A best practices approach to caries management.

UNLABELLED: Caries management by risk assessment represents best practices and is an evidence-based model that focuses on treating and preventing disease at the patient level rather than a surgical/restorative approach at the tooth level. BACKGROUND: Dental caries is a multifactorial, biofilm and pH mediated disease that affects people of all ages and disproportionally affects certain populations at epidemic proportions. Simply restoring cavitated teeth does nothing to resolve the disease. At the heart of the CAMBRA philosophy is identifying the patient's unique risk level for future caries disease. This can be done by completing a caries risk assessment (CRA). Several easy to use CRA questionnaires are available. Once the patient's unique risk level has been determined, preventive and therapeutic interventions, based on the specific risk level, can then be implemented. METHODS: Landmark publications, original research, and systematic reviews are analyzed and reviewed to form the basis for this shift in patient care related to caries disease. CONCLUSIONS: Caries management by risk assessment has emerged as the new paradigm in patient care and represents an evidence-based, best practices approach with the potential for significant advantages over traditional methods.

Systematic review and meta-analysis on the effect of self-assembling peptide P11-4 on arrest, cavitation, and progression of initial caries lesions.

BACKGROUND: Simple noninvasive evidence-based interventions for caries are needed to overcome limitations in the restorative paradigm. The self-assembling peptide P11-4 is a noninvasive intervention that regenerates enamel in initial caries lesions. STUDIES REVIEWED: The authors conducted a systematic review and meta-analysis on the effectiveness of the P11-4 products Curodont Repair (Credentis; now manufactured by vVARDIS) (CR) and Curodont Repair Fluoride Plus (Credentis; now manufactured by vVARDIS) on initial caries lesions. Primary outcomes were lesion progression after 24 months, caries arrest, and cavitation. Secondary outcomes were changes in merged International Caries Detection and Assessment System score categories, quantitative light-induced fluorescence (QLF; Inspektor Research System), esthetic appearance, and lesion size. RESULTS: Six clinical trials met the inclusion criteria. Results of this review represent 2 primary and 2 secondary outcomes. When compared with parallel groups, use of CR likely results in a large increase in caries arrest (relative risk [RR], 1.82 [95% CI, 1.32 to 2.50]; 45% attributable risk [95% CI, 24% to 60%]; number needed to treat [NNT], 2.8) and likely decreases lesion size by a mean (SD) of 32% (28%). The evidence also suggests that use of CR results in a large reduction in cavitation (RR, 0.32 [95% CI, 0.10 to 1.06]; NNT, 6.9) and is uncertain about lowering merged International Caries Detection and Assessment System score (RR, 3.68 [95% CI, 0.42 to 32.3]; NNT, 19). No studies used Curodont Repair Fluoride Plus. No studies reported adverse esthetic changes. PRACTICAL IMPLICATIONS: CR likely has clinically important effects on caries arrest and decreased lesion size. Two trials had nonmasked assessors, and all trials had elevated risks of bias. The authors recommend conducting longer trials. CR is a promising treatment for initial caries lesions. The protocol for this systematic review was registered a priori with PROSPERO (304794).

Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association.

BACKGROUND: An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs together with the ADA Science and Research Institute's program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated caries lesions in patients with vital, nonendodontically treated primary and permanent teeth. TYPES OF STUDIES REVIEWED: The authors searched for systematic reviews comparing carious tissue removal (CTR) approaches in Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Trip Medical Database. The authors also conducted a systematic search for randomized controlled trials comparing direct restorative materials in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of the evidence and formulate recommendations. RESULTS: The panel formulated 16 recommendations and good practice statements: 4 on CTR approaches specific to lesion depth and 12 on direct restorative materials specific to tooth location and surfaces involved. The panel conditionally recommended for the use of conservative CTR approaches, especially for advanced lesions. Although the panel conditionally recommended for the use of all direct restorative materials, they prioritized some materials over the use of others for certain clinical scenarios. PRACTICAL IMPLICATIONS: The evidence suggests that more conservative CTR approaches may decrease the risk of adverse effects. All included direct restorative materials may be effective in treating moderate and advanced caries lesions on vital, nonendodontically treated primary and permanent teeth.

Direct materials for restoring caries lesions: Systematic review and meta-analysis-a report of the American Dental Association Council on Scientific Affairs.

BACKGROUND: The goal of restoring caries lesions is to protect the pulp, prevent progression of the disease process, and restore the form and function of the tooth. The purpose of this systematic review was to determine the effect of different direct restorative materials for treating cavitated caries lesions on anterior and posterior primary and permanent teeth. TYPE OF STUDIES REVIEWED: The authors included parallel and split-mouth randomized controlled trials comparing the effectiveness of direct restorative materials commercially available in the United States placed in vital, nonendodontically treated primary and permanent teeth. Pairs of reviewers independently conducted study selection, data extraction, and assessments of risk of bias and certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. The authors conducted pair-wise meta-analyses to summarize the evidence and calculated measures of association and their 95% CIs. RESULTS: Thirty-eight randomized controlled trials were eligible for analysis, which included data on Class I and Class II restorations on primary teeth and Class I, Class II, Class III, Class V, and root surface restorations on permanent teeth. Included studies assessed the effect of amalgam, resin composite, compomer, conventional glass ionomer cement, resin-modified glass isomer cement, and preformed metal crowns. Moderate to very low certainty evidence suggested varying levels of effectiveness across restorative materials. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Owing to a relatively low event rate across various outcomes indicating restoration failure, there was limited evidence to support important differences between direct restorative materials used in practice.

New directions in the etiology of dental caries disease.

This review explores the multifactorial etiology of dental caries disease. Current theories suggest that a singular focus on mutans streptococci and lactobacillus as the sole causative microbiological agents is no longer a viable strategy in treatment of this prevalent disease. Dental caries is an infectious transmissible disease process where a cariogenic biofilm in the presence of an oral status that is more pathological than protective leads to the demineralization of dental hard tissue.

Clinical Instructions for Using Silver Diamine Fluoride (SDF) in Dental Caries Management.

Manufacturer instructions for 38% silver diamine fluoride (SDF) are limited to current FDA clearance for tooth desensitization. There is a need for instructions to provide best-practice recommendations for off-label use of SDF for caries prevention and arrest. METHODS: The authors considered existing clinical approaches to the use of 38% SDF at pH 10 for the prevention and arrest of active dental caries, in light of the best current evidence. Application of SDF, with or without subsequent direct restoration, is included. The content was reviewed by stakeholders including but not limited to those listed on the consensus statement (Appendix A, below). RESULTS: 38% SDF for the prevention and arrest of active caries lesions, as well as compatibility with common direct restorative materials, such as glass-ionomer cement and resin composite, has a foundation in the scientific literature. A practical decision-flow diagram and accompanying best practices for treatment of caries lesions, based on clinical access and intention to restore, were developed based on available evidence and expert clinical observation when no evidence was available. CONCLUSIONS: Based on the best available evidence, a logical approach can be adopted regarding the practical use of 38% SDF for caries prevention and arrest. PRACTICAL IMPLICATIONS: SDF used as per these instructions for prevention on high-risk tooth surfaces and arrest of active caries lesions has a place in the practitioner's dental caries management armamentarium. When SDF is applied to active lesions, it can be used with or without subsequent restoration, depending on clinical context, expert judgment, and patient input.

A clinician's guide to CAMBRA: a simple approach.

Caries risk assessment identifies those factors that are pathologic and suggests ways an astute clinician can implement protective strategies that can prevent progression and/or return the patient to health. Caries management by risk assessment (CAMBRA) focuses on treating and preventing the cause of the disease at an early stage, rather than waiting until it causes damage to tooth structure. This article summarizes and simplifies information previously published about CAMBRA implementation from the perspective of today's practicing clinician. The most recent science on prevention, remineralization, antimicrobials, and pH, as well as the use of fluoride, xylitol, and casein phosphopeptide-amorphous calcium phosphate (CCP-ACP) is also discussed.

Dental Care for Geriatric and Special Needs Populations.

This article reviews considerations for oral health care associated with the most common causes of mortality and morbidity in older adults. Many of these diseases result in functional or cognitive impairments that must be considered in treatment planning to ensure appropriate, safe, and effective care for patients. Many of these considerations parallel those of adults who have lived with developmental disabilities over a lifetime and similar principles can be applied. Systemic diseases, conditions, and their treatments can pose significant risks to oral health, which requires prevention, treatment, and advocacy for oral health care as integral to chronic disease management.

Secondary Sjögren syndrome: A case report using silver diamine fluoride and glass ionomer cement.

BACKGROUND AND OVERVIEW: The authors describe dental treatment for a patient with a complex medical history of secondary Sjögren syndrome with systemic lupus erythematosus and rheumatoid arthritis. CASE DESCRIPTION: An 18-year-old woman's rheumatology group referred her for oral evaluation; she had secondary Sjögren syndrome, systemic lupus erythematosus, and rheumatoid arthritis. The patient had multiple advanced carious lesions, extreme sensitivity, and hyposalivation. The patient selected a minimally invasive treatment plan that focused on silver diamine fluoride (SDF), partial caries removal, and glass ionomer cement (GIC) restorations. The SDF treatment and GIC restorations were successful in arresting carious lesions and restoring form and function but may not completely prevent new carious lesions from forming in the future. CONCLUSIONS AND PRACTICAL IMPLICATIONS: The case shows that using less invasive treatments, such as SDF and GIC restorations can be used to manage complex cases involving extreme caries risk and be preferable to endodontic treatment and extractions.

Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association.

BACKGROUND: An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated evidence-based clinical recommendations for the arrest or reversal of noncavitated and cavitated dental caries using nonrestorative treatments in children and adults. TYPES OF STUDIES REVIEWED: The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane database of systematic reviews to identify randomized controlled trials reporting on nonrestorative treatments for noncavitated and cavitated carious lesions. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and move from the evidence to the decisions. RESULTS: The expert panel formulated 11 clinical recommendations, each specific to lesion type, tooth surface, and dentition. Of the most effective interventions, the panel provided recommendations for the use of 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide-amorphous calcium phosphate. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Although the recommended interventions are often used for caries prevention, or in conjunction with restorative treatment options, these approaches have shown to be effective in arresting or reversing carious lesions. Clinicians are encouraged to prioritize use of these interventions based on effectiveness, safety, and feasibility.

New directions in interorganizational collaboration in dentistry: the CAMBRA Coalition model.

Caries management by risk assessment (CAMBRA) represents a paradigm shift in the management of dental decay. It treats dental caries as an infectious disease that is curable and preventable. The science supporting CAMBRA has been present for quite some time; however, its clinical adoption, until recently, remained slow. This article analyzes the Western CAMBRA Coalition, a special collaboration of diverse groups of independent organizations based in the western region of the United States. This coalition, which has formed an interorganizational collaborative (IOC), has evolved over four years and has led to significant progress in the clinical adoption of CAMBRA. Theoretical perspectives of reasons and the conditions that drive organizations to collaborate will be applied to the CAMBRA model, concluding that IOCs offer great benefits in promoting CAMBRA as well as future innovations in dental treatments.

Curing the silent epidemic: caries management in the 21st century and beyond.

Caries is the most prevalent disease of children and is epidemic in some populations. A risk-based approach to managing caries targets those in greatest jeopardy for contracting the disease, as well as provides evidence-based decisions to treat current disease and control it in the future. This paper outlines key concepts necessary to effectively manage and reduce caries based on the most current science to date. Subsequent articles will outline a roadmap to success in curing dental caries.

The role of dental hygienists, assistants, and office staff in CAMBRA.

The role of the dental team in caries management by risk assessment is critical to successful patient outcomes. Positive patient interactions and communication, proper appointment scheduling, diagnostics and data gathering, as well as implementation of noninvasive or minimally invasive procedures can be the responsibility of all members of the dental team. This article will evaluate the role of the clinical and administrative staff in maintaining a practice with a focus on disease prevention and management..

Caries risk assessment in practice for age 6 through adult.

The aim of this article is to present a practical caries risk assessment procedure and form for patients who are age 6 through adult. The content of the form and the procedures have been validated by outcomes research after several years of experience using the factors and indicators that are included.

Clinical protocols for caries management by risk assessment.

This article seeks to provide a practical, everyday clinical guide for managing dental caries based upon risk group assessment. It is based upon the best evidence at this time and can be used in planning effective caries management for any patient. In addition to a comprehensive restorative treatment plan, each patient should have a comprehensive caries management treatment plan. Some sample treatment plans are included.

Caries management by risk assessment: implementation guidelines.

ACT This consensus statement supports implementation of caries management by risk assessment in clinical practice by using the following principles: modification of the oral flora, patient education, remineralization, and minimal operative intervention. The statement includes a list of supporters.

The Effect of Calibration on Caries Risk Assessment Performance by Students and Clinical Faculty.

Caries management requires a complete oral examination and an accurate caries risk assessment (CRA). Performing Caries Management by Risk Assessment (CAMBRA) is inefficient when the caries risk level assignment is incorrect. The aim of this study was to evaluate the ability of faculty members and students at one U.S. dental school to correctly assign caries risk levels for 22 CRA cases, followed by calibration with guidelines on how to use the CRA form and a post-calibration test two months after calibration. Inter-examiner reliability to a gold standard (consensus of three experts) was assessed as poor, fair, moderate, good, and very good. Of the 162 students and 125 faculty members invited to participate, 13 students and 20 faculty members returned pre-calibration tests, for response rates of 8% and 16%, respectively. On the post-calibration test, eight students and 13 faculty members participated for response rates of 5% and 10%, respectively. Without guidelines and calibration, both faculty members and students when evaluated as one group performed only poor to fair in assigning correct caries risk levels. After calibration, levels improved to good and very good agreements with the gold standard. When faculty and students were evaluated separately, in the pre-calibration test they correctly assigned the caries risk level on average in only one-quarter of the cases (students 24.1%±13.3%; faculty 23.6%±17.5%). After calibration, both groups significantly improved their correct assignment rate. Faculty members (73.8% correct assignments) showed even significantly higher correct assignment rates than students (47.7% correct assignments). These findings suggest that calibration with a specific set of guidelines improved CRA outcomes for both the faculty members and students. Improved guidelines on how to use a CRA form should lead to improved caries risk assessment and proper treatment strategy for patients.

Managing caries in the 21st century: today's terminology to treat yesterday's disease.

BACKGROUND: For more than a century, dentistry has been treating the disease of dental caries largely by restoring teeth. Research in the microbiological and chemical mechanisms of the caries process over the past two decades suggests a fundamental rethinking of solely using this type of treatment approach. METHODS: A clinician's understanding of how the field has advanced has been impeded by the inconsistent use of dental terminology. This article will focus on defining dental caries and its related terms. CONCLUSIONS: The term "caries," although used very liberally in the field, should be further defined in its context of use to avoid confusion, until which time an accepted international terminology system is developed. PRACTICE IMPLICATIONS: Reducing or eliminating ambiguity in terminology used in managing dental caries is the first step in consistent diagnosis, detection, and finally treatment.

The Effects of Faculty Calibration on Caries Risk Assessment and Quality Assurance.

Accurate caries risk assessment (CRA) plays a pivotal role in managing the disease of dental caries. The aim of this quality assurance study was to determine if faculty calibration training using a specific set of guidelines in a single session would improve the faculty members' CRA decision making. A calibration seminar was held in December 2014 at the Virginia Commonwealth University School of Dentistry, during which seven completed CRA forms for simulated patients were used to test 55 faculty members' risk assignment level before and after an instructional lecture was given. The results showed a statistically significant increase in the proportion of faculty members responding correctly for five of the seven cases on the pre- and posttests (p<0.01). One case showed no significant increase in correct responses (p=0.07), and on the seventh case, which presented low caries risk, there was a significant decrease in the percentage responding correctly (p<0.0001) due to an increase in the proportion overestimating caries risk. This study's findings were consistent with those in previous studies that, without calibration, faculty members are not necessarily accurate at CRA diagnosis. Since the calibration training improved these faculty members' caries risk assessment scoring, future studies should extend to evaluations for both faculty and students.

Digital imaging fiber-optic trans-illumination, F-speed radiographic film and depth of approximal lesions.

BACKGROUND: Detection of early carious lesions is a prerequisite to an optimal preventive and minimal surgical intervention strategy. The authors conducted this study to determine whether Digital Imaging Fiber-Optic Trans-Illumination (DIFOTI) (Electro-Optical Sciences, Irvington, N.Y.) could be useful in evaluating early approximal lesions and to compare radiographs produced with F-speed film with both histologic lesion depth and cavitation. METHODS: The authors created artificial approximal lesions in vitro in extracted teeth over 14 weeks and imaged them using a "bitewing-like" view every two weeks with DIFOTI and F-speed radiographic film. At the end of the 14 weeks, the authors examined the lesions for surface cavitation using visual and tactile methods. They then thin-sectioned the lesions and subjected them to histologic analysis using polarized light microscopy (PLM). RESULTS: DIFOTI was not able to measure the depth of a lesion in any of the samples. It was, however, able to show surface changes associated with early demineralization as early as two weeks. The depth of a lesion measured using F-speed radiographic film was not statistically different from the depth of a lesion measured with PLM histologic analysis (P > .05). None of the lesions showed any signs of surface cavitation after 14 weeks of demineralization. CONCLUSIONS AND CLINICAL IMPLICATIONS: DIFOTI technology should not be used to decide between surgical or chemical treatment strategies based on lesion depth. We found that F-speed radiographic film was accurate in the approximating the depth of the lesion histologically. Ideally, the clinical decision whether to cut the tooth should be made based on cavitation rather than histologic lesion depth.