NIH Consensus Statement on Dental Caries Management

There has been a great reduction in oral health caries in the United States over the last 30 years. At the same time, segments of the population with low access to dental care continue to suffer tremendously from the disease. To address the best way to remedy this, the National Institutes of Health (NIH) commissioned a Consensus Development Conference (CDC) on the Diagnosis and Management of Dental Caries Throughout Life, intended to assess current prevention, detection, and treatment methods. The public forum, composed of nonadvocate panels of investigators and experts, took place some time ago. Following are some key points of the consensus statement issued from the conference.

1. What are the best methods for detecting early and advanced dental caries?
No single mode of diagnosis is capable of detecting all carious lesions. The methods currently used to diagnose caries (visual-tactile, radiographic, and electrical conductance examinations) are most sensitive to substantial, cavitated lesions. They are considerably less effective in detecting early caries, noncavitated caries, root surface caries, secondary caries, or caries adjacent to existing restorations. New diagnostic methods specific to site and severity of caries are thus clearly needed, and digital imaging systems appear to have great potential here. Some of the new treatments emerging in this area include fiber-optic transillumination and light or laser fluorescence.

2. What are the best indicators for an increased risk of dental caries?
Most data pertaining to caries-risk assessment comes from accumulated caries experience rather than methodical, regulated study. Because the etiology of caries is so complex, more and higher-quality longitudinal, multifactor studies are greatly needed to more precisely define and account for the numerous correlations linked to caries incidence.

Nonetheless, the panel concurs that there are in practice some helpful and consistent risk indicators: (1) past caries experience, especially for assessing children's risk; (2) inadequate exposure to fluoride; (3) any physical or mental illness and any oral application or restoration that compromises the maintenance of optimal oral health; (4) fermentable carbohydrate consumption; (5) lower salivary flow, associated with certain medical conditions and therapies; (6) mutans streptococci; (7) gingival recession, especially in elderly populations; and (8) lower indices of socioeconomic status.

3. What are the best methods available for the primary prevention of dental caries initiation throughout life?
Water fluoridation and the use of fluoridated toothpaste are generally recognized as highly effective means of preventing primary dental caries. Therefore, the panel focused on identifying other methods that might be of additional benefit. There is moderate-to-strong evidence that the following might help prevent primary caries: (1) acidulated phosphate fluoride gel (APF) applied one to two times a year; (2) fluoride varnish applied to permanent teeth; (3) chlorhexidine gel; (4) pit and fissure sealants; and (5) noncariogenic sweeteners (especially xylitol) as constituents of gum, candy, or dentifrice. Preventive strategies appear to be more effective when combined with one another. They also appear to have a greater impact on patients with a lower DMSF (decayed, missing, and filled surfaces) baseline, indicating that they perhaps may be of greater benefit to high-risk populations.

4. What are the best treatments available for reversing or arresting the progression of early dental caries?
Arresting dental caries depends entirely on early and accurate diagnosis. The science of identifying early signs of caries is a developing field, one which the panel also identifies as the next crucial era in dental care. The strategies which have proven most effective as primary interventions often are also effective in reversing or arresting early lesions. In addition to the methods listed above (fluoride, chlorhexidine, sealants, antimicrobials, combination treatments), there are data which suggest that office-based behavioral interventions may effectively help arrest the progression of dental caries.

5. How should clinical decisions regarding prevention and/or treatment be affected by detection methods and risk assessment?
Dentistry is moving toward a paradigm of managing caries with an emphasis on nonsurgical, preventive interventions. Caries is no longer defined by its final, most conspicuous stage, and restorations are no longer seen as its single antidote. As caries comes to be understood as a multifactorial, multistage process that extends from infection to demineralization to cavitation, more and higher-quality research is urgently needed to better explain and define its complex stages of development and the varied factors affecting its growth. Longitudinal studies with evidence of long-term retention and functioning of teeth are most markedly lacking. (Such studies also go a long way toward influencing third-party payers to support the adoption of novel techniques into the practice of dentistry.) Since research in this field is still in its early stages, guidelines for practice need to be formed based on reviews of literature and consensus.

6. What are promising new research directions for the prevention, diagnosis, and treatment of dental caries?
The panel has significant concerns about the quality of the clinical research on dental caries thus far; the designs of most studies lag significantly relative to the current standard in most medical and scientific fields. In its preliminary remarks on the promising new research that might develop in this area, then, the panel explicitly stresses that all future research must greatly intensify its standards. New clinical research needs to move in several directions:

• 
  the epidemiology of primary and secondary caries: information on natural history, treatment, and outcomes of treatment across ages and population
• diagnostic methods: both established and new devices
• clinical trials: strictly conforming to contemporary standards of design, implementation, analysis, and reporting
• risk assessment: research systematically
• clinical practice: effectiveness, quality of care, outcomes, appropriateness
• genetics: genetic markers of diagnosis, prognosis, and therapeutic value

Conclusions
"The panel was disappointed in the overall quality of the clinical data set that it reviewed… There was a clear impression that clinical caries research is underfunded, if not undervalued". Current diagnostic and treatment practices do not allow for the control of early, noncavitated dental caries. According to the panel, these practices will not suffice for bringing the practice of oral health care into the next era of caries management.

Want to learn more? Visit http://odpod.nih.gov/concensus/cons/115/115_statement.htm.