The Core Curriculum in Cariology: Fiction or Reality? Challenges About Implementation.

INTRODUCTION: The Core Curriculum in Cariology (CCC) was developed by ORCA and ADEE in 2010. This article summarizes challenges for the implementation of the CCC at university/country level identified at the "Education Platform" of the ORCA 2022 conference in Cagliari, Sardinia. METHODS: Participants from Universities from 3 European (Italy, Poland, and UK), 2 Asian (India and Russia), and 3 American countries (Brazil, Colombia and USA) led the presentations, discussion, and generation of statements. Presentations were transcribed and summarized through qualitative content analysis. Key themes were identified, transformed into key topics, and sent to the panel for agreement. RESULTS: Regardless of the wide variety of dental schools per country, from few (Poland n=10) to many (India n=318, Brazil n=563), or from country/continent itself, frequent challenges to CCC implementation were highlighted. These included: lack of agreement on a basic CCC as standard (96%), insufficient support or reimbursement for caries prevention and management (90%), separation between cariology and restorative dentistry (68%), focus on restorative/surgical management with prevention and non-operative management being disconnected (73%). The group agreed that the integration of cariology and restorative dentistry remains essential to enhancing evidence-based decision-making, resulting in a shift of emphasis from cure to care. CONCLUSION: There is variation in the level of implementation of the CCC. A frequent challenge is the disconnect between cariology and restorative dentistry. The CCC should be disseminated and promoted as a uniform blueprint/framework to facilitate the implementation of a common cariology curriculum among universities within each country, as well as internationally.

Assessing the Acceptability of Less Invasive Caries Removal Techniques for treating Deep Carious Lesions: A Conjoint Survey among Dentists Practicing in a Midwestern American State.

This study identified factors that influence dentists' decisions regarding less invasive caries removal techniques such as stepwise removal (SW) and selective removal (SE) using a marketing research technique, conjoint analysis. A survey was sent to 1,434 dentists practicing in Iowa. Dentists were randomly assigned to receive a questionnaire to rate the likelihood they would use either SW/SE in hypothetical clinical scenarios. The scenarios were carefully created by conjoint design and included three relevant attributes: depth of lesion, hardness of carious dentin, and patient age. Descriptive and conjoint analyses were performed to assess trade-offs between these attributes, using SPSS. The study revealed that depth of lesion was the most important factor in the dentists' decisions (49 importance value) when choosing a SW to treat a deep carious lesion, followed by hardness of carious dentin and patient age (21 importance value). For the SE group, depth of the lesion was also the predominant factor when selecting a treatment. The study also identified that a high proportion of dentists (24.9%) indicated they would never consider using SW or SE under any circumstances. Our survey showed that depth of lesion was the most important reason to select a less invasive caries removal method. The high proportion of dentists indicating they would never consider selective caries removal (SE) techniques suggests that these less invasive options are underutilized.

Mutans Streptococci and Dental Caries: A New Statistical Modeling Approach.

Survival analyses have been used to overcome some of the limitations encountered with other statistical analyses. Although extended Cox hazard modeling with time-dependent variables has been utilized in several medical studies, it has never been utilized in assessing the complex relationship between mutans streptococci (MS) acquisition (time-dependent covariate) and time to having dental caries (outcome). This study involved secondary analyses of data from a prospective study conducted at the University of Alabama at Birmingham. Low socioeconomic status, African-American preschool children from Perry County, AL, USA (n = 95) had dental examinations at age 1 year and annually thereafter until age 6 years by three calibrated dentists. Salivary MS tests were done at ages 1, 1.5, 2, 2.5, 3, and 4 years. The patterns of and relationship between initial MS detection (time-dependent covariate) and dental caries experience occurrence were assessed, using extended Cox hazard modeling. The median time without MS acquisition (50% of the children not having positive MS test) was 2 years. Approximately 79% of the children had positive salivary MS tests by the age of 4 years. The median caries experience survival (50% of the children not having dental caries) was 4 years. During the follow-up period, 65 of the children (68.4%) had their initial primary caries experience. Results of the extended Cox hazard modeling showed a significant overall/global relationship between initial caries experience event at any given time during the follow-up period and having a positive salivary MS test at any time during the follow-up period (hazard ratio = 2.25, 95% CI 1.06-4.75). In conclusion, the extended Cox modeling was used for the first time and its results showed a significant global/overall relationship between MS acquisition and dental caries. Further research using causal mediation analysis with survival data is necessary, where the mediator "presence of MS" is treated as a time-dependent variable.

Factors Associated with Reevaluation of the Stepwise Excavation Procedure: An 8-Year Retrospective Study.

Although the stepwise excavation procedure (SWP) has been shown to be an effective caries treatment technique, studies reporting its application outside of controlled clinical trials are limited. We performed a retrospective study from patient record data to assess the proportion of patients who had an SWP reevaluated within 18 months at The University of Iowa College of Dentistry (UICOD) between 2004 and 2012, and evaluated the association between different variables and this outcome. A total of 1,985 SWPs were performed in 1,326 patients, with 518 patients having had reevaluation within 18 months. Bivariate analysis and logistic regression modeling revealed strong associations between explanatory variables such as provider type, tooth type, patient age, number of recalls and the calendar year in which the SWP was done and reevaluation status. There was also evidence of association with dental insurance status. Other characteristics such as gender, distance traveled to the UICOD, number of surfaces treated and tooth arch did not show any significant association. In general, patients were more likely to have reevaluation when seen by faculty members or residents, the procedure was performed in molars/pre-molars, they were older, they had more recalls and were seen earlier in the study period. These results suggest that decisions to use SWP should consider patient demographics and treatment characteristics such as provider level, tooth type, patient age and number of recalls. The impact of treatment year may reflect program heterogeneity or temporal changes in external societal factors.

Acceptance of Minimally Invasive Dentistry Among US Dentists in Public Health Practices.

PURPOSE: Little is known about use or acceptance of minimally invasive dentistry (MID) in the USA, particularly in public health settings. The purpose of this study was to assess opinions concerning MID among dentists in public-health practices. MATERIALS AND METHODS: A cross-sectional study was conducted to assess the views of dentists in public-health practices concerning MID using an online survey instrument among National Network for Oral Health Access (NNOHA) and American Association of Community Dental Programs (AACDP) members. Specific questions focused on diagnostic and preventive techniques, and whether MID was considered to meet the standard of care in the US Results: Overall, 86% believed that MID met the standard of care for primary teeth, and 77% did so for permanent teeth. The majority of respondents also agreed that fluoride varnish prevents caries and atraumatic restorative techniques (ART) are an effective caries treatment for children and adults. According to logistic regression results, dentists who had continuing education courses in MID and agreed that ART was an effective treatment for adults were more likely to report that MID met the standard of care for permanent teeth. Subjects who believed that fluoride varnish was effective as caries prevention for children were more likely to view MID as meeting the standard of care for primary teeth. CONCLUSIONS: There appears to be a paradigm shift toward a MID philosophy, and most responding public health dentists believed that MID meets the standard of care for primary and permanent teeth in the US.

Predictors of survival of large non-occlusal non-incisal glass-ionomer restorations in older adults.

PURPOSE: This study aimed to investigate the predictors of survival of non-occlusal non-incisal glass-ionomer restorations as a surrogate for root surface restorations among older adults. METHODS: In a retrospective cohort analysis using the University of Iowa College of Dentistry electronic dental records, we included 721 patients aged 65+ who received 2+ surface non-occlusal non-incisal glass ionomer restorations placed from January 2005 - December 2011. Restorations were followed until September 2017 or until they were deemed to have failed. RESULTS: At baseline, participants' mean age was 77.6 ± 8.2 years, and 45.8% were females. Most patients were self-pay (65.2%). Most restorations were placed by residents and dental students (82.7%) and included only two surfaces (95.6%). About half (49.1%) failed during follow-up, with a median survival time of 3.7 years. The time ratio for lower incisors compared to other teeth was 0.6 (p = .006), for three-and-four-surface restorations compared to two was 0.7 (p = .007), for faculty as providers compared to residents and students was 1.4 (p = .039), and for the Geriatric & Special Needs Clinic compared to others was 0.8 (p = .013). Time ratios less than one indicate association with shorter durations for restorations, and time ratios greater than one indicate association with longer durations for restorations. CONCLUSION: Tooth type, number of restored surfaces, provider type, and clinic were all significant factors associated with survival of these restorations.

Effect of polishing direction on the marginal adaptation of composite resin restorations.

PROBLEM: Polishing composite resin restorations may lead to marginal defects and gap formation. PURPOSE: To assess the effect of polishing direction on the marginal adaptation of composite resin restorations using two composite resins and two polishing systems. MATERIALS AND METHODS: Forty extracted human molars were sectioned along their mesio-distal axis. Buccal and lingual enamel was flattened and a triangular preparation, 0.87-mm deep and 3-mm wide, representing two 60° bevels, was performed. Specimens were randomly assigned to eight groups (N = 20) and restored with two composite resins: a nanofilled (Filtek Supreme Ultra, 3M ESPE, St. Paul, MN, USA) or a microhybrid (Point 4, Kerr, Orange, CA, USA) and finished with two polishing techniques: polishing discs (Sof-Lex XT, 3M ESPE) or rubber polishers (HiLuster Plus, Kerr, Bioggio, Switzerland). On each specimen, both margins were polished with the same technique, one margin from composite resin to tooth and the other from tooth to composite resin. Replicas were made for field emission scanning electron microscope observation (200×) and quantitative margin analysis was performed based on four criteria. Data were analyzed with a paired-sample t-test, a two-sample t-test, and one-way analysis of variance or their nonparametric analog. RESULTS: Significant differences were found in most groups between polishing directions with better marginal adaptation from composite resin to tooth than from tooth to composite resin. Differences between composite resins and polishing techniques seemed to be dependent on certain combinations of composite resin, polishing technique, and polishing direction. CONCLUSION: Polishing from composite resin to tooth leads to better marginal adaptation than polishing from tooth to composite resin. CLINICAL SIGNIFICANCE: The results obtained from this in vitro study suggest that polishing direction influences the marginal adaptation of composite resins and that polishing from composite resin to tooth structure should be clinically performed whenever possible on accessible margins to preserve marginal integrity and esthetics.

Generalized permanent dentition fluorosis severity becomes less evident over time among a birth cohort.

Objectives: There are relatively few cohort studies which have examined changes in fluorosis appearance over time, and none of these have assessed changes in generalized fluorosis. In this analysis, we quantified and assessed changes in multiple measures of generalized fluorosis severity through childhood, adolescence, and young adulthood. Methods: Participants were from the Iowa Fluoride Study, a birth cohort recruited from 1992 to 1995. Permanent dentition fluorosis exams were carried out at ages 9, 13, 17, and 23 years using the Fluorosis Risk Index (FRI). Generalized fluorosis was assessed using mean FRI scores at the tooth- and person-level as well as a five-category measure of generalized fluorosis. Generalized fluorosis prevalence and severity was summarized at each time point and differences in adjacent time points were assessed using gamma statistics, signed-rank tests, and plotting changes in generalized fluorosis between adjacent time points. Results: We observed a statistically significant decline in the percentage of non-zero mean FRI scores at later exam ages at both the person- and tooth-levels. Based on our five-category generalized fluorosis measure, there were 34.0%-54.1% of participants with generalized fluorosis at baseline for each tooth group, and these percentages declined to 8.9%-27.2% at the age 23-year exam. Conclusions: We observed a statistically significant decline in generalized fluorosis severity scores and overall prevalence at later exam ages across all three measures of generalized fluorosis severity. This trend should be accounted for when estimating the prevalence of fluorosis in a population using fluorosis severity data collected in children and adolescents.

Integrating patient-centered caries management in dental education-A practical approach.

Caries management is undergoing an evolution in dental education. This is part of a larger change in thinking focused on the person/patient as well as procedures to bring health to people. This perspective attempts to tell the story of the dental education culture regarding caries management from perspectives of evidence-based care; caries as a disease of a person, not only a tooth; and the management of high-risk and low-risk individuals. Culturally and organizationally, the integration of basic, procedural, behavioral, and demographic perspectives for dental caries has happened at different rates for some decades. The involvement of students, teaching faculty, course directors, and administration is essential in this process.

Role of mutans streptococci, acid tolerant bacteria and oral Candida species in predicting the onset of early childhood caries.

Aim: Early childhood caries is the most common chronic infectious disease in children in the United States. This study, which is part of a larger, longitudinal study exploring oral microbiological components of caries development in children, reports on the impact of total mutans streptococci (MS), total acid tolerant bacteria and Candida species on the development of dental caries in a subset of these children. Of particular interest was the relationship between caries development and co-colonization of mutans streptococci and Candida species. Methods: Children between the ages of 12 and 47 months displaying no evidence of dental caries were recruited for a longitudinal study (n = 130). Twelve age- and gender-matched pairs were selected. In each pair, one child developed caries during the study, and one did not. Whole mouth plaque samples were collected by swab at baseline and every 6 months thereafter for a duration of 18 months and spiral plated for microbial counts (CFU/ml). Cut-offs based on percent of total cultivable flora were designated for all microbial measures. A scoring system designated the Plaque Microbial Index (PMI) was developed for use in statistical analyses to assess potential predictive factors for caries risk assessment. Results: Children who developed caries were significantly more likely to harbor higher percentages of acid tolerant bacteria (p = 0.003), MS (p < 0.001) and have Candida species present (p < 0.001) at ≥1 visit leading up to caries onset. Mean PMI scores derived from the aforementioned microbial measures, were higher for caries active children than caries free children (p = 0.000147). Co-colonization of MS and Candida species was significantly associated with caries development (p < 0.001) and detection of both at the same visit had a 100% positive predictive value and 60% negative predictive value for caries development. Conclusion: In children who developed caries, there was a statistically significant association with the percent of total flora that was acid tolerant, the percent of MS, the presence of Candida and co-colonization of MS and Candida species. Combining these microbial measures into PMI scores further delineated children who developed caries from those who remained caries-free. These microbiological measures show potential as predictive factors and risk assessment tools for caries development.

Prevalence of non-cavitated lesions and progression, regression, and no change from age 9 to 23 years.

OBJECTIVES: Some non-cavitated caries lesions (D1 ), the initial stage of caries, progress to cavitation. This article reports participant-level and surface-level D1 prevalence and changes in status of D1 lesions through different periods from age 9 to 23. METHODS: The Iowa Fluoride Study (IFS) participants were followed longitudinally; all permanent tooth surfaces were examined clinically for caries at ages 9, 13, 17, and 23 using standardized criteria for sound (S), questionable (D0 ), non-cavitated (D1 ), cavitated (D2+ ), filled (F), or missing due to decay (M). D1 lesions at the beginning of each interval were reassessed at each follow-up age to determine transitions (to the 5 categories or no transition). RESULTS: The sample had relatively high socioeconomic status (SES), with about 52%-55% high SES, 32-35% middle SES, and 12-13% low SES. Person-level prevalences of D1 lesions were 23%, 38%, 60%, and 45% at ages 9, 13, 17, and 23, respectively. Surface-level prevalences were less than 1% at ages 9 and 13, 3% at 17, and 2% at 23. Thirteen percent of D1 s at age 9 progressed at 13, 18% progressed from 13 to 17, and 11% progressed from 17 to 23. The percentages regressing (to sound or D0 ) were 72%, 54%, and 72%, respectively. CONCLUSION: Non-cavitated lesions were more prevalent at age 17 than at ages 9, 13, and 23. The high rates of regression compared to progression or no change suggest that many non-cavitated lesions do not progress to cavitated lesions and could be reversed; therefore, surgical intervention should not be the treatment of choice for incipient lesions.

Longitudinal associations between children's dental caries and risk factors.

UNLABELLED: Dental caries is a common disease in children of all ages. It is desirable to know whether children with primary, mixed, and permanent dentitions share risk factors for cavitated and non-cavitated caries. OBJECTIVE: To assess the longitudinal associations between caries outcomes and modifiable risk factors. METHODS: One hundred and fifty-six children in the Iowa Fluoride Study met inclusion criteria of three dental examinations and caries-related risk factor assessments preceding each examination. Surface-specific counts of new non-cavitated caries and cavitated caries at the primary (Exam 1: age 5), mixed (Exam 2: age 9) and permanent (Exam 3: age 13) dentition examinations were outcome variables. Explanatory variables were caries-related factors, including averaged beverage exposure frequencies, tooth brushing frequencies, and composite water fluoride levels collected from 3-5, 6-8, and 11-13 years, dentition category, socioeconomic status, and gender. Generalized linear mixed models (GLMMs) were used to explore the relationships between new non-cavitated or cavitated caries and caries-related variables. RESULTS: Greater frequency of 100 percent juice exposure was significantly associated with fewer non-cavitated and cavitated caries surfaces. Greater tooth brushing frequency and high socioeconomic status (SES) were significantly associated with fewer new non-cavitated caries. Children had significantly more new cavitated caries surfaces at the mixed dentition examination than at the primary and permanent dentition examinations. CONCLUSIONS: There were common caries-related factors for more new non-cavitated caries across the three exams, including less frequent 100 percent juice exposure, lower tooth brushing frequency and lower SES. Less frequent 100 percent juice exposures might be associated with higher exposures to several other cariogenic beverages.

Mixed dentition cavitated caries incidence and dietary intake frequencies.

PURPOSE: This study examined risk factors for children having new cavitated caries between 5 and 9 years old. METHODS: Subjects were Iowa Fluoride Study cohort children (mostly Caucasian and of relatively high socioeconomic status) with both primary and mixed dentition caries exams and at least 2 diet diaries recorded between 5 and 8 years old (N=198). Using surface-specific transitions, combined counts of new cavitated caries (d(2-3)f and/or D(2-3)F) were determined from 4 primary second molars, 8 permanent incisors, and 4 permanent molars. Food and beverage intake frequencies were abstracted. Other factors were assessed using periodic questionnaires. Logistic regression identified predictors of new cavitated caries. RESULTS: Thirty-seven percent had new cavitated caries. The mean new cavitated caries count for all children was 1.17 surfaces (±2.28 SD). In multivariable logistic regression, the following were significantly associated (P<.10) with having new cavitated caries: noncavitated caries experience at 5 years old (odds ratio [OR]=2.67, P=.03); cavitated caries experience at 5 years old (OR=3.39, P=.004); greater processed starch at snack frequency (OR=3.87, P=.07); being older (OR=1.68, P=.04); and less frequent tooth-brushing (P=.001). CONCLUSION: Results suggested that increased tooth-brushing frequency and reduced consumption of processed starches as snacks may reduce caries incidence in younger school-aged children.

Repair versus replacement of defective direct restorations: A cross-sectional study among US dentists.

BACKGROUND: Repair increases the longevity of restorations and is well-accepted by patients. In this study, the authors assessed the acceptance of dental restoration repair by dentists and determined the main variables of repair versus replacement of defective restorations. METHODS: A 15-item questionnaire was developed and distributed electronically to the American Dental Association Clinical Evaluators panel members (n = 785) during a 2-week period in 2019. Descriptive, bivariate, and multivariable analyses were conducted. RESULTS: Of the 387 respondents, 83.7% stated that they repair defective restorations, and 16% stated that they always replace them. Reasons to forego a restoration repair among dentists who perform repairs included defect size and carious lesion extension (42%) and negative personal experience or lack of success (37.9%). However, the latter was considerably higher for dentists who do not perform repairs (60.7%). The most commonly cited patient-related reason and tooth condition to repair restorations were limited patient finances (67%) and noncarious marginal defects (86%), respectively. Neither sex nor age group was significantly associated with the practice of restoration repair (P = .925 and P = .369, respectively). However, sole proprietors were more likely to perform repairs than those in an employee, associate, or contractor practice setting (P = .008). The most significant reason to forego restoration was negative experience or lack of success (P = .002). CONCLUSIONS: Restoration repair is considered a treatment option for managing defective restorations. Negative personal experience or lack of success and practice setting influenced the dentists' decision to repair or replace a defective restoration. PRACTICAL IMPLICATIONS: Understanding dentists' clinical challenges and practice environment is necessary when advocating for this approach.

Tobacco-free community coalitions: opportunities for enhancing oral cancer prevention programs.

BACKGROUND: This study identified oral cancer (OC) education and tobacco reduction collaboration within tobacco-free community coalitions (TFCC). METHODS: Data from 4 TFCC were collected via educational intervention surveys and structured focused group Interviews. RESULTS: Of the 52 participants, 96% were aware that tobacco products are risk factors for OC, yet 33% were unaware of the high OC impact locally. About 90% agreed that primary care providers and dentists should provide OC screenings and tobacco cessation. CONCLUSION: There is a need for provider endorsement and public demand for OC screenings. Opportunity exists for partnering and collaborative OC prevention with TFCC.

Management of initial carious lesions: Iowa survey.

BACKGROUND: The authors explore Iowa dentists' agreement with the International Caries Classification and Management System (ICCMS) in the nonsurgical management of initial carious lesions in patients at low, moderate, and high caries risk and identify factors related to their agreement. METHODS: Electronic surveys were mailed to 916 actively practicing dentists who are alumni of the College of Dentistry at The University of Iowa. Questions included clinical scenarios that used text, clinical photographs, and radiographic images of initial carious lesions. Dentists were asked what type of treatment they would recommend. Treatment options included no treatment, nonsurgical treatment, or surgical treatment. Logistic regression analyses were used to assess associations among agreement with ICCMS, characteristics of the dentist's practice, and patients' caries risk level. RESULTS: A total of 138 Iowa dentists responded to the survey. Agreement with ICCMS regarding nonsurgical management of initial carious lesions for patients at low, moderate, and high risk levels were 73%, 59%, and 51% respectively. Compared with their counterparts, dentists who agreed with the recommendations for nonsurgical treatment were more likely to dry the teeth during caries detection (95% confidence interval [CI], 1.02 to 12.67, P = .0468), use magnification (95% CI, 1.16 to 7.17, P = .0225) for caries detection, have graduated less than 20 years ago (P = .0024), practice in public health settings (P = .0089), and perform a caries risk assessment (95% CI, 1.10 to 4.29, P = .0262). CONCLUSIONS: Dentists who dry teeth, use magnification for caries detection, graduated in the past 20 years, practice in a public health setting, and perform a caries risk assessment were significantly more likely to make decisions that were consistent with the guidelines of the ICCMS. PRACTICAL IMPLICATIONS: Knowledge of evidence-based options personalized for a patient's risk status is essential for applying the best management of initial caries lesions.

Masking and Penetration Ability of Various Sealants and ICON in Artificial Initial Caries Lesions In Vitro.

PURPOSE: The purpose of the present in vitro study and survey was to compare the masking ability and the penetration capacity of three resin composite sealers as well as a resin infiltrant in shallow artificial caries lesions. MATERIALS AND METHODS: Panels of artificial initial caries lesion with an average depth of 200 µm were created on buccal and lingual surfaces of 75 extracted human molars. Specimens were randomly assigned to 5 groups: ICON (DMG America), Biscover LV (Bisco), Optiguard (Kerr Hawe), Permaseal (Ultradent), and control (no treatment). Teeth were hemi-sectioned yielding two halves, each with a panel of artificial caries lesion. Lesions on one hemi-section were used to assess the esthetic improvement following caries lesion penetration with the 4 resins based on photographs evaluated using a 100-mm visual analogue scale (VAS) by 17 raters. Lesions on opposite hemi-sections were used to measure the resin penetration area percentage (PA%) and the resin penetration depth percentage (PD%) visualized using a confocal laser scanning microscope (CLSM, Leica). RESULTS: ICON, Optiguard, and Permaseal yielded significantly greater average VAS scores compared to Biscover. The mean PA% and PD% were significantly higher for ICON, intermediate for Optibond and Permaseal, and significantly lower for Biscover. A moderately large positive correlation was noticed between the average VAS scores and the penetration measures. CONCLUSION: All the resin sealers (Biscover, Optiguard, and Permaseal) penetrated the artificial initial caries lesions. However, ICON resulted in the deepest penetration and the largest penetration area percentages. The masking ability of Optiguard and Permaseal of the artificial caries lesions was similar to ICON.

Survival analysis of caries incidence in African-American school-aged children.

OBJECTIVES: To conduct an assessment of time-dependent covariates related to dental caries of the permanent dentition among a low socioeconomic status, understudied cohort of children, incorporating time-dependent covariates through the application of extended Cox proportional hazards modeling. METHODS: This study modeled the time to first cavitated dental caries in permanent teeth among school-aged children and assessed factors associated with this event. A cohort of 98 low socioeconomic status African-American children with mean age of 5.85 years at baseline was recruited in Uniontown, Alabama and followed prospectively for 6 years. None of these children had dental caries on permanent teeth at baseline, and oral examinations were performed annually. Caries-free survival curves were generated to describe time to event (having first decayed, filled, or missing permanent surface). Bivariate and multivariable extended Cox hazards modeling was used to assess the relationships between time-dependent and time-independent covariates and time to event. RESULTS: Twenty-eight children (28.6 percent) had their first permanent tooth caries event during the 6-year follow-up. Multivariable results showed that greater consumption of water was associated with lower dental caries hazard, while previous primary tooth caries experience was associated with greater dental caries hazard after adjustment for frequency of consumptions of milk, added-sugar beverages, and 100 percent juice. CONCLUSIONS: There was a global/overall significant caries protective effect of water consumption during the school-age period of child development.

CariesCare practice guide: consensus on evidence into practice.

This CariesCare practice guide is derived from the International Caries Classification and Management System (ICCMS) and provides a structured update for dentists to help them deliver optimal caries care and outcomes for their patients. This '4D cycle' is a practice-building format, which both prevents and controls caries and can engage patients as long-term health partners with their practice. CariesCare International (CCI™) promotes a patient-centred, risk-based approach to caries management designed for dental practice. This comprises a health outcomes-focused system that aims to maintain oral health and preserve tooth structure in the long-term. It guides the dental team through a four-step process (4D system), leading to personalised interventions: 1st D: Determine Caries Risk; 2nd D: Detect lesions, stage their severity and assess their activity status; 3rd D: Decide on the most appropriate care plan for the specific patient at that time; and then, finally, 4th D: Do the preventive and tooth-preserving care which is needed (including risk-appropriate preventive care; control of initial non-cavitated lesions; and conservative restorative treatment of deep dentinal and cavitated caries lesions). CariesCare International has designed this practice-friendly consensus guide to summarise best practice as informed by the best available evidence. Following the guide should also increase patient satisfaction, involvement, wellbeing and value, by being less invasive and more health-focused. For the dentist it should also provide benefits at the professional and practice levels including improved medico-legal protection.