added to caregiver counseling to prevent early childhood caries, we conducted a two-year randomized, dental-examiner-masked clinical trial. Initially, 376 caries-free children, from low-income Chinese or Hispanic San Francisco families, were enrolled (mean age +/- standard deviation, 1.8 +/- 0.6 yrs). All families received counseling, and children were randomized to the following groups: no fluoride varnish, fluoride varnish once/year, or fluoride varnish twice/year. An unexpected protocol deviation resulted in some children receiving less active fluoride varnish than assigned. Intent-to-treat analyses showed a fluoride varnish protective effect in caries incidence, p < 0.01. Analyzing the number of actual, active fluoride varnish applications received resulted in a dose-response effect, p < 0.01. Caries incidence was higher for 'counseling only' vs. 'counseling + fluoride varnish assigned once/year' (OR = 2.20, 95% CI 1.19-4.08) and 'twice/year' (OR = 3.77, 95% CI 1.88-7.58). No related adverse events were reported. Fluoride varnish added to caregiver counseling is efficacious in reducing early childhood caries incidence.
Article
Full-text available
Dental caries, otherwise known as tooth decay, is one of the most prevalent chronic diseases of people worldwide; individuals are susceptible to this disease throughout their lifetime. Dental caries forms through a complex interaction over time between acid-producing bacteria and fermentable carbohydrate, and many host factors including teeth and saliva. The disease develops in both the crowns and roots of teeth, and it can arise in early childhood as an aggressive tooth decay that affects the primary teeth of infants and toddlers. Risk for caries includes physical, biological, environmental, behavioural, and lifestyle-related factors such as high numbers of cariogenic bacteria, inadequate salivary flow, insufficient fluoride exposure, poor oral hygiene, inappropriate methods of feeding infants, and poverty. The approach to primary prevention should be based on common risk factors. Secondary prevention and treatment should focus on management of the caries process over time for individual patients, with a minimally invasive, tissue-preserving approach.
Article
Full-text available
Despite marked improvements over the past century, oral health in America is a significant problem: caries is the most common chronic disease of childhood. Much oral health research examines influences primarily in the oral cavity or focuses on a limited number of individual-level factors. The purpose of this article was to present a more encompassing conceptual model of the influences on children's oral health. The conceptual model presented here was derived from the population health and social epidemiology fields, which have moved toward multilevel, holistic approaches to analyze the complex and interactive causes of children's health problems. It is based on a comprehensive review of major population and oral health literatures. A multilevel conceptual model is described, with the individual, family, and community levels of influence on oral health outcomes. This model incorporates the 5 key domains of determinants of health as identified in the population health literature: genetic and biological factors, the social environment, the physical environment, health behaviors, and dental and medical care. The model recognizes the presence of a complex interplay of causal factors. Last, the model incorporates the aspect of time, recognizing the evolution of oral health diseases (eg, caries) and influences on the child-host over time. This conceptual model represents a starting point for thinking about children's oral health. The model incorporates many of the important breakthroughs by social epidemiologists over the past 25 years by including a broad range of genetic, social, and environmental risk factors; multiple pathways by which they operate; a time dimension; the notion of differential susceptibility and resilience; and a multilevel approach. The study of children's oral health from a global perspective remains largely in its infancy and is poised for additional development. This work can help inform how best to approach and improve children's oral health.
Article
Full-text available
The aim was to evaluate the efficacy of topical fluoride varnish applications on white spot lesion (WSL) formation in adolescents during treatment with fixed orthodontic appliances. The study design was a double-blinded randomized placebo-controlled trial with two parallel arms. The subjects were 273 consecutive 12- to 15-year-old children referred for maxillary treatment with fixed orthodontic appliances. The patients were randomly assigned to a test or a control group with topical applications of either a fluoride varnish (Fluor Protector) or a placebo varnish every 6th week during the treatment period. The outcome measures at debonding were incidence and progression of WSL on the upper incisors, cuspids and premolars as scored from digital photographs by 2 independent examiners. The attrition rate was 5%. The mean number of varnish applications was 10 (range 4-20) in both groups. The incidence of WSL during the treatment with fixed appliances was 7.4% in the fluoride varnish compared to 25.3% placebo group (p < 0.001). The mean progression score was significantly lower in the fluoride varnish group than in the placebo group, 0.8 +/- 2.0 vs. 2.6 +/- 2.8 (p < 0.001). The absolute risk reduction was 18% and the number needed to treat was calculated to 5.5. The results from the present study strongly suggest that regular topical fluoride varnish applications during treatment with fixed appliances may reduce the development of WSL adjacent to the bracket base. Application of fluoride varnish should be advocated as a routine measure in orthodontic practice.
Article
Full-text available
Background: The frequency with which patients should attend for a dental check-up and the potential effects on oral health of altering recall intervals between check-ups have been the subject of ongoing international debate for almost 3 decades. Although recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, 6-monthly dental check-ups have traditionally been advocated by general dental practitioners in many developed countries. Objectives: To determine the beneficial and harmful effects of different fixed recall intervals (for example 6 months versus 12 months) for the following different types of dental check-up: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus preventive advice plus scale and polish. To determine the relative beneficial and harmful effects between any of these different types of dental check-up at the same fixed recall interval. To compare the beneficial and harmful effects of recall intervals based on clinicians' assessment of patients' disease risk with fixed recall intervals. To compare the beneficial and harmful effects of no recall interval/patient driven attendance (which may be symptomatic) with fixed recall intervals. Search strategy: We searched the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Reference lists from relevant articles were scanned and the authors of some papers were contacted to identify further trials and obtain additional information. Date of most recent searches: 5th March 2007. Selection criteria: Trials were selected if they met the following criteria: design - random allocation of participants; participants - all children and adults receiving dental check-ups in primary care settings, irrespective of their level of risk for oral disease; interventions - recall intervals for the following different types of dental check-ups: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus scale and polish plus preventive advice; e) no recall interval/patient driven attendance (which may be symptomatic); f) clinician risk-based recall intervals; outcomes - clinical status outcomes for dental caries (including, but not limited to, mean dmft/DMFT, dmfs/DMFS scores, caries increment, filled teeth (including replacement restorations), early carious lesions arrested or reversed); periodontal disease (including, but not limited to, plaque, calculus, gingivitis, periodontitis, change in probing depth, attachment level); oral mucosa (presence or absence of mucosal lesions, potentially malignant lesions, cancerous lesions, size and stage of cancerous lesions at diagnosis). In addition the following outcomes were considered where reported: patient-centred outcomes, economic cost outcomes, other outcomes such as improvements in oral health knowledge and attitudes, harms, changes in dietary habits and any other oral health-related behavioural change. Data collection and analysis: Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two review authors. Authors were contacted, where deemed necessary and where possible, for further details regarding study design and for data clarification. A quality assessment of the included trial was carried out. The Cochrane Collaboration's statistical guidelines were followed. Main results: Only one study (with 188 participants) was included in this review and was assessed as having a high risk of bias. This study provided limited data for dental caries outcomes (dmfs/DMFS increment) and economic cost outcomes (reported time taken to provide examinations and treatment). Authors' conclusions: There is insufficient evidence from randomised controlled trials (RCTs) to draw any conclusions regarding the potential beneficial and harmful effects of altering the recall interval between dental check-ups. There is insufficient evidence to support or refute the practice of encouraging patients to attend for dental check-ups at 6-monthly intervals. It is important that high quality RCTs are conducted for the outcomes listed in this review in order to address the objectives of this review.
Article
Full-text available
Dental caries is a chronic, cumulative disease, but no studies have investigated longitudinal patterns of caries experience. The objective of this study was to identify and describe developmental trajectories of caries experience in the permanent dentition to age 32. Longitudinal caries data for 955 participants in a longstanding birth cohort study were analyzed by trajectory analysis. Three caries experience trajectories were identified by the SAS macro PROC TRAJ; these were categorized as "high" (approximately 15%), "medium" (approximately 43%), and "low" (approximately 42%) DMFS (Decayed, Missing, and Filled Surfaces). All were relatively linear, although the higher trajectories were more "S-shaped". This effect disappeared following adjustment for the number of unaffected surfaces remaining at each age, suggesting that, among individuals following a similar caries trajectory, caries rate is relatively constant across time.
Article
Full-text available
A barrier to providing sealants is concern about inadvertently sealing over caries. This meta-analysis examined the effectiveness of sealants in preventing caries progression. We searched electronic databases for comparative studies examining caries progression in sealed permanent teeth. We used a random-effects model to estimate percentage reduction in the probability of caries progression in sealed vs. unsealed carious teeth. Six studies, including 4 randomized-controlled trials (RCT) judged to be of fair quality, were included in the analysis (384 persons, 840 teeth, and 1090 surfaces). The median annual percentage of non-cavitated lesions progressing was 2.6% for sealed and 12.6% for unsealed carious teeth. The summary prevented fraction for RCT was 71.3% (95%CI: 52.8%-82.5, no heterogeneity) up to 5 years after placement. Despite variation among studies in design and conduct, sensitivity analysis found the effect to be consistent in size and direction. Sealing non-cavitated caries in permanent teeth is effective in reducing caries progression.
Article
Full-text available
The fissure-sealing of newly erupted molars is an effective caries prevention treatment, but remains underutilized. Two plausible reasons are the financial disincentive produced by the dental remuneration system, and dentists' lack of awareness of evidence-based practice. The primary hypothesis was that implementation strategies based on remuneration or training in evidence-based healthcare would produce a higher proportion of children receiving sealed second permanent molars than standard care. The four study arms were: fee per sealant treatment, education in evidence-based practice, fee plus education, and control. A cost-effectiveness analysis was conducted. Analysis was based on 133 dentists and 2833 children. After adjustment for baseline differences, the primary outcome was 9.8% higher when a fee was offered. The education intervention had no statistically significant effect. 'Fee only' was the most cost-effective intervention. The study contributes to the incentives in health care provision debate, and led to the introduction of a direct fee for this treatment.
Book
This book focuses on oral health promotion and the impact of systemic disease in the development of oral disease, as well as how to introduce, apply, and communicate prevention to a patient with a defined risk profile. Prevention in Clinical Oral Health Care integrates preventive approaches into clinical practice, and is a valuable tool for all health care professionals to integrate oral health prevention as a component of their overall preventive message to the patient. Discusses risk-based approaches to prevent problems such as caries, periodontal disease, and oral cancer. Topics are written at a level that can be understood by both practicing dental health team members and by dental hygiene and dental students so strategies can be applied to better understand the patient's risk for oral disease and how to prevent future disease. Identifies the barriers, oral health care needs, and preventive strategies for special populations such as children, the elderly, and the physically or mentally disabled. Explores the development of a culturally sensitive dental practice and strategies to make the dental environment more welcoming to individuals with different cultural backgrounds. Discusses how to gather patient information, the synthesis of the patient's data, and the application of the information collected in order to evaluate the patient's risk for disease.
Article
In April 1992, the fluoride concentration in the Blue Mountains water supply was adjusted to 1 mg/L. Baseline dmft/DMFT has been determined in children attending schools in the region and in the adjacent reference region of Hawkesbury, fluoridated since 1968. The aim of this study was to evaluate the effect of the water fluoridation programme in the Blue Mountains. In 2003, children attending the same schools were sampled. Residential history data were obtained by questionnaire and caries experience was assessed according to WHO guidelines. The analysis was restricted to lifelong resident children aged 5-11 years. The baseline and follow-up dmft scores for Blue Mountains children aged 5-8 years were 2.36 and 0.67, respectively. The age-adjusted decrease in odds of experiencing one or more dmft due to fluoridation was 0.26 (CI(95) 0.19, 0.37). The corresponding DMFT scores for Blue Mountains children aged 8-11 were 0.76 and 0.21 and the corresponding decrease in odds of experiencing one or more DMFT due to fluoridation was 0.25 (CI(95) 0.16, 0.40). Tooth decay reduction observed in the Blue Mountains corresponds to high rates reported elsewhere and demonstrates the substantial benefits of water fluoridation.
Article
To examine the relative contribution of current caries activity, past caries experience, and dentists' subjective assessment of caries risk classifications. Administrative data from two dental plans were analyzed to determine dentists' risk classification, as well as current caries activity and previous caries experience at the time of the classification. The performance of these predictors in identifying patients who would experience subsequent caries was then modeled using logistic regression. In both plans, current caries activity alone had relatively low sensitivity and high specificity in identifying patients who would experience subsequent caries. Sensitivity improved, but at the cost of specificity when previous caries experience was included in the models. Further improvement in sensitivity accrued when dentists' subjective assessment was included, but performance was different in the two plans in terms of false-positives. Consideration of previous caries experience tends to strengthen the predictive power of caries risk assessments. Dentists' subjective assessments also tend to improve sensitivity, but overall accuracy may suffer.
Article
Background: A Caries Management Clinic was established for patients at high risk of caries aiming to reduce caries incidence to close to zero. That is, to prevent new lesions on existing sound surfaces, along the susceptible restoration margins, and to remineralize existing cavitated and non-cavitated lesions. Twenty patients attended the clinic every two weeks from April to December 2005. Methods: The Caries Management System is a ten-step non-invasive strategy to arrest and remineralize early lesions and includes consideration of the patient at risk, the status of each individual lesion, patient management, clinical management, and monitoring. Results: After six months, there was a 42 per cent increase in gingival sites having Gingival Index scores of zero, and a 21 per cent decrease in sites having Gingival Index scores of 2 compared to baseline (χ2 = 137.67, 4 df, p = 0.00001). Ready to change (RTC) patients had significantly fewer sites scored GI ≤ 2 compared to not-RTC patients (p = 0.01). Compared with the not-RTC patients, RTC patients were more than twice as likely to have fewer sites scored GI ≤ 2 (RR = 2.43, 95% CI (1.24, 4.71), p = 0.01). A total of 100 out of 146 smooth non-cavitated carious surfaces at baseline have remineralized after six months, 99 per cent of sound surfaces remained sound, and 23 new lesions were observed in six of the 20 patients (α2 = 292, 7 df, p = 0.00001). About half of proximal surfaces showing bitewing scores of grade 1 or 2 had regressed (α2 = 86.66, 56 df, p = 0.0001) and 95 per cent of proximal sound surfaces at baseline, as diagnosed via bitewing radiographs, remained sound. Conclusions: This audit revealed that the implementation of the non-invasive approach to caries management which combined intensive coaching in oral hygiene maintenance, special home care and intensive monitoring in a clinic for high-risk patients was able to reduce gingival inflammation and maintain low plaque levels, at least within the scope of this short-term review.
Article
This paper reviews the efficacy of an intensive, preventive-based, non-invasive approach to the management of dental caries within a randomized controlled trial. The primary efficacy measure was the two-year DMFS increment. Changes in risk status, fluoride history, number of emergency visits and toothaches, along with demographic variables such as age, gender, health problems, and the location of the dental practice attended were measured. Regression analysis was undertaken to adjust for potential confounding variables. Nine hundred and two patients were recruited within 22 dental practices between May 2005 and March 2006. Baseline DMFS did not differ significantly between the control and study groups (p = 0.83). Age (p < 0.001), health status (p = 0.005), baseline risk (p < 0.001) and fluoride history (p < 0.001) were all independent significant predictors of two-year DMFS increment. Gender approached significance (p = 0.08). There were no statistically significant differences between the groups in the incidence of toothaches (p = 0.1) or number of treatment visits required (p = 0.35). There was a significant difference in the two-year incremental DMFS score in the study group compared to the control group (mean difference 2.2; p < 0.001). After adjusting for confounding variables the difference in the DMFS increment between the control and study groups remained significant (mean difference 1.7; p < 0.001). The results indicate efficacy of the preventive programme. 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, on a relatively short-term basis (two years). While encouraging, it will be essential that these results are followed over a longer period of time in order to determine whether the benefits are maintained.
Article
To perform a comprehensive decision-tree analysis for the management of the suspicious/incipient occlusal lesion on a molar tooth. A quantitative decision tree was constructed to assess the expected utility value of three global strategies to dentally manage the incipient or suspicious occlusal carious lesion. A preventive strategy offered an optimal expected utility value (0.98 utile) compared with the other two strategies of visual inspection (0.84 utile) or referring to one of four diagnostic tests (0.74-0.82 utile). Although the general conclusion of this analysis agrees with current recommendations, this analysis offers a more complete mathematical model that provides a unified value for each strategy (i.e. expected utility value) thus allowing for complex quantitative comparison between strategies. This paper provides a specific example of how decision-tree analysis can be a powerful tool in guiding dental practice.
Article
Caries prevention might benefit from the use of toothpastes containing over 1500 ppm F. With few clinical studies available, the aim of this pH-cycling study was to investigate the dose response between 0 and 5000 ppm F of de- and remineralization of advanced (> 150 microm) enamel lesions. Treatments included sodium and amine fluoride, and a fluoride-free control. Mineral uptake and loss were assessed from solution calcium changes and microradiographs. Treatments with 5000 ppm F both significantly enhanced remineralization and inhibited demineralization when compared with treatments with 1500 ppm F. Slight differences in favor of amine fluoride over sodium fluoride were observed. The ratio of de- over remineralization rates decreased from 13.8 to 2.1 in the range 0 to 5000 ppm F. As much as 71 (6)% of the remineralized mineral was calculated to be resistant to dissolution during subsequent demineralization periods. With 5000-ppm-F treatments, more demineralizing episodes per day (10 vs. 2 for placebo) would still be repaired by remineralization.
Article
Abstract Dental caries is a transmissible bacterial disease process caused by acids from bacterial metabolism diffusing into enamel and dentine and dissolving the mineral. The bacteria responsible produce organic acids as a by-product of their metabolism of fermentable carbohydrates. The caries process is a continuum resulting from many cycles of demineralization and remineralization. Demineralization begins at the atomic level at the crystal surface inside the enamel or dentine and can continue unless halted with the end-point being cavitation. There are many possibilities to intervene in this continuing process to arrest or reverse the progress of the lesion. Remineralization is the natural repair process for non-cavitated lesions, and relies on calcium and phosphate ions assisted by fluoride to rebuild a new surface on existing crystal remnants in subsurface lesions remaining after demineralization. These remineralized crystals are acid resistant, being much less soluble than the original mineral.
Article
Topically applied fluoride gels have been widely used as a caries-preventive intervention in dental surgeries and school-based programs for over two decades. To determine the effectiveness and safety of fluoride gels in the prevention of dental caries in children and to examine factors potentially modifying their effect. Multiple electronic database searches, reference lists of articles, journal handsearch, selected authors and manufacturers. Randomized or quasi-randomized controlled trials with blind outcome assessment, comparing fluoride gel with placebo or no treatment in children up to 16 years during at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces (D(M)FS). Inclusion decisions, quality assessment and data extraction were duplicated in a random sample of one third of studies, and consensus achieved by discussion or a third party. Study authors were contacted for missing data. The primary outcome measure was the prevented fraction (PF), that is the caries increment in the treatment group expressed as a percentage of the control group. Random effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random effects meta-regression analyses. Twenty-five studies were included, involving 7747 children. For the 23 that contributed data for meta-analysis, the D(M)FS pooled prevented fraction estimate was 28% (95% CI, 19% to 37%; p<0.0001). There was clear heterogeneity, confirmed statistically (p<0.0001). The effect of fluoride gel varied according to type of control group used, with D(M)FS PF on average being 19% (95% CI, 5% to 33%; p<0.009) higher in non-placebo controlled trials. A funnel plot of the 23 studies indicated a relationship between prevented fraction and study precision. Only two trials reported on adverse events. There is clear evidence of a caries-inhibiting effect of fluoride gel. The best estimate of the magnitude of this effect, based on the 14 placebo-controlled trials, is a 21% reduction (95% CI, 14 to 28%) in D(M)FS. This corresponds to an NNT of 2 (95% CI, 1 to 3) to avoid 1 D(M)FS in a population with a caries increment of 2.2 D(M)FS/year, or an NNT of 24 (95% CI, 18 to 36) based on an increment of 0.2 D(M)FS/year. There is little information concerning deciduous dentition, on adverse effects or on acceptability of treatment. Future trials should include assessment of potential adverse effects.
Article
Fluoride varnishes applied professionally two to four times a year would substantially reduce tooth decay in children. Fluoride is a mineral that prevents tooth decay (dental caries). Since widespread use of fluoride toothpastes and water fluoridation, the value of additional fluoride has been questioned. Fluoride varnishes can be professionally applied at a frequency from two to four times a year. The review of trials found that fluoride varnish can substantially reduce tooth decay in both milk teeth and permanent teeth. However, more high quality research is needed to be sure of how big a difference the treatment makes, and to study acceptability and adverse effects
Article
Early childhood caries (ECC) is a significant dental problem for many low-income and minority children in the United States. The diagnosis, prevention, and management of ECC have been based upon both experiential knowledge and scientific evidence. In the prevention and management of ECC, the focus has been on modifying the dental, infectious, and behavioral determinants of the disease. The purpose of this concept paper is to expand the paradigm used to understand the etiology of ECC and design programs to prevent and manage this condition.
Article
The frequency with which patients should attend for a dental check-up and the potential effects on oral health of altering recall intervals between check-ups have been the subject of ongoing international debate for almost 3 decades. Although recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, 6-monthly dental check-ups have traditionally been advocated by general dental practitioners in many developed countries. To determine the beneficial and harmful effects of different fixed recall intervals (for example 6 months versus 12 months) for the following different types of dental check-up: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus preventive advice plus scale and polish. To determine the relative beneficial and harmful effects between any of these different types of dental check-up at the same fixed recall interval. To compare the beneficial and harmful effects of recall intervals based on clinicians' assessment of patients' disease risk with fixed recall intervals. To compare the beneficial and harmful effects of no recall interval/patient driven attendance (which may be symptomatic) with fixed recall intervals. We searched the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Reference lists from relevant articles were scanned and the authors of some papers were contacted to identify further trials and obtain additional information. Date of most recent searches: 9th April 2003. Trials were selected if they met the following criteria: design- random allocation of participants; participants - all children and adults receiving dental check-ups in primary care settings, irrespective of their level of risk for oral disease; interventions -recall intervals for the following different types of dental check-ups: a) clinical examination only; b) clinical examination plus scale and polish; c) clinical examination plus preventive advice; d) clinical examination plus scale and polish plus preventive advice; e) no recall interval/patient driven attendance (which may be symptomatic); f) clinician risk-based recall intervals; outcomes - clinical status outcomes for dental caries (including, but not limited to, mean dmft/DMFT, dmfs/DMFS scores, caries increment, filled teeth (including replacement restorations), early carious lesions arrested or reversed); periodontal disease (including, but not limited to, plaque, calculus, gingivitis, periodontitis, change in probing depth, attachment level); oral mucosa (presence or absence of mucosal lesions, potentially malignant lesions, cancerous lesions, size and stage of cancerous lesions at diagnosis). In addition the following outcomes were considered where reported: patient-centred outcomes, economic cost outcomes, other outcomes such as improvements in oral health knowledge and attitudes, harms, changes in dietary habits and any other oral health-related behavioural change. Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two authors. Authors were contacted, where deemed necessary and where possible, for further details regarding study design and for data clarification. A quality assessment of the included trial was carried out. The Cochrane Oral Health Group's statistical guidelines were followed. Only one study (with 188 participants) was included in this review and was assessed as having a high risk of bias. This study provided limited data for dental caries outcomes (dmfs/DMFS increment) and economic cost outcomes (reported time taken to provide examinations and treatment). There is insufficient evidence from randomised controlled trials (RCTs) to draw any conclusions regarding the potential beneficial and harmful effects of altering the recall interval between dental check-ups. There is insufficient evidence to support or refute the practice of encouraging patients to attend for dental check-ups at 6-monthly intervals. It is important that high quality RCTs are conducted for the outcomes listed in this review in order to address the objectives of this review.
Article
Despite the fact that it is largely preventable, dental caries (decay) remains one of the most common chronic diseases of early childhood. Dental decay in young children frequently leads to pain and infection necessitating hospitalization for dental extractions under general anaesthesia. Dental problems in early childhood have been shown to be predictive of not only future dental problems but also on growth and cognitive development by interfering with comfort nutrition, concentration and school participation. To review the current evidence base in relation to the aetiology and prevention of dental caries in preschool-aged children. A search of MEDLINE, CINALH and Cochrane electronic databases was conducted using a search strategy which restricted the search to randomized controlled trials, meta-analyses, clinical trials, systematic reviews and other quasi-experimental designs. The retrieved studies were then limited to articles including children aged 5 years and under and published in English. The evidence of effectiveness was then summarized by the authors. The review highlighted the complex aetiology of early childhood caries (ECC). Contemporary evidence suggests that potentially effective interventions should occur in the first 2 years of a child's life. Dental attendance before the age of 2 years is uncommon; however, contact with other health professionals is high. Primary care providers who have contact with children well before the age of the first dental visit may be well placed to offer anticipatory advice to reduce the incidence of ECC.
Article
While national surveys have found that African-Americans have a higher prevalence and severity of dental caries than white-Americans, there are only a few descriptive studies of the prevalence and severity of dental caries in low-income urban African-Americans. This study assessed the prevalence, severity and determinants of dental caries, using the International Caries Detection and Assessment System (ICDAS). A representative sample of low-income families (a caregiver and a child aged 0-5 years) was selected from low-income census tracts in the city of Detroit, Michigan. Of the 12,655 randomly selected housing units, 10,695 were occupied and 9781 were successfully contacted (91.5%). There were 1386 families with eligible children in the contacted households; and of those, 1021 were interviewed and examined at a permanent examination center organized for this study. This represents an overall response rate of 73.7%. At the center, trained staff interviewed the main caregivers of the selected children, and trained and calibrated dentists examined the caregiver and her/his child. Data used in this study included information gathered from the social, behavioral and parenting questionnaires, the Block Food Frequency Questionnaire (total sugar intake), and data collected from community and census databases. Over 90% of the adults (ages 14-70 years, average 29.3) had at least one noncavitated carious lesion and 82.2% had at least one primary cavitated lesion. Negative binomial regression models found that the age of caregivers and the number of churches in neighborhoods were negatively associated with the number of noncavitated tooth surfaces. Cavitated tooth surfaces were positively associated with age, oral hygiene status, being worried about teeth, a recent visit to a dentist, and the number of grocery stores in the neighborhoods. However, the number of cavitated tooth surfaces was negatively associated with preventive dental visits, positive rating of oral health status and the number of dentists in a community. Dental caries, especially at the noncavitated stage, is highly prevalent in low-income African-American adults in Detroit. A significant increase in the mean number of missing teeth was observed after the age of 34 years. This study found that different individual, social, and community risk indicators were associated with noncavitated versus cavitated tooth surfaces.
Article
In the absence of effective caries preventive methods, operative care became established as the means for caries control in general practice. Water fluoridation resulted in a declining caries incidence which decreased further following the advent of fluoridated toothpaste. The challenge today is to develop a non-invasive model of practice that will sustain a low level of primary caries experience in the younger generation and reduce risk of caries experience in the older generations. The Caries Management System is a ten step non-invasive strategy to arrest and remineralize early lesions. The governing principle of this system is that caries management must include consideration of the patient at risk, the status of each lesion, patient management, clinical management and monitoring. Both dental caries risk and treatment are managed according to a set of protocols that are applied at various steps throughout patient consultation and treatment. The anticipated outcome of implementing the Caries Management System in general dental practice is reduction in caries incidence and increased patient satisfaction. Since the attainment and maintenance of oral health is determined mainly by controlling both caries and periodontal disease, the implementation of the Caries Management System in general practice will promote both outcomes.
Article
This article presents evidence-based clinical recommendations for use of pit-and-fissure sealants developed by an expert panel convened by the American Dental Association Council on Scientific Affairs. The panel addressed the following clinical questions: Under what circumstances should sealants be placed to prevent caries? Does placing sealants over early (noncavitated) lesions prevent progression of the lesion? Are there conditions that favor the placement of resin-based versus. glass ionomer cement sealants in terms of retention or caries prevention? Are there any techniques that could improve sealants' retention and effectiveness in caries prevention? Staff of the ADA Division of Science conducted a MEDLINE search to identify systematic reviews and clinical studies published after the identified systematic reviews. At the panel's request, the ADA Division of Science staff conducted additional searches for clinical studies related to specific topics. The Centers for Disease Control and Prevention also provided unpublished systematic reviews that since have been accepted for publication. The expert panel developed clinical recommendations for each clinical question. The panel concluded that sealants are effective in caries prevention and that sealants can prevent the progression of early noncavitated carious lesions. These recommendations are presented as a resource to be considered in the clinical decision-making process. As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner's professional judgment and the patient's needs and preferences. The evidence indicates that sealants can be used effectively to prevent the initiation and progression of dental caries.
Article
The authors analyzed studies of decayed, missing and filled (DMF) rates for surfaces and teeth in Norway published during the last 30 years. The result of active fluoride therapy combined with a change in criteria for when to place restorations led to a marked reduction in the need for restorations. The authors reviewed independent, cross-sectional DMF studies of representative samples of young adults performed every 10 years during the period 1973 through 2006. The clinicians involved in the studies used standardized and calibrated methods. The authors of this article also reviewed an additional series of studies collecting DMF data from representative samples of 15-year-old adolescents that also had been carried out independently from 1979 through 1996. In these studies, the investigators examined clinical records and bitewing radiographs with attention to progression of carious lesions and restorative treatments. The authors noted a marked reduction in the mean decayed, missing and filled surface (DMFS) scores from 1973 through 2006 in the two adult groups. They also found a significant decrease in treatment of caries. The reduction was most marked after the mid-1990s. They noted that the most dramatic change in the data from the 15-year-olds resulted from a change in the treatment criteria during the 1980s. Approximal lesions in enamel were monitored by the investigators of those studies in combination with the use of fluoride toothpaste. A caries treatment approach based on active caries-preventive treatment and restrictive criteria for restoration placement are good bases for reducing the need for restorations as shown in cross-sectional studies reviewed.
Guidelines for prescribing dental radiographs
  • American Association
  • Us
  • Drug Food
  • Administration
American Dental Association, US Food and Drug Administration. Guidelines for prescribing dental radiographs. 2004. URL: 'http:// www.ada.org'. Accessed January 2009.
Caries control for the individual patient Dental caries: the disease and its clinical management
  • Kidd Eam
  • Nyvad
Kidd EAM, Nyvad B. Caries control for the individual patient. In: Fejerskov O, Kidd EAM, eds. Dental caries: the disease and its clinical management. Oxford: Blackwell Munksgaard, 2003:303– 312.
CDC Dental Sealant Systematic Review Work Group Effectiveness of sealants in managing caries lesions
  • Griffin So
  • E Oong
  • W Kohn
  • B Vidakovic
  • Gooch
  • J Bader
  • J Clark
  • Fontana
  • Mr
  • Rozier Dm Rj Meyer
  • Ja Weintraub
  • Zero
  • Dt
Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, CDC Dental Sealant Systematic Review Work Group: Bader J, Clark-son J, Fontana MR, Meyer DM, Rozier RJ, Weintraub JA, Zero DT. Effectiveness of sealants in managing caries lesions. J Dent Res 2008;87:169–174.
Caries and restoration prevention Address for correspondence: Professor RW Evans Faculty of Dentistry The University of Sydney C24A
  • Ia Mjor
  • D Holst
  • Hm Eriksen
Mjor IA, Holst D, Eriksen HM. Caries and restoration prevention. J Am Dent Assoc 2008;139:565–570. Address for correspondence: Professor RW Evans Faculty of Dentistry The University of Sydney C24A, 1 Mons Road Sydney NSW 2145
Australian Research Centre for Population Oral Health. The use of fluorides in Australia: guidelines
Australian Research Centre for Population Oral Health. The use of fluorides in Australia: guidelines. Aust Dent J 2006;51:195-199.