2008
1
Update in Caries Diagnosis,
Management, and Prevention
Jenny Dennings, Veronika Stiles, Sarah Thornley, Katherine Yee
University of Michigan E-Learning Program
HYGDCE 482 001 W08
April 15, 2008
2
Background
Dental caries in adults and children continues to be a major health problem facing our country,
especially amongst populations at or near poverty.1 Dental caries remains to be the most common chronic
disease in children.1 Approximately 25 percent of the children and adolescents ages 5 to17, account for 80
percent of the dental caries.1 Ninety four percent of all adults 18 and over have evidence of treated or
untreated coronal caries.1 Dental caries is caused by the interrelationship of multiple factors over time.2
Dental caries is now recognized as an infectious, transmissible, multifactorial disease of bacterial origin.3
The cause of dental caries is related to a number of factors that are categorized into host susceptibility,
microorganisms, and substrate.2 All of these factors must intersect during a defined period of time, along
a continuum, for caries to occur.2 The dental hygienist plays a pivotal role in the prevention of dental
caries through fluoride application, dietary counseling, as well as oral hygiene education and instruction.
Etiology
Dental caries is caused by mutans streptococci (a group that includes Streptococcus mutans and
Streptococcus sobrinus species) and lactobacilli (Lactobacillus species) that live in the biofilm that attach
to teeth.4 These bacteria metabolize dietary fermentable carbohydrates (sugars and cooked starch) to
produce acids.4 These acids diffuse into the tooth structures and dissolve the calcium and phosphate
minerals (carbonated hydroxyapatite), a process called demineralization.4 If the acid attacks are infrequent
and of short duration, saliva can help repair the damage by neutralizing the acid and replacing minerals
and fluoride lost from the tooth, a process called remineralization.4 When the flow of saliva is low and the
bacterial level is high along with increased frequency of cariogenic snacks, the dental caries process is
initiated.4
The resulting acid environment created when the bacterial plaque acts on fermentable
carbohydrates results in a substantial change in the plaque pH.4 At rest, the pH of plaque is neutral. When
fermentable carbohydrates are ingested, the plaque pH drops rapidly to create an acidic environment
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conducive to demineralization. Demineralization occurs when the pH drops from neutral 7.0 to 5.5 or
lower; this is the critical pH.4 After the ingestion of fermentable carbohydrates stops, the pH generally
returns to neutral in 30 to 60 minutes. A variety of factors mediate the return to a neutral pH. Saliva
plays a key role in that it neutralizes acids and provides minerals and proteins that protect the teeth.4
Once calcium and phosphate are lost from the tooth structure and the pH in the adjacent
environment returns to neutral, the area experiences remineralization.4 Minerals in the saliva and minerals
precipitated out of the tooth are available to redeposit on the tooth surface.4 The deposition of minerals
remineralizes the weakened tooth structure, which repairs the initial carious lesion.4 This ongoing process
of destruction and repair occurs with each carbohydrate challenge.4
Assessment
Due to the multifactorial nature of caries disease, assessment of caries risk status should be
incorporated in the initial diagnostic caries screening. Caries risk assessment is a systematic process
based on the patient’s past and present caries experience and known risk factors or indicators for disease. 2
Longitudinal assessment, which includes multiple measures of an existing carious lesion and evaluation
of risk factors over time, is mandatory to determine carious activity.2 Longitudinal assessment is the most
indicative and reflective measure of carious activity.2 The rationale for using a longitudinal risk
assessment approach is to accommodate appropriate management and prevention strategies to the
individual patient.2
There are multiple caries risk assessment models available for dental health professionals to
implement. Examples of caries risk assessment models include, but are not limited to the Cariogram,
Caries Risk Assessment Tool (CAT), and Caries Management by Risk Assessment (CAMBRA).2
Cariogram is a computer program showing a graphic picture that illustrates a possible overall caries risk
scenario.5 CAT is broad approach to risk assessment, considering the effects of both systemic disease and
behavioral factors in determining caries risk.2 CAMBRA is a system of protocols for the clinical
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management of caries by risk factor level of an individual patient.6 These caries risk assessment models
take into consideration a thorough assessment of the patient’s medical, dental, social, and preventative
history; dietary screening; clinical determinants of caries status and history; salivary function assessment;
fluoride exposure; and tooth morphology.2
A patient’s history review (medical, dental, dietary, and preventative) is an essential part of the
responsible assessment in order to prepare appropriate caries management, intervention and prevention
treatment plans. Dental health care professionals should pay special attention to the medical conditions
that might impact oral health status and affect patient’s caries risk. The use of dietary assessment relative
to dental caries control has proven to be helpful to many people.7 Components of a dietary assessment can
include clinical evaluation, food frequency checklist, and food record.7
A patient’s caries history is considered a central indicator of caries risk.2 The assessment of caries
status and history should incorporate the assessment of number of past restorations; current lesions; stage
of the lesions (enamel/dentin); and history of extraction of teeth because of caries.2 There are various
methods for the detection of carious lesions in dentistry. The diagnosis of carious lesions has been
primarily a visual process, based on clinical inspection and review of radiographs for years. 8 However, a
number of studies have concluded that the use of dental explorer is not adequate for detecting early
occlusal caries due to false negative and false positive diagnoses, depending on dentists’ interpretation.9-13
Furthermore, radiographs are not as efficient in detection of occlusal lesions, until they are well
advanced.14 Currently emerging diagnostic tools for caries detection may offer a more “objective”
assessment of early caries lesions. Some of the newest diagnostic methods include fiber optic
transillumination (FOTI), laser fluorescence and digital radiography. FOTI is an examination tool that
uses visible light to illuminate the approximal surface from which a lesion is observed through the
marginal ridge.2 One of the most well-tested laser fluorescence devices is DIAGNOdent (KaVo America
Corp, Lake Zurich, Ill).6 DIAGNOdent is based on red laser light induced fluorescence and is used for
detection of approximal and occlusal caries as an effective adjunct to the conventional methods.15,16
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However, the presence of plaque and debris worsens the performance of the laser fluorescence method.17
Amalgam restorations can also interfere with a correct DIAGNOdent reading.18 In addition, the increased
likelihood of false-positive diagnoses compared to conventional methods limits DIAGNOdent usefulness
as a principal diagnostic tool.19 Digital radiographs are very comparable in their quality to the
conventional radiographs.20 The ability to enhance digital images and alter display ratios of image sizes
can result in better diagnostic validity.21 Although the diagnosis of dental caries can be enhanced by
emerging diagnostic tools, such as DIAGNOdent, a combination of visual-tactile examination and either
conventional or digital radiography still identifies the majority of carious lesions.20
Salivary assessment (hyposalivation) should be based on patient’s current medications and social
habits review. The following questions can be asked during xerostomia screening: Does your mouth feel
dry when eating a meal? Do you have difficulty swallowing food and/or do you have to aid swallowing
process? Is the amount of saliva in your mouth “too little” most of the time?2 Tooth morphology should
also be taken into consideration during the clinical examination, as deep and retentive pits and fissures on
occlusal surfaces and exposed root surfaces relate to caries risk.2
Caries risk assessment and reassessment provided by oral health professionals must be an integral
component of long-term patient care.2 Patient’s caries risk level assignment aids in determination of
appropriate caries management, intervention and prevention procedures.6
Management/Intervention
Science is advancing caries management beyond restorative dentistry and moving it towards
evidence-based methods to measure the disease process.22 Today, managing the caries process goes
beyond placing dental restorations.6 Dental professionals should create a comprehensive caries
management plan along with the treatment plan for patients.6 An assessment tool using caries
management by risk assessment (CAMBRA) can determine the risk factor level.6 The caries management
plan determines the use of antimicrobials, fluoride, and sealants. It also aids in determining the frequency
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of radiographs and periodic oral exams. According to CAMBRA, the levels of caries risk include low,
moderate, high and extreme high risk.3,6
A low risk patient is someone who may have dental knowledge and likely maintains good oral
hygiene and regular dental visits.3 This patient tends to use the resources of fluoride found in water and
toothpaste. New carious lesions have been absent for at least a year. Any demineralized areas appear a
chalky white; they are remineralized and hardened.3 If this patient has sealants placed previously, they
may be visible in the pits and fissures and previous restorations are intact.3 The recommendation for bitewing radiographs for a low risk patient is every 24-26 months.23
A medium risk patient is one who has some risk factors identified and may not maintain regular
dental visits.6 Their oral hygiene usually is not maintained on a daily basis; there are signs of
demineralization in the proximal areas and gingival margins that may be detected. More aggressive
recommendations and motivation need to be implemented with this type of patient. The patient would
benefit from professionally applied fluoride treatment.3 It is also recommended that a prescription for
fluoride is given to the patient for home use.6 Additionally, a patient can be placed under medium risk if
there has been a presence of the carious disease in the past year, has several previous restorations or has
orthodontic appliances.3 The recommendation for bite-wing radiographs for the medium risk patient is 1824 months.23 This type of patient has the potential to move to the high risk class and needs to be
monitored more than a patient in low risk category.3
The high risk and extreme high risk class have similar characteristics. The extreme risk would be
a special needs patient or a patient high risk with severe xerostomia.6 The risk assessment discloses that
this patient could have poor oral hygiene, irregular dental visits, inadequate fluoride use, the use of
smokeless tobacco and habits of snacking on cariogenic foods. The high risk patient has had two or more
carious lesions in the past year and there is evidence of active carious lesions which could mean an
elevation of Streptococcus mutans as well as Lactobacillus in the saliva.3 Chlorhexidine can be applied in
a varnish form. The evidence shows chlorhexidine will reduce the Streptococcus mutans.3 Fluoride should
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be dispensed professionally in the office and the patient should be applying it twice a day at home.3 The
recommendation for bite-wing radiographs is every six-twelve months.3 The high risk patient should be
seen for a periodic exam every three to six months and reevaluated frequently.
Prevention
Prevention of dental caries includes measures to prevent the occurrence, arrest the progress and
reduce the consequences of the disease.2 There are three prevention phases that can categorize all patients,
with the goal being to prevent caries lesions from forming. These phases are called the primary,
secondary and tertiary phases of prevention. Primary prevention is aimed toward preventing the initial
occurrence.24 This would include counseling at the earliest possible time to encourage healthy habits that
would lead to the decreased risk of caries development. Secondary prevention is directed to early
detection and intervention, along with preventing the disease progression.2 This phase is considered the
non-operative phase.2 In addition to administering fluoride to aid in remineralization, treatment would
also incorporate counseling. The final phase is the tertiary prevention phase, which addresses the
alleviation of disability and loss of function.2 This is considered the operative phase which includes the
restorative treatment.2 The dental hygienist’s objective in addressing dental caries is to prevent the
process entering the tertiary phase. This is accomplished by modifying harmful risk factors, and
promoting healthy behaviors.
All three phases of prevention can benefit from the use of fluoride. Caries remineralization
therapy can effectively arrest or reverse the progression of incipient proximal caries lesions.25
Remineralization of tooth structure can be accomplished via a series of topical fluoride applications over
time using a combination of both in-office and at-home fluoride agents.25
Fluoride therapy has been the cornerstone of caries preventative strategies since the introduction
of water fluoridation over 5 decades ago.26 Fluoride inhibits the initiation and progression of carious
lesions.26 Intensive laboratory and epidemiological research on the mechanism of action of fluoride in
preventing caries indicates that the predominant effect of fluoride is topical.27 This occurs mainly through
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promotion of remineralization of early carious lesions and by reducing demineralization in sound tooth
enamel.27 The use of topically applied fluorides has increased over recent decades.28 Fluoride containing
dentifrices, mouthrinses, gels and varnishes are widely used both alone or in different combinations.28
Fluoride gels and varnishes are typical methods of professional topical fluoride application.28 Fluoride
mouthrinses and dentifrices are the main forms of self-applied fluoride therapy.28
Dietary modification is another important aspect of dental caries prevention. The first approach
to treating dental caries as an infectious disease is to eliminate as many causative factors as possible. 7
Fermentable carbohydrate exposures should be eliminated between meals and at the completion of
meals.7 Furthermore, concentrated sweets and highly acidic foods should be limited to occasional
exposure.7 Patients should be encouraged to select snacks from noncarbohydrate food groups.7
The daily use of dental floss and other interdental aids are also important in the prevention
process. The effective use of these aids contributes to oral health by removing dental biofilm.7 Combined
with dietary risk factors, this biofilm accumulated in the concavities and proximal surfaces allows for the
caries process to begin.
The studies on the role of sugar substitutes such as sorbitol and xylitol have indicated that they
decrease the rate of dental caries development.29 Sorbitol slows down the process, while xylitol has shown
the greatest reduction of caries formation.29 Xylitol has demonstrated that it reduces the levels of
Streptococcus mutans.29 Furthermore, chewing gum with xylitol may decrease the incidence of dental
caries.29
Dental sealants are a simple, cost effective preventative measure to manage dental caries.30 The
utilization of dental sealants can be increased through public awareness, consumer education, and by
establishing reimbursement by insurance companies.30 Many schools in high risk areas are offering
sealant programs to eliminate the barrier of insurance coverage.30
Prevention of dental caries requires a multidirectional approach. Dental hygienists need to
evaluate all risk factors and provide evidence-based direction for the patient. This would include dietary
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modification, administering fluoride and healthy home care habits. Since the infectious disease of dental
caries is preventable, dental hygienists can play a pivotal role in the prevention process.
Conclusion
As dental caries remains to be one of the most prevalent oral diseases, the dental hygienists need
to work together on a national and state level to increase the awareness of the devastating lifelong effects
of dental caries. Collaborating efforts with the dentists, legislators, state dental boards and other health
care professionals is an important step towards reducing the gap between the low risk and high risk
individuals. There is a strong need for management of caries by individual risk assessment, specifically
directed to high-risk groups and populations.1 Dental hygienists play a preventative role in reducing these
numbers by utilizing their clinical skills, evidence-based knowledge and expertise to arrest the occurrence
of dental caries.
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