October 2009, Volume 30, Issue 8
Published by AEGIS Communications
Adding Caries Diagnosis to Caries Risk Assessment: The Next Step in Caries Management by Risk Assessment (CAMBRA)
Steven Steinberg, DDS
In the quest to conquer dental caries, caries management by risk assessment (CAMBRA) is a significant tool. Using CAMBRA methodology, the clinician identifies the cause of disease by assessing each patient’s risk factors. By managing risk factors, the clinician then corrects the problems. Through the use of risk assessment, CAMBRA focuses on predicting likelihood of disease. In addition, the present condition of the patient needs to be addressed. That is to say, a diagnosis is needed. This article suggests that including a diagnosis with risk assessment adds to the understanding and improves management of dental caries. A simplified caries treatment protocol is presented, using these concepts.
Historically, dentists have used a surgical model for the treatment of dental caries. Management of the disease consisted of treating cavitations with restorations.1 Eventually, it became clear that restorations dealt with an end result of the disease rather than its etiologic causes.1 A new paradigm took shape that is perhaps best exemplified using the caries management by risk assessment (CAMBRA) model.2 Using CAMBRA methodology, the clinician identifies the cause of disease by assessing each patient’s risk factors. Then, the clinician corrects the problems (by managing the risk factors), using specific treatment recommendations.
This paradigm is in alignment with advances in medical science for the past 20 years, in which physicians identify and treat patients by risk levels rather than treating everyone the same.3 CAMBRA is a significant risk assessment tool with its focus on predicting the likelihood of disease. In addition, the present state of the patient must be assessed. In medicine, this is called a diagnosis. Without understanding the concept of diagnosis, the dentist cannot fully understand, use, or evaluate risk. This article examines the benefits of combining diagnosis with risk and prognosis assessment for better understanding and management of dental caries. A simplified caries treatment protocol is presented, using these concepts.
In the medical and dental fields, consistent use of terminology is important. This fosters better communication between healthcare professionals and patients. Many terms used in dental practice originate in medicine. Thus, it is beneficial to note how a term is used in medicine and then evaluate its application in dentistry. Is it used similarly or, if not, is there a good reason for the variation? If so, dentistry should continue using it for its own purposes, or change its use. This paper will focus on the terms diagnosis, prognosis, and risk assessment to improve the understanding and management of dental caries.
In medicine, a patient presents with a set of complaints and signs. Diagnosis is “the art or act of identifying a disease from its signs and symptoms,”4 and answers two questions: 1) “Does this patient have a disease?” and 2) “If so, what does this patient have?” Another step is the establishment of a prognosis. If a physician diagnoses cancer, the patient’s first question is: “Will I live?” If the patient is told he or she has diabetes mellitus, the next concern is: “How will this impact my life?” The patient wants the prognosis. Knowing the diagnosis is not sufficient. For treatment planning, in addition to identifying a disease, the physician needs to predict the outcome in regard to no treatment compared with one or more treatments (prognosis). Diagnosis is for today; prognosis is for the future. With both a diagnosis and prognosis, much better treatment plans can be developed. Although medical conditions differ from caries, the concepts of diagnosis and prognosis still apply. The power of the CAMBRA paradigm is its excellent focus on prognosis. In this respect, dentistry is in alignment with medicine. What is missing is a similar focus on diagnosis.
Dentists do not diagnose caries in the classic medical sense of making a differential diagnosis. Dentists generally do not need to think in terms of identifying the patient’s disease. They know the disease is caries. However, rather than state that this patient has caries disease, a dentist asks: “Does this tooth or tooth surface have caries?”5 When focused at the tooth level, diagnosis of caries as a phenomenon affecting the whole patient, if it occurs, is not easily distinguishable. The result is that a diagnosis of caries can be understood as a list of restorative treatments without reference to the patient’s disease. This can lead to individualized treatments of each tooth without looking at the patient as a whole. Such thinking can lead to a predominantly surgical approach rather than a more generalized chemotherapeutic one with surgical treatment as a secondary consideration.
Bader and Shugars5 have suggested that historically during examinations, a process of pattern recognition occurs. Presentations of caries are stored in practitioners’ memories in the form of various “caries scripts,” which often end with a decision regarding intervention, rather than the probable diagnosis. If features from a caries script match a patient’s tooth, the practitioner automatically recommends an intervention. No diagnosis is made, and no explicit estimation of the probability of caries being present or occurring in the future has been made. The practitioner simply matches the patient’s tooth with a routinely recommended treatment. This tendency toward pattern-matching has led to a large variation in both diagnostic and therapeutic decision-making, implying that some dentists provide better or more efficient dental care than their peers when faced with similar patients.6 To address this problem, dentists must choose consistently the best intervention, thus requiring a better dental diagnostic process.
The word diagnosis can be used in two ways. Diagnosis refers to both the state of the patient and the process used to decide the patient’s state. A diagnosis is the identification of a particular disease, condition, or particular state. Diagnosis is also the process used in identifying or determining the nature and cause of the disease or injury through evaluation of the patient’s history, examination, and laboratory data. Prognosis and risk analysis can be included in this process. CAMBRA uses this process but refers to it as a risk analysis. CAMBRA does not give a formal diagnosis of disease at present; rather, it frames all discussion in terms of the future, ie, prognosis and risk.
Prognosis is a prediction of the probable disease course and outcome or the likelihood of recovery.7 Risk refers to the likelihood of initial disease onset. Prognosis predicts status of the patient who already shows the disease; risk is the likelihood that a given disease may develop.8 In dentistry, the concepts of risk and prognosis have been combined and, currently, only the term risk is used. CAMBRA incorporates both new and existing disease into its risk analysis. This does not appear to be a serious problem in terminology. When communicating with other healthcare providers, risk analysis can be understood to include prognosis. The core principles supporting risk-based caries management are decades old. In the past 10 years in particular, CAMBRA has become accepted as the most current concept in caries management.2
In 2003, two issues of the Journal of the California Dental Association were dedicated to reviewing the scientific basis for CAMBRA, culminating in a consensus statement9 and risk assessment forms. More recently, two issues in 2007 of the Journal of the California Dental Association featured updates on CAMBRA.2 With CAMBRA methodology, the clinician identifies the cause of disease by assessing risk factors for each patient. Based on the evidence, the clinician then corrects the problems by managing risk factors, using specific treatment recommendations, including behavioral, chemical, and minimally invasive procedures. Both the risk assessment and interventions are based on the concept of altering the caries balance10—a model (Figure 1) in which pathologic factors (bacteria, absence of healthy saliva, and poor dietary habits [ie, frequent ingestion of fermentable carbohydrates]) battle protective factors (saliva and sealants, antibacterials, fluoride, and diet). Evidence has shown, with the use of CAMBRA, early damage to teeth from dental caries may be reversed and manifestations of the disease perhaps prevented.10
While CAMBRA is a major and significant advance in caries management, there is still the issue of diagnosis. Why is diagnosis important? First, it is a statement of whether the patient has caries. Second, in combination with risk and prognosis, it forms the basis for treatment decisions and then enables a professional to advise and inform the patient. In addition, it is useful for measuring the health of groups and determining the attributes, exposures, and treatments that influence health. Diagnosis is required to identify whether a preventive or therapeutic modality is necessary. Finally, such a determination is a key moment when the causal explanation of the disease is connected to the value that the patient places on health. In medicine, above the commitment to the scientific paradigm is the moral and ethical commitment to patients. Causes and explanations are in the realm of science. Values are in the purview of patients. Patients value their health. For the patient with caries, there are tangible outcomes that conflict with that value. Those outcomes include cavitation that a patient can feel, pain, inability to chew, esthetics, tooth loss, and halitosis. Patients do not care about demineralization, white spot lesions, etc.—they do not perceive those outcomes. Patients come to the dental professional for a status report on tangible outcomes as well as causal explanations. At the moment of diagnosis, the dentist should also discuss the importance of intangible outcomes, as well. Without a diagnosis, the practitioner’s moral and ethical connection to the patient is removed. That is why, in addition to risk assessment, the dentist must make a diagnosis for today.
Dental Caries Defined
Three key points must be kept in mind when diagnosing or defining caries. First, caries is a tooth biofilm disease caused by metabolic activity of acidogenic bacteria. Second, caries is a multi-factorial process of tooth demineralization and remineralization. Third, in caries, tangible outcomes affect the way the patient feels, functions, or survives. A definition for dental caries accounts for all three of these points:
Caries is a condition, an emergent property, that exists at any point in a person’s life where there is a detectable imbalance between protective factors and pathologic factors such that the process of demineralization of tooth structure by acid from bacteria in the tooth biofilm exceeds the patient’s ability to remineralize tooth structure. This process can lead to negative outcomes that are tangible to the patient and affect how the patient feels, functions, and survives.
The Patient with Caries Is Out of Balance
In a state of health, all of a patient’s systems are balanced. With disease, one or more of those systems are not. Caries is an excellent example of such a system. When the tooth-biofilm mineral interchange system is balanced, a state of health exists. Health or healing is present in any moment when remineralization equals or exceeds the disease process of demineralization. Whereas when the system is not balanced, either from a decrease in protective factors or an increase in pathologic factors, demineralization predominates. Caries is a disturbance in normal physiology, involving many factors and arising when the patient is out of balance and demineralization prevails.
In the most recent scientific caries paradigm, the ecological plaque hypothesis proposed by Marsh, the tooth biofilm is the focus of the imbalance.11,12 This paradigm shifts from the concepts of classical medical infections that present with simple and specific bacterial species to an appreciation of ecologic principles. The dental plaque biofilm is seen as an ecologic environment. Bacteria are part of a consortium whose properties are more than the bacterial species and other components. Caries is a plaque-mediated disease that develops at a site when the homeostatic mechanism, which normally maintains a beneficial and balanced relationship between the resident oral microflora and the host, breaks down. One or more major ecologic pressures are necessary for pathogens to out-compete other members of the resident microflora and achieve levels needed for disease to occur. Caries lesions arise during a drift in the metabolic events and a drop in pH levels, resulting in a net loss of mineral. Lesions, thus, are a result of an imbalance in physiologic equilibrium between tooth mineral and biofilm fluid. Understanding caries can lead to prevention and potential therapies that are accomplished not only by targeting the pathogen directly but also indirectly by interfering with the ecologic pressure responsible for the selection of the pathogen.
Caries and Lesions
People have caries; teeth have lesions.13 Caries is a disease in a patient’s mouth and manifests on individual teeth; however, the diagnosis is not only of the whole mouth but, in fact, involves the whole person. Caries is an idea of a specific process, and an idea (caries) cannot be removed from a tooth surgically. However, the lesion, the tangible result of the caries process, can be removed surgically.
Caries is an emergent property. “Emergent entities (properties or substances) ‘arise’ out of more fundamental entities and yet are ‘novel’ or ‘irreducible’ with respect to them.”14 For example, it is sometimes said that consciousness is an emergent property of the brain.
This phenomenon was seen earlier in the ecological plaque hypothesis. In the case of caries, the parts are all of the factors positive and negative, microscopic and macroscopic, personal and social, etc, that contribute to an individual’s caries status. Caries status emerges in a whole person, not only in the parts.
Caries Lesion Detection, Classification, and Analysis Is Done at the Tooth Surface Level
Before a patient can receive a caries diagnosis, the dentist needs to detect and assess lesions. Lesions are not diagnosed; their presence is detected, their location and appearance is classified, and their characteristics are assessed. Lesion detection is accomplished through the use of visual, tactile, and/or technologic tools (eg, radiographs, DIAGNOdent, KaVo, Lake Zurich, IL; QLF™, Inspektor Dental Care, Amsterdam, The Netherlands; DIFOTI®, Electro-Optical Sciences, Irvington, NY; Logicon Caries Detector™ Software, Kodak Dental Systems, Atlanta, GA; Midwest Caries I.D.™, DENTSPLY Professional, York, PA). Lesion classification and assessment includes the International Caries Detection and Assessment System (ICDAS), G.V. Black’s classification system, surface location, and lesion activity. Lesion activity implies changes over time. Using diagnosis, prognosis, and risk assessment, the dentist can now establish a treatment plan (Table 1).
Establishing a Treatment Plan
Detection includes data gathering, lesion classification, and lesion assessment. This includes taking a history of past caries experience, evaluation of between-meal carbohydrate habits, saliva status, and the use of protective factors, such as fluoride, antimicrobial agents, and remineralization agents. Saliva is tested as needed. At this point, further gathering of information focuses on the teeth.
Lesion classification and assessment can be accomplished in several ways. In the past, dentists have classified lesions by anatomic surface description (smooth surface, pit and fissure, and interproximal) or Black’s classification system. More modern assessment systems are ICDAS and a caries lesion activity assessment. ICDAS is a collaborative initiative that remains a work in progress. A committee has been developing an evidence-based framework for defining, validating, and, in the future, refining a unique system of caries criteria, which will facilitate meaningful international comparisons of caries results.15 This standardized system should lead to better quality information to aid decisions. The system consists of a set of criteria, predominantly visual, that code (on a scale of 0 to 9) for a range of the characteristics of clean, dry teeth in a consistent way that promotes a valid comparison, regardless of locations.
Caries lesion activity assessment shows much promise as a detection technique. The development of the caries lesion is a dynamic process of demineralization of the dental hard tissues by the acid byproducts of bacterial metabolism in the overlay biofilm, alternating with periods of remineralization.3,18,19 The bacteria in the plaque on the intact tooth surface metabolize the available sugar, with lactic acid as the most important acid produced. Acid penetrates the solid yet microscopically permeable tooth surface, removing calcium and phosphate from the subsurface tissue, resulting in demineralization and subsequently an initial white spot lesion. Remineralization can and does occur. Saliva can buffer the low pH in the plaque and, with the raised pH, calcium and phosphate are deposited, remineralizing the tooth. The key is the intact tooth surface. If it remains intact (noncavitated), remineralization using medications is possible. After cavitation, the process is not manageable with medications alone; restorative therapy is needed as well.
The question for the clinician then becomes: “Is the lesion remineralizing, or is the caries process continuing?” To answer this, caries lesion activity needs to be understood. An active lesion is not progressing toward cavitation (demineralizing). An inactive lesion is not or is healing (remineralizing). The natural history of the caries lesion is episodic with periods of demineralization and remineralization, depending on various risk factors. The status of any lesion is based on color, surface texture, and longitudinal radiographic findings. White spot lesions can be active or inactive. Active lesions have a porous surface that, with the explorer, feels rough and appears chalky. Inactive lesions have a relatively nonporous surface that is smooth, shiny, and hard (remineralized surfaces can be stained from oral minerals).20-22
2. Caries Diagnosis
On any given day, a patient can fall into one of three diagnostic groups: caries active, caries balanced, or caries undetermined.
Caries Active Diagnosis is the term applied to a patient who has disease present. The patient is out of balance. Following a generalized, mouth-wide evaluation, the dentist has determined this patient has active disease. There is an imbalance between protective factors and pathologic factors such that the process of demineralization of tooth structure by acid from bacteria in the tooth biofilm exceeds the patient’s ability to remineralize tooth structure. The dentist should take care not to confuse caries active diagnosis with a caries active lesion. The first is caries diagnosis while the second is lesion detection. Having one noncavitated caries active lesion is enough to qualify for the caries active diagnosis.
Caries Balanced Diagnosis is used for a healthy state in respect to caries. However, there is never a situation in which no caries process exists. As long as a patient has teeth, he or she will have microscopic biochemical activity at the tooth surface. Some demineralization will always be present. The patient with a caries balanced diagnosis at this point has remineralization equaling or exceeding the microscopic demineralization. However, a patient may appear to be in a balanced condition today while simultaneously being at risk of becoming imbalanced because of certain factors.
Caries Undetermined Diagnosis is applied when characteristics of both groups are present. It can be difficult to assess a precise cutoff in some cases. The presence of numerous factors that must be evaluated regarding numerous teeth contributes to increased uncertainty in assessment. The assumption often is made that a set of criteria exist, which always are met by patients with disease but never met by those without disease. Health and disease, it is assumed, thus form a dichotomy. However, disease processes such as caries are better understood as a continuum throughout a range of states. The Caries Undetermined Diagnosis reflects the fact that for dental caries, health and disease are not a dichotomy. This does not mean that the dentist simply watches the patient. The fact that it cannot be said for sure that such a patient is balanced means that the dentist must institute at least some level of increased preventive intervention.
3. Prediction of Disease
Featherstone devised three categories (Figure 1): risk indicators, risk factors, and protective factors.10 In addition to a diagnosis for today, the likelihood of future disease needs to be established. Risk indicators are existing signs of an advanced disease process. They are examples of what is happening, not how disease occurred. They are clinical observations and detection modalities used to identify risk-level status. Examples include visible cavitation, active white spot lesions on smooth surfaces, and any restorations in the past 3 years. Risk factors are biologic predisposing factors for disease onset or progression. They describe how disease has occurred and include a mix of clinical findings and behavioral elements. The classic risk assessment factors are used to identify this risk-level status. Examples include acidogenic bacteria, plaque biofilm, frequent intake of carbohydrates between meals, subnormal saliva, and anatomic tooth issues. Both risk indicators and risk factors increase the likelihood of disease, and protective factors decrease this likelihood. Protective factors are a mix of clinical, behavioral, and therapeutic elements that alone or together aid in remineralization and/or prevent demineralization. Examples include adequate saliva, fluoride use, antibacterial use, xylitol use, and the use of amorphous calcium phosphate (ACP)-containing products (Prospec™ MI Paste, GC America, Inc, Alsip, IL; Arm & Hammer® Enamel Care®, Church & Dwight Co, Inc, Princeton, NJ; Relief® ACP Oral Care Gel, Discus Dental, Culver City, CA).
Using all the information gathered at this point, an assessment of the future risk and/or prognosis is accomplished by categorizing caries risk level Four risk categories have been created: low, moderate, high, and extreme risk. Refer to the CAMBRA guidelines; in particular, those in the October 2007 issue of the Journal of the California Dental Association.2 Ultimately, the dental professional must use his or her knowledge of today’s best evidence, along with clinical expertise and judgment, to ascertain a risk level. For the beginner, the author has introduced a quite simplified risk level analysis23,24 (Figure 2).Using that simplified risk analysis will enable the reader to understand more readily the combination of diagnosis and risk that follows in step 4. Once understood, the reader can then apply this methodology to the CAMBRA guidelines.
A high-risk patient is one who has at least one existing cavitation. Once a patient has a cavitation, surgical therapy/restorations will be necessary. This classification system is treatment-based rather than biologically based. In addition to the cavitation, there may exist active white spot lesions elsewhere in the mouth. Their existence does not matter in respect to classification of high risk. They will matter in respect to moderate risk. There are two ways to become a moderate-risk patient. As just noted, the patient could have caries active lesions that are noncavitated (rough, chalky white spots) without other teeth exhibiting cavitation. The active lesions lead to a caries active diagnosis. Because the patient has no cavitations, he or she cannot be characterized as high-risk. (In this risk classification system, all patients with cavitations are considered high risk.) Thus, such patients have moderate risk. Alternatively, a patient who is presently caries balanced can have several risk factors. For example, a patient with xerostomia or orthodontic brackets is at risk for disease. These patients could present at this time without any lesions, symptoms, or findings and be presently balanced. Clearly, however, they are at risk for disease because of their risk factors. This is a patient at moderate risk who has a caries-balanced diagnosis. The third group, low-risk patients, consists of most patients. These are individuals who present with no signs or symptoms and virtually no risk factors. This is a simplified beginner’s approach to risk assessment. With knowledge and experience, this should be integrated into the full CAMBRA system.
4. Treatment Groups by Combined Diagnosis and Risk-Prognosis Status
Notice that in the preceding paragraph that focused on a description of risk assessment, it was necessary to include diagnostic categorization for a full explanation of those risk assessment categories. This is one example of the advantages of combining diagnostic and risk categories. A second advantage is the creation of treatment groups, each of which can have a specific, sensible protocol. More importantly, it will be shown that combining diagnostic and risk categories brings clarity as to whether a preventive or therapeutic modality is being used.
A set of five treatment groups can be established through the combination of the diagnostic categories of step 2 with the simple risk-level analysis of step 3. A matrix can be used to create the groupings. As seen in Figure 3, caries diagnosis is identified in the top row, creating two columns. Caries risk level is identified in the left column, creating three rows.
The low-risk patient can have only a caries-balanced diagnosis. This patient is represented in the top left combination box. Any patient with caries-active diagnosis, thus demonstrating some level of caries disease, cannot be low-risk. Therefore, there is no caries-active low-risk patient and the top right combination box is empty.
The middle two combination boxes refer to the two moderate-risk groups that were discussed above. Patients who show no evidence of active disease and thus have a caries-balanced diagnosis can nonetheless exhibit risk factors for active disease. Examples of this caries-balanced moderate-risk grouping would be patients with xerostomia or orthodontic banding who have not yet exhibited any evidence of active disease. This grouping is represented in the middle left combination box. The middle right combination box represents the caries-active moderate-risk patient. This patient presents with caries-active white spot lesions that place the patient into the caries-active grouping. However, these patients do not demonstrate any cavitations and therefore are at a moderate-risk level.
The lower two combination boxes represent high-risk patients. As discussed earlier in the simplified risk categorization system, the presence of a cavitation places a patient in the high-risk category. Using these criteria, a patient cannot simultaneously have a cavitation and the caries-balanced diagnosis. Therefore, the lower left combination box is empty. More advanced systems, in particular CAMBRA, using other criteria might make use of this combination box.
The lower right combination box contains two categorizations of caries-active high-risk patients. First, there is the patient who has one or more cavitated lesions. This is the average caries-active high-risk patient. However, some patients demonstrate very high levels of activity. In particular, patients with cavitations as well as xerostomia or special needs have extremely high risk and are so designated. These patients need a more aggressive protocol than the average caries-active high-risk patient.
The net result is the five treatment categories for the protocol:
- Caries-Balanced Low-Risk
- Caries-Balanced Moderate-Risk
- Caries-Active Moderate-Risk
- Caries-Active High-Risk
- Caries-Active Extreme-Risk
5. Treatment Plan
At this point, a treatment plan can be formulated. Combining the previous steps of detection, diagnosis, and prediction of disease empowers the dentist to create an improved treatment plan. A more detailed explanation of what follows can be found in the previously cited publications.1,3,9,23-26
Three treatment plans are followed for patients who have a diagnosis of caries (Table 2). The disease management plan treats the caries disease, and the restorative therapy plan treats the cavitations that result from the disease. If necessary, after the first two steps, a cosmetic treatment plan can be instituted.
Each of the five treatment groups previously established has a protocol (Table 3). One group consists of patients who are at low-risk and are caries-balanced. The average patient in most practices fits into this group. These patients should have a 6-month recall interval. At the recall appointment, no fluoride varnish needs to be applied. The patient should receive a new diagnosis, and a risk assessment or prognosis should be done. At-home fluoride use consists of standard 1,000-ppm toothpaste.
Moderate-risk caries-balanced patients have risk factors but, as of yet, no signs of disease. Because they are at risk, clinicians manage that risk through a preventive regimen. At home, xylitol gum should be chewed for 5 minutes, four to five times per day, totaling about 8 g a day. In addition, MI paste 5,000-ppm toothpaste and over-the-counter (OTC) rinses should be used. The recall interval should be 6 months. At these visits, patients should receive a fluoride varnish for further protection. At the continuing care visit, rediagnose and assess risk or prognosis.
Moderate-risk caries-active patients have disease. They typically demonstrate one or more active white spot lesions. Because of their state, these patients should receive chemotherapeutics to treat the disease, encourage remineralization, and lower their risk. Treatment begins with 3 fluoride varnish applications within 10 days, and the patient should begin a chlorhexidine regimen. Chlorhexidine rinse 0.12% is used, 0.5 oz before bed daily for 1 week per month, and then monthly for 6 to 12 months. Xylitol gum should be chewed for 5 minutes, four or five times per day, totaling about 8 g per day. At the 6-month point, a test for bacterial levels (CRT® bacteria caries risk test, Ivoclar Vivadent AG, Schaan, Liechtenstein; or Saliva-Check Mutans, GC America Inc., Alsip, IL) should be performed. The continuing care visits should be every 3 months and include fluoride varnish applications. The patient should receive a new diagnosis, and a risk assessment or prognosis should be done. At home, xylitol gum, MI paste, and 5,000-ppm fluoride toothpaste plus OTC rinses should be used.
There are two groups of high-risk patients: caries-active high-risk and caries-active extreme-risk. These patients have three treatment plans: chemotherapeutic, restorative, and cosmetic. Both groups should receive the entire chemotherapeutic regimen given to the caries-active moderate-risk group. There are some differences: In the caries-active high-risk group, chlorhexidine rinse should be used for 6 months, a bacterial level test should be performed at 6 months, and 5,000-ppm toothpaste should be used twice a day at home; in the extreme-risk group, chlorhexidine rinse should be used for 12 months, a bacterial level test should be performed at 12 months, and 5,000-ppm toothpaste should be used twice a day, with one application daily in a custom tray. At the 3-month visit, the patient should receive a new diagnosis and a risk assessment or prognosis should be done.
Prevention vs Therapeutics
When studying Table 3, several interesting points emerge. Increased clarity regarding the terms prevention and therapeutics can be achieved. In the past, dentists were preventing cavitations. They were also treating existing cavitations surgically. Now, dentists are preventing demineralization. The tools consist of fluoride varnish, xylitol gum, and ACP paste. Dentists are also treating existing demineralization chemotherapeutically, ie, remineralization. Here, the tools are fluoride varnish, chlorhexidine rinse, xylitol gum, and ACP paste. After remineralization, dentists once again attempt to prevent further demineralization—they are trying to avoid re-demineralization. Once again, the tools are fluoride varnish, xylitol gum, and ACP paste. With the exception of chlorhexidine rinse, which is used for treating disease only, the other three tools of fluoride varnish, xylitol gum, and ACP paste are used for both prevention and therapeutics. A dentist cannot determine whether he or she is preventing or treating disease based on the agents being used. Rather, the dentist must use a diagnosis alone to ascertain the modality being used and only then can that be communicated to the patient. From Table 3, it is clear that the first two categories (caries-balanced) are prevention oriented while the last three categories (caries-active) are engaged in therapeutic treatments. Only when therapy is successful, ie, remineralization is accomplished, and the diagnosis switches from active to balanced, can prevention continue. Only through the use of diagnosis can a dentist identify the preventive as opposed to therapeutic modalities.
In the quest to conquer caries, CAMBRA is a significant tool. Using risk assessment, CAMBRA’s focus is on predicting disease. In addition to the future condition of the patient, the present condition needs to be addressed. This article has argued that including a diagnosis with the risk assessment adds to the understanding and improves management of caries. Diagnosis is the moment when the dental professional connects the dental caries disease paradigm with the values of the patient.
The patient who has caries is out of balance. People have caries; teeth have lesions. Caries lesion detection, classification, and analysis are done at the tooth surface. Patients can receive a diagnosis of caries-active, caries-balanced, or caries-undetermined. Risk and prognosis assessments are accomplished by classifying all patients as low-, moderate-, or high-risk. For an improved treatment plan, a combination of diagnosis and risk/prognosis assessment leads to five treatment groups, each with an appropriate protocol for managing the disease process.
In the end, there are three treatment plan stages: a management plan that treats the caries disease, a restorative plan that repairs the cavitations, and, only then, a plan that addresses esthetic considerations. Surgical treatment does not manage the disease. Assuming that a restoration is sealed, the filling is of secondary importance to the biofilm that will now cover it. Management of the biofilm–tooth interface using chemotherapeutics is the primary consideration. Today, dentists manage caries with medicine instead of a drill.
1. Steinberg S. A paradigm shift in the treatment of caries. Gen Dent. 2002;50(4):333-338.
2. Young DA, Featherstone JDB, Roth JR. Curing the silent epidemic: caries management in the 21st century and beyond. J Calif Dent Assoc. 2007;35(10):681-685.
3. Anderson MH, Bales DJ, Omnell KA. Modern management of dental caries: the cutting edge is not the dental bur. J Am Dent Assoc. 1993;124(6):37-44.
4. Webster’s Dictionary. Springfield, MA: Miriam-Webster; 1967.
5. Bader JD, Shugars DA. What do we know about how dentists make caries related treatment decisions? Community Dent Oral Epidemiol. 1997;25(1): 97-103.
6. Baelum V, Nyvad B, Grondahl HG, et al. The foundations of good diagnostic practice. In: Fejerskoy O, Kidd E, eds. Dental Caries: The Disease and its Clinical Management. 2nd ed. Copenhagen, Denmark: Blackwell Munksgaard; 2008:105.
7. The American Heritage Dictionary of the English Language. 4th ed. Boston, MA: Houghton Mifflin; 2003.
8. Gay J. Clinical epidemiology and evidenced-based medicine glossary: epidemiology terminology. July 2005. Available at: http://www.vetmed.wsu.edu/courses-jmgay/GlossEpiTerminology.htm. Accessed Oct 30, 2008.
9. Featherstone JD, Adair SM, Anderson MH, et al. Caries risk management by risk assessment: consensus statement. April 2003. J Calif Dent Assoc. 2003;31(3):257-269.
10. Featherstone JDB, Domejean-Orliaguet S, Jenson L, et al. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703-713.
11. Marsh PD. Dental Plaque as a microbial biofilm. Caries Res. 2004;38(3):204-211.
12. Marsh PD. Dental plaque as a biofilm and a microbial community—implications for health and disease. BMC Oral Health. 2006;6(suppl 1):S14.
13. Jenson L. UCSF clinical guidelines for managing caries by risk assessment. Presented at: 7th Annual Conference of the World Congress of Minimally Invasive Dentistry; August 19, 2006; Seattle, WA.
14. Stanford Encyclopedia of Philosophy Web site. http://plato.stanford.edu/entries/properties-emergent. Accessed May 26, 2009.
15. Pitts NB, Stamm JW. International Consensus Workshop on Caries Clinical Trials (ICW-CCT)—final consensus statements: agreeing where the evidence leads. J Dent Res. 2004;83(spec iss C):C125-C128.
16. Pitts N. Review of the ICW-CCT meeting, the importance of early detection and the philosophy/approach to ICDAS. In: Stookey G, ed. Early Detection of Dental Caries III. Indianapolis, IN: Indiana University School of Dentistry; 2003:1-17.
17. International Caries Detection and Assessment System. Patient centered total caries management. Available at: http://www.icdas.org. Accessed Oct 30, 2008.
18. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc. 2000;131(7):887-899.
19. Harris NO, Christen AG. Primary Preventive Dentistry. Stamford, CT: Appleton and Lange; 1995:274-275.
20. Zero DT. Application of clinical models in remineralization research. J Clin Dent. 1999;10:74-85.
21. Nyvad B, Fejerskov O. Assessing the stage of caries lesion activity on the basis of clinical and microbiological examination. Community Dent Oral Epidemiol. 1997;25(1):69-75.
22. Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Res. 1999;33(4): 252-260.
23. Steinberg S. A modern paradigm for caries management, part 1. Diagnosis and treatment. Dent Today. 2007;26(2):134-139.
24. Steinberg S. A modern paradigm for caries management, part 2. A practical protocol. Dent Today. 2007;26(6): 76-79.
25. Featherstone JD. Caries management by risk assessment. Presented at: American Dental Association Annual Scientific Session; August 2005; Sacramento, CA.
26. Hayes C. The effect of non-cariogenic sweeteners on the prevention of dental caries: a review of the evidence. J Dent Educ. 2001;65(10):1106-1109.
About the Author
Steven Steinberg, DDS