Question: Do we need to diagnose and treat caries differently?
By Marisol Tellez, BDS, MPH, PhD | Jeffrey M. Rosenberg, DDS | Joel H. Berg, DDS, MS Question:
Dr. Tellez
Traditionally there has been a major emphasis in the dental educational system on the technical skills in the management of dental caries rather than the understanding of the disease. The current clinical approaches are heavily biased toward detecting tooth demineralization sites and repairing damaged teeth with surgical approaches, while efforts to control cariogenic bacteria, reduce plaque acidogenicity, and enhance remineralization are limited. Unfortunately, operative care has remained the central management strategy for caries control in general practice, which has impacted negatively caries epidemiology and clinical outcomes.
Given the current understanding of dental caries, the standards of care for both caries diagnosis and caries management are now very different than they were during the time when caries was diagnosed at the cavitation level only, there was no widespread use of fluoride, and the development of restorative materials which adhere to tooth structure was in its infancy. Caries is understood to be a dynamic process that occurs at the molecular level and can be diagnosed before irreversible loss of tooth structure occurs. Dental research has led to the development of efficacious primary preventive caries strategies that can arrest non-cavitated caries lesions and lead to their remineralization. In spite of this, the profession has not efficiently used these measures, as remuneration systems do not encourage their use and no reward is given for the arrest of ongoing disease by non-operative treatment techniques. The lag between the current understanding of dental caries and the developments in modern management of the process demands that the global dental profession returns to the basics of prevention and implement protocols that sustain low levels of primary caries in young populations and prevent primary and secondary caries among the elderly. We are in debt of redirecting the management of dental caries from a restorative (surgical) approach to a medical (preventive) approach to achieve sustainable improvements in delivering what we currently know as the best evidence possible for the detection, assessment, diagnosis, and management of the disease.
Dr. Rosenberg
The first step in any treatment decision is a proper diagnosis. For contemporary caries diagnosis and treatment, establishing the caries risk level is essential. High-risk caries patients need more aggressive diagnostic and treatment strategies, including behavioral modifications, to reduce future risk. Risk assessment with salivary tests, pH analysis, fluorescence cameras and digital radiography can be used to diagnose caries as well as analyze risk. Monitoring of suspicious lesions with image processing under magnification, fluorescence, and digital radiographic analytics is important because low-risk caries patients can shift to moderate or high risk groups through changes in salivary flow, pH, and diet.
Enamel preservation is an essential component to caries treatment. Ultimately, a tooth’s lifespan depends on dentin protection. Minimal preparation techniques include the use of sealants, air abrasion, hydroabrasion, and preventative resins. The thinking in these situations is fillings should go on teeth rather than in them. I have advocated for a “pre-etch” technique to go along with this thinking.
Stem cell research will likely be a part of a regenerative technology to treat caries and there is still the likelihood that a vaccine may be developed to eliminate the caries-causing bacteria. The studies on xylitol excite me as to the possibility of smart sugars to inactivate the acid-producing capability of Streptococcus mutans. Behavioral modification treatments to reduce caries risk include biofilm removal, the use of xylitol, remineralizing toothpastes and rinses, and fluoride applications.
I hope research and manufacturers will continue to develop techniques and materials that will be efficient and simple enough for every dentist to use and will complement the materials and trends that we currently have.
Dr. Berg
tal caries is a biofilm-induced and saliva-mediated acid demineralization of enamel and dentin. If left untreated, the infection can spread into the pulp and surrounding tissues and cause pain, swelling, and other health consequences. Although the expenditure in the United States alone on dental caries is around $60 billion annually, most of this money is spent on restorative treatment related to the effects of dental caries, and does not treat the disease itself. This is because to date, we have not had effective or cost-effective technologies/methods to detect the dental caries process at such an early stage that a halting or reversal of the process can be achieved prior to cavitation of the tooth, at which point surgical restorative interventions are required.
Therefore, many of the new technologies being developed or applied to identify the progression of the dental caries process at an early stage are essential in order to treat the disease via medical or other non-surgical methods. I am pleased that a multitude of varying techniques, technologies, energy sources, and applications are being employed to identify the caries disease process in its earliest stage of progression, so that surgical intervention might be averted. This is particularly important in the case of early childhood caries, which is on the rise in the United States, and will become a worldwide crisis as developing countries add more fermentable carbohydrates to their children’s diets, many of whom have little or no access to dental care. The creation of early-detection methods will not only allow the early treatment of caries via non-surgical means, but will facilitate the development of medicinal therapeutics to treat caries in its earliest phases. Manufacturers of drugs and devices to treat caries will undoubtedly invest more into such development when the outcomes can be seen much earlier, and that such outcomes are true identifications of progressing disease that needs to be treated. Clearly, a new era of caries management is before us, as sensitive and specific caries risk assessment and early caries lesion detection become essential elements of our daily practice.
About the Authors
Marisol Tellez, BDS, MPH, PhD | Dr. Tellez is an associate professor in the Department of Dental Public Health Sciences at the Kornberg School of Dentistry of Temple University in Philadelphia, Pennsylvania.
Jeffrey M. Rosenberg, DDS | Dr. Rosenberg has a private practice, The Dental Healthcare Group, in Philadelphia, Pennsylvania.
Joel H. Berg, DDS, MS | Dr. Berg is the Associate Dean for Hospital Affairs, and professor and chair of the Department of Pediatric Dentistry at the University of Washington, School of Dentistry, and the director of the Department of Dentistry at Seattle Children’s Hospital, in Seattle, Washington.
