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DOI:10.1038/nrdp.2017.30

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Citation for published version (APA):Pitts, N. B., Zero, D. T., Marsh, P. D., Ekstrand, K., Weintraub, J. A., Ramos-Gomez, F., ... Ismail, A. (2017).Dental caries. Nature Review Disease Primers, 3, [17030]. DOI: 10.1038/nrdp.2017.30

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Download date: 22. May. 2018

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FinalsubmittedandacceptedVersionfromNigelPittsasatMarch17th2017

Dentalcaries

NigelB.Pitts1,DomenickT.Zero2,PhilD.Marsh3,KimEkstrand4,JaneA.Weintraub5,Francisco

Ramos-Gomez6,JunjiTagami7,SvanteTwetman4,GeorgiosTsakos8,AmidIsmail9

1DentalInnovationandTranslationCentre,King'sCollegeLondonDentalInstitute,Floor17TowerWing,Guy'sHospital,GreatMazePondRoad,London,SE19RT,UK.2DepartmentofCariologyOperativeDentistryandDentalPublicHealth,OralHealthResearchInstitute,IndianaUniversitySchoolofDentistry,Indianapolis,Indiana,USA.3DepartmentofOralBiology,SchoolofDentistry,UniversityofLeeds,Leeds,UK.4DepartmentofOdontology,UniversityofCopenhagen,Copenhagen,Denmark.5DepartmentofDentalEcology,UniversityofNorthCarolinaSchoolofDentistry,ChapelHill,NorthCarolina,USA6UCLACenterChildren’sOralHealth-UCCOHandSectionofPediatricDentistry,UCLASchoolofDentistry,UniversityofCaliforniaLosAngeles,LosAngeles,California,USA.7CariologyandOperativeDentistry,TokyoMedicalandDentalUniversity,Tokyo,Japan.8DepartmentofEpidemiologyandPublicHealth,UCL,London,UK.9RestorativeDentistry,MauriceH.KornbergSchoolofDentistry,TempleUniversity,Philadelphia.USA.Competinginterests:N.B.P.hasreceivedhonorariaandcorporateandsocialresponsibilitysupportfromColgate,consultationfeesfromCalcivisandholdsstockinaKingsCollegeLondonspin-out,Reminova.D.T.Z.hasreceivedcontractedresearchfundingfromJohnson&Johnson,GlaxoSmithKlein,C3-Jian,andNoveomeBiotherapeutics.P.D.M.,K.E.,J.A.W.,F.R.-G.,J.T.,S.T.,G.T.,A.I.havenoconflicts.

Authorcontributions

Introduction (N.B.P.); Epidemiology (N.B.P.); Mechanisms/pathophysiology (D.T.Z. and P.D.M.);Diagnosis,screeningandprevention(K.E.andJ.A.W.);Management(F.R.-G.,J.T.andS.T.);Qualityoflife(G.T.);Outlook(A.I.);overviewofPrimer(N.B.P.).

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Abstract|Dentalcariesisabiofilm-mediated,sugar-driven,multifactorial,dynamicdiseaseresulting

inthephasicdemineralizationandremineralisationofdentalhardtissues.Cariescanoccur

throughoutlife,bothinprimaryandpermanentdentitions,andcandamagethetoothcrownand,in

laterlife,alsoexposedrootsurfaces.Thebalancebetweenpathologicalandprotectivefactors

influencestheinitiationandprogressionofcaries.Thisinterplaybetweenfactorsunderpinsthe

classificationofindividualsandgroupsintocariesriskcategoriesallowinganincreasinglytailored

approachtocare.Dentalcariesisanunevenlydistributed,preventablediseasewithconsiderable

economicandqualityoflifeburdens.Thedailyuseoffluoridetoothpasteisseenasthemainreason

fortheoveralldeclineofcariesworldwideoverrecentdecades.ThisPrimeraimstoprovideaglobal

overviewofcaries,acknowledgingthehistoricaleradominatedbyrestorationoftoothdecayby

surgicalmeans,butitfocussesoncurrent,progressiveandmoreholisticlong-term,patient-centred,

tooth-preservingpreventivecare.

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[H1]Introduction

Dentalcariesinvolvesinteractionsbetweenthetoothstructure,themicrobialbiofilmformedonthe

toothsurface(Figure1)andsugars,aswellassalivaryandgeneticinfluences1.Thedynamiccaries

processconsistsofrapidlyalternatingperiodsoftoothdemineralisationandremineralisationwhich,

ifnetdemineralisationoccursoversufficienttime,resultsintheinitiationofspecificcarieslesionsat

certainanatomicalpredalictionsitesontheteeth.Itisimportanttobalancethepathologicaland

protectivefactorswhichinfluencetheinitiationandprogressionofdentalcaries.Protectivefactors

promoteremineralisationandlesionarrest,whereaspathologicalfactorsshiftthebalanceinthe

directionofdentalcariesanddiseaseprogression1(Figure2).Thedailyuseoffluoridetoothpasteis

seenbymanyauthoritiesasthemainreasonfortheoveralldeclineofcariesworldwideoverrecent

decades;themodeofactionofsuchtoothpastesisconcernedwithshiftingthebalanceoftheoral

biofilmtowardshealth.

Thereisnotadirectcorrelationbetweentheextentofacarieslesionandwhetherornotpainand

discomfortisfelt.However,severetoothache,whenitoccurs,canbedisablingandinfectionand

sepsisarisingasaconsequenceofcariesspreadingtoinvolvethedentalpulpcanoccasionallylead

toserioussystemicconsequences(suchasspreadinglocalinfectionand,veryrarelytreatment-

relateddeath(asacomplicationofanaesthesia),aswellastotoothloss.

Theclinicaldetectionofcariesistraditionallymadebydetailedvisualinspectionofcleanteethby

trainedexaminers.Althoughsharppointeddentalprobes(orexplorers)arestilloftenused,they

providelittleadditionaldiagnosticbenefitandcandosomedamage.Dentalradiographsorother

supportivediagnosticmethodsarealsoneededinclinicalpracticetodetectthoselesionswhich

remainhiddentovisualassessment,particularlythosesituatedonapproximaltoothsurfaces(that

is,thosesurfacesthatformcontactsbetweenadjacentteeth).

Althoughtheravagesofcariescanmaketeethappeartobehighlyvulnerabletodestructionby

disease,fromanevolutionarybiologyperspectivehumanteethareahighvaluedorgansystem

involvedintheprehensionandprocessingoffood,andcanalsofunctionindefense,sexual

attractionandphoneticarticulation2.Theoutersurfaceofthetoothcrowniscomposedofthe

hardestsubstanceinthebody(enamel)(Figure1)withaspecializedfluid(saliva)beingsecreted

throughoutthedaytopreserveitsintegrity.Themorphologyofthemoderndentitionhasevolved

mainlybasedonourdietarypreferences,whichhavechangedoverthemillennia2.Interestingly,

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dietshighinsugartendtobesoftandoftenliquid;teetharenotrequiredfortheiringestion,which

mayexplainwhyteethcanberapidlylost.

TheaimofthisPrimeristoprovideabalancedinternationaloverviewofdentalcaries,bothasa

complex,multi-factorialdiseaseandasadynamicallyfluctuatingdiseaseprocess.Thearticlecovers

thefullrangeofperspectivesfromepidemiologytoqualityoflife—viapathophysiology,diagnosis,

riskassessmentandprevention.Publichealthaspectsareanimportantcomplement,butnot

coveredindepthforreasonsofspace.Currentresearchevidenceishelpingtochartthewayforward

toamorebiologically-basedwayofplanninganddeliveringcariespreventionandcare,atboththe

populationandindividuallevels.Theseconsiderationsunderpinthedevelopmentofscience,

practiceandpolicytooptimisepatientcareandhealth.

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[H1]Epidemiology

Epidemiological studies of caries have been undertaken formany decades and some of the data

available through WHO and other organisations gives an impression that we have plentiful

comparableglobaldata.However,inordertoevaluateandplanpolicy,epidemiologyshouldprovide

data meeting the following specification: timely, accurate and understandable data for key age

groups on the total amount of disease present (prevalence), the rate of disease progression

(incidence) and disease trends over time. In addition, information on variations in disease levels

between and within countries, including the estimates and trends in health inequalities (that is,

differences inhealthstatusbetweengroupswithinpopulations),areneeded.However,wedonot

currentlyhaveaccurate,up–to-date, clinicallymeaningful informationacross theglobe thatmeets

thesespecifications.Dentalcariesisstillaneglectedtopic,despitetheacknowledgmentoftheWHO

thatisstillamajorhealthprobleminmostindustrializedcountries,where60-90%ofchildrenand

the vastmajority of adults are affected by dental caries3. Although caries has been considered a

diseaseofchildhood,inrealityitcontinuesintoadulthood4,wherehealthinequalitiesremain5.

Dentalcariesareconsideredtobethesinglemostcommonchronicchildhooddisease,andits

prevalenceisthoughttohaveincreasedrecentlyinchildrenages2-5yearsglobally,makingthisage

groupaglobalpriorityactionarea6,7,8.Censusdatafrom2007reportedthatforUSchildrenaged2to

5,cariesprevalenceinprimaryteethshowedanincrease,fromapproximately24%to28%between

1988–1994and1999–2004withcariesratesbeinghigherinchildrenlivinginpoorhouseholdsor

thosefromethnicminorities9.InamorerecentNationalHealthandNutritionExaminationSurvey

(NHANES),from2011-2012approximately23%ofUSchildrenages2-5yearshaddentalcariesin

primaryteeth.Inaddition,thesamedatarevealedthatapproximately10%ofUSchildrenages2-5

yearshaduntreateddentalcaries.Dentalcariesprevalenceshowsmarkeddifferencesindifferent

regionsoftheUS.InarecentstudyusingtheNHANESdatafrom1999-2004,childreninLACounty,

oneofthelargestUScounties,weremorelikelytoexperiencedentalcariesthantheaverage

numberacrosstheUS.Nearly40%ofpreschoolchildrenresidinginLACountyhaddentalcariesin

primarydentitioncomparedto28%ofsameagechildrenintheUS.ChildrenresidinginLACounty

hadlessfavorableoralhealththanchildrenintheUSin1999-2004withethnicminoritieshavingthe

worst10.Earlychildhoodcaries(ECC)–averyseveretypeofcariesinchildrenisacommon

bacterially-mediatedandmultifactorialdiseasecharacterizedbymarkeddecayoftheteethof

children≤6yearsofagewhichisthoughtbysometobetransmissiblefromcaretakerstotheir

childrenbutisfullypreventable.RepresentativeinternationaldataispatchyonECC,asmost

countriesonlyreportcariesfromage5or6years.

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Traditionally, low caries prevalence has been observed in the developing countries, whereas the

prevalenceishigher indevelopedcountries.3Thisgeographicsituationhasbecomemorecomplex

due to speed of economic development and rapid changes in habits and diet inmany countries.

Although there might be gender or ethnic differences, they are minor compared with by sugar

consumption,lifestyleandeconomicdifferences.

The traditional global index used tomeasure caries in epidemiological studies— but not clinical

practice— is theDMF (Decayed,MissingandFilled) index,which isanumerical countofaffected

teethperindividualcollectedateithertheTooth(DMFT)ortoothSurfacelevel(DMFS).Thecountof

DMFTforanindividualorgrouprecordstheircariesexperience(thatis,thetotalofbothcurrentand

past caries). The index canbeusedat thedifferentdiagnostic thresholdswhichaffectbothmean

DMFTandtheproportionofindividualsaffected11,12,13.Dependingonthecriteriaused,proportionof

15-yearoldsvariesbetween11-52%(Figure3)14.

Effortsareunderwayworldwidetoimproveourunderstandingofcariesepidemiologybyimproving

methodologies and optimising them for use in epidemiological field work, while also keeping

compatibility with systems used in a fully equipped dental practice. In epidemiology, the

InternationalCariesDetectionandAssessmentSystem(ICDAS)“Epimodifications”12,whichcanbe

usedalongsidetheWHObasicreportingcriteria13,havenowbeenused inmanycountries,15along

withthemorerecentsimplifiedmerged-codesoption16 (Figure3).ThemergedICDAScodes,which

arecloser to thoseused inclinicalpractice,considerssoundsurfacesandthreestagesofcariesas

opposedtosoundsurfacesandsixstagesofcariesinthefullcodesICDASoption.Itisalsopossibleto

combineclinicalandradiographicfindingstorevealthefullprevalenceofcaries17.Recentworkbya

numberofEuropeanorganisationshasshown—bywayofaglobalexample—thatmostofcurrent

nationalcariesdataforDMFTlevelsin12-year-oldchildrenarenotcomparableacrossEurope15.This

highlightstherealchallengesfacingepidemiologicalstudiesoncarieswhereapparentlycomparable

resultsfromacrossanumberofcountrieshave,infact,beencollectedatdifferenttime-pointswith

veryvariablelevelsoftrainingandcalibrationandrecordcariesatdifferentthresholds.

WhenoralhealthtopicswereaddedtotheongoingGlobalBurdenofDiseaseStudy18,oraldiseases

were found to be highly prevalent, affecting approximately 3.9 billion people worldwide. The

methodologyusedinthismajorstudyisusefulbecauseitallowscomparisonwithotherdiseasesin

terms of burden, but also novel from a caries epidemiology since it does not use theDMF Index

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(whichhasbeenusedglobally for the last60years).Untreatedcaries inpermanentteethwasthe

mostprevalentconditionevaluatedacrossallmedical conditions,withaglobalprevalenceof35%

forallagescombinedwith2.4billionpeopleaffected.Notethatsomeofthesepermanentteethwill

havebeeninchildrenandadolescents.Untreatedcariesinprimaryteethinchildrenrankedthe10th

inprevalence,affecting621millionchildrenworldwide.

[H1]Mechanisms/pathophysiology

Themechanismsandpathophysiologyunderlyingthedevelopmentofdentalcariesarenow

increasinglywell-understoodandarebestconsideredfirstfromthehardtissue-relatedaspects(as

thediseaseaffectsthecalcifieddentaltissues)andthenfromthemicrobiology(biofilm)-related

aspects(astheserepresentthedriverofthecariesprocessifhomeostaticimbalanceismaintained)

(Figure1).However,becauseofthemultifacetednatureofthediseaseprocess,thesefactorsare

notindependent.Thedentalhardtissuesthatareexposedtotheoralenvironment(crownsand

laterrootsfollowinggingivalrecession)arethetargetsofthecariesdiseaseprocessandalltooth

surfacesaresusceptiblethroughoutanindividual’slifetime.However,carieswillnotoccurinthe

absenceofacariogenic(pathogenic)dentalbiofilmandfrequentexposuretodietarycarbohydrates,

mainlyfreesugars19,20,andthuscariesmustbeconsideredadietary-microbialdisease21.Amodern

conceptofcariesalsoincludesconsiderationofhowbehavioural,social,andpsychologicalfactorsas

wellasbiologicfactorsareinvolved22,23,24.Theimportanceoffluorideinmodifyingdisease

expressioncannotbeoveremphasised25(Box1).Perhapsdentalcariescanbebestdescribedasa

complexbiofilm-mediateddiseasethatcanbemostlyascribedtobehavioursinvolvingfrequent

ingestionoffermentablecarbohydrate(sugarssuchasglucose,fructose,sucrose,andmaltose)

andpoororalhygieneincombinationwithinadequatefluorideexposure.

[H2]Demineralizationandremineralization

Dentalcariestypicallystartatandbelowtheenamelsurface(theinitialdemineralisationissub-

surface)andistheresultofaprocesswherethecrystallinemineralstructureofthetoothis

demineralizedbyorganicacidsproducedbybiofilmbacteriafrommetabolismofdietary

fermentablecarbohydrates,primarilysugars.Althoughawiderangeoforganicacidscanbe

generatedbydentalbiofilmmicroorganisms,lacticacidisthepredominantendproductfromsugar

metabolism26andisconsideredtobethemainacidinvolvedincariesformation.Asacidsbuildupin

thefluidphaseofthebiofilm,thepHdropstothepointwhereconditionsatthebiofilm-enamel

interphacebecomeundersaturatedandaciddemineralizesthetoothmineralsothesurfacelayerof

thetoothispartiallydemineralized27.Thelossofmineralleadstoincreasedporosity,wideningofthe

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spacesbetweentheenamelcrystalsandsofteningofthesurface,whichallowstheacidstodiffuse

deeperintothetoothresultingindemineralizationofthemineralbelowthesurface(sub-surface

demineralization).Thebuild-upofreactionproducts,mainlycalciumandphosphate,from

dissolutionofthesurfaceandsub-surfaceraisethedegreeofsaturationandcanpartiallyprotectthe

surfacelayerfromfurtherdemineralization.Also,thepresenceoffluoridecaninhibitthe

demineralizationofthesurfacelayer28.Oncesugarsareclearedfromthemouthbyswallowingand

salivarydilution,thebiofilmacidscanbeneutralizedbythebufferingactionofsaliva.ThepHof

biofilmfluidreturnstowardneutralityandbecomessufficientlysaturatedwithcalcium,phosphate,

andfluorideionssothatdemineralizationstopsandre-depositionofmineral(remineralization)is

favoured.Duetothedynamicnatureofthediseaseprocess,theveryearly(subclinical)stagesof

cariescanbereversedorarrestedespeciallyinthepresenceoffluoride.

Asdemineralizationprogressesintothesubsurfaceoftheenamelanddentininthecaseofroot

caries,withacontinuingacidchallengeandpHdroptherateofminerallossbecomesgreaterinthe

subsurfacethanatthesurface,resultingintheformationasubsurfacelesion.Whensufficient

mineralislost,thelesionappearsclinicallyasawhitespot.Thisisaclinicallyimportantstageofthe

cariesprocess,sincethelesioncanbearrestedorreversedbymodifyingthecausativefactorsor

applyingpreventivemeasures;however,therepairprocessistypicallymostlyrestrictedtothe

surfacelayer.

Atthisstageinitsdevelopment,initial-stagecaries(ICDAScodes1and2)areconsiderably

demineralised,theymaywithchangesinthelocalecology,dietarypracticesandfluorideavailability

arrestandremainastheyare(inactivelesionswhichdonotprogressbutremainsstillrecognisable

asascarbecauseofthechangesintheopticalpropertiesoftheenamel),remineraliseand

effectivelyheal(re-precipitationofmineralinthelesionandpossiblysomesuperficialsurfacewear

resultinginanapparentlysoundsurface),orremainactiveandprogresstoamoreextensivestageof

destruction.

Ifthecariesprocessprogressesfurther,thesurfaceporosityincreaseswiththeformationof

microcavitationsinenamel(ICDAScode3)orinrootcaries—aprogressivesofteningofthesurface

dentinelayer.Incariesofthetoothcrownthesurfacelayerofthelesionmayeventuallycollapse,

resultinginphysicalcavitation(amacroscopichole–ICDAScode5or6).Evenatthismoreextensive

stageofcariesseverity,alesionmayinoptimalcircumstancesstillarrest,althoughthebiofilm

retainingcavitywillpersist.Whenanirreversiblestageoflesionextentisreached(typicallyinmost

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developedcountriesICDAS5&6),combinedwithsymptomsand/orconsiderationsofthefunctional

oraestheticneedsofthepatient,operativeinterventionisindicated.Ifthecariesprocesscontinues

eventuallythedentalpulpwillbecompromisedandeitherarootcanaltreatmentortooth

extractionwillbenecessary.

Foroptimaltoothhealth,themaingoalistomaintainthemineralhomeostasisoftoothsurfaces.

Sinceteetharefrequentlyexposedtoacidicconditionseitherfrombiofilmordietaryacids,the

abilitytoremineralizeisessentialtomaintainingtoothintegrity.Salivaisessentialforpreservation

oftoothhealthbyprovidingthemineralsnecessaryforremineralization.Lowlevelsoffluoride

greatlyenhancethisprocess,whichlargelyexplainstheremarkableeffectivenessoffluoridein

multipledeliveryformsinreducingdentalcaries(Box1)28.

Dentalcariesisadynamicdiseaseprocessinvolvingrepeatedcyclesofdemineralizationand

remineralizationthroughouttheday27,29.Teetharemostsusceptibletocarieswhentheyfirsteruptin

themouthandovertimebecomemoreresistanttosubsequentacidchallenge.Theclinical

implicationisthatthereshouldbegreaterfocusonmonitoringthecariesstatusofteethand

deliveringpreventivecareduringtheperiodswhenteethareerupting.

[H2]Microbiologyanddentalbiofilms

[H3]Oralmicrobiotainhealth.Themouth,suchasothersurfacesofthebody,iscolonizedfrom

birthbyadiversearrayofmicroorganisms(theoralmicrobiota)30.Themostcommongroupof

microorganismsarebacteria,butyeasts,viruses,mycoplasmas,protozoaandArchaeacanbe

present.Theoralmicrobiotahasasymbioticormutualisticrelationshipwiththehost.Theresident

oralmicroorganismsbenefitfromawarmandnutritioushabitatprovidedbythehostand,inreturn,

acttorepelinvadingmicrobes,contributetothehostdefences,andengageincross-talkwiththe

hosttodown-regulatepotentiallyexcessivepro-inflammatoryresponsestocommensalbacteria31.

Salivaplaysacriticalroleinmaintainingthisbeneficialmicrobiotabybufferingtheoralenvironment

ataneutralpH(optimalforthegrowthandmetabolismofmostoftheoralmicrobiota),while

providingproteinsandglycoproteinsasnutrients.

[H3]Dentalbiofilms.Theoralmicrobiotagrowsonsurfacesasstructurallyandfunctionally

organisedcommunitiesofinteractingspecies,termeddentalplaque32,33.Dentalplaqueisan

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exampleofabiofilm,theformationofwhichinvolvesanumberofstages34.Toothsurfacesare

coveredbyaconditioningfilmofproteinsandglycoproteins(theacquiredpellicle)thatarederived

mainlyfromsaliva,butalsocontainscomponentsfrombacteriaandtheirproducts,gingival

crevicularfluid(thatseepsfromthejunctionbetweenthegumandthetooth),blood,andfood35

(Figure1).Theacquiredpellicleprovidesbindingsitesforadherencebyearlybacterialcolonizersof

thetoothsurfaceleadingtodentalbiofilmformation,andalsoactsasphysicalbarrierpreventing

aciddiffusion36.

Bacteriacanbeheldweaklyandreversiblynearthesurfacebylong-rangevanderWaalforces(force

thatdonotinvolvecovalentorionicbonds)betweentheexternallayersofthebacteriumandthis

conditioningfilm.Attachmentbecomesstrongerandmorepermanentifinteractionsoccurbetween

moleculesonthebacterium(adhesins)andcomplementaryreceptorsintheconditioningfilm32.

Secondarycolonisingspeciesattachtotheearlycolonisers(coadhesion),andthecomplexityofthe

biofilmincreases.Thebiofilmundergoesmaturation,andnumeroussynergisticandantagonistic

microbialinteractionsoccur37.Amatrixisformed,composedofbacterialexopolymers(polymer

secretedintheexternalenvironment),includingpolysaccharidesderivedfromsugarmetabolismand

DNA;thematrixhelpstoretainthebiofilmonthesurfaceandcaninfluencethepenetrationand

movementofmoleculeswithinthebiofilm37,38.Thebiofilmprotectthebacteriaagainstantimicrobial

agents.Thecompositionofthesebiofilmsvariesondifferentsurfacesofthetoothduetosubtle

differencesinthelocalenvironmentalconditions.

[H3]Microbialaetiologyofdentalcaries.Thenormallysynergisticrelationshipbetweenthe

residentmicrobiotaandthehostisdynamicandcanbeperturbedbychangesinlifestyleor

alterationstothebiologyofthemouth;thesechangescanpredisposesitestodisease.Riskfactors

forcariesincludethefrequentconsumptionoffermentabledietarycarbohydrates(especially

sucrose)39and/orareducedsalivaflow40.Numerouscross-sectionalandlongitudinal

epidemiologicalstudieshavereportedashiftinthebalanceofthemicrobiotaatsiteswithcaries

comparedwithsiteswithsoundsurfaces.Earlystudiesofcarieslesionsfoundhigherproportions

andincidenceofStreptococcusmutansandS.sobrinuscomparedwithsoundenamel;lactobacilli

wereisolatedfromadvancedlesions40.Theseobservationsledtotheproposalthatcariesareonly

causedbyalimitedsubsetofthemanyspeciesfoundindentalbiofilms(the‘specificplaque

hypothesis’)41.However,asmoreepidemiologicalstudieswereperformed,carieswereobservedin

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theapparentabsenceofthesebacteria,whereastheseorganismscouldpersistonothersurfaces

thatremainedsound.

Subsequentlaboratorystudiesconfirmedthatotherbacteriafoundwithindentalbiofilmscouldalso

generatealowpHfromsugars,whereasotherscouldreducethepotentiallydamagingeffectof

lacticacidbyusingitasanutrientsourceandconvertingthemtoweakeracids,orbygenerating

alkalifromthemetabolismofarginineorureainsaliva.Thesefindingsprovidedsupportforthe

‘non-specificplaquehypothesis’,inwhichcariesisaconsequenceofthenetmetabolicactivityofthe

biofilm41.Morerecently,studiesusingclassicalcultureormolecularapproacheshavefound

associationsbetweencariesandothergroupsofacid-producingandacid-toleratingbacteria,

includingarangeofBifidobacterium,ActinomycesandPropionibacteriumspecies,andScardovia

wiggsiae.

Subsequently,alternativeconceptshavebeenproposedbasedonecologicalprinciplesthat

describetheeventsassociatedwithcaries42,43;theseecologicalplaquehypothesesarenowgenerally

accepted as the most plausible explanations of the microbial aetiology of caries (Figure 4). The

original‘ecologicalplaquehypothesis’recognizedtheconsistencyofbacterialfunction(thatis,rapid

acid production and tolerance of the acidic conditions generated) in the absence of specificity in

bacterialname,andemphasizedtheessentialrequirementofacaries-conduciveenvironment(that

is,sugar-richdietand/orlowsalivaflow).Microorganismswithtraitsthatarerelevanttocariescan

be present in biofilms on sound enamel, but at a level or activity that is too low to be clinically

relevant42.Cariesisaconsequenceofanunfavorableshiftinthebalanceoftheresidentmicrobiota

drivenbychangesinthedentalenvironment.Theregularexposureofplaquetofermentabledietary

sugars results in repeated conditions of low pH in the biofilmswhichwill favour the growth and

metabolismofacid-toleratingbacteriawhileinhibitingbeneficialorganismsthatpreferentiallygrow

atneutralpH. Implicit in thishypothesis is theconcept thatdiseasecanbecontrollednotonlyby

directly inhibiting the implicated bacteria but also by interfering with the factors that drive the

deleteriousshifts inthemicrobiota(that is, reducingtheamountandfrequencyofsugar intaketo

prevent acidic conditions, or promoting the use of snacks containing alternative sweeteners that

cannot be metabolized to acid by oral bacteria)42. The ecological plaque hypothesis has recently

been developed further to reflect the ability of some oral bacteria to adapt to acid stress during

regular andprolonged conditions of lowpH [the ‘extended caries ecological hypothesis’]43. Again,

acidificationof theplaqueacts as themain factor selectinganacid-generatingandacid-tolerating

bacterialcommunity,thedevelopmentofwhichwillincreasetheriskofcaries43.

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Dentalcaries,therefore,isnotanexampleofaclassicinfectiousdiseasebutisa

consequenceofanecologicalshiftinthebalanceofthenormallybeneficialoralmicrobiota,driven

byachangeinlifestyleandoralenvironment.Anappreciationoftheseprinciplesopensupnew

avenuesforcariesprevention.

[H2]Environmentanddentalcaries

Althoughbiofilmformationisanaturalprocessandisanessentialstepforcariesformation,the

presenceofabiofilmonatoothsurfaceisnotinandofitselfanindicationthatdiseaseispresent.It

isonlyafteracomplexinteractionofhostfactors,includingthetoothsurface,acquiredpellicleand

saliva,andfreesugarsinthedietthatthepresenceofthedentalbiofilmcanleadtodisease

expressionovertime.

Theuniqueenvironmentalconditionsthatexistofeachtoothsiteexplainthehighlylocalizedand

complexnatureofthecariesprocesswherebycariescanoccurataspecificlocationofthetooth

surfaceandnotonanadjacenttoothsurfaceevenwhenbothappeartobecoveredbybiofilm27.

Theseincludetooth-relatedfactorsthatimpactacidsolubility(forexample,toothcomposition

(imperfectlyformedstructureasinhypoplasias)andstructure,andpre-eruptiveandpost-eruptive

fluorideexposure,post-eruptiveageofthetooth),andthosethatinfluencebiofilmthicknessand

pathogenicitybycreatingareasofplaquestagnation(forexample,toothmorphology,archform,

occlusionandtoothposition)36,37.Developmentdefects(forexample,enamelhypoplasia,a

conditioncharacterizedbythinenamel)mayleadtoincreaseacidsolubilityandlossofsurface

structurecreatingsitesofplaquestagnationandincreasedriskofcariesinprimaryteeth44.Caries

susceptibilitycanalsobeaffectedbyproximityofteethtosalivaryglandorifices,andsalivaryfilm

thicknessandvelocityatspecifictoothsites36,37.Dentalappliances(suchasorthodonticappliances

anddentures)andfaultyrestorationscanalsoincreasecariessusceptibilityatspecifictoothsitesby

creatingareasofstagnationencouragingbiofilmformation27.

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[H1]Diagnosis,screeningandprevention

Diagnosis,riskassessment,screeningandpreventionareallvitallyimportantconsiderationsforthe

successfulunderstandingandcontrolofdentalcariesatboththeindividualandpopulationlevels.In

manycountriesscreeninghasaspecificpublichealthmeaningdiscretefromclinicalpractice,butthis

topicisbeyondthescopeofthisPrimer.Thefocushereisonwhathappensattheindividualpatient

level,wherehighnumbersofpatientsinteractwithoralhealthprofessionalsaroundtheworldona

dailybasis.Itmustbeemphasisedthat,inordertopreventandcontrolcaries,bothpublichealth

andindividuallevelinterventionsneedtobeoptimisedandaligned.

TheInternationalDentalFederation(FDI)1,45anddedicatedmeetings46havereviewedthecaries

systemsthatareavailable.Althoughexcellentworkhasbeencarriedoutinsomecountriesin

developingarangeofassessmentsystems(Box3),thereisashortageofcomprehensive,

internationallyapplicable,evidence-informed,holisticclinicalsystems,letaloneonesdevelopedby

formalconsensusprocesses.Therefore,whilstfullyacknowledgingthattherearearangeofother

systemsforundertakingsomepartsoftheclinicaltasksrequiredtoinformmoderncaries

management,wewillusetheInternationalCariesClassificationandManagementSystem(ICCMS47-

50)asaunifyingframeworktoillustratethekeypoints(Figure5).InICCMS,theelementsofcaries

riskassessmentatboththepatientandintra-orallevels,togetherwiththeclassificationofcariesby

staginglesionseverityandassessinglesionactivitybasedontheICDASsystemarebroughttogether

withdecisionmaking.Thisinformationisusedtoproduceapersonalisedcareplanwhichcanthen

beundertakenwithanemphasisontooth-preservingcariespreventionandcontrol,followedbyrisk

basedfollow-upplan(dentalrecall).47-50Thefourkeyelementsofthesystem(simplifiedforgeneral

practiceasthe“4DICCMSCariesManagement”)allowsacomprehensiveassessmentand

formulationofapersonalisedcariescareplanFigure5.

[H2]Prevention

[H3]Publichealthmanagement.Thegoalofdentalcariespreventionistopreservesound

toothstructure,preventdemineralizationofenamelandpromotenaturalhealing

processes46.Interventionscanbeimplementedatthepopulationlevelwithhealthpolicy,

legislation,regulationandpublichealthapproachestopromotehealthybehavioursand

14

impactbroadersocialdeterminantsofhealth51,52.Preventionapproachesmaytargetan

entirepopulation(forexample,waterfluoridationandsugartaxes)toassureequity,or

higher-riskgroupstoseektoincreasecost-effectiveness.Thesubjectoffluorideandcariesis

consideredinBox1,whilethereisfurtherconsiderationoffluoridesandcariesprevention

inBox2.Somecariesriskfactorsatthepopulationlevelincludelowfamilyincome,

restricteddentalcareaccess,lowfluorideexposure,loworalhealthliteracyandhighcaries

prevalence.Researchisongoingtofindthebestwaystotargethighcaries-riskindividuals.

Preventionprogrammescanbetargetedatgroupswithmedicalorspecialhealthcareneeds

suchasthosewithcompromisedimmunity(forexample,HIVandleukemia),cognitiveor

developmentaldisabilitiesthatcanmakeoralhygienedifficult,geneticdisordersthatare

associatedwithoralconditions(forexample,cleftlipandpalate,ectodermaldysplasia),

salivarydysfunctionfromSjögrensyndrome,diabetes,orfrequentuseofsomemedications

thatcausedrymouth(forexample,antihistamines).

Sincedentalcariesisamulti-factorialdisease,complementaryinterventionsmaybemoreeffective

thansingleinterventions.TheWHO’soralhealthactionplanemphasizestheneedfororalhealth

preventionprogrammestobecombinedwithotherchronicdiseasepreventionandeducational

programmesandpoliciessharingcommonriskfactors53.Inthefuturesharedelectronichealth

records,mobilesmartdevicesandsocialmediamayassistintheseefforts54.TheAlliancefora

Cavity-FreeFuture(aninternationalpublichealthadvocacycharity)haschaptersworldwide

promotingacomprehensiveagendaofactivitiesandresourcestopreventcariesinitiationand

progression.Advocacyandeducationeffortsincludeincreasingpublicawarenessandbehaviour

changetoimproveoralhygieneanddecreasesugarconsumption,advancingresearchandclinical

cariesmanagement55.56.

Manywatersuppliescontainnaturallyoccurringamountsoffluoride.Communitywaterfluoridation,

theadjustmentoffluoridetocommunitywatersuppliestoobtainoptimallevelsforcaries

prevention,isacost-effective,equitable,population-approachthatbestmeetspublichealthcriteria

andbenefitsallagegroups(Box2)57.TheUnitedStatesPublicHealthServicerecommendsthe

concentrationof0.7mg/ltomaximizecariespreventionwhileminimizingtheriskofdental

fluorosis58.Thisapproachislikelytoprovidesocietalcost-savings59.TheWHOrecommendsahigher

concentration(1.5mg/l)butflagsthattheexpectedvolumeofwaterconsumedandintakeof

fluoridefromothersourcesshouldbeconsideredwhensettingnationalstandards60.

15

Saltfluoridation,oftencombinedwithiodizedsalt,isaneffective,frequentlyusedpopulation-based

methodofcariesprevention.ItisusedprimarilyinEurope,CentralandSouthAmericawhere

fluorideinthedrinkingwaterislow,communitywaterfluoridationisnotfeasible,andotherforms

offluorideareusedlessfrequently61.Thefluorideconcentrationinsaltisusually250-300partper

million(ppm).Itistheleastexpensivemethodofcariesprevention62.Milkfluoridationprogrammes

havebeenusedinsomecountriessuchasHungaryandtheUK.63.64

Dentalsealantsareprofessionallyappliedresinmaterialbrushedontothecaries-pronepitand

fissuredgroovesoftheocclusalchewingsurfacesofchildren’smolars(backteeth)toprevent

diseaseinsoundteethorarrestprogressionofinitialnon-cavitatedcariouslesions65.Theapplication

doesnotrequirelocalanaesthesiaandsealantscanbeappliedinschool-basedprogrammeswith

portableequipment.Sealantprogrammesareaneffectivecommunityapproach66thatcanbecost-

effectivewhenappliedtochildrenathighercaries-riskorfromlow-incomefamilies67.IntheUnited

States,schoolswithmanychildrenenrolledintheFreeandReducedPriceMealProgramare

targetedforschool-basedinterventions68.

Althoughpreventivestrategiesshouldbecosteffectiveandresultinsocietalcostsaving,prevention

programmesincurmanyup-frontcosts,whereasthesavingsgainedbyaverteddiseaseand

treatmentmaytakeyearstoaccrue69.Theimpactofdentalpainandinfectiononqualityoflifealso

needstobeconsidered.Economicassessmentsofpreventivestrategiesdependonmanyfactors

includingcariesprevalence,personnelandmaterialcosts,interventioneffectivenessandtimeframe.

Examplesofresultsfromtwodifferentpopulationsfollowforcomparison(Box4)70,71.

[H3]Individualpatientlevel.Manyofthesameapproachesandtechnologiesusedatthepopulation

levelarealsoappropriateforuseinthedentalofficeorcommunitycliniclevel.Arangeofevidence

basedtoolkits72,.clinicalguidelines73,74Cochranesystematicreviews75,takentogetherwiththeWHO

Guidelineonsugarconsumption76,providearichevidencebasetosupportcariespreventionin

individualspresentingatthedentaloffice.Thisisbuiltaroundadvicetolimitamountandfrequency

ofsugarintake(alsolinkedalsotoobesityanddiabetesprevention)aswellasthefrequentuseof

fluoridecontainingtoothpastes,supplementedaccordingtocariesriskstatusbyfissuresealantsand

moreintensivepreventiveinterventions.

16

[H2]Diagnosis

[H3]Riskassessment

ThefirstelementinassessinganindividualforcariesaccordingtotheICCMSsystemistodetermine

patient-levelcariesriskbytakingacomprehensivehistoryaskingaseriesofquestionsknowntobe

associatedwith increased caries risk or caries protective factors. This includes assessment of the

medicalhistory,and the relevantsocialhistory, forexamplewhere thepatient isbornandraised,

the present residence, education level, and occupation. Finally, the patient is asked about diet

conditions intermsofamountofsugar intakeandfrequencyperday,numberof inbetweenmeal

snacks and the typeof toothpasteused; all information important to assess the caries risk at the

individuallevel77.

AwiderangeofriskassessmenttoolscanbeusedandarecompatiblewiththeICCMSSystem.One

such risk assessment is Cariogram78 , forwhich there ismore evidence than formany alternative

systems; studies have shown moderate accuracy on children and young adults79. Others include

CAMBRAandother risk factorsquestionnaires fromanumberofUniversitiesarealternatives.The

Cariogramuses9predicators in its full form:DMFT,relateddiseases,dietcontent,diet frequency,

amountofplaque,levelsofmutansstreptoccocci,fluorideuse,salivasecretion,andbuffercapacity.

A lowscore(0,1) indicatesthataparticularpredictorcontributesto lowrisk,whereasahighscore

(2,3)tohighrisk,anoverallriskcanbeestimated,ifthepatient’sprofileremainsstable78.

Theriskassessment(independentofhowit isderived)canbebuilt later intotheICCMScariesrisk

likelihoodmatrix49,50,whichcombinesclinicalcariesactivitywithrisklevelassessment.Eventually,it

ispossible toassess if thepatient is in low,moderateorhigh riskof gettingmorenew lesionsor

progressionof theexisting caries lesions,within thenext fewyears. The riskofdevelopingdental

caries can be lowered by effective dietary advice, improved plaque control and increased use of

fluoride,forexamplebyusing1450ppmfluoridatedtoothpasteinsteadof1050ppmtoothpaste80,

assumingthatthepatientiscompliant.

[H3]Clinicalassessments

Inorderto findandassessanycaries lesionson individual toothsurfaces,aclinicalexamination is

performed (thedetectandassesselementof the ICCMS4Dmethodology).Thegoal is to findany

caries lesions present and assess their severity, activity and the risk factors at the tooth level.

Assessmentscanincludesalivasecretion(andinsomecountriesbuffercapacityandthepresenceof

mutans streptococci is measured). Whilst these latter tests are deemed to have some value in

17

patientmotivation, increasing knowledge as to the complexity of thebiofilm ismaking such tests

lessclinicallyrelevant.Thelevelofplaquepresentisassessedclinicallyasithelpsinassessingcaries

activity.Professionaltoothcleaningthenallowstheidentificationofinitial-stagelesions81andlater-

stagelesionswhicharebestdetectedonclean(plaquefree)dryteeth.Locationofgingivalbleeding

duetogentleprobingisalsonotedasafurtherindicatoroflesionactivity.Clinicalexaminationalone

will, formanypatients,be insufficient inmakinga completeassessmentof caries. This isbecause

usingvisualexaminationalonethedentist/dentalhygienistsmaymissagreatnumberofinitialand

evensomemoreseverelesions(Figure6A).82,83

Thenthemouthisdriedbymeansofcottonrolls,andtheindividualtoothisexaminedbyusingthe

dentalcompressedairsyringe.Lesionseverityisthenassessedaccordingtotheclinicalappearance

ofthetoothsurfaces47,48,49,50.Althoughformanyyearsandinmanycountriesdentistshaveuseda

sharp explorer of dental probe to press into tooth fissures, it is now accepted that there is little

diagnosticbenefitfromthetactileelementanditmayconvertaninactivelesionintoanactiveone.

Anassessmentofcariesactivityofthedetectedandstagedlesionscanthenbemade.IntheICDAS

classificationsystem48,84,85,severalpredictorsareused:thelocationofthelesion(plaquestagnation

areaornot);thecolourofthelesion(whitishversusbrownish);tactilefeeling(rough,smooth)when

a blunted probe is run over the lesions, whether the lesion is matte or shiny, cavitated or non-

cavitated;andfinally,ifthelesionislocatedalongthegingivallineandwhetherthegingivableeds

afterprobingornot.Ifthelesionhasmoreofthefollowingcharacteristics(plaquestagnationarea,

whitish, rough tactile feeling, matted, cavitated, and gingiva bleeding) versus the other

characteristics,thelesioniscategorizedasactiveandthefinaldiagnosisofthelesionwillbeinitial,

moderateorextensiveactive.Ifnot,lesionsareclassifiedasinitial,moderateorextensivearrested

(inactive)47.

[H3]Radiographicassessment

Radiographicexaminationshavebeenanimportantpartofcariesassessmentseversincediagnostic

radiography became available (Figure 6B). However, there is a delicate balance to be struck in

balancingthediagnosticbenefitagainstthesmallbutrealrisksofusingionizingradiationelectively.

Thereforedecisionsas towhenandhowoften to takedental radiographs forcariesdetectionwill

dependuponfactorssuchastheresultofathoroughclinicalexamination,thepatient’scariesrisk

status,theirageandwhenradiographswerelasttaken.Theso-calledbitewingradiographprovides

18

valuableinformationforcariesinthetoothcrowns,butthesemustbesupplementedbyadditional

viewsforsomepatients.

AlthoughthedoseofionizingradiationhasreducedwithimprovementsinX-raygenerationandthe

speedandsensitivityoffilmsandsensors,thereisstillaresponsibilitytokeepexposuresaslowas

reasonably achievable and to use other diagnostic information where available to minimize

radiographic exposures. Examples of clinical indications for a radiograph could be: suspicion of a

carieslesionforasurfacethatisnoteasilyinspectedvisuallyandassessmentofthedepthofalesion

whichis,atleastpartly,visibleclinically.

Itshouldbeappreciatedthatclinicallyforsomesurfaces,particularlyapproximalsurfaceswherethe

site of caries attack cannot be visualized directly, radiographic information can be pivotal in

assessing the extent of caries lesions in terms of depth towards the dental pulp. However, this

informationhastobecombinedwithknowledgeaboutcariesactivitystatusandoverallcariesrisk

when integrating all information into a personalized care plan including decisions to treat non-

operatively or operatively (the D for Decide in the 4D System). Other situations where the

radiographic information can be invaluable include suspicious occlusal fissures where, in a high

fluorideenvironment,anapparentlysmall lesionmayonoccasionextendradiographically intothe

innerdentine.Theseexampleshighlighttheimportanceofcombiningandintegratingtheclinicaland

the radiographic information inorder tobe able tomakeaccuratediagnoses fromwhich tobuild

appropriate care plans. Recall frequency for both clinical and radiographic examination should be

decidedonanindividualisedbasis,accordingtocariesrisk.

At the end of the clinical and then the radiographic examination information on lesions visually

detectedand/orradiographicallydetectedcanbecombinedinordertomakeadiagnosis(Figure6).

19

[H1]Management

Managementofinactiveandactive(withvariousdegreeofseverityisoutlinedbelowandinFigure

7.

[H2]Initiallesions

Theinitiallesion(evenwhenactive)ismanagedthroughnon-operativecareusingremineralization

therapy,involvingbehaviouralchangesandpromotionofmineralizationoverdemineralization,

typicallybyusingfluoride-containingprocucts.1Remineralizationisaimedatstoppingprogressionof

thelesionorideally,reversingit.Aspartofthemineralizationtherapy,managementshouldinvolve

reviewingthedietaryandoralhygienebehaviours(plaquecontrol)ofthepatient,followedby

educationandencouragingbehaviouralchanges86.

Fluorideisabletoincreasetherateandmagnitudeofremineralizationofinitiallesions87,88.Fluoride

canbedeliveredtopicallyeitheraspaste,gelorvarnishbyadentalprofessionalorintheformof

toothpaste,gelormouthwashathomesettings89(Box1).Theacidulatedfluoridatedproductshave

alowpH3.0-4.0.ReducingthepHofthefluoridevehiclehasbeendemonstratedinthelaboratoryto

prolongtheingressofmineralionsintothelesionbypreventingtheblockageofsuperficialenamel

pores,precentingaccesstothedeeperareasofthelesion86,90.Ideally,fullrecoveryofaninitial

carieslesionwouldbeachievedwhencalciumandphosphatearepenetratingathighenough

concentrationsinthepresenceofslightlyelevatedconcentrationsoffluoride91.Salivaisthemost

importantsourceofionsaroundteethanditsflowcanbeenhancedthroughchewingsugar-free

gums92.Fluoridateddrinkingwaterhasprovedtobeeffectivebyincreasingthelocalconcentration

ofthisioninsalivaandplaque93.Morerecently,attemptshavebeenmadetofurtherenhancethe

remineralizationpotentialbyincorporatingwater-solublebioavailablecalciumandfluorideinto

topicalproductssuchassugar-freegums,dentalcreamsandvarnishes.Theseformulationsinclude

caseinphosphopeptide-stabilizedamorphouscalciumphosphateandphosphoryloligosaccharidesof

calciumandtheirfluoridecontainingvariations94,95,96.Earlyresearchworkssuggestthatthese

formulationsmaybeneficialanti-cariogeniceffects;however,evidenceisyettobuildup.94,95,96.

Althoughanon-surgicalapproachtothemanagementofinitiallesionsappearstobethemost

beneficial,minimalinterventiontherapycanbeusedaswell.Pitandfissuresealantshavebeen

appliedusingresinbasedmaterialandglassionomercement.Anewlydevelopedresinbased

productwithsurfacepre-reactedglass-ionomerfillerisexpectedtoreleasefluoridesustainably

20

becauseofitsabilitytorechargefluorideion97.Thesefillersreleaseotherionsenhancingtooth

mineralformation98.

Whenaninitiallesionisfound,long-termmonitoringalongwithmanagingthecariesriskfactorsis

anoptiontoconsider.Asurgicalinterventioncanbeconsideredonlyiftheinitiallesionadvances99,

100,101.

[H2]Moderatelesions

Thegoalofnon-invasivemanagementofmoderatelesions(Figure7)istoarrestfurtherprogression

andregainlostminerals.Twooptionsareavailable.

[H3]Mechanical blocking. Clinical evidence shows that non-cavitated lesions on occlusal surfaces

can be arrested with resin-based fissure sealants102. Extrinsic substrates are blocked as acids

producedbythebiofilmcannotreachtheenamelandthenumberofbacteriainthecariousdentine

isreduced.Theprocedurerequiresstrictdryconditionsandthesealantsmustberegularlychecked

andmaintained. A related technology to arrest proximal lesions is resin infiltration of the dentin

layer103.Lesionslimitedtotheouterthirdofthedentinaretreatedwitharesinthatpenetratesand

repairs subsurface pores. Although long-term results are lacking, it seems clear that the micro-

invasivetreatmentsdisplaylowerlong-termcoststhaninvasivetherapy104,105.

[H3] Fluorides. Self and professionally applied fluorides can remineralise and arrest caries lesions

(Box 1). Topically applied silver diamine fluoride is a cost-effective alternative to arrest early

childhoodcariesandrootcarieslesionsinfrailelderly,especiallywhenotheroptionsareabsent106,

107.

Inthenearfuture,novelnanotechnologiesbasedonpeptidesandhydroxyapatitecrystalstogether

withbiofilmengineeringareexpectedtoadvancethenoninvasiverestorativeoptionsformoderate

carieslesions108,109.

[H2]Extensivelesions

Extensive lesions are stillmost commonly subjected to classical standard care; the demineralized

tissuesarecompletelyremovedandreplacedwithafillingmaterial.However,thedevelopmentof

adhesive techniques without need of mechanical retention (that is, composite resins or tooth-

21

coloured mixtures of plastic and glass) has allowed dentists to adopt a more tooth-preserving

approach.Yet low-qualityevidencesuggests that resincomposites lead tohigher failure ratesand

risk of secondary caries than amalgam (metal-coloured mixture of mercury and other metals)

restorations.110

Arecentdevelopmentisthestepwiseorpartialcariesremovalinwhichonlythesuperficiallayersof

the lesions are removed. Systematic reviews have concluded that this approach reduces the

incidenceofpulpexposureandfavorcariesarrestandtertiarydentinformation(thatis,layingdown

newprotectivedentine in response to an advancing caries lesion in bothprimary andpermanent

teeth)100,111.Althoughthesetechniquesshowclinicaladvantageovercompletecariesremoval, it is

tooearlytorecommendcertainclinicalstrategies.Itmustalsobeunderlinedthatthedecayedteeth

must be vital and free from symptoms. Furthermore, the success depends on an appropriate

restorationthatcompletelysealsthetoothandkeepsremainingbacteriainthedeeperdentinlayers

dormant. A disputedmode ofmanaging advanced asymptomatic lesions in primarymolars is the

Hall-technique112.Thetoothisnotpreparedintheconventionalway,butiscoveredbyapreformed

stainless steel crown with a superior clinical performance when compared with traditional

conventionalrestorativecare113.

[H2Childrenwithaveryhighcariesrisk

Topreventcariesandhavesuccessfulmanagementoforaldiseases,perinatalandinfant

oralhealthcareareessentialaspectsofearlyintervention,whichfacilitatebehavioural

changesandallowforgoodoralhealth114.Anessentialstepistostarteducatingcaregivers

andtheirhealthcareprovidersontheimportanceofdentalcareduringpregnancyand

infancy,withthedevelopmentofchild-specificoralhealthmeasuresandmethodsto

preventoraldiseases115.ThisisespeciallyimportantforchildrenwhoareathighriskofEarly

ChildhoodCaries(ECC)development.Althoughthereisnomechanisticdifferenceinthe

pathologyandprinciplesofcarebetweenECCandotherformsofcariesinchildrenor

adults,theissuesrelatedtoECChavemoretodowithspecificbehaviouralriskfactors,most

importantlynighttimebottleusewithsugarybeveragesandjuices.Althoughanatomical

differencesbetweenprimaryandpermanentteeth(suchastheenamelismuchthinnerin

primaryteethandthuscariescanprogressfasterintodentin)exist,themechanisms,

pathophysiologyandtreatmentapproachesarenotdifferentbetweenbothtypes.However,

22

clinicalmanagementfortheyoungerpatientandtheinvolvementofcarergiversbringsits

ownchallenges.

CariesManagementbyRiskAssessment(CAMBRA)isanevidence-basedapproachadaptedtothe

specificneedsofthesubsetofthechildpopulationwithECCwhoexperienceaveryaggressivecaries

challenge.115,116CAMBRAforECCassistsprovidersinastructuredmannertofirstlyassesscariesrisk

andriskonprogressionatanearlyageinapatient-centeredapproach,basedonageanddental

statusandriskfactors;secondlytailoraspecificindividualizedcareorpreventivemanagementplan,

beforedecidingonasurgicalmodality;thirdlyformaliseafollow-upplanbasedonriskandageof

thechild;andfourthlyensurespecificguidanceforthecaretakerswithtargetedself-management

goalsbasedontheage,riskandneedofeachindividualpatientatanygiventime.Thisversionof

CAMBRAprovidestheinformationtoassesstheriskofcariesdevelopmentanddiseaseprogression

inyoungchildrenaslow,moderate,orhighrisk.

Assessmentscanalsobedonethroughtheuseofthisriskassessmenttechniqueonthreespecific

domains:riskand/orbiologicalfactorssuchascontinualbottleuse,sleepingwithabottle,frequency

andtypesofsnacks,childtakinganymedicationsandsomeotherriskfactors;protectivefactorswith

questionssuchastheuseoffluoridatedtapwater,useoffluoridatedtoothpasteortheuseofxylitol

(recommendedbysomebutwithmixedevidence)onacontinuousbasis;andclinicalfindingswhere

providerscanassessthepresenceofearlydemineralizedcariesenamelsurfaces,orcavitiesatvery

earlyage,presenceofplaquebiofilm,lackofsalivaryflow,amongothers117,118.

ThroughtheseguidelinesforchildrenprovidedbyCAMBRA,earlyinterventioncanbeconductedin

primarycaresettingsbyanyqualifiedpediatrichealthcareprovider.Furthermore,providersare

recommendedtouseminimallyinvasivetreatmentssuchasfluoridevarnish119.Athome,the

caregivershouldbeguidedandsupportedtoadoptgoodoralhealthbehavioursfortheirchildren

andthemselvesandtousefluoridatedtoothpasteassoonasthefirsttoothappearswithasmall

amountnomorethanagrainofricetoprotecttheteethfromdevelopingcaries120.Ultimately,

thesepracticeswillbenefitinthepreventionandself-managementofECCandhavethepotentialto

deliverbetterpractice,improveclinicaloutcomesandreducetheoverallburdenofdiseaseinyoung

children121.

[H2]Followup/Recall

23

The final elementof continuing caries care is toestimatewhen thepatientneeds to come to the

clinic again, and this depends on the patient’s age and actual caries-risk status. It is no longer

deemed appropriate that all patients should be recalled every sixmonths. If the risk-assessment

indicateslowrisk,thenextvisitcanbepostponedmorethanoneyearforadults,moderatetohigh

risk imply that the recall should be shorter. After a suitable risk-based recall interval the caries

managementcyclestartsagain(Figure5).

[H1]Qualityoflife

Havingconsideredthescientific,clinicalandpublichealthaspectsofcariesitisimportantto

appreciatetheimpactthatthediseasehasonqualityoflifeacrossthelife-course.Thedemographic

transitiontowardsageingsocietiesandtheoralhealthtransitionwithconsiderablymorepeople

keepingtheirnaturalteethintooldagehasresultedinarelativeshiftintheburdenofuntreated

cariestowardsadults122.Cariesisstillahighlyprevalentconditionamongadults(18-65)andolder

adults(>65)122,123,124,butalsoinchildren,evenamongveryyoungchildrenaffectingtheirprimary

dentition122,125.

Toothacheisstillprevalentamongchildrenandadolescents,andisstronglyassociatedtodental

caries,particularlyamonglowersocioeconomicpositiongroupswithanestimated5-6%increasein

probabilityoftoothacheforeachadditionalprimarytoothwithcariesexperience126.Inthemost

recentnationalstudyintheUK,18%of12-year-oldsand15%of15-year-oldsreportedtoothache127.

Despitethefactthatdentalcariescanbeasymptomatic,particularlyatitsinitialstages,cariesis

associatedwithdiminishedqualityoflifeforpeopleaffectedandtheirfamilies128.Amongchildren,

cariesisassociatedwithnegativeimpactsonarangeofdailylifeactivities129,130andthiswasthe

casealsoamongveryyoungchildrenwherecarieswasassociatedwithworseoralhealthrelated

qualityoflifeintermsofperceptionsofbothchildrenandtheirparents131.Similarly,toothacheand

toothdecayaretheconditionsmostcommonlyassociatedwithworseoralhealthrelatedqualityof

lifeonadults.AmongadultsinEngland,WalesandNorthernIreland,16%reportedfrequentand

17%severeimpactsontheirdailylifeduetotheiroralconditions,buttherespectiveprevalencefor

bothfrequentandsevereoralimpactswas24%amongthosewithdecayand38%amongthosewith

experienceofseverecariesasexpressedthroughthePUFA(pulpitis,ulceration,fistulaorabscess)

index123.Globally,untreatedcariesaccountedforalmost5milliondisabilityadjustedlifeyears

(DALYs)in2010,withafurther4.5millionDALYsattributedtoexcessivetoothloss.Caries

contributedtoDALYsacrossthedifferentagesbutmoresoforchildrenandyoungandmiddle-aged

adults.Indeed,cariesarethepredominantoralhealthcauseofDALYsamongpeopleaged≤35years.

24

Ontheotherhand,extensivetoothloss,wasprevalentandanimportantcontributortoDALYs

amongmiddleagedandolderadults18.

Theimpactofdentalcariesisnotlimitedtooralsymptomsandthedetrimentalinfluenceonthe

qualityoflife.Cariesinprimarydentitionisassociatedwithmalnutrition132;childrenwithsevere

earlychildhoodcarieshaverelativelypoornutritionalhealthforarangeofnutrientscomparedto

caries-freecontrols133,134.Otherstudieshaveshownalinkbetweencariesexperienceandpoorchild

growthandlowweightgain135-138.Theevidenceonwhethertreatmentforcariesconsiderably

enhancesgrowthisinconclusive139-142andfurthermethodologicallyrobuststudieswithlonger

follow-upperiodsareneededinthatrespect.However,treatingseveredentalcariesinchildren

resultedinsignificantlyreducedtoothacheandsepsis,andimprovedsatisfactionwithteethand

smileaswellasappetitecomparedwithchildreninwhomdentalcarieswerenottreated.142Apart

fromgrowthanddevelopment,cariesalsonegativelyaffectsschooling,aschildrenwithpooreroral

healthweremorelikelytohavehigherratesofschoolabsenceandalsoperformpoorlyinschool

comparedwithchildrenwithbetteroralhealth.143,144Finally,excessivedentalcarieshasbeenlinked

withconsiderablyincreasedriskofhospitalisationandthereforealsohascostimplications.128,145

Theaforementionedimpactsofcariesdisproportionatelyaffectthemoredeprivedgroupsinthe

society123,126,127,131,146,inlinewiththeevidenceonclearsocioeconomicinequalitieswithhigherrisk

ofcarieslesionsorexperienceamongthoseinlowersocioeconomicpositions147.Thishighlightsthe

importanceoffocussingnotonlyonbehaviouralandbiologicalriskfactorsbutalsoonthebroader

socialandenvironmentaldeterminantsofthedisease148.

[H1]Outlook

Dentalcariesremainsoneofthemostprevalentglobalchronicdiseases.9,149Foratleastacentury,

dentalcarieshasbeenmanagedsurgically.Publichealthmeasures,suchaswaterfluoridationand

topicalfluorides,havehadconsiderableimpactontheburdenofdentalcariesindeveloped

countries.However,thefailuretoeradicateorhalttheburdenofthisdiseaseinmanypartsofthe

world,aswellasvulnerablepopulationgroupsindevelopedcountries,meansthatdentalcaries

remainsamajorpublichealthproblem.

25

Intheemergingeraofhealthoutcomesandvalue-basedhealthcaresystems150,thesuccessand

paymentfortheprovisionofhealthcarewillbedeterminednotonlybythetypeandnumberof

proceduresprovidedtopatientsbutalsobythefinalhealthoutcomesachieved.Managementof

dentalcariesshouldmoveforwardtoamodelwherehealthoutcomesformthebasisfor

compensationandarethefocusofdentalcare.Accordingly,themajoroutcomeofcaries

managementclinically,personallyoratacommunitylevelisthepreservationoftoothstructureand

maintenanceofteethinahealthystate(outcome1).Asecondoutcomewouldbetocontrolinitial

stagesandarresttheirprogressionorreversethecariesprocesstowardshealth(outcome2).These

twooutcomesprecedetheoutcomeofrestoringlosttoothstructureandfunctionofdecayedteeth

(outcome3),whichisthecurrentmajoroutcomethatisbeingreimbursedbythirdpartypayersor

patientsallovertheworld.Inordertoachievethesethreeoutcomes,processoutcomesmustbe

evaluatedthroughoutthecarecycleandbereimbursedaccordingly.

Dentistsandotherdentalprofessionalsmuststagethecariesprogress,assessriskfactors(onthe

dental,medical,biological,behavioural,andsociallevel),developcomprehensivemanagement

planstopreventnewcariesbasedonriskstatusofpatients,controlinitiallesions,restorecavitated

lesions,rehabilitatethedentition,anddevelopafollow-upplan54.Assessingandreimbursing

dentiststoevaluatealltheseprocessoutcomesisasimportantasreimbursingthemforachieving

thehealthoutcomesthroughproceduresbecauseitisthroughtheseoutcomesthatdentalhealthis

achieved.Thereisnodoubtthatvaluingthenewlyproposedoutcomesrepresentsarevolutionary

changeindentalcareglobally,whichasstatedbeforehassofarbeenfocusedondeliveryof

procedures.Aprocedure-focusedsystemofreimbursementisnotobsoletebutratheritmust

becomepartofalargermodelofhealthpromotingsystemofcare.Implementationofanew

paradigmindentalpracticeandeducation,asexpected,willnotbeeasyandwilltaketime.

Fortunately,thereareafewpracticalexamplesofsuccessinchangingparadigmsofcareindentistry.

Forexample,inthe1970sand1980s,aseriesofclinicaltrialscomparednon-surgicalandsurgical

periodontaltherapiesandfoundthatformostlevelsofseverityofperiodontaldiseasesboth

modalitiesproducedsimilaroutcomes151.Whiletherewasvociferousreactionfromsupportersof

thesurgicalmodalitiesofcare,theemergenceofevidenceledtoaradicalshiftovertwodecades

towardsnon-surgicalcare.Itmaybethatsimilarchangestoalessinterventionalapproachtocaries

managementcanchangepractice152.Anotherpragmaticmodelforimplementationisthe

developmentanddisseminationofguidelinesandpoliciesthatdirectdentistsintoadoptingthe

desiredbehaviours.Dentistsareusedtoadopting,thoughwithsomehesitation,standardsdictated

26

bydentalinsurancecompanies,governmentagencies,licensingboardsorhealthauthorities.The

primeexampleofthechangeinbehaviourduetopoliciesistheadoptionofinfectioncontrol

measuresandstandardsforoccupationalhealthandradiationsafety.

Otherthanthosetwopragmaticexperiences,thereisdearthofevidenceonimplementationof

changesindentalpractice153.Continuingeducationandarticlesindentaljournals,whilenecessary,

arebythemselvesinsufficientintheireffectivenesstoinfluencechangeinpracticesofpractitioners.

Thecasetosupportthisconclusionisclearintheadoptionofpit-and-fissuresealants.Although

sealantsarebasedonthesamematerialsasresincompositefillings,theiradoptionhasbeenslower

thantherapidgrowthinuseoftoothcolouredfillingmaterials154.Thereasonforthismaybe

becausewhensealantsarepromoted,basedupontheevidence155,asaprocedureofchoicefornon-

surgicalmanagementofinitialcarieslesions,theyreplaceastandardoperativeprocedurethat

dentistshaveadoptedasthenorm.Bycontrast,tooth-colouredrestorativematerialsreplaced

amalgam“silver”fillingmaterials,whichdentistsandpatientsstartedtoabandonasanormbecause

ofconcernsabouttheexposuretomercuryandaesthetics.

Itisexpectedthattheproposedintegratedcariesmanagementsystemandvalue-baseddentalcare

requireformany,butnotall,changesinthecurrentnormsofpractice.Thewaytomoveforwardin

implementationwillrequireamulti-prongedstrategy,collectiveengagementofalldentists,

educators,andpolicymakers,andresearchstudiesthatassesstheoutcomesofthenewproposed

paradigmofcariesmanagement,andrefineitasneeded.Itshouldbeappreciatedthattimescales

andtippingpointsinimplementationarenotoriouslyunpredictable.

Theburdenofdentalcariesintheworldisconsiderableintermsofcost,lossoftimefromworkand

school,insomecasesseverefacialandsystemicinfections,andrarelydeath.Hence,itisimperative

thatthenewapproachdescribedinthisPrimerisimplementednow.Acollaborationamongdental

schools,clinics,andprofessionalandgovernmentagenciesmustbeformedtocreatealearning

organizationthatshareexperiencesandassistinconductingresearchofthepreviouslydescribed

outcomes.TheinitialstepsofthisworkareunderwaywithaconsensusproductionofaGuidein

cariesmanagementforpractitionersandeducators49.Fortunately,therearetodaynewtoolsthat

canaidandempowerchangingnormsofpracticeandcollectingoutcomedata.Theuseof

computerizedreminders,electronicauditandfeedback,andstop-and-godecisionalgorithmsin

electronichealthrecords,providenewvenuestohelpinchangingpractitionerbehaviours.Auditand

feedbackhavebeenfoundtobemodestlyeffectiveinchanginghealthcarebehaviours156.

27

Incorporationofinstantaneousauditandfeedbackinelectronichealthrecordscouldprovide

reminderstopractitionerstofollowstandardsofcareduringthecareprocess.

Thetaskaheadwillbetodevelopnewtoolsandreimbursementincentivesaswellasforma

collaborationtocoordinatetheimplementationofthenewcariesmanagementsystemacrossfields.

Thecollaborationwillalsodesignandassistpartnersinconductingresearchonoutcomesofthenew

cariesmanagementsystem.Itistimenowtostarttheprocessofmovingtowardspreservingtooth

structure,ratherthanretortingitwithartificialmaterials.

28

Textboxes

Box1|Fluorideandcaries

Thebenefitsoffluorideoncariespreventionandarrestaregenerallyacceptedbydentalresearchers

andpracticingprofessionalsworldwide.Theseincludecommunity-basedmethodsoffluoride

delivery(water,milkandsaltfluoridation)andabroadrangeoffluorideagents(paste,gel,foam,

rinse,solution,varnish,drops,tablets).Theuseoffluoridesintoothpoastesiscreditedwiththe

overallglobalreductionincariesinmanycountriesoverrecentdecadesastoothbrushingwith

toothpasteissowidelyacceptedasabehaviouralnormassociatedwithbothhealthandgrooming.

Thepreventivecontributionofthefluoridetoothpasteoutweighsthatfrombrushingperse.Flossing

ispracticedtoaveryvariableextentandtheevidenceforacariespreventiveeffectislimited.

Fluoridecancomeinvariousformulationsmainlysodiumfluoride(NaF),acidulated

fluorophosphates(APF)orstannousfluoride(SnF2).Fluoridetoothpasteisthemostwidelyused

formoffluoridedeliveryworldwide.Fluoridedentifrices(fluoridecontainingpaste)haveshownin

numerousclinicaltrialstobeeffectiveanticariesagents.Thebenefitisseentobederivedfromthe

frequentlowdoseapplications.

Topicalfluorideuseathighconcentrations(>2,500ppm)providesthedrivingforcetopenetratethe

dentalbiofilmadjacenttothetoothsurface,deliveringfluoridetotoothsurfaceandmore

importantlyconcentratesitinincipientlesions.Attheselevels,fluorideisshowntodecreaserateof

enameldemineralizationandincreasedrateofenamelremineralization.Thereisalsoarelationship

betweenhigherfluorideconcentrationandprolongedretentionoffluorideintheoralcavity.High

fluoridelevelsarenecessaryfortheformationoffluoridereservoir(calciumfluoride-likedeposits)

onthetoothsurfaceandindentalplaque.Veryhighfluoridelevelscanalsohaveatransient

bactericidaleffect,butthiswouldrequirerepeatedfrequentapplicationsofprofessionallyapplied

highconcentrationfluoridewhichisnotpractical.

ReferencesBox1:87,157-163.

29

Box2|Fluoridesandcariesprevention:evidenceandcontroversialaspects.

Fluoridehasakeyandwidespreadroleincariespreventionandcontrolwhichhasbeen

demonstratedbyarangeofevidencefordecades.Theevidenceforeffectivenessfortheprotection

andtreatmentofspecificindividualsthroughfluoridetoothpastes,gelsandvarnishesisclearand

hasbeendemonstratedconvincinglyinanumberofCochraneSystematicReviews.Useoffluoridein

thiswayislargelyuncontroversial,althoughinsomecountriesenvironmentlobbieshavevoiced

concernsataphilosophicalasopposedtoascientificlevel.

Despitethelonghistoryofsuccessfuluseofwaterfluoridationasapublichealthintervention

(wheretheconcentrationoffluorideindrinkingwateriseithermaintainedormodifiedtoalevel

between0.7mg/l1.5mg/ltomaximizecariespreventionwhileminimizingtheriskofdental

fluorosis.TheWHOrecommendsthatwatervolumeconsumedandintakefromothersources

shouldbeconsideredwhensettingnationalstandards60,butthissubjecthasinsomecountriesbeen,

andinmanycountriescontinuestobe,controversial.Incountrieswherecontroversyexists,the

centralargumentisaroundthebalancebetweenpublicbenefitononehandandtheperceived

medicationofindividualswithouttheirconsentontheother.Also,ifyoungchildrenswallowtoo

muchfluorideatanageduringwhichtheirpermanentteethareforming,thereisariskofmarks

developingonthoseteeth.Thisiscalled‘dentalfluorosis’.Mostfluorosisisverymild,withfaint

whitelinesorstreaksvisibleonlytodentistsundergoodlightingintheclinic.Morenoticeable

fluorosis,whichislesscommon,maycauseaestheticconcerns.Despitethevociferousarguments

andscarestoriesaboutthedangersofwaterfluoridation,ithasbeensupportedinmanycountries

fordecadesandisstillsupportedbyawiderangeofmedical,publichealthanddentalbodies

worldwide.Thereisapaucityofrecenthighqualitystudiesofthemagnitudeofthebenefit

achievablebywaterfluoridation–whichmaynotbeashighaswasestimatedbeforethe

widespreaduseoffluorideinthedietandintoothpastesandbeforeconsiderablelifestylechanges.

However,thebenefitisstilljudgedtobesubstantialforcariesinchildren164.Therearealso

influentialcritiquesofthesystematicreviewmethodologyusedintherecentCochranereviewthat

maintainthepotentialbenefitsofusingwidereligibilitycriteriaforstudiesinsuchreviewsinorder

toachieveafullerunderstandingoftheeffectivenessofwaterfluoridation.165Alternativesatthe

communitylevelincludebothsaltandinsomeplacesmilkfluoridation;howevertheevidencefor

theseinterventionsismorelimited.

30

Box3|Protocolstoriskassessandclassifydentalcaries

Riskassessmentprotocols:forexample,CariogramandCariesManagementbyRiskAssessment

• ResearchtoolsforexampletheNyvadcriteriaforassessingcarieswithafocusonactivity.

• Epidemiologicalcaries“indices”suchas:WHOBasicMethods,InternationalCariesDetection

andAssessment(ICDAS)andtheCariesAssessmentSpectrumandTreatment(CAST)Index.

• Operativedentistrybasedclassifications:Black’sClassificationSystem(early1900s),

AmericanDentalAssociationCariesClassificationSystem(incorporatesICDAS),Mount-Hume

ClassificationSystemandSite-Stage(SI/STA)ClassificationSystem.

31

Box4|Economicassessmentsofpreventivemeasures.

Comparedtomanydiseases,healtheconomicassessmentsofcariespreventionatboththepublic

healthandindividuallevelsarescarce.Traditionalstudieshavefocussedonshorttermcomparisons

ofdifferenttypesofrestorativematerials,orcomparingafissuresealantagainstaconventional

filling,butnottakingintoaccountthelongtermscostsandconsequencesofrepeatedreplacement

ofrestorationswhenthediseaseisnotcontrolled,norpatientpreferences.Fewrobuststudies

lookingatthecostsandbenefitsofusingbehaviouralchangetechniquestomodifycariesriskorof

usinganticipatoryguidanceormodifyingoralhealthliteracyexist.Thesetopicsneedfurther

researchacrossdisciplines–asdohealtheconomicevaluationsoftheintegrateduseofpreventive

managementsystemsattheIndividual,dentalpracticeandregionallevels.Twocasereportsare

outlinedbelow.

• Theestimatedcost-effectivenessofcariespreventionprogrammesforchildreninChile

comparedtonointerventionwereevaluatedusingeconomicmodels70.Saltfluoridation,

communitywaterfluoridationandschool-basedmilkfluoridationprovidedthemostcost-savings

fromasocietalperspective,followedbyschool-basedfluoridemouthrinseprogrammes.School-

basedprogrammesusingfluoride-gelapplication,dentalsealants,andsupervisedtoothbrushing

usingfluoridetoothpastewereeffective,butdidnotyieldsocietalsavingswithinasix-yeartime

frame.Dentalsealantprogrammeswouldbecost-savingifappliedtochildrenathighcariesrisk.

• DynamicmodellingtocomparedifferentapproachesforpreventingECCinalow-income

MedicaidenrolledpopulationinNewYork71foundnetsavingsfromcommunitywater

fluoridation,motivationalinterviewingespeciallyifimplementedforcaregiversofchildren

younger≤2years,andtoothbrushingprogramswithfluoridetoothpastewithina10-yeartime

frame.Fluoridevarnishprogrammeswererecommendedfortheyoungestchildrenathighrisk,

suchasdonebypaediatricmedicalprovidersinNorthCarolina’sIntotheMouthsofBabes

Program166.

32

Figure1:Normaltoothanatomyanddevelopingdentalbiofilm.Thetooth’shardtissueconsistsof

enamel,dentinandcementum.Enamelisahardmaterialcomposedalmostexclusivelyofmineral

(mainlycomposedofhydroxyapatite[Ca10(PO4)6(OH)2])andcoversthedentineonthecrownofthe

tooth.Cementumisabonematrixlikesubstancecomposedofmineralandcollagen;itcoversthe

rootofthetooth.Thedentalpulpformsthecentralpartandcontainsconnectivetissue,blood

vesselsandnerves.Teetharecoveredbyasalivarypelliclelayerconsistingofproteinsand

glycoproteins,whichfacilitatesbindingoftheoralmicrobiotatotheteeth;thisstructureiscalledthe

dentalbiofilm(alsoknownasdentalplaque).Thebiofilmshutsoffthesurfaceenamelfromthe

salivaandoralcavityandproducesaprotectedmicro-environmentatthetoothsurface.Gums

(gingiva)surroundtheteeth.Inhumans,primaryteetheruptaround6monthsofage;theseare

graduallyreplacedbypermanentteethfromaround6yearsofage.

Figure2:Balancingpathologicalandprotectivefactorsindentalcaries.Afocusonoptimisingthe

protectivefactors(thosefavouringhealthyteeth)willpromoteremineralisationandshiftthe

dynamicbalanceofthecariesprocessinthedirectionofhealthandlesionarrest.Afailureto

mitigatetheeffectsofthepathologicalfactorswillpromotedemineralisationandshiftthedynamic

balanceinthedirectionofdiseaseinitiationanddiseaseprogression.

Figure3: Impactofdifferentdiseasedetectionthresholdsonepidemiologicalsurveys.Whichever

classificationsystemsareused inepidemiological researchondentalcaries, resultsdependonthe

detection threshold employed. The so-called icebergmetaphor for caries is illustrated graphically.

The tipof the iceberg is representedby the11%ofchildrenwithobviouscavitateddentinedecay

(whichistheWHOBasicSurveysconvention).Aslesionswithobviousvisualdecayindentine,clinical

cavitateddecayinenamelandclinicalvisualdecayinenamelareaddedtheproportionofchildren

withdentalcariesisseentoincrease12,13 ; in thisexampleto21%,25%and52%respectively14.,Dataare

based on 15 year-old children examined in the National Child Dental Health Survey (CDHS) of

England,WalesandNorthernIrelandundertakenin201314.Radiographs(iftheycanbetaken)would

revealevenmoreofthetotalicebergofdisease17.

Figure4Ecologicalplaquehypothesistoexplaintheaetiologyofdentalcaries.Theecological

plaquehypothesisdescribesthedifferencesseeninthemicrobiotafromsoundandcarioussitesasa

consequenceofachangeinoralenvironmentalconditions.Anincreasedfrequencyoffermentable

sugarintakeresultsinthebiofilmspendingmoretimeatalowpH,whichwillselectforbacteriathat

33

growpreferentiallyunderacidicconditions.Thegrowthofbacteriaassociatedwithsoundsurfacesis

thendisadvantaged,whichovertimeresultsinanincreaseintheproportionsandactivityof

cariogenicspeciesatasiteandaheightenedriskofcaries.Thisriskisraisedinindividualswith

impairedsalivaflowandsugar-richdiet,butreducedinthosewithappropriateoralhygieneand

exposuretofluoride.

Figure 5: Overview of the ICCMSä system with its four key elements. The International Caries

ClassificationandManagementSystem (ICCMS) is ahealthoutcomes focused system thataims to

maintain health and preserve tooth structure. It uses a simple form of the “ICDAS” caries

classification model to stage caries severity and assess lesion activity in order to derive an

appropriate, personalised, preventive, risk-adjusted, tooth preservingmanagement plan. The four

keystepsinthis4Dmodelare:determinepatientlevelcariesriskthroughatargetedhistory;detect

andassesscarieslesionseverityandactivity;decideonapersonalisedcariescareplanwithelements

at both the whole patient and at the specific tooth levels; and then do the appropriate tooth-

preserving and patient level caries prevention and control interventions. The cycle then re-starts

afterarisk-basedfollow-upinterval.

Figure6:Clinicalandradiographicappearanceofthestagesofseverityoftoothdecay.Clinical

appearance(parta)andbitewingradiograph(partb)ofthesametooth.Examplesofsound

andExtensivecariessurfacesareshownonthebiting(orocclusal)surfaces,whichcontain

developmentaldepressionsandgrooves(pitsandfissures)thatcollectdentalbiofilmand

arecariespredilectionsites.Theinitialandmoderatestagelesionexamplesshow

approximalsurface(whereadjacentteethareincontact).Cariesalsodevelopsonthefree

smoothsurfaces(adjacenttocheeks,lipsandtongue).

Figure7:ICCMSäcariesmanagementplan.ICCMS™proposesacomprehensiveassessmentand

personalisedcariescareplanbasedonintegratedinformationderivedfromassessingboththecaries

lesionsandtheiractivityatatoothsurfacelevelaswellasthelikelihoodfornewcariesandforcaries

lesionprogression.Basedonlesionextent,activityandrisk,thepersonalisedcareisdividedinto

specificitemsforpreventingnewcariesonsoundsurfaces,providingnon-operative(thatis,non-

surgical)careforsomelesionstocontrolthecariesprocessandprovidingminimallyinvasivetooth

preservingoperative(surgical)careonlywherethisisunambiguouslyindicated.Riskreductionand

managementisalsoacontinuingfeatureofthecareplan.

34

References

1. PittsN.B.&Zero,D.T.WhitePaperonDentalCariesPreventionandManagement.FDIWorld

DentalFederationhttp://www.fdiworlddental.org/sites/default/files/media/documents/2016-

fdi_cpp-white_paper.pdf(2016).

2. Koussoulakou,D.S.,Margaritis,L.H.&Koussoulakos,S.L.Acurriculumvitaeofteeth:evolution,

generation,regeneration.IntJBiolSci5,226-43(2009).

3. Petersen.P-E.,Bourgeois,D.,Ogawa,H.,Estupinan-Day,S.&Ndiaye,C.Theglobalburdenof

oraldiseasesandriskstooralhealth.BulletinoftheWorldHealthOrganization.83,661-669

(2005).

4. Broadbent,J.M.,Thomson,W.M.&Poulton,R.Trajectorypatternsofdentalcariesexperiencein

thepermanentdentitiontothefourthdecadeoflife.J.Dent.Res.87,69–72(2008).

5. Pitts,N.etal.GlobalOralHeathInequalitiesDentalCariesTaskGroup-ResearchAgenda.Adv.

Dent.Res.23,98-200(2011).

6. AmericanAcademyofPediatricDentistry.AmericanAcademyofPediatricDentistryreference

manual2014-2015.Pediatr.Dent.,36(6referencemanual),1-140.(2014).

7. USDepartmentofHealthandHumanServices.OralHealthinAmerica:AReportoftheSurgeon

General.NationalInstituteofDentalandCraniofacialResearch.

https://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/executivesummary.htm(2000).

8. Dye,B.A.etal.TrendsinpediatricdentalcariesbypovertystatusintheUS.Int.J.Paedi.Dent.

20(2),132-43(2010).

9. Dye,B.A.etal.Trendsinoralhealthstatus:UnitedStates,1988-1994and1999-2004.Vital

HealthStat.11(248),1-92(2007).

10. Dye,B.A.,Vargas,C.M.,Fryar,C.D.,Ramos-Gomez,F.,&Isman,R.Oralhealthstatusofchildren

inLosAngelesCountyandintheUnitedStates,1999-2004.CommunityDentOralEpidemiol.45,

135-144(2016)

11. Pitts,N.B.DiscoveringDentalPublicHealth:fromFishertotheFuture.CommunityDentalHealth

11,172-178(1994).

12. Topping,G.V.&Pitts,N.B.inMonographsinOralSciencevol21-Detection,Assessment,

DiagnosisandMonitoringofCaries:Clinicalvisualcariesdetection.(ed.Pitts,N.)15-41(2009).

13. Kühnisch,J.etal.OcclusalcariesdetectioninpermanentmolarsaccordingtoWHObasic

methods,ICDASIIandlaserfluorescencemeasurements.CommunityDent.OralEpidemiol.36

(6),475-84(2008).

35

14. Pitts,N.B.,Chadwick,B.&Anderson,T.Children’sDentalHealthSurvey2013Report2:DentalDiseaseandDamageinChildreninEngland,WalesandNorthernIreland.(London:Healthand

SocialCareInformationCentre,2015).

15. Patel,R.N.etal.VariabilityofMethodologiesUsedtoDetermineNationalMeanDMFTScoresfor

12-Year-OldChildreninEuropeanCountries.CommunityDentalHealth2016,33,286-291

(2016).

16. PittsN,MeloP,MartignonS,EkstrandK,IsmailA.Cariesriskassessment,diagnosisand

synthesisinthecontextofaEuropeanCoreCurriculuminCariology.Eur.J.Dent.Educ.15

(Suppl.1)23–31,(2011).

17. Agustsdottir,H.etal.Cariesprevalenceofpermanentteeth:anationalsurveyofchildrenin

IcelandusingICDAS.CommunityDent.OralEpidemiol.38,299-309(2010).

18. Marcenes,W.etal.Globalburdenoforalconditionsin1990-2010:asystematicanalysis.J.Dent.

Res.92,592-7(2013).

19. Moynihan,P.J.&Kelly,S.A.Effectoncariesofrestrictingsugarsintake:systematicreviewto

informWHOguidelines.J.Dent.Res.93,8-18(2014).

20. Sheiham,A.&James,W.P.DietandDentalCaries:ThePivotalRoleofFreeSugars

Reemphasized.J.Dent.Res.94(10),1341-7.(2015).

21. Zero,D.T.etal.Thebiology,prevention,diagnosisandtreatmentofdentalcaries:scientific

advancesintheUnitedStates.J.Am.Dent.Assoc.140Suppl1,25S-34S(2009).

22. Reisine,S.&Litt,M.Socialandpsychologicaltheoriesandtheirusefordentalpractice.Int.Dent.

J.43,279-87(1993).

23. Fejerskov,O.Conceptsofdentalcariesandtheirconsequencesforunderstandingthedisease.CommunityDent.OralEpidemiol.25,5-12(1997).

24. Selwitz,R.H.,Ismail,A.I.&Pitts,N.B.Dentalcaries.Lancet369,51-9(2007).

25. Zero,D.T.Sugars-thearchcriminal?CariesRes.38,277-85(2004).

26. Takahashi,N.Microbialecosystemintheoralcavity:metabolicdiversityinanecologicalniche

anditsrelationshipwithoraldiseases.(ed.WatanabeM,T.N.,TakadaH)(Elsevier,Oxford,

2005).

27. Zero,D.T.Dentalcariesprocess.Dent.Clin.NorthAm.43,635-64(1999).

28. tenCate,J.M.&Featherstone,J.D.Mechanisticaspectsoftheinteractionsbetweenfluorideand

dentalenamel.Crit.Rev.OralBiol.Med.2,283-96(1991).

29. Featherstone,J.D.Thecontinuumofdentalcaries--evidenceforadynamicdiseaseprocess.J.

Dent.Res.83,Spec.NoC,C39-42(2004).

36

30. Wilson,M.inMicrobialinhabitantsofhumans.Theirecologyandroleinhealthanddisease.

(CambridgeUniversityPress,Cambridge,2005).

31. Devine,D.A.,Marsh,P.D.&Meade,J.Modulationofhostresponsesbyoralcommensalbacteria.

J.OralMicrobiol.7,26941(2015).

32. Nobbs,A.H.,Jenkinson,H.F.&Jakubovics,N.S.Sticktoyourgums:mechanismsoforalmicrobial

adherence.J.Dent.Res.90,1271-8(2011).

33. Zijnge,V.etal.Oralbiofilmarchitectureonnaturalteeth.PLoSOne5,e9321(2010).

34. Wright,C.J.etal.Microbialinteractionsinbuildingofcommunities.Mol.OralMicrobiol.28,83-

101(2013).

35. Scannapieco,F.A.Saliva-bacteriuminteractionsinoralmicrobialecology.Crit.Rev.OralBiol.

Med.5,203-48(1994).

36. Hara,A.T.&Zero,D.T.Thecariesenvironment:saliva,pellicle,diet,andhardtissue

ultrastructure.Dent.Clin.NorthAm.54,455-67(2010).

37. Jakubovics,N.S.,Yassin,S.A.&Rickard,A.H.Communityinteractionsoforalstreptococci.Adv.

Appl.Microbiol.87,43-110(2014).

38. Klein,M.I.,Hwang,G.,Santos,P.H.,Campanella,O.H.&Koo,H.Streptococcusmutans-derived

extracellularmatrixincariogenicoralbiofilms.Front.Cell.Infect.Microbiol.5,10(2015).

39. Sheiham,A.&James,W.P.Areappraisalofthequantitativerelationshipbetweensugarintake

anddentalcaries:theneedfornewcriteriafordevelopinggoalsforsugarintake.BMCPublic

Health14,863(2014).

40. Loesche,W.J.RoleofStreptococcusmutansinhumandentaldecay.MicrobiologicalReviews50,

353-380(1986).

41. Rosier,B.T.,DeJager,M.,Zaura,E.&Krom,B.P.Historicalandcontemporaryhypothesesonthe

developmentoforaldiseases:arewethereyet?Front.Cell.Infect.Microbiol.4,92(2014).

42. Marsh,P.D.Aredentaldiseasesexamplesofecologicalcatastrophes?Microbiology149,279-294

(2003).

43. Takahashi,N.&Nyvad,B.Cariesecologyrevisited:microbialdynamicsandthecariesprocess.

CariesRes.42,409-18(2008).

44. Hong,L.,Levy,S.M.,Warren,J.J.&Broffitt,B.Associationbetweenenamelhypoplasiaand

dentalcariesinprimarysecondmolars:acohortstudy.CariesRes.43,345-53(2009).

45. Fisher,J.&Glick,M.FDIWorldDentalFederationScienceCommittee(2012).Anewmodelfor

cariesclassificationandmanagement:theFDIWorldDentalFederationcariesmatrix.J.Am.

Dent.Assoc.143(6):546–551(2012).

37

46. Ismail,A.etal.Cariesmanagementpathwayspreservedentaltissuesandpromoteoralhealth.

CommunityDentOralEpidemiol.41,e12–e40(2013).

47. Pitts,N.B.&Ekstrand,K.R.InternationalCariesDetectionandAssessmentSystem(ICDAS)andits

InternationalCariesClassificationandManagementSystem(ICCMS)-methodsforstagingofthe

cariesprocessandenablingdentiststomanagecaries.CommunityDent.OralEpidemiol.41,

e41-e52(2013).

48. ICDASFoundation.InternationalCariesDetectionandAssessmentSystem(ICDAS).Whatis

ICDAS.https://www.icdas.org/what-is-icdas(2017).

49. Pitts,N.B.etal.ICCMS™GuideforPractitionersandEducators.ICDASFoundation

https://www.icdas.org/uploads/ICCMS-Guide_Full_Guide_With_Appendices_UK.pdf(2014).

50. Ismail,A.,Pitts,N.B.&Tellez,M.Theinternationalcariesclassificationandmanagementsystem

(ICCMSTM)anexampleofacariesmanagementpathway.BMCOralHealth15,1.3Suppl.1

(2015).

51. Watt,R.G.Socialdeterminantsoforalhealthinequalities:implicationsforaction.Community

Dent.OralEpidemiol.40,Suppl2:44-8(2012).

52. Jürgensen,N.&Petersen,P.E.Promotingoralhealthofchildrenthroughschools--resultsfroma

WHOglobalsurvey.CommunityDent.Health30,204-18(2013).

53. WHOWorldHealthOrganization.Oralhealth:actionplanforpromotionandintegrateddisease

prevention.WHOIRIShttp://apps.who.int/iris/bitstream/10665/21909/1/b120_10-en.pdf

(2006).

54. Weintraub,J.A.Sustainableoralhealthinterventions.J.PublicHealthDent.71,Suppl1:S95-96

(2011).

55. Panagakos,F.Partnersinprevention:Awinningapproachforcommunitiesandcompanies.J.

Evid.BaseDent.Pract.12,58-61(2012).

56. AllianceforaCavity-FreeFuture.Aboutus.TakeacloserlookattheAlliance.TheAllianceforaCavity-FreeFuture(ACFF),www.allianceforacavityfreefuture.org/en/us/about-us(2016).

57. GuidetoCommunityPreventiveServices.DentalCaries(Cavities):CommunityWater

Fluoridation.TheCommunityGuidewww.thecommunityguide.org/oral/fluoridation.html(2013).

58. USDHHSfederalpaneloncommunitywaterfluoridation.U.S.PublicHealthService

Recommendationforfluorideconcentrationindrinkingwaterforthepreventionofdental

caries.PublicHealthReports.130,1-14(2015).

59. Griffin,S.O.,Jones,K.&Tomar,S.L.Aneconomicevaluationofcommunitywaterfluoridation.J

PublicHealthDent.61,78-86(2001).

38

60. WHOWorldHealthOrganization.Guidelinesfordrinking-waterquality,4thed.42.(World

HealthOrganization,Geneva,2011).

61. Pollick,H.F.Saltfluoridation:areview.C.D.A.J.41,395-404(2013).

62. Marthaler,T.M.Saltfluoridationandoralhealth.Acta.Med.Acad.42,140-155(2013).

63. Bánóczy,J.,Rugg-Gunn,A.&Woodward.M.Milkfluoridationforthepreventionofdentalcaries.

ActaMedAcad.42,156-167(2013).

64. Yeung,C.A.,Chong,L.Y.&Glenny,A.M.Fluoridatedmilkforpreventingdentalcaries.Cochrane

DatabaseSyst.Rev.3(9),CD003876(2015).

65. Wright,J.T.etal.Evidence-basedclinicalpracticeguidelinefortheuseofpit-and-fissure

sealants.AreportoftheAmericanDentalAssociationandtheAmericanAcademyofPediatric

Dentistry.J.Am.Dent.Assoc.147,672-682(2016).

66. GuidetoCommunityPreventiveServices.DentalCaries(Cavities):School-BasedDentalSealant

DeliveryPrograms.TheCommunityGuide

www.thecommunityguide.org/oral/schoolsealants.html(2013).

67. Griffin,S.O.etal.CentersforDiseaseControlandPrevention(CDC).UseofdentalcareandeffectivepreventiveservicesinpreventingtoothdecayamongU.S.Childrenandadolescents--

MedicalExpenditurePanelSurvey,UnitedStates,2003-2009andNationalHealthandNutrition

ExaminationSurvey,UnitedStates,2005-2010.MMWRSurveill.Summ.63,Suppl2,54-60

(2014).

68. Siegal,M.D.&Detty,A.M.Doschool-baseddentalsealantprogramsreachhigherriskchildren?

J.PublicHealthDent.70,181-7(2010).

69. Weintraub,J.A.,StearnsS.C.,Rozier,R.G.&Huang,C.C.Treatmentoutcomesandcostsofdental

sealantsamongchildrenenrolledinMedicaid.AmJPublicHealth.91,1877-1881(2001).

70. Mariño,R.,Fajardo,J.&Morgan,M.Cost-effectivenessmodelsfordentalcariesprevention

programmesamongChileanschoolchildren.CommunityDent.Health29,302-8(2012).

71. Edelstein,B.L.,Hirsch,G.,FroshM.&Kumar,J.ReducingearlychildhoodcariesinaMedicaid

population:asystemsmodelanalysis.J.Am.Dent.Assoc.146,224-32(2015).

72. PublicHealthEngland.Deliveringbetteroralhealth:anevidence-basedtoolkitforprevention-Thirdedition.(PublicHealthEngland,London,2014).

73. SIGNScottishIntercollegiateGuidelinesNetwork(SIGN).SIGN138Dentalinterventionstopreventcariesinchildren(HealthcareImprovementScotland,2015).

74. Weyant,R.J.etal.,Topicalfluorideforcariesprevention:executivesummaryoftheupdated

clinicalrecommendationsandsupportingsystematicreview.J.Am.Dent.Assoc.144(11):1279–

1291(2013).

39

75. Marinho,V.C.C.etal.Topicalfluoride(toothpastes,mouthrinses,gelsorvarnishes)for

preventingdentalcariesinchildrenandadolescents.CochraneDatabaseSystRev4(4):CD002782

(2003).

76. WHOWorldHealthOrganization.WHOGuideline:Sugarsintakeforadultsandchildren(World

HealthOrganization,Geneva,2015).

77. Disney,J.A.etal.TheUniversityofNorthCarolinaCariesRiskAssessmentstudy:further

developmentsincariesriskprediction.CommunityDent.OralEpidemiol.20,64-75(1992).

78. Bratthall,D.&HänselPetersson,G.Cariogram--amultifactorialriskassessmentmodelfora

multifactorialdisease.CommunityDent.OralEpidemiol.33(4),256-64(2005).

79. Twetman,S.,Ekstrand.K,&Keller,M.Caries–enbiofilmmedieretsygdom.Tandlægebladet17,

1-6(Englishsummary)(2013).

80. WalshT,WorthingtonHV,GlennyA-M,AppelbeP,MarinhoVCC,ShiX.Fluoridetoothpastesof

different concentrations for preventing dental caries in children and adolescents. Cochrane

DatabaseSyst.Rev.(1):CD007868(2010).

81. Carvalho,J.C.,Ekstrand,K.R.&ThylstrupA.Dentalplaqueandcariesonocclusalsurfacesoffirstpermanentmolarsinrelationtostageoferuption.J.Dent.Res.68,773-9(1989).

82. Mejàre,I.Bitewingexaminationtodetectcariesinchildrenandadolescents--whenandhow

often?Dent.Update32,588-90(2005).

83. Ridell,K.,Olsson,H.&MejàreI.Unrestoreddentincariesanddeepdentinrestorationsinwedish

adolescents.CariesRes.42,164-70(2008).

84. Ekstrand,K.R.,Bruun,G.&Bruun,M.Plaqueandgingivalstatusasindicatorsforcaries

progressiononapproximalsurfaces.CariesRes.32,41-5(1998).

85. Ekstrand,K.R.,Martignon,S.,Ricketts,D.J.&Qvist,V.Detectionandactivityassessmentof

primarycoronalcarieslesions:amethodologicstudy.Oper.Dent.32,225-35(2007).

86. Amaechi,B.T.Remineralizationtherapiesforinitialcarieslesions.Curr.OralHealthRep.2,95-

101(2015).

87. Zero,D.T.Dentifrices,mouthwashes,andremineralization/cariesarrestmentstrategies.BMC

OralHealth6Suppl1,S9(2006).

88. TenCate,J.M.&Fetherstone,J.D.Mechanisticaspectsoftheinteractionsbetweenfluorideand

dentalenamel.Crit.Rev.OralBiol.Med.2,283-296,(1991).

89. Newbrun,E.Topicalfluoridesincariespreventionandmanagement:aNorthAmerican

perspective.JDentEduc65,1078-1083,(2001).

90. Lee,Y.E.etal.Comparisonofremineralizationeffectofthreetopicalfluorideregimenson

enamelinitialcariouslesions.JDent.38(2),166-71(2010).

40

91. Amaechi,B.T.&vanLoveren,C.Fluoridesandnon-fluorideremineralizationsystems.Monogr.

OralSci.23,15-26(2013).

92. Kandelman,D.&Gagnon,G.A24-monthclinicalstudyoftheincidenceandprogressionof

dentalcariesinrelationtoconsumptionofchewinggumcontainingxylitolinschoolpreventive

programs.J.Dent.Res.69,1771-1775(1990).

93. Featherstone,J.D.Preventionandreversalofdentalcaries:roleoflowlevelfluoride.Community

Dent.OralEpidemiol.27,31-40(1999).

94. Reynolds,E.C.,Cai,F.,Shen,P.&Walker,G.D.Retentioninplaqueandremineralizationof

enamellesionsbyvariousformsofcalciuminamouthrinseorsugar-freechewinggum.J.Dent.

Res.82,206-211(2003).

95. Kitasako,Y.,Sadr,A.,Hamba,H.,Ikeda,M.&TagamiJ.Gumcontainingcalciumfluoride

reinforcesenamelsubsurfacelesionsinsitu.J.Den.Res.91,370-375(2012).

96. Hamba,H.,Nikaido,T.,Inoue,G.,Sadr,A.&Tagami,J.EffectsofCPP-ACPwithsodiumfluoride

oninhibitionofbovineenameldemineralization:aquantitativeassessmentusingmicro-

computedtomography.J.Dent.39,405-13(2011).

97. Tay,F.R.etal.Theglass-ionomerphaseinpresin-basedrestorativematerials,J.Dent.Res.80,

1808-1812,(2001).

98. Ito,S.etal.Effectsofsurfacepre-reactedglass-ionomerfillersonmineralinductionby

phosphoprotein.J.Dent.39,72–9(2011).

99. Holmgren,C.,Gaucher,N.,Decerle,N.&Doméjean,S.MinimalinterventiondentistryII:part3.

Managementofnon-cavitated(initial)occlusalcarieslesions–non-invasiveapproachesthrough

remineralizationandtherapeuticsealants.Br.Dent.J.216,237-243(2014).

100. Ricketts,D.,Lamont,T.,Innes,N.P.,Kidd,E.&Clarkson,J.E.Operativecariesmanagementin

adultsandchildren.CochraneDatabaseSyst.Rev.3:CD003808(2013).

101. Kidd,E.,&Fejerskov,O.Changingconceptsincariology:fortyyearson.DentalUpdate40(4),277-286(2013).

102. Zandona,A.F.&Swift,E.J.Jr.Criticalappraisal.Evidenceforsealingversusrestorationofearlycarieslesions.J.Esthet.Restor.Dent.27(1),55-8(2015).

103. Meyer-Lueckel,H.,Bitter,K.&Paris,S.Randomizedcontrolledclinicaltrialonproximalcaries

infiltration:three-yearfollow-up.CariesRes.46,544-8(2012).

104. Schwendicke,F.,Meyer-Lueckel,H.,Stolpe,M.,Dörfer,C.E.&Paris,S.Costsandeffectivenessof

treatmentalternativesforproximalcarieslesions.PLoSOne.27,9(1):e86992(2014).

105. Schwendicke,F.,Stolpe,M.,Meyer-Lueckel,H.&Paris,S.Detectingandtreatingocclusalcaries

lesions:acost-effectivenessanalysis.J.Dent.Res.94,272-80(2015).

41

106. Wierichs,R.J.&Meyer-Lueckel,H.Systematicreviewonnoninvasivetreatmentofrootcaries

lesions.J.Dent.Res.94,261-71(2015).

107. Duangthip,D.,Jiang,M.,Chu,C.H.&LoE.C.Non-surgicaltreatmentofdentincariesinpreschool

children-systematicreview.BMCOralHealth,15:44(2015).

108. Clarkson,B.H.&Exterkate,R.A.M.Noninvasivedentistry:Adreamorreality?CariesRes.

49(suppl1),11-17(2015).

109. Marsh,P.D.,Head,D.A.&Devine,D.A.Prospectsoforaldiseasecontrolinthefuture-an

opinion.J.OralMicrobiol.6,261-76(2014).

110. RasinesAlcaraz,M.G.etal.Directcompositeresinfillingsversusamalgamfillingsforpermanent

oradultposteriorteeth.CochraneDatabaseSyst.Rev.31,3:CD005620(2014).

111. Ferreira,J.M.,Pinheiro,S.L.,Sampaio,F.C.&deMenezes,V.A.Cariesremovalinprimaryteeth--a

systematicreview.QuintessenceInt.43,e9-15(2012).

112. Innes,N.P.,Evans,D.J.&Stirrups,D.R.TheHallTechnique;arandomizedcontrolledclinicaltrial

ofanovelmethodofmanagingcariousprimarymolarsingeneraldentalpractice:acceptability

ofthetechniqueandoutcomesat23months.BMCOralHealth7:18(2007).

113. Seale,N.S.&Randall,R.Theuseofstainlesssteelcrowns:asystematicliteraturereview.Pediatr

Dent.37,145-60(2015).

114. Gajendra,S.&Kuma,J.V.,Oralhealthandpregnancy:areview.N.Y.StateDent.J.70(1),40-4,

_2004).

115. AAPDCouncilonClinicalAffairs.GuidelineonCaries-riskAssessmentandManagementfor

Infants,ChildrenandAdolescents.(AmericanAcademyofPediatricDentistry,CouncilonClinical

Affairs;2013).

116. Ramos-Gomez,F.J.Amodelforcommunity-basedpediatricoralhealth:implementationofan

infantoralcareprogram.Int.J.Dent.156821(2014).

117. Ramos-Gomez,F.&Ng,M.W.Intothefuture:keepinghealthyteethcariesfree:pediatric

CAMBRAprotocols.J.Calif.Dent.Assoc.39(10),723-33(2011).

118. InstituteofMedicine.OralHealthLiteracy.RoundtableonHealthLiteracy;BoardonPopulation

HealthandPublicHealthPractice(NationalAcademiesPress,WashingtonDC.2003).

119. Karlinsey,R.L.&Pfarrer,A.M.FluoridePlusFunctionalizedβ-TCP:APromisingCombinationfor

RobustRemineralization.(ed.tenCate,J.M.)AdvancesinDentalResearch.24(2),48-52(2012).

120. ADAReport.Fluoridetoothpasteuseforyoungchildren.TheJournaloftheAmericanDental

Association,145(2),190-191(2014).

121. Ramos-Gomez,F.&Ng,M-W.IntotheFuture:KeepingHealthyTeethCariesFree:Pediatric

CAMBRAProtocols.JournaloftheCaliforniaDentalAssociation39(10),723-733(2011).

42

122. Kassebaum,N.J.etal.Globalburdenofuntreatedcaries:asystematicreviewand

metaregression.J.Dent.Res.94(5),650-8(2015).

123. White,D.A.etal.AdultDentalHealthSurvey2009:commonoralhealthconditionsandtheir

impactonthepopulation.BDJ213,567-572(2012).

124. Thomson,W.M.Epidemiologyoforalhealthconditionsinolderpeople.Gerodontology31(Suppl.

1),9–16(2014).

125. Vernazza,C.R.,Rolland,S.L.,Chadwick,B.&Pitts,N.Cariesexperience,thecariesburdenandassociatedfactorsinchildreninEngland,WalesandNorthernIreland2013.BrDentJ.221(6),

315-20(2016).

126. Slade,G.D.Epidemiologyofdentalpainanddentalcariesamongchildrenandadolescents.

CommunityDentalHealth18,219-227(2001).

127. Ravaghi,V.,Holmes,R.D.,Steele,J.G.,Tsakos,G.Theimpactoforalconditionsonchildrenin

England,WalesandNorthernIreland2013.BrDentJ.221(4),173-8(2016).

128. Casamassimo,P.S.,Thikkurissy,S.,Edelstein,B.L.&MaioriniE.Beyondthedmft:thehumanand

economiccostofearlychildhoodcaries.JAmDentAssoc.140,650–657(2009).

129. Krisdapong,S.,Prasertsom,P.,Rattanarangsima,K.&Sheiham,A.Relationshipsbetweenoral

diseasesandimpactsonThaischoolchildren'squalityoflife:evidencefromaThainationaloral

healthsurveyof12-and15-year-olds.CommunityDentOralEpidemiol.40,550-9(2012).

130. Montero,J.etal.Oralhealth-relatedqualityoflifein6-to12-year-oldschoolchildreninSpain.

Int.J.Paediatr.Dent.26(3),220-230(2016).

131. Abanto,J.etal.Impactofdentalcariesandtraumaonqualityoflifeamong5-to6-year-old

children:perceptionsofparentsandchildren.CommunityDent.OralEpidemiol.42,385-94

(2014).

132. Psoter,W.J.,Reid,B.C.&Katz,R.V.Malnutritionanddentalcaries:areviewoftheliterature.

CariesRes.39,441-447(2005).

133. Schroth,R.J.etal.VitaminDstatusofchildrenwithsevereearlychildhoodcaries:acase-control

study.BMCPediatr.13:174(2013).

134. Schroth,R.J.,Levi,J.,Kliewer,E.,Friel,J.&Moffatt,M.E.Associationbetweenironstatus,iron

deficiencyanaemia,andsevereearlychildhoodcaries:acase-controlstudy.BMCPediatr.13:22

(2013).

135. Ayhan,H.,Suskan,E.&Yildirim,S.Theeffectofnursingorrampantcariesonheight,body

weightandheadcircumference.J.Clin.Pediatr.Dent.20,209–212(1996).

136. Sheiham,A.Dentalcariesaffectsbodyweight,growthandqualityoflifeinpre-schoolchildren.

Br.Dent.J.201(10):625-6(2006).

43

137. Oliveira,L.B,Sheiham,A.&BöneckerM.Exploringtheassociationofdentalcarieswithsocial

factorsandnutritionalstatusinBrazilianpreschoolchildren.EurJOralSci116:37–43(2008).

138. Alkarimi,H.A.,Watt,R.G.,Pikhart,H.,Sheiham,A.&Tsakos,G.Dentalcariesandgrowthin

school-agechildren.Pediatrics.133:e616-23(2014).

139. Acs,G.,Shulman,R.,Ng,M.W.&Chussid,S.Theeffectofdentalrehabilitationonthebody

weightofchildrenwithearlychildhoodcaries.Pediatr.Dent.21:109–113(1999).

140. MalekMohammadi,T.,Wright,C.M.&Kay,E.J.Childhoodgrowthanddentalcaries.Community

DentHealth26,38–42(2009).

141. Gemert-Schriks,M.C.M.etal.Theinfluenceofdentalcariesonbodygrowthinprepubertal

children.ClinicalOralInvestigations15,141-149(2010).

142. Alkarimi,H.A.,etal.Impactoftreatingdentalcariesonschoolchildren'santhropometric,dental,

satisfactionandappetiteoutcomes:arandomizedcontrolledtrial.BMCPublicHealth.12,706

(2012).

143. Jackson,S.L.,Vann,W.F.Jr.,Kotch,J.B.,Pahel,B.T.&Lee,J.Y.Impactofpoororalhealthon

children'sschoolattendanceandperformance.Am.J.PublicHealth.101,1900–1906(2011).

144. Krisdapong,S.,Prasertsom,P.,Rattanarangsima,K.&Sheiham,A.Schoolabsencedueto

toothacheassociatedwithsociodemographicfactors,dentalcariesstatus,andoralhealth-

relatedqualityoflifein12-and15-year-oldThaichildren.J.PublicHealthDent.73(4),321-8

(2013).

145. Griffin,S.O.,Gooch,B.F.,Beltrán,E.,Sutherland,J.N.&Barsley,R.Dentalservices,costs,andfactorsassociatedwithhospitalizationforMedicaid-eligiblechildren,Louisiana1996-97.J.Public

HealthDent.60,21–27(2000).

146. Moles,D.Epidemicofdentalabscesses?Dentalabscesseshaveincreasedmostamongpoorer

people.B.M.J.336,1323(2008).

147. Schwendicke,F.etal.Socioeconomicinequalityandcaries:asystematicreviewandmeta-

analysis.JDentRes.94,10-8(2015).

148. Fisher-Owens,S.A.etal.Influencesonchildren'soralhealth:aconceptualmodel.Pediatrics.

120,e510-20(2007).

149. Bagramian,R.A.,Garcia-D-Gody,F.&Volpe,R.A.AmJDent.22,3-8(2009).

150. Porter,M.E.NewEngJMed.36,109-112(2009).

151. Kaldahl,W.B.,Kalkwarf,K.L.&Patil,K.D.AreviewofLongitudinalStudiesthatcompared

PeriodontalTherapies.JPeriodontol.64,243-253(1993).

152. Innes,N.&Evans,D.Associationbetweenparentalguiltandoralhealthproblemsinpreschool

children.BrDentJ.206,549-50(2009).

44

153. Eccles,M.P.etal.Developingclinicalpracticeguidelines:targetaudiences,identifyingtopicsfor

guidelines,guidelinegroupcompositionandfunctioningandconflictsofinterest.

ImplementationScience,7,60(2012).

154. Tellez,M.Gray,S.L,Gray,S.,Lim,S.&Ismail,A.I.Sealantsanddentalcaries:dentists'

perspectivesonevidence-basedrecommendations.JADA,142,1033-40(2011).

155. Beauchamp,J.etal.Evidence-basedclinicalrecommendationsfortheuseofpit-and-fissure

sealants:areportoftheAmericanDentalAssociationCouncilonScientificAffairs.Dent.Clin.

NorthAm.53(1),131-47(2009).

156. Phelan,M.P.etal..Amultifacetedinterventiontoimproveelectronichealthrecord(EHR)

nursingdocumentationforemergencydepartmentblooddraws.AcademicEmergencyMedicine,

22(5SUPPL.1),S322(2015).

157. Fejerskov,O.,Thylstrup,A.&Larsen,M.J.Rationaluseoffluoridesincariesprevention.A

conceptbasedonpossiblecariostaticmechanisms.ActaOdontol.Scand.39(4),241–249(1981).

158. FluorideRecommendationsWorkGroup.Recommendationsforusingfluoridetopreventand

controldentalcariesintheUnitedStates.CentersforDiseaseControlandPreventionMMWR

https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm(2001).

159. Hellwig,E.&Lennon,A.´M.SystemicversusTopicalFluoride.CariesRes.38,258–262(2004).

160. Margolis,H.C.,Moreno,E.C.&Murphy,B.J.Effectoflowlevelsoffluorideinsolutiononenamel

demineralisationinvitro.J.Dent.Res.65,23-29(1986).

161. Marinho,V.C.,Higgins,J.P.,Logan,S.&Sheiham,A.Topicalfluoride(toothpastes,mouthrinses,

gelsorvarnishes)forpreventingdentalcariesinchildrenandadolescents.CochraneDatabase

Syst.Rev.4:CD002782(2003).

162. tenCate,J.M.Currentconceptsonthetheoriesofthemechanismofactionoffluoride.Acta

Odontol.Scand.57(6),325-329(1999).

163. tenCate,J.M.&Featherstone,J.D.Mechanisticaspectsoftheinteractionsbetweenfluorideand

dentalenamel.CRCCrit.Rev.OralBiol.Med.2,283-296(1991).

164. Iheozor-Ejiofor,Z.,etal.Waterfluoridationforthepreventionofdentalcaries.Cochrane

DatabaseofSystematicReviewsIssue6,CD010856(2015).

165. Rugg-Gunn,A.J.etal.Critiqueofthereviewof'Waterfluoridationforthepreventionofdental

caries'publishedbytheCochraneCollaborationin2015.BritishDentalJournal220,335-340

(2016).

166. Pahel,B.T.,Rozier,R.G.,Stearns,S.C.&Quiñonez,R.B.EffectivenessofpreventivedentaltreatmentsbyphysiciansforyoungMedicaidenrollees.Pediatrics127,e682-e689(2011).

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Fig 1

Nature Reviews | Disease Primers

Manuscript number NNRDP_15_048 Pitts 15|3|17

Nature Reviews | Disease Primers

Root

CrownEnamel

Dentine

Pulp chamber

Gum

Bone

Peridontal ligament

Cementum

Root canal

Nerves andblood vessels

Enamel Pellicle

Bacteria

Fig 3

Fig 2

Nature Reviews | Disease Primers

Manuscript number NNRDP_15_048 Pitts 15|3|17

Nature Reviews | Disease Primers

Pathological factors• Frequent consumption of dietary sugars• nade uate uoride• Poor oral hygiene• Salivary dysfunction

Protective factors• Healthy diet• rushing with uoride toothpaste twice daily• rofessional topical uoride• Preventive and therapeutic sealants • Normal salivary function

Demineralization Remineralization

High caries risk Low caries riskModerate caries risk

DiseaseLesion progression

HealthLesion arrest or regression

Nature Reviews | Disease Primers

Decaywith

pulpalinvolvementCDHS code 3ICDAS code 6

Cavitateddentine cariesCDHS code 2CICDAS code 5

Visual dentine cariesCDHS code 2VICDAS code 4

Enamel change with cavitationCDHS code ACICDAS code 3

Visual change in enamelCDHS code AV

ICDAS codes 1 and 2

Subclinical decay

Unseenenameldecay

Unseenenameldecay

11%

21%

25%

52%

Proportion ofcaries depending on the detectionthreshold used

Sound

Moderatecaries

Extensivecaries

Initial-stagecaries

Fig 4

Fig 5

Nature Reviews | Disease Primers

Manuscript number NNRDP_15_048 Pitts 15|3|17

Nature Reviews | Disease Primers

Increasedsugar intake

Stress

NeutralpH

S. sanguinis,S. gordonii Health

CariesMutans streptococci,lactobacilli andbifidobacteria

Increasedlow pH

challenges

More frequent acid

production

Environmentalshift

Ecologicalshift

Disease

ral hygiene and uoride inta

e

ariogenic diet and low saliva

ow

Nature Reviews | Disease Primers

Risk-basedrecall

interval

DeterminePatient-level

caries risk (history)

DoAppropriate

tooth-preserving and patient-level caries

prevention and control (management)

ICCMS™ 4Dcaries management

Detect and assessCaries staging

and activity(classification and

intra-oral risk)

DecidePersonalised

care plan(decision making)

Fig 6

Fig 7

Nature Reviews | Disease Primers

Manuscript number NNRDP_15_048 Pitts 15|3|17

Nature Reviews | Disease Primers

Sound(ICDAS 0)

Initial lesion(ICDAS 1–2)

Moderate lesion(ICDAS 3–4)

Extensive lesion(ICDAS 5–6)

a

b

Nature Reviews | Disease Primers

High Moderate Low

Management of individual lesions

Sound(preventing new caries)

Tooth preservingoperative care of lesions

Non-operative careof lesions (control)

Extensiveactive caries

lesions

Moderateactive caries

lesions

Initialactive caries

lesions

Allinactive caries

lesions

Caries lesions and activity by tooth surface Likelihood for new caries and/or progression

ManagementPersonalised caries prevention;

control and tooth preserving operative care

Management at the patient level

Leads to, in most cases Leads to, in some cases

Risk management

Do