Ó 2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd
Community Dent Oral Epidemiol 2012; 41; e53–e63 All rights reserved
Caries management by risk assessment
Douglas A. Young1 and John D. B. Featherstone2 1 Department of Dental Practice, University of the Pacific, San Francisco, CA, USA, 2 School of Dentistry, University of California, San Francisco, CA, USA
Young DA, Featherstone JDB. Caries management by risk assessment. Community Dent Oral Epidemiol 2013; 41: 1–12. © 2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd Abstract – Caries disease is multifactorial. Whether caries disease will be expressed and damage dental hard tissue is dependent on the patient’s own unique make-up of pathogenic risk factors and protective factors. Objectives: This manuscript will review the science of managing caries disease based on assessing caries risk. Methods: The caries balance/imbalance model and a practical caries risk assessment procedure for patients aged 6 years through adult will illustrate how treatment options can be based on caries risk. Results: Neither the forms nor the clinical protocols are meant to imply there is currently only one correct way this can be achieved, rather are used in this manuscript as examples only. Conclusions: It is important to have the forms and protocols simple and easy to understand when implementing caries management by risk assessment into clinical practice. The science of CAMBRA based on the caries balance/imbalance model was reviewed and an example protocol was presented.
The caries management by risk assessment (CAMBRA) philosophy is built on the understanding that dental caries is a disease initiated by a complex biofilm (rather than any one pathogen), which changes dynamically with its environment and the local chemistry of the tooth site, pellicle, and saliva. This is in stark contrast to the classic medical model of ‘one pathogen-one disease’, thus, rather than focusing on the elimination of any one pathogen, caries management must determine which of many factors is causing the expression of disease and takes corrective action. For purposes of this paper, the phrase ‘caries management by risk assessment’ or ‘CAMBRA’ will be used to describe this risk-based approach to prevent, reverse and, when necessary, repair damage to teeth using minimally invasive methodologies (1). CAMBRA is not a trade name for products or a company, nor is it a caries risk assessment (CRA) form, it is a concept for managing dental caries and its manifestations. In its simplest form, it means (i) assessing the risk for future caries lesions, (ii) reducing the pathological factors, (iii) enhancing the protective factors, doi: 10.1111/cdoe.12031
Key words: caries; caries management; caries protocols; caries risk assessment; CAMBRA; remineralization Douglas A. Young, Department of Dental Practice, University of the Pacific, San Francisco, 2155 Webster St. Rm. 400, San Francisco, CA 94115, USA Tel.: +1 415 749 3308 Fax: +1 415 749 3339 e-mail: [email protected]
and (iv) minimally invasive restorative care resulting in control of the disease.
The caries balance/imbalance model The caries balance/imbalance model is a visual representation of the multifactorial nature of the dental caries disease. It illustrates the determining factors of caries disease, and it is the dynamic interaction of the biofilm with the oral environment. It is the local environment that determines how the biofilm will behave at any given tooth site and if the disease is severe enough to result in demineralization and visible changes to the tooth site. By collecting actual patient information about the patient’s unique caries balance an astute clinician can ‘assess’ the risk of future demineralization based on weighing all the disease indicators and risk factors against existing protective factors. This is process is called a CRA. The caries balance/imbalance (Fig. 1) is the balance among disease indicators, risk factors and
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Fig. 1. The caries balance/imbalance. Adapted from Featherstone JD et al. (2)
protective factors and determines whether dental caries progresses, halts, or reverses. Refer to Appendix and the text below for more detail on disease indicators. Cavities/dentin refers to frank cavities or lesions well into the dentin by radiograph. Restorations 3 times daily) snacking between meals, (iv) deep pits and fissures, (v) recreational drug use, (vi) inadequate saliva flow by observation or measurement, (vii) saliva reducing factors (medications/radiation/ systemic), (viii) exposed roots, and (ix) orthodontic appliances.
Caries protective factors Caries protective factors are biological or therapeutic factors that can collectively offset the pathologic challenge presented by the above caries risk factors (also refer to Appendix). The more severe the caries risk factors are, the higher the intensity of protective factors must be to keep the patient in balance or to reverse the caries process. Figure 1 only lists a few that are known to be highly protective and can be remembered by ‘SAFER’. They are as follows: Saliva and sealants Antibacterials Fluoride and calcium/phosphate (as supportive to fluoride not a replacement) (9) Effective lifestyle habits Risk-based reassessment Industry is responding to the need for more and better products to treat dental caries disease and the current list in Appendix is sure to expand in the near future. Currently, the protective factors listed in Appendix are as follows: (i) lives/work/ school located in a fluoridated community, (ii) fluoride toothpaste at least once daily, (iii) fluoride toothpaste at least two times daily, (iv) fluoride mouthrinse (0.05% NaF) daily, (v) 5000 ppm F fluoride toothpaste daily, (vi) fluoride varnish in last 6 months, (vii) office fluoride topical in last 6 months, (viii) chlorhexidine prescribed/used
daily for 1 week each of last 6 months or other antibacterial agent of choice based on current evidence. (ix) xylitol gum/lozenges four times daily in the last 6 months, (x) calcium and phosphate supplement paste during last 6 months, and (xi) adequate saliva flow (>1 ml/min stimulated). Fluoride toothpaste frequency is included as studies have shown that brushing twice daily or more is significantly more effective than once a day or less (10). Any or all of these protective factors can contribute to keep the patient ‘in balance’ and to enhance remineralization, which is the natural repair process of the early carious lesion.
Hard tissue exam and charting (by location, severity, and activity) The existence of previous or current disease is the highest predictor of future disease. Therefore a careful hard tissue exam must precede the CRA to detect signs of previous or existing caries disease (disease indicators). There are many ways to record hard tissue findings. The following example is a simple approach that mimics clinical practice and considers both precavitated and cavitated caries lesions. Occlusal: chart ICDAS Codes (11) noting deep pits or fissures. See Table 2 (For description of ICDAS for clinical practice see http:// www.icdas.org/clinical-practice) Approximal: chart depth of lesions noted on bitewing radiographs as E1, E2, D1, D2, or D3 and note activity if possible (see approximal lesion management later this article) Facial/Lingual; visual and tactile exam (round end of explorer or ball ended probe) noting: (i) active white spots (dull, rough surface) (ii) inactive white spots (smooth, shiny and hard) (iii) active brown spots (tan to tooth colored, dull, rough surface) (iv) inactive brown spots (smooth, shiny, and hard) (v) cavitations still in enamel (vi) cavitations extending into dentin
• • •
Caries risk assessment A CRA is simply a way to formalize and expand upon the patient’s caries balance/imbalance in the most predicable fashion to diagnose current caries
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disease, to help predict future disease, and to determine what factors are out of balance so evidence-based clinical decisions can be made (8, 12). The CRA may draw upon relevant historical data of the patient such as medical history (medications and systematic disease), dental history (previous caries experience), social history (recreational drugs, alcohol, smoking), dietary history, and any other personal or cultural habits that could contribute to caries disease. Lastly, a CRA may also include additional tests such as saliva/pH/buffer assessment and bacterial load assessment. These test all have lower levels of evidence, yet the real benefit may be as a teaching and motivating tool to help modify patient behaviors. Implementation of a CRA in clinical practice is best carried out by the use of a CRA form, insuring each patient will be systematically assessed in the same manner, which is based on the best available research. The CRA form presented here is based upon published science and outcomes measures of the use of the form (5, 6). The items in the form have been trimmed to include only those that had significant relationships to the onset of future cavitation in thousands of patients. The aim is to keep the form and procedure as simple and rapid as possible for use in practice, to keep to one page, and to have only proven components included. The CRA form presented here is based on the caries balance/imbalance theory, and the factors evaluated were discussed previously. Although there are several published CRA forms, the one shown in Appendix was chosen to use as an example in this manuscript because the content of the form and the procedures have been validated by published outcomes research using a large cohort of patients (5, 6). The included items all had statistically significant odds ratios relating to the future onset of cavitation. To use the form (Appendix): Simply circle the Yes answers, count them up and visualize how these will affect the balance at the bottom of the form. Some clinicians have reported improved results by engaging the patient early by handing out the form in the reception room and letting them self-select answers for questions they are familiar with. This allows the practitioner to readily determine low, moderate, high, or extreme risk while saving valuable time as well. Extreme risk is high risk plus major salivary dysfunction (hyposalivation). Low risk should indicate that there is a very low risk of future dental caries disease, provided no deleterious changes are made. On the
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other hand, high risk indicates the high likelihood of new caries lesions in the near future (a year or 2). If there is doubt about low or high risk, then the classification is moderate. There are several other versions of CRA forms available, and clinical outcomes of using many risk indicators and factors are summarized in a systematic review by Zero et al. (13). In addition, there are differences in the relative predictive value given to different factors in the literature (e.g., according the 2001 NIH Consensus Conference on Dental Caries, presence of mutant streptococci alone is no more than weakly predictive of clinical caries activity) (14). However, none of these other forms have published outcomes results. The ADA offers caries assessment forms for patients 0–6 years old, and those over 6 years of age. The forms can be found here: http://www.ada.org/sections/professionalResources/pdfs/topic_caries_over6.pdf. In addition, the AAPD also offers their form for children under 6 at: http://www.ada.org/sections/professionalResources/pdfs/topics_caries_under6.pdf. All these forms vary from each other in some way or another; however, all of them agree that caries experience is the strongest predictor of future caries disease, even though they may use different variables to describe caries experience. In addition, they all measure the other etiological factors involved in the disease in some manner; the weight that these other factors receive varies from form to form, in part because the literature on risk assessment (except for past caries experience) is very limited. Any CRA form should systematically ‘weigh’ the factors research has proven to be pathogenic against the protective factors that are known to protect from caries disease. The astute clinician can then manipulate these environmental factors via treatment interventions that will tip the caries balance to favor health. As not all factors have equal predictive value, the questions used in any CRA form must be ‘weighted’ is some fashion. The weighting system shown in Appendix is a visual weighting system created by the three-column format based on outcomes research and statistical odds ratios mentioned previously. Other forms may use a mathematical weighting system. The end result of any CRA is to combine historical and current clinical data, information from the CRA form, including any additional test such as saliva or pH assessment and bacterial load assessment, to ultimately allow a determination of an
Caries management by risk assessment
overall caries risk for your patient. This will help establish a caries disease diagnosis and disease activity level (caries active or caries inactive). Caries risk changes with time and needs to be reassessed as time goes on.
Chemical intervention protocols Once caries risk diagnosis is made (low, moderate, high, or extreme risk), there must be therapeutic intervention protocols attached to the risk level for that patient, so that treatment options along with prognosis can be presented to the patient and a treatment plan formulated. The level and type of risk is used to determine the level and type of corrective therapeutic intervention. Note that currently there is no consensus on correct treatment protocol, just as there is no one correct way to assess the caries risk of the patient. The process of management based on caries risk was recently validated by a randomized clinical trial where the test group using CRA, based on salivary fluoride levels and bacterial load (MS and LB), to drive chemical treatment decisions (chlorhexidine and/or fluoride) had lower mean caries increment compared to the control group, which did not employ risk assessment or chemical based treatments (restorative only) (8). The fact that multiple treatment interventions may be necessary to treat a complex multifactorial disease, by nature does not lend itself well to future randomized clinical trials and systematic reviews. With that said, Table 1 lists an example protocol of interventions that could be used based on the caries risk level of the patient. Table 1 is a modified version of an example protocol previously published for age 6 to adult based on caries risk category (10). The eight interventions summarized in Table 1 are the following: (i) sealants (resin-based or glass ionomer), (ii) saliva assessment (flow and bacterial load measurement), (iii) antibacterials, (iv) fluoride, (v) factors favorable for remineralization (pH control calciumphosphate topical supplements), (vi) effective lifestyle habits, (vii) frequency of radiographs, and (viii) frequency of caries recare exams (Table 1).
Minimally invasive restorative options Caries risk assessment should be a mandatory part of every initial examination and every caries
re-care appointment, because caries risk is likely to change with time. If an interventive therapy is applied successfully, the aim is to lower the caries risk. Once a caries risk diagnosis is made, appropriate prevention or therapeutic protocols are started based on caries risk (low, moderate, high or extreme risk). If caries lesions (precavitated or cavitated) are present, the decision to treat chemically versus surgically based on the site, extent, and activity of the caries lesion must be made (see summary Table 3). This requires early detection and precise terminology (refer to previous mentioned Hard Tissue Exam and Charting). Bacteria are physically too large to fit into diffusion channels of intact enamel; thus, intact enamel prevents bacterial ingress into the dentin. In contrast, cavitation through the enamel should trigger surgical procedures. Caries risk status may or may not have any bearing on the restorative phase of treatment; it is not an absolute requirement. At the occlusal site, the ICDAS system may help determine the extent of preventive and/or restorative treatment (see Table 2). Caries risk status may help drive the decision to place a sealant or not (e.g., sealants are a recommended option for high caries risk patients) (15). On the approximal surface, most dentists rely heavily on the bitewing radiograph (conventional or digital). Based on a review of the scientific literature American Dental Association Council on Scientific Affairs determined that the diagnostic quality of digital images is comparable to that of conventional films (16–18). One way to record radiographic radiolucency depth is to divide the enamel in half (E1 = outer ½ of enamel. E2 = inner ½ of enamel) and dentin into thirds (D1 = outer 1/3 of dentin, D2 = middle 1/3 of dentin, and D3 = inner 1/3 of dentin). Radiographic radiolucency in the enamel (E1, E2) have low chance of being cavitated (14) and should be treated chemically. If left untreated therapeutically, the likelihood of progressing to cavitation is high (6). Radiographic radiolucency well into dentin (D2, D3) is more likely cavitated (14) and should be restored. It is the radiographic radiolucencies that just penetrate the dentinal enamel junction (D1), which trouble many dentists. Many were taught in dental school that early D1 lesions are the ‘ideal board patient’, yet most of these lesions may not be cavitated. In the US, activity of these lesions is rarely considered and the use of elastomeric separation to confirm cavitation is
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Not indicated (optional for primary prevention of at risk deep pits and fissures) Sealants are recommended per ICDAS code (see Table 3) for secondary prevention
Low risk
Low resting pH, low stimulated flow or pH may indicate need for supplementation
OTC fluoride toothpaste used bid OTC fluoride toothpaste used bid. 0.05% NaF rinse bid. Varnish applied every 4–6 months 5000 ppm toothpaste used od or bid. 0.05% NaF rinse bid. Varnish applied every 3–4 months
Not indicated
Xylitol therapy 2–3 times/day for a total daily dose of 6–10 g If patient has high levels of acidogenic bacteria then treating with the following agents it must be understood that the evidence is very limited for antibacterials and pH neutralization, such as chlorhexidine, sodium hypochlorite, povidine iodine, essential oils, per manufacturer ’s instructions. Retest bacterial load test in 1 month, discuss and motivate patient, and repeat as needed
Saliva testing is optional or may be done for purposes of baseline records Measure resting and stimulated flow and pH especially if hyposalivation is suspected Objective measurement of acidogenic bacterial load via culturing or direct measurement of plaque ATP Consider supplementing if topical fluoride alone is not effective Required if xerostomia is three present
Recession or sensitive roots may indicate need for supplementation
Fluoride (topical)
Factors favorable for remineralization (pH, Ca2+ and PO34 )
Antibacterials
F
Saliva
A
Encourage healthy dietary habits, low frequency of fermentable carbohydrates, adequate protein intake and effective oral hygiene practices using motivational interviewing techniques. Substitute xylitol for sucrose
Effective lifestyle habits
E
Every 4–6 months
Every 3–4 months
Every 18–24 months
Every 6–18 months
Every 3 months
Every 6 months
Every 24–36 months
Every 6 months until no new caries lesions
Recare
Radiographs
R
Patients with one (or more) cavitated lesion(s) are high risk patients. Patients with one (or more) cavitated lesion(s) and hyposalivation are extreme risk patients. All restorative work to be done with the minimally invasive philosophy in mind. Existing smooth surface lesions that do not significantly penetrate the DEJ and are not cavitated should be treated chemically not surgically. For extreme risk patients with multiple cavitations, some choose to use caries control procedures with glass ionomer materials until caries progression is halted and/or reversed followed my more permanent restorative care. Patients with appliances (RPDs, Orthodontics) require excellent oral hygiene together with intensive fluoride therapy (e.g. high fluoride toothpaste and fluoride varnish every 3 months). If antibacterial therapy is tried, it should be done in conjunction with fluoride therapy (and every attempt be made not to interfere with the fluoride intervention). A 1 month initial treatment evaluation may be helpful for positive reinforcement. Patients must maintain good oral hygiene (a powered toothbrush may be helpful to high and extreme risk patients). A diet low in frequency of fermentable carbohydrates is recommended. It is important to know the amount of xylitol in the product being recommended. Xylitol products should contain 100% xylitol (daily dosages of 6–10 g/day for antimicrobial effects) and pose extreme health risks to family pets, especially dogs.
Extreme risk
High risk
Moderate risk
Sealants
Caries risk level
S
Table 1. SAFER CAMBRA example protocolfor patients 6-adult
Young & Featherstone
Caries management by risk assessment Table 2. Example occlusal protocola based on ICDAS code and caries risk level
a
All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined to enemel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part of the preparation in dentin and the preparation extends to a second surface (note: the second surface does not have to be in dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamel is immature, or where fissure preparation is not desired, or where rubber damn isolation is not practical. Patients should be given a choice in sealant placement and material selection. b Patients with one (or more) cavitated lesion(s) are high risk patients. c Patients with one (or more) cavitated lesion(s) and xerostomia are extreme risk patients. Adapted from Jenson et al. (11).
even more rare. At this site, caries risk status may not help in treatment decision. In other words, you should not justify surgical treatment based on high-risk status. All risk categories should receive the benefit of remineralization therapy on noncavitated lesions. On the facial and lingual surfaces, direct visual and tactile examination is possible, making the decision easy. It is also much easier to assess lesion activity and to monitor the progress of remineralization therapy. If restoration is necessary on the root area, a high-risk status may preclude one to use a fluoride releasing material
such as conventional glass ionomer cement (Tables 2 and 3) (19).
Treatment planning and behavioral change Individualized, evidence-based treatment options along with prognosis is presented to the patient and decisions are made based on the patient’s wants and needs. Implementation of the treatment phase requires the clinician to assist the patient in modification of behaviors that favor health. This
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Young & Featherstone Table 3. Site specific risk-based management
SITE SPECIFIC RISK-BASED MANAGEMENT SITE
EXTENT Initial caries management stage (non-surgical approach)
OCCLUSAL SITE
ICDAS code 0
ICDAS code 1
Moderate caries management stage (*** minimal removal of caries and tissue)
ICDAS code 2
ICDAS code 3
ICDAS code 4
ICDAS code 5
Severe caries management stage (conventional restorative approach) ICDAS code 6
Management Low Risk: Sealants not indicated for inactive lesions; All Risk Levels: continue nonsurgical preventive maintenance; however Minimal removal of tooth structure to ensure adequate sealants may be considered optional for primary seal for dental material used. prevention of at risk (deep) pits and fissures. Moderate Risk: sealants recommended *High or ** Extreme Risk: sealants recommended APPROXIMAL SITE
Radiographic E0 ****
Management
Chemical treatment or preventive maintenance.
Chemical or preventive therapy. Demonstration of lesion progression or regression and/or elastomeric tooth separation preferred before surgical intervenƟon is considered.
Minimally invasive restoration probable (but not absolute) based on lesion progression, regression, or tooth separaƟon.
Minimally invasive restoration needed. Conservative caries removal when near the pulp; ensure adequate seal for dental material used.
Non-cavitated lesions InacƟve AcƟve
ParƟally cavitated lesions
Fully cavitated lesions
Fully cavitated lesions
ParƟally cavitated lesions May receive nonsurgical chemical therapy or minimally invasive restoraƟon depending on clinician and paƟent discussion of treatment opƟons.
Fully cavitated lesions
Fully cavitated lesions
FACIAL/LINGUAL SITE
(shiny, smooth)
Radiographic E1
Radiographic D1 (outer 1/3 dentin)
Radiographic D2 (middle 1/3 dentin)
All Risk Levels: Conservative caries removal when near the pulp; ensure adequate seal for dental material used. Radiographic D3 (inner 1/3 dentin)
(matt, rough)
Non-cavitated lesions Management AcƟve white or brown spot lesions receive chemical therapies based on caries risk assessment (CRA).
Minimally invasive restoraƟon
ConservaƟve caries removal when near the pulp; ensure adequate seal for dental material used.
Lesion activity assessment (adapted from Kim Ekstrand) (Parameters in red indicate activity; in black, no activity) – Initial caries risk status: high, moderate, or low; Visual appearance: cavitation/shadow, whitish, or brownish; Location of the lesion: plaque stagnation area, natural, or not; Tactile feeling: rough enamel/soft dentin, or smooth enamel/hard dentin; Gingival status (if the lesion is located near the gingiva): inflammation, bleeding on probing, or no inflammation, no bleeding on probing; surface luster: matt, shiny; Plaque: sticky, not sticky; Age of the lesion: 3 years. a All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined to enamel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part of the preparation in dentin and the preparation extends to a second surface (Note: the second surface does not have to be in dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamel is immature, or where fissure preparation is not desired, or where rubber dam isolation is not practical. Patients should be given a choice in sealant placement and material selection. b Patients with one (or more) cavitated lesion(s) are high risk patients. c Patients with one (or more) cavitated lesion(s) and xerostomia and/or hyposalivation are extreme risk patients. d Notations system used here: on bitewing radiographs as E1 (outer ½ of enamel), E2 (inner ½ of enamel), D1 (outer 1/3 of dentin), D2 (middle 1/3 of dentin), or D3 (inner 1/3 of dentin) and note the progression/regression from previous radiographs if possible #33.
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Caries management by risk assessment
will require skill in obtaining patient cooperation in use of the recommended therapeutic interventions. In doing so, it is important to give patients encouragement and clear instructions on what they need to do (20).
7.
8.
Summary Dental caries is a complex multifactorial disease that cannot be controlled by restoration alone (8). A CRA is a way to predict risk of future disease, but it is also a systematic way to identify factors that are out of balance that could lead to demineralization on a susceptible patient. To assist the clinician in assessing caries risk, several forms and procedures are in existence, of which one form and one example protocol was used in this paper to illustrate the science of caries management by risk assessment, CAMBRA. CAMBRA is not a trade name for products or a company, nor is it a CRA form, it is a concept for managing dental caries and its manifestations. In its simplest form it means (i) assessing the risk for future cries lesions, (ii) reducing the pathological factors, (iii) enhancing the protective factors, and (iv) minimally invasive restorative care resulting in control of the disease.
9.
10.
11.
12. 13. 14.
15.
References 1. Young DA, Featherstone JD, Roth JR, Anderson M, Autio-Gold J, Christensen GJ et al. Caries management by risk assessment: implementation guidelines. J Calif Dent Assoc 2007;35:799–805. 2. Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc 2007;35:703–7, 10–3. 3. Featherstone JD. The caries balance: contributing factors and early detection. J Calif Dent Assoc 2003;31:129–33. 4. Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31–40. 5. Domejean-Orliaguet S, Gansky SA, Featherstone JD. Caries risk assessment in an educational environment. J Dent Educ 2006;70:1346–54. 6. Domejean S, White JM, Featherstone JD. Validation of the cda cambra caries risk assessment – a six-year
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19. 20.
retrospective study. J Calif Dent Assoc 2011;39: 709–15. Featherstone JDB, Gansky SA, Hoover CI, RapozoHilo M, Weintraub JA, Wilson RS et al. A randomized clinical trial of caries management by risk assessment. Caries Res 2005;39:295 (abstract #25). Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS et al. A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment). Caries Res 2012;46:118–29. Rethman MP, Beltran-Aguilar ED, Billings RJ, Hujoel PP, Katz BP, Milgrom P et al. Nonfluoride caries-preventive agents: executive summary of evidencebased clinical recommendations. J Am Dent Assoc 2011;142:1065–71. Curnow MM, Pine CM, Burnside G, Nicholson JA, Chesters RK, Huntington E. A randomised controlled trial of the efficacy of supervised toothbrushing in high-caries-risk children. Caries Res 2002;36:294–300. Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez FJ, Spolsky VW, Young DA. Clinical protocols for caries management by risk assessment. J Calif Dent Assoc 2007;35:714–23. Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent 2004;2(Suppl 1):259–64. Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ 2001;65:1126–32. Diagnosis and management of dental caries throughout life. National Institutes of Health Consensus Development Conference Statement, March 26–28, 2001. J Dent Educ 2001;65:1162–8. Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal R, Gooch B et al. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the american dental association council on scientific affairs. J Am Dent Assoc 2008;139:257–68. American Dental Association Council on Scientific Affairs. The use of dental radiographs: update and recommendations. J Am Dent Assoc 2006;137: 1304–12. White SC, Yoon DC. Comparative performance of digital and conventional images for detecting proximal surface caries. Dentomaxillofac Radiol 1997;26:32–8. Syriopoulos K, Sanderink GC, Velders XL, van der Stelt PF. Radiographic detection of approximal caries: a comparison of dental films and digital imaging systems. Dentomaxillofac Radiol 2000;29:312–8. Young DA. The use of glass ionomers as a chemical treatment for caries. Pract Proced Aesthet Dent 2006;18:248–50. Peltier B, Weinstein P, Fredekind R. Risky business: influencing people to change. J Calif Dent Assoc 2007;35:794–8.
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Appendix Appendix 1. Caries risk assessment form for ages 6 years through adult. Adapted from Featherstone JD et al. (2) Patient Name: Assessment Date:
CHART #: DATE: Is this (please circle) Baseline or Recall
Disease Indicators (Any one YES signifies likely “High Risk” and to do a bacteria load test**) New/Progressing visible cavitations or radiolucencies into dentin New/Progressing approximal enamel Lesions by radiograph New/Active White spots on smooth surfaces Restoration for caries lesion in the last 3 years (for initial exam or within the last 1 year for recall/POE exam)
YES = CIRCLE YES
YES = CIRCLE
YES= CIRCLE
YES YES YES
Risk Factors (Biological predisposing factors) MS and LB both medium or high (by culture or ATP bioluminescence **) Visible heavy plaque on teeth Frequent snack (> 3x daily between meals) Deep pits and fissures Recreational drug use Inadequate saliva flow by observation or measurement (**If measured note the flow rate below) Saliva reducing factors (medications/radiation/systemic) Exposed roots Orthodontic appliances
YES YES YES YES YES YES YES YES YES
Protective Factors Lives/work/school fluoridated community YES Fluoride toothpaste at least once daily YES Fluoride toothpaste at least 2x daily YES Fluoride mouthrinse (0.05% NaF) daily YES 5000 ppm F fluoride toothpaste daily YES Fluoride varnish in last 6 months YES Office F topical in last 6 months YES Chlorhexidine prescribed/used one week each of last 6 YES months Xylitol gum/lozenges 4x daily last 6 months YES Calcium and phosphate paste during last 6 months YES Adequate saliva flow (> 1 ml/min stimulated) YES ** Biofilm Assessment: ATP bioluminescence: _______ or culture MS:_______LB:_______ Stimulated Salivary Flow Rate:_______ ml/min. Stimulated pH______ Date: _________ Resting Salivary Flow Rate: _______ ml/min. Resting pH ________ Date: _________ Buffering Capacity test:______________Consistency of resting saliva: thick-stringy-ropey vs watery VISUALIZE CARIES BALANCE (Use circled indicators/factors above) (EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION) CARIES RISK ASSESSMENT (CIRCLE): EXTREME HIGH MODERATE
Doctor signature/#:
How tooth decay happens (to be given to each patient) Tooth decay is caused by acid-producing bacteria that live in your mouth. The bacteria feed on what you eat, especially sugars (including fruit sugars) and cooked starch (bread, potatoes, rice, pasta,
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LOW
Date:
etc.). Within just a few minutes after you eat, or drink, the bacteria begin producing acids as a byproduct of their digesting your food. Those acids can penetrate and dissolve the minerals (calcium and phosphate) in your teeth. If the acid attacks are infrequent and of short duration, your saliva can
Caries management by risk assessment
help to repair the damage by neutralizing the acids and supplying minerals and fluoride that can replace those lost from the tooth. However if: (i) your mouth is dry, (ii) you have too much acid exposure, or (iii) you snack frequently, then the tooth mineral lost by attacks of acids is too great and cannot be repaired. This is the start of tooth decay and leads to cavities.
bad bacteria that cause tooth decay and can be useful in patients at high risk for tooth decay. Fluorides. Fluorides help to make the tooth more resistant to being dissolved by the bacterial acids. Fluorides are available from a variety of sources such as drinking water, toothpaste, over-the-counter rinses, and products prescribed by your dentist such as brush-on gels or high-fluoride toothpastes used at home or gels, foams, and varnishes applied in the dental office. Daily use is very important to help protect against the acid attacks. Factors favorable for remineralization. Calcium and phosphate at the proper pH is necessary for tooth repair. Normally, this is carried out by your saliva but when you have a lack of saliva (dry mouth) or when fluoride alone is not effective, you may consider supplementing with calcium/phosphate and acid-neutralizing products.
Methods of controlling tooth decay Saliva. Saliva is critical for controlling tooth decay. It neutralizes acids and provides minerals and proteins that protect the teeth. If you cannot brush after a meal or snack, you can rinse or chew some sugarfree gum. This will stimulate the flow of saliva to help neutralize acids and bring lost minerals back to the teeth. Sugar-free candy or mints could also be used, but some of these contain acids themselves. These acids will not cause tooth decay, but they can slowly dissolve the enamel surface directly over time (a process called erosion). Some sugar-free gums are designed to help fight tooth decay and are particularly useful if you have a dry mouth (many medications can cause a dry mouth). Some gums contain baking soda that neutralizes the acids produced by the bacteria in plaque. Sealants. Sealants are plastic or glass ionomer coatings bonded to the biting surfaces of back teeth to protect the deep grooves from decay. In some people, the grooves on the surfaces of the teeth are too narrow and deep to clean with a toothbrush, so they may decay in spite of your best efforts. Sealants are an excellent preventive measure used for children and young adults at risk for this type of decay. They do not last forever and should be inspected once a year and replaced if needed.
Effective lifestyle habits. Improving diet by reducing the number of sugary and starchy foods, snacks, drinks, or candies can help reduce the development of tooth decay. That does not mean you can never eat these types of foods, but you should limit their consumption particularly when eaten between main meals. Gum that contains xylitol as its first listed ingredient will stimulate saliva and is the gum of choice. If you have a dry mouth, you could also fill a drinking bottle with water and add a couple teaspoons of baking soda for each 8 ounces of water and swish and spit with it frequently throughout the day. Toothpastes containing baking soda are also available by several companies. Effective oral hygiene practices plaque removal: Removing the plaque from your teeth on a daily basis is helpful in controlling tooth decay. Plaque can be difficult to remove from some parts of your mouth especially between the teeth and in grooves on the biting surfaces of back teeth. If you have an appliance such as an orthodontic retainer or partial denture, remove it before brushing your teeth. Brush all surfaces of the appliance also.
Antibacterial mouth rinses. Rinses that your dentist can prescribe are able to reduce the numbers of
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Community Dent Oral Epidemiol 2012; 41; e53–e63 All rights reserved
Caries management by risk assessment
Douglas A. Young1 and John D. B. Featherstone2 1 Department of Dental Practice, University of the Pacific, San Francisco, CA, USA, 2 School of Dentistry, University of California, San Francisco, CA, USA
Young DA, Featherstone JDB. Caries management by risk assessment. Community Dent Oral Epidemiol 2013; 41: 1–12. © 2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd Abstract – Caries disease is multifactorial. Whether caries disease will be expressed and damage dental hard tissue is dependent on the patient’s own unique make-up of pathogenic risk factors and protective factors. Objectives: This manuscript will review the science of managing caries disease based on assessing caries risk. Methods: The caries balance/imbalance model and a practical caries risk assessment procedure for patients aged 6 years through adult will illustrate how treatment options can be based on caries risk. Results: Neither the forms nor the clinical protocols are meant to imply there is currently only one correct way this can be achieved, rather are used in this manuscript as examples only. Conclusions: It is important to have the forms and protocols simple and easy to understand when implementing caries management by risk assessment into clinical practice. The science of CAMBRA based on the caries balance/imbalance model was reviewed and an example protocol was presented.
The caries management by risk assessment (CAMBRA) philosophy is built on the understanding that dental caries is a disease initiated by a complex biofilm (rather than any one pathogen), which changes dynamically with its environment and the local chemistry of the tooth site, pellicle, and saliva. This is in stark contrast to the classic medical model of ‘one pathogen-one disease’, thus, rather than focusing on the elimination of any one pathogen, caries management must determine which of many factors is causing the expression of disease and takes corrective action. For purposes of this paper, the phrase ‘caries management by risk assessment’ or ‘CAMBRA’ will be used to describe this risk-based approach to prevent, reverse and, when necessary, repair damage to teeth using minimally invasive methodologies (1). CAMBRA is not a trade name for products or a company, nor is it a caries risk assessment (CRA) form, it is a concept for managing dental caries and its manifestations. In its simplest form, it means (i) assessing the risk for future caries lesions, (ii) reducing the pathological factors, (iii) enhancing the protective factors, doi: 10.1111/cdoe.12031
Key words: caries; caries management; caries protocols; caries risk assessment; CAMBRA; remineralization Douglas A. Young, Department of Dental Practice, University of the Pacific, San Francisco, 2155 Webster St. Rm. 400, San Francisco, CA 94115, USA Tel.: +1 415 749 3308 Fax: +1 415 749 3339 e-mail: [email protected]
and (iv) minimally invasive restorative care resulting in control of the disease.
The caries balance/imbalance model The caries balance/imbalance model is a visual representation of the multifactorial nature of the dental caries disease. It illustrates the determining factors of caries disease, and it is the dynamic interaction of the biofilm with the oral environment. It is the local environment that determines how the biofilm will behave at any given tooth site and if the disease is severe enough to result in demineralization and visible changes to the tooth site. By collecting actual patient information about the patient’s unique caries balance an astute clinician can ‘assess’ the risk of future demineralization based on weighing all the disease indicators and risk factors against existing protective factors. This is process is called a CRA. The caries balance/imbalance (Fig. 1) is the balance among disease indicators, risk factors and
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Fig. 1. The caries balance/imbalance. Adapted from Featherstone JD et al. (2)
protective factors and determines whether dental caries progresses, halts, or reverses. Refer to Appendix and the text below for more detail on disease indicators. Cavities/dentin refers to frank cavities or lesions well into the dentin by radiograph. Restorations 3 times daily) snacking between meals, (iv) deep pits and fissures, (v) recreational drug use, (vi) inadequate saliva flow by observation or measurement, (vii) saliva reducing factors (medications/radiation/ systemic), (viii) exposed roots, and (ix) orthodontic appliances.
Caries protective factors Caries protective factors are biological or therapeutic factors that can collectively offset the pathologic challenge presented by the above caries risk factors (also refer to Appendix). The more severe the caries risk factors are, the higher the intensity of protective factors must be to keep the patient in balance or to reverse the caries process. Figure 1 only lists a few that are known to be highly protective and can be remembered by ‘SAFER’. They are as follows: Saliva and sealants Antibacterials Fluoride and calcium/phosphate (as supportive to fluoride not a replacement) (9) Effective lifestyle habits Risk-based reassessment Industry is responding to the need for more and better products to treat dental caries disease and the current list in Appendix is sure to expand in the near future. Currently, the protective factors listed in Appendix are as follows: (i) lives/work/ school located in a fluoridated community, (ii) fluoride toothpaste at least once daily, (iii) fluoride toothpaste at least two times daily, (iv) fluoride mouthrinse (0.05% NaF) daily, (v) 5000 ppm F fluoride toothpaste daily, (vi) fluoride varnish in last 6 months, (vii) office fluoride topical in last 6 months, (viii) chlorhexidine prescribed/used
daily for 1 week each of last 6 months or other antibacterial agent of choice based on current evidence. (ix) xylitol gum/lozenges four times daily in the last 6 months, (x) calcium and phosphate supplement paste during last 6 months, and (xi) adequate saliva flow (>1 ml/min stimulated). Fluoride toothpaste frequency is included as studies have shown that brushing twice daily or more is significantly more effective than once a day or less (10). Any or all of these protective factors can contribute to keep the patient ‘in balance’ and to enhance remineralization, which is the natural repair process of the early carious lesion.
Hard tissue exam and charting (by location, severity, and activity) The existence of previous or current disease is the highest predictor of future disease. Therefore a careful hard tissue exam must precede the CRA to detect signs of previous or existing caries disease (disease indicators). There are many ways to record hard tissue findings. The following example is a simple approach that mimics clinical practice and considers both precavitated and cavitated caries lesions. Occlusal: chart ICDAS Codes (11) noting deep pits or fissures. See Table 2 (For description of ICDAS for clinical practice see http:// www.icdas.org/clinical-practice) Approximal: chart depth of lesions noted on bitewing radiographs as E1, E2, D1, D2, or D3 and note activity if possible (see approximal lesion management later this article) Facial/Lingual; visual and tactile exam (round end of explorer or ball ended probe) noting: (i) active white spots (dull, rough surface) (ii) inactive white spots (smooth, shiny and hard) (iii) active brown spots (tan to tooth colored, dull, rough surface) (iv) inactive brown spots (smooth, shiny, and hard) (v) cavitations still in enamel (vi) cavitations extending into dentin
• • •
Caries risk assessment A CRA is simply a way to formalize and expand upon the patient’s caries balance/imbalance in the most predicable fashion to diagnose current caries
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disease, to help predict future disease, and to determine what factors are out of balance so evidence-based clinical decisions can be made (8, 12). The CRA may draw upon relevant historical data of the patient such as medical history (medications and systematic disease), dental history (previous caries experience), social history (recreational drugs, alcohol, smoking), dietary history, and any other personal or cultural habits that could contribute to caries disease. Lastly, a CRA may also include additional tests such as saliva/pH/buffer assessment and bacterial load assessment. These test all have lower levels of evidence, yet the real benefit may be as a teaching and motivating tool to help modify patient behaviors. Implementation of a CRA in clinical practice is best carried out by the use of a CRA form, insuring each patient will be systematically assessed in the same manner, which is based on the best available research. The CRA form presented here is based upon published science and outcomes measures of the use of the form (5, 6). The items in the form have been trimmed to include only those that had significant relationships to the onset of future cavitation in thousands of patients. The aim is to keep the form and procedure as simple and rapid as possible for use in practice, to keep to one page, and to have only proven components included. The CRA form presented here is based on the caries balance/imbalance theory, and the factors evaluated were discussed previously. Although there are several published CRA forms, the one shown in Appendix was chosen to use as an example in this manuscript because the content of the form and the procedures have been validated by published outcomes research using a large cohort of patients (5, 6). The included items all had statistically significant odds ratios relating to the future onset of cavitation. To use the form (Appendix): Simply circle the Yes answers, count them up and visualize how these will affect the balance at the bottom of the form. Some clinicians have reported improved results by engaging the patient early by handing out the form in the reception room and letting them self-select answers for questions they are familiar with. This allows the practitioner to readily determine low, moderate, high, or extreme risk while saving valuable time as well. Extreme risk is high risk plus major salivary dysfunction (hyposalivation). Low risk should indicate that there is a very low risk of future dental caries disease, provided no deleterious changes are made. On the
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other hand, high risk indicates the high likelihood of new caries lesions in the near future (a year or 2). If there is doubt about low or high risk, then the classification is moderate. There are several other versions of CRA forms available, and clinical outcomes of using many risk indicators and factors are summarized in a systematic review by Zero et al. (13). In addition, there are differences in the relative predictive value given to different factors in the literature (e.g., according the 2001 NIH Consensus Conference on Dental Caries, presence of mutant streptococci alone is no more than weakly predictive of clinical caries activity) (14). However, none of these other forms have published outcomes results. The ADA offers caries assessment forms for patients 0–6 years old, and those over 6 years of age. The forms can be found here: http://www.ada.org/sections/professionalResources/pdfs/topic_caries_over6.pdf. In addition, the AAPD also offers their form for children under 6 at: http://www.ada.org/sections/professionalResources/pdfs/topics_caries_under6.pdf. All these forms vary from each other in some way or another; however, all of them agree that caries experience is the strongest predictor of future caries disease, even though they may use different variables to describe caries experience. In addition, they all measure the other etiological factors involved in the disease in some manner; the weight that these other factors receive varies from form to form, in part because the literature on risk assessment (except for past caries experience) is very limited. Any CRA form should systematically ‘weigh’ the factors research has proven to be pathogenic against the protective factors that are known to protect from caries disease. The astute clinician can then manipulate these environmental factors via treatment interventions that will tip the caries balance to favor health. As not all factors have equal predictive value, the questions used in any CRA form must be ‘weighted’ is some fashion. The weighting system shown in Appendix is a visual weighting system created by the three-column format based on outcomes research and statistical odds ratios mentioned previously. Other forms may use a mathematical weighting system. The end result of any CRA is to combine historical and current clinical data, information from the CRA form, including any additional test such as saliva or pH assessment and bacterial load assessment, to ultimately allow a determination of an
Caries management by risk assessment
overall caries risk for your patient. This will help establish a caries disease diagnosis and disease activity level (caries active or caries inactive). Caries risk changes with time and needs to be reassessed as time goes on.
Chemical intervention protocols Once caries risk diagnosis is made (low, moderate, high, or extreme risk), there must be therapeutic intervention protocols attached to the risk level for that patient, so that treatment options along with prognosis can be presented to the patient and a treatment plan formulated. The level and type of risk is used to determine the level and type of corrective therapeutic intervention. Note that currently there is no consensus on correct treatment protocol, just as there is no one correct way to assess the caries risk of the patient. The process of management based on caries risk was recently validated by a randomized clinical trial where the test group using CRA, based on salivary fluoride levels and bacterial load (MS and LB), to drive chemical treatment decisions (chlorhexidine and/or fluoride) had lower mean caries increment compared to the control group, which did not employ risk assessment or chemical based treatments (restorative only) (8). The fact that multiple treatment interventions may be necessary to treat a complex multifactorial disease, by nature does not lend itself well to future randomized clinical trials and systematic reviews. With that said, Table 1 lists an example protocol of interventions that could be used based on the caries risk level of the patient. Table 1 is a modified version of an example protocol previously published for age 6 to adult based on caries risk category (10). The eight interventions summarized in Table 1 are the following: (i) sealants (resin-based or glass ionomer), (ii) saliva assessment (flow and bacterial load measurement), (iii) antibacterials, (iv) fluoride, (v) factors favorable for remineralization (pH control calciumphosphate topical supplements), (vi) effective lifestyle habits, (vii) frequency of radiographs, and (viii) frequency of caries recare exams (Table 1).
Minimally invasive restorative options Caries risk assessment should be a mandatory part of every initial examination and every caries
re-care appointment, because caries risk is likely to change with time. If an interventive therapy is applied successfully, the aim is to lower the caries risk. Once a caries risk diagnosis is made, appropriate prevention or therapeutic protocols are started based on caries risk (low, moderate, high or extreme risk). If caries lesions (precavitated or cavitated) are present, the decision to treat chemically versus surgically based on the site, extent, and activity of the caries lesion must be made (see summary Table 3). This requires early detection and precise terminology (refer to previous mentioned Hard Tissue Exam and Charting). Bacteria are physically too large to fit into diffusion channels of intact enamel; thus, intact enamel prevents bacterial ingress into the dentin. In contrast, cavitation through the enamel should trigger surgical procedures. Caries risk status may or may not have any bearing on the restorative phase of treatment; it is not an absolute requirement. At the occlusal site, the ICDAS system may help determine the extent of preventive and/or restorative treatment (see Table 2). Caries risk status may help drive the decision to place a sealant or not (e.g., sealants are a recommended option for high caries risk patients) (15). On the approximal surface, most dentists rely heavily on the bitewing radiograph (conventional or digital). Based on a review of the scientific literature American Dental Association Council on Scientific Affairs determined that the diagnostic quality of digital images is comparable to that of conventional films (16–18). One way to record radiographic radiolucency depth is to divide the enamel in half (E1 = outer ½ of enamel. E2 = inner ½ of enamel) and dentin into thirds (D1 = outer 1/3 of dentin, D2 = middle 1/3 of dentin, and D3 = inner 1/3 of dentin). Radiographic radiolucency in the enamel (E1, E2) have low chance of being cavitated (14) and should be treated chemically. If left untreated therapeutically, the likelihood of progressing to cavitation is high (6). Radiographic radiolucency well into dentin (D2, D3) is more likely cavitated (14) and should be restored. It is the radiographic radiolucencies that just penetrate the dentinal enamel junction (D1), which trouble many dentists. Many were taught in dental school that early D1 lesions are the ‘ideal board patient’, yet most of these lesions may not be cavitated. In the US, activity of these lesions is rarely considered and the use of elastomeric separation to confirm cavitation is
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Not indicated (optional for primary prevention of at risk deep pits and fissures) Sealants are recommended per ICDAS code (see Table 3) for secondary prevention
Low risk
Low resting pH, low stimulated flow or pH may indicate need for supplementation
OTC fluoride toothpaste used bid OTC fluoride toothpaste used bid. 0.05% NaF rinse bid. Varnish applied every 4–6 months 5000 ppm toothpaste used od or bid. 0.05% NaF rinse bid. Varnish applied every 3–4 months
Not indicated
Xylitol therapy 2–3 times/day for a total daily dose of 6–10 g If patient has high levels of acidogenic bacteria then treating with the following agents it must be understood that the evidence is very limited for antibacterials and pH neutralization, such as chlorhexidine, sodium hypochlorite, povidine iodine, essential oils, per manufacturer ’s instructions. Retest bacterial load test in 1 month, discuss and motivate patient, and repeat as needed
Saliva testing is optional or may be done for purposes of baseline records Measure resting and stimulated flow and pH especially if hyposalivation is suspected Objective measurement of acidogenic bacterial load via culturing or direct measurement of plaque ATP Consider supplementing if topical fluoride alone is not effective Required if xerostomia is three present
Recession or sensitive roots may indicate need for supplementation
Fluoride (topical)
Factors favorable for remineralization (pH, Ca2+ and PO34 )
Antibacterials
F
Saliva
A
Encourage healthy dietary habits, low frequency of fermentable carbohydrates, adequate protein intake and effective oral hygiene practices using motivational interviewing techniques. Substitute xylitol for sucrose
Effective lifestyle habits
E
Every 4–6 months
Every 3–4 months
Every 18–24 months
Every 6–18 months
Every 3 months
Every 6 months
Every 24–36 months
Every 6 months until no new caries lesions
Recare
Radiographs
R
Patients with one (or more) cavitated lesion(s) are high risk patients. Patients with one (or more) cavitated lesion(s) and hyposalivation are extreme risk patients. All restorative work to be done with the minimally invasive philosophy in mind. Existing smooth surface lesions that do not significantly penetrate the DEJ and are not cavitated should be treated chemically not surgically. For extreme risk patients with multiple cavitations, some choose to use caries control procedures with glass ionomer materials until caries progression is halted and/or reversed followed my more permanent restorative care. Patients with appliances (RPDs, Orthodontics) require excellent oral hygiene together with intensive fluoride therapy (e.g. high fluoride toothpaste and fluoride varnish every 3 months). If antibacterial therapy is tried, it should be done in conjunction with fluoride therapy (and every attempt be made not to interfere with the fluoride intervention). A 1 month initial treatment evaluation may be helpful for positive reinforcement. Patients must maintain good oral hygiene (a powered toothbrush may be helpful to high and extreme risk patients). A diet low in frequency of fermentable carbohydrates is recommended. It is important to know the amount of xylitol in the product being recommended. Xylitol products should contain 100% xylitol (daily dosages of 6–10 g/day for antimicrobial effects) and pose extreme health risks to family pets, especially dogs.
Extreme risk
High risk
Moderate risk
Sealants
Caries risk level
S
Table 1. SAFER CAMBRA example protocolfor patients 6-adult
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Caries management by risk assessment Table 2. Example occlusal protocola based on ICDAS code and caries risk level
a
All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined to enemel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part of the preparation in dentin and the preparation extends to a second surface (note: the second surface does not have to be in dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamel is immature, or where fissure preparation is not desired, or where rubber damn isolation is not practical. Patients should be given a choice in sealant placement and material selection. b Patients with one (or more) cavitated lesion(s) are high risk patients. c Patients with one (or more) cavitated lesion(s) and xerostomia are extreme risk patients. Adapted from Jenson et al. (11).
even more rare. At this site, caries risk status may not help in treatment decision. In other words, you should not justify surgical treatment based on high-risk status. All risk categories should receive the benefit of remineralization therapy on noncavitated lesions. On the facial and lingual surfaces, direct visual and tactile examination is possible, making the decision easy. It is also much easier to assess lesion activity and to monitor the progress of remineralization therapy. If restoration is necessary on the root area, a high-risk status may preclude one to use a fluoride releasing material
such as conventional glass ionomer cement (Tables 2 and 3) (19).
Treatment planning and behavioral change Individualized, evidence-based treatment options along with prognosis is presented to the patient and decisions are made based on the patient’s wants and needs. Implementation of the treatment phase requires the clinician to assist the patient in modification of behaviors that favor health. This
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Young & Featherstone Table 3. Site specific risk-based management
SITE SPECIFIC RISK-BASED MANAGEMENT SITE
EXTENT Initial caries management stage (non-surgical approach)
OCCLUSAL SITE
ICDAS code 0
ICDAS code 1
Moderate caries management stage (*** minimal removal of caries and tissue)
ICDAS code 2
ICDAS code 3
ICDAS code 4
ICDAS code 5
Severe caries management stage (conventional restorative approach) ICDAS code 6
Management Low Risk: Sealants not indicated for inactive lesions; All Risk Levels: continue nonsurgical preventive maintenance; however Minimal removal of tooth structure to ensure adequate sealants may be considered optional for primary seal for dental material used. prevention of at risk (deep) pits and fissures. Moderate Risk: sealants recommended *High or ** Extreme Risk: sealants recommended APPROXIMAL SITE
Radiographic E0 ****
Management
Chemical treatment or preventive maintenance.
Chemical or preventive therapy. Demonstration of lesion progression or regression and/or elastomeric tooth separation preferred before surgical intervenƟon is considered.
Minimally invasive restoration probable (but not absolute) based on lesion progression, regression, or tooth separaƟon.
Minimally invasive restoration needed. Conservative caries removal when near the pulp; ensure adequate seal for dental material used.
Non-cavitated lesions InacƟve AcƟve
ParƟally cavitated lesions
Fully cavitated lesions
Fully cavitated lesions
ParƟally cavitated lesions May receive nonsurgical chemical therapy or minimally invasive restoraƟon depending on clinician and paƟent discussion of treatment opƟons.
Fully cavitated lesions
Fully cavitated lesions
FACIAL/LINGUAL SITE
(shiny, smooth)
Radiographic E1
Radiographic D1 (outer 1/3 dentin)
Radiographic D2 (middle 1/3 dentin)
All Risk Levels: Conservative caries removal when near the pulp; ensure adequate seal for dental material used. Radiographic D3 (inner 1/3 dentin)
(matt, rough)
Non-cavitated lesions Management AcƟve white or brown spot lesions receive chemical therapies based on caries risk assessment (CRA).
Minimally invasive restoraƟon
ConservaƟve caries removal when near the pulp; ensure adequate seal for dental material used.
Lesion activity assessment (adapted from Kim Ekstrand) (Parameters in red indicate activity; in black, no activity) – Initial caries risk status: high, moderate, or low; Visual appearance: cavitation/shadow, whitish, or brownish; Location of the lesion: plaque stagnation area, natural, or not; Tactile feeling: rough enamel/soft dentin, or smooth enamel/hard dentin; Gingival status (if the lesion is located near the gingiva): inflammation, bleeding on probing, or no inflammation, no bleeding on probing; surface luster: matt, shiny; Plaque: sticky, not sticky; Age of the lesion: 3 years. a All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined to enamel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part of the preparation in dentin and the preparation extends to a second surface (Note: the second surface does not have to be in dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamel is immature, or where fissure preparation is not desired, or where rubber dam isolation is not practical. Patients should be given a choice in sealant placement and material selection. b Patients with one (or more) cavitated lesion(s) are high risk patients. c Patients with one (or more) cavitated lesion(s) and xerostomia and/or hyposalivation are extreme risk patients. d Notations system used here: on bitewing radiographs as E1 (outer ½ of enamel), E2 (inner ½ of enamel), D1 (outer 1/3 of dentin), D2 (middle 1/3 of dentin), or D3 (inner 1/3 of dentin) and note the progression/regression from previous radiographs if possible #33.
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will require skill in obtaining patient cooperation in use of the recommended therapeutic interventions. In doing so, it is important to give patients encouragement and clear instructions on what they need to do (20).
7.
8.
Summary Dental caries is a complex multifactorial disease that cannot be controlled by restoration alone (8). A CRA is a way to predict risk of future disease, but it is also a systematic way to identify factors that are out of balance that could lead to demineralization on a susceptible patient. To assist the clinician in assessing caries risk, several forms and procedures are in existence, of which one form and one example protocol was used in this paper to illustrate the science of caries management by risk assessment, CAMBRA. CAMBRA is not a trade name for products or a company, nor is it a CRA form, it is a concept for managing dental caries and its manifestations. In its simplest form it means (i) assessing the risk for future cries lesions, (ii) reducing the pathological factors, (iii) enhancing the protective factors, and (iv) minimally invasive restorative care resulting in control of the disease.
9.
10.
11.
12. 13. 14.
15.
References 1. Young DA, Featherstone JD, Roth JR, Anderson M, Autio-Gold J, Christensen GJ et al. Caries management by risk assessment: implementation guidelines. J Calif Dent Assoc 2007;35:799–805. 2. Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc 2007;35:703–7, 10–3. 3. Featherstone JD. The caries balance: contributing factors and early detection. J Calif Dent Assoc 2003;31:129–33. 4. Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31–40. 5. Domejean-Orliaguet S, Gansky SA, Featherstone JD. Caries risk assessment in an educational environment. J Dent Educ 2006;70:1346–54. 6. Domejean S, White JM, Featherstone JD. Validation of the cda cambra caries risk assessment – a six-year
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retrospective study. J Calif Dent Assoc 2011;39: 709–15. Featherstone JDB, Gansky SA, Hoover CI, RapozoHilo M, Weintraub JA, Wilson RS et al. A randomized clinical trial of caries management by risk assessment. Caries Res 2005;39:295 (abstract #25). Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS et al. A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment). Caries Res 2012;46:118–29. Rethman MP, Beltran-Aguilar ED, Billings RJ, Hujoel PP, Katz BP, Milgrom P et al. Nonfluoride caries-preventive agents: executive summary of evidencebased clinical recommendations. J Am Dent Assoc 2011;142:1065–71. Curnow MM, Pine CM, Burnside G, Nicholson JA, Chesters RK, Huntington E. A randomised controlled trial of the efficacy of supervised toothbrushing in high-caries-risk children. Caries Res 2002;36:294–300. Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez FJ, Spolsky VW, Young DA. Clinical protocols for caries management by risk assessment. J Calif Dent Assoc 2007;35:714–23. Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent 2004;2(Suppl 1):259–64. Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ 2001;65:1126–32. Diagnosis and management of dental caries throughout life. National Institutes of Health Consensus Development Conference Statement, March 26–28, 2001. J Dent Educ 2001;65:1162–8. Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal R, Gooch B et al. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the american dental association council on scientific affairs. J Am Dent Assoc 2008;139:257–68. American Dental Association Council on Scientific Affairs. The use of dental radiographs: update and recommendations. J Am Dent Assoc 2006;137: 1304–12. White SC, Yoon DC. Comparative performance of digital and conventional images for detecting proximal surface caries. Dentomaxillofac Radiol 1997;26:32–8. Syriopoulos K, Sanderink GC, Velders XL, van der Stelt PF. Radiographic detection of approximal caries: a comparison of dental films and digital imaging systems. Dentomaxillofac Radiol 2000;29:312–8. Young DA. The use of glass ionomers as a chemical treatment for caries. Pract Proced Aesthet Dent 2006;18:248–50. Peltier B, Weinstein P, Fredekind R. Risky business: influencing people to change. J Calif Dent Assoc 2007;35:794–8.
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Appendix Appendix 1. Caries risk assessment form for ages 6 years through adult. Adapted from Featherstone JD et al. (2) Patient Name: Assessment Date:
CHART #: DATE: Is this (please circle) Baseline or Recall
Disease Indicators (Any one YES signifies likely “High Risk” and to do a bacteria load test**) New/Progressing visible cavitations or radiolucencies into dentin New/Progressing approximal enamel Lesions by radiograph New/Active White spots on smooth surfaces Restoration for caries lesion in the last 3 years (for initial exam or within the last 1 year for recall/POE exam)
YES = CIRCLE YES
YES = CIRCLE
YES= CIRCLE
YES YES YES
Risk Factors (Biological predisposing factors) MS and LB both medium or high (by culture or ATP bioluminescence **) Visible heavy plaque on teeth Frequent snack (> 3x daily between meals) Deep pits and fissures Recreational drug use Inadequate saliva flow by observation or measurement (**If measured note the flow rate below) Saliva reducing factors (medications/radiation/systemic) Exposed roots Orthodontic appliances
YES YES YES YES YES YES YES YES YES
Protective Factors Lives/work/school fluoridated community YES Fluoride toothpaste at least once daily YES Fluoride toothpaste at least 2x daily YES Fluoride mouthrinse (0.05% NaF) daily YES 5000 ppm F fluoride toothpaste daily YES Fluoride varnish in last 6 months YES Office F topical in last 6 months YES Chlorhexidine prescribed/used one week each of last 6 YES months Xylitol gum/lozenges 4x daily last 6 months YES Calcium and phosphate paste during last 6 months YES Adequate saliva flow (> 1 ml/min stimulated) YES ** Biofilm Assessment: ATP bioluminescence: _______ or culture MS:_______LB:_______ Stimulated Salivary Flow Rate:_______ ml/min. Stimulated pH______ Date: _________ Resting Salivary Flow Rate: _______ ml/min. Resting pH ________ Date: _________ Buffering Capacity test:______________Consistency of resting saliva: thick-stringy-ropey vs watery VISUALIZE CARIES BALANCE (Use circled indicators/factors above) (EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION) CARIES RISK ASSESSMENT (CIRCLE): EXTREME HIGH MODERATE
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How tooth decay happens (to be given to each patient) Tooth decay is caused by acid-producing bacteria that live in your mouth. The bacteria feed on what you eat, especially sugars (including fruit sugars) and cooked starch (bread, potatoes, rice, pasta,
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etc.). Within just a few minutes after you eat, or drink, the bacteria begin producing acids as a byproduct of their digesting your food. Those acids can penetrate and dissolve the minerals (calcium and phosphate) in your teeth. If the acid attacks are infrequent and of short duration, your saliva can
Caries management by risk assessment
help to repair the damage by neutralizing the acids and supplying minerals and fluoride that can replace those lost from the tooth. However if: (i) your mouth is dry, (ii) you have too much acid exposure, or (iii) you snack frequently, then the tooth mineral lost by attacks of acids is too great and cannot be repaired. This is the start of tooth decay and leads to cavities.
bad bacteria that cause tooth decay and can be useful in patients at high risk for tooth decay. Fluorides. Fluorides help to make the tooth more resistant to being dissolved by the bacterial acids. Fluorides are available from a variety of sources such as drinking water, toothpaste, over-the-counter rinses, and products prescribed by your dentist such as brush-on gels or high-fluoride toothpastes used at home or gels, foams, and varnishes applied in the dental office. Daily use is very important to help protect against the acid attacks. Factors favorable for remineralization. Calcium and phosphate at the proper pH is necessary for tooth repair. Normally, this is carried out by your saliva but when you have a lack of saliva (dry mouth) or when fluoride alone is not effective, you may consider supplementing with calcium/phosphate and acid-neutralizing products.
Methods of controlling tooth decay Saliva. Saliva is critical for controlling tooth decay. It neutralizes acids and provides minerals and proteins that protect the teeth. If you cannot brush after a meal or snack, you can rinse or chew some sugarfree gum. This will stimulate the flow of saliva to help neutralize acids and bring lost minerals back to the teeth. Sugar-free candy or mints could also be used, but some of these contain acids themselves. These acids will not cause tooth decay, but they can slowly dissolve the enamel surface directly over time (a process called erosion). Some sugar-free gums are designed to help fight tooth decay and are particularly useful if you have a dry mouth (many medications can cause a dry mouth). Some gums contain baking soda that neutralizes the acids produced by the bacteria in plaque. Sealants. Sealants are plastic or glass ionomer coatings bonded to the biting surfaces of back teeth to protect the deep grooves from decay. In some people, the grooves on the surfaces of the teeth are too narrow and deep to clean with a toothbrush, so they may decay in spite of your best efforts. Sealants are an excellent preventive measure used for children and young adults at risk for this type of decay. They do not last forever and should be inspected once a year and replaced if needed.
Effective lifestyle habits. Improving diet by reducing the number of sugary and starchy foods, snacks, drinks, or candies can help reduce the development of tooth decay. That does not mean you can never eat these types of foods, but you should limit their consumption particularly when eaten between main meals. Gum that contains xylitol as its first listed ingredient will stimulate saliva and is the gum of choice. If you have a dry mouth, you could also fill a drinking bottle with water and add a couple teaspoons of baking soda for each 8 ounces of water and swish and spit with it frequently throughout the day. Toothpastes containing baking soda are also available by several companies. Effective oral hygiene practices plaque removal: Removing the plaque from your teeth on a daily basis is helpful in controlling tooth decay. Plaque can be difficult to remove from some parts of your mouth especially between the teeth and in grooves on the biting surfaces of back teeth. If you have an appliance such as an orthodontic retainer or partial denture, remove it before brushing your teeth. Brush all surfaces of the appliance also.
Antibacterial mouth rinses. Rinses that your dentist can prescribe are able to reduce the numbers of
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