Introduction of the disease, prevalence and global impact
Dental caries is the most common dental disease that requires restorative treatment. In 2010, the Global Burden of Disease Study reviewed the prevalence of 291 diseases from 1990 to 2010 and determined that untreated caries in adults was the most prevalent condition, impacting 2.4 billion people, or 35% of the world population.1 Caries affects the entire spectrum of the general population, with 92% of adults between ages 20 and 64 having had dental caries in their permanent teeth.2 Despite a general trend of decline in caries rates since the 1970s in the US, significant disparities in caries rates exist in different racial, socioeconomic, educational, and age groups.2 Dental caries is considered one of the two most prevalent global oral health burdens.3 Direct treatment costs due to dental diseases worldwide are estimated at $298 billion annually, representing an average of 4.6% of total global health expenditures.4 In many low-income countries, if treatment were available, the costs of dental caries alone in children would exceed the total health care budget for children.4 Dental caries is also one of the most prominent non-communicable diseases worldwide, following cardiovascular diseases, diabetes, cancer, and chronic obstructive pulmonary disease.4,5 Prevention and caries risk assessment are clearly important and necessary. Caries risk for the elderly population is especially concerning because, many times, these patients need more dental restorations, or have multiple missing teeth, dexterity difficulties, or oral hygiene compliance issues. Recurrent caries around existing dental restorations can result in their premature failure and increased health care costs.
Pathogenesis and classification
The main cariogenic bacteria are Mutans streptcococci (MS) and Lactobacilli species.6,9,10 Caries formation also requires host substrate, presence of biofilm, fermentable carbohydrates, and time.9 For caries to be initiated, dental plaque usually has a high proportion of MS present. MS possess high adherence to the tooth surface, produces high levels of acid from sugars, and are acid tolerant.6 Lactobacilli and Gram-positive bacteria are commonly isolated from the oral cavity and are highly acidogenic organisms as well, but they have low affinity to the tooth surface. Therefore, Lactobacilli and Gram-positive bacteria are more related to advancing rather than initiating caries.6 Dental caries is the result of the metabolic activities of these bacteria growing within biofilm on tooth surfaces. The acid produced during the process causes demineralization, which increases porosity in the enamel and decreases translucency of the surface color.7 As a result, white opaque lesions occasionally are observed. As the disease progresses, the porosity of the enamel causes staining from food and cavitation of the surface. Over time, the caries turns brown or black.7 Many factors influence the speed and propensity of caries formation. These factors include tooth location, tooth anatomy, the presence of carbonated hydroxyapatite within enamel, saliva quantity and quality, biofilm formation, and host diet.7 Based on
The age and prevalence of untreated caries is shifting from children to adults.2 Caries incidence has three peaks at the ages of 6, 25, and 70 years old.2 While young patients are susceptible to caries often due to diet, the older population is prone to dental caries as a result of microflora change due to reduced salivary flow rate, long-term medications, root surface exposure, prosthesis wearing, and an impaired immune system.
Caries diagnosis and risk assessment
It is important to make an appropriate diagnosis and risk assessment of caries in order to tailor treatments. More importantly, developing an assessment benchmark to evaluate risk level of each individual is also crucial when it comes to preventive care. Traditionally, the visual-tactile caries diagnosis is the most known method and is widely used by clinicians. The “stickiness” tactile sensation or resistance to withdrawal of a sharp dental explorer confirms the presence of dental caries. However, the research does not support that such practice increases sensitivity or specificity compared to visual examination alone of a dry tooth.8 Probing can also irreversibly damage the tooth surface, causing a sound remineralizable subsurface lesion to become a cavitated lesion, which is much more prone to caries progression. Using a round-ended periodontal probe has been suggested, and using gentle strikes across the tooth surface has been recommended to be less invasive.8 On the other hand, probing does render necessary information when it comes to root caries to detect the softness of the lesion.8 Other ways to enhance visual diagnostic methods include using fiberoptic transillumination, tooth separation, and magnification. Another widely used caries detection method is dental radiography. A certain amount of mineral loss has to occur for the caries to be detected on the radiograph. The two-dimensional image is also affected by the thickness of the surrounding soft and hard tissues, the projection angles, receptor resolution, and examiner’s skills, making detection of minimally demineralized tooth surfaces difficult.8 Currently, other novel caries detection methods are available. They are based on either certain types of light source, such as laser-fluorescence transillumination, or electronic current, such as electrical conductance measurement methods. Within the scope of research of this position statement, there seems to be no perfect caries diagnostic tool at this time. Clinicians should reserve these novel tools for adjunct caries detection, as false positive readings might drive overtreatment in some scenarios.7
Currently, the most widely accepted and the most successful assessment tool is Caries Management by Risk Assessment (CAMBRA).9-11 A questionnaire that evaluates the pathological and protective factors in the caries balance model allows clinicians to determine a patient’s caries risk. Based on different risk levels, evidence-based treatment alternatives can be considered, and the one that best favors the positive balance of protective factors compared to pathologic factors can be chosen. These treatment options can be an array of behavioral, minimally invasive, chemical, dietary, and restorative techniques.9
Current treatment options and their limitations
The most common method of caries removal is with mechanical drilling using an air-driven turbine or an electric handpiece. Other methods include air abrasion, laser, and chemical solutions.
After surgically removing caries from a tooth, clinicians perform either a direct restoration, such as amalgam or composite resin, or an indirect restoration such as an inlay, onlay, or crown. While amalgam is suitable for non-esthetic areas (see ACP position statement on dental amalgam), composite resin based materials have gained popularity. There is concern that composite resin has inferior properties and may not be as durable for restoration of posterior teeth after caries removal. Research comparing long- term studies indicates that the main reasons for long-term failure of such restorations are often secondary caries, related to patients’ caries risks, and fracture, related to the presence of a lining, as well as patient force factors, such as bruxism.12 Recurrent caries is among the most common complications for indirect restorations.13 In addition, the most common complication associated with a fixed dental prosthesis (FDP) is also recurrent caries. The mean recurrent caries rate diagnosed affecting an FDP abutment tooth is 18%.13 These data all indicate that if there are not preventive measures put in place after caries removal, the chance of caries recurrence on any restoration in the same oral environment can be very high. In a high caries risk individual, it may be a better option to replace missing teeth with dental implants.
According to the CAMBRA protocol, each individual is designated a risk level and prescribed treatment with the goal of decreasing risk.11 Frequent recall visits combined with dental radiographs, prophylaxis,
Some elderly patients require special considerations because of multiple co-morbidities and compliance issues. Systemic diseases, medication-induced dry mouth, a carbohydrate rich diet, decreased dexterity, and gingival recession render the elderly very susceptible to caries. Preventive measures should take priority, and operative interventions are used only if needed to improve the oral condition.7 Removable dental prostheses (RDP) may complicate the oral environment and increase caries risks.7 RDP should be prescribed only to improve esthetics and function. Many patients can function comfortably with a shortened dental arch.7
Innovative preventive and operative treatment options on the horizon
Newer approaches to reducing caries can be classified based on their mechanism of action. There are measures to help remineralize tooth surfaces, such as a miniature fluoride-releasing device attached to a tooth, application of amorphous calcium phosphate, ozone therapy to modify biofilm, probiotic substitution, non-acid producing bacteria replacement therapy, and laser treatment or medications to modify surface composition leading to an increased enamel resistance to demineralization.8
Conclusion It is the position of the American College of Prosthodontists that caries risk assessment and prevention is an important part of patient management in order to improve oral health care outcomes.
References
1. Kassebaum NJ, Bernabé E, Dahiya M, et al: Global burden of untreated caries: a systematic review and metaregression. J Dent Res 2015;94:650-658
2. NIH: National Institute of Dental and Craniofacial Research.
www.nidcr.nih.gov/datastatistics/finddatabytopic/dentalcaries/. Accessed August 29, 2016
3. Listl S, Galloway J, Mossey PA, et al: Global economic impact of dental diseases. J Dent Res 2015;94:1355- 1361
4. Petersen PE. World Health Organization global policy for improvement of oral health: World Health Assembly 2007. Int Dent J 2008;58:115-121
5. Petersen PE: The World Oral Health Report 2003: continuous improvement of oral health in the 21st century- the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31:3-24
6. Loesche WJ: Role of Streptococcus mutans in human dental decay. Microbol Rev 1986;50:353-380
7. Fejerskov O, Nyvad B, Kidd E: Dental Caries. The Disease and Its Clinical Management (ed 3). Ames, IA, Wiley Blackwell, 2015.
8. Pitts N: Detection, Assessment, Diagnosis and Monitoring of Caries. Basel, Switzerland, Karger, 2009
9. Featherstone JDB: The caries balance: Contributing factors and early detection. J Calif Dent Assoc 2003;31:129-133
10. Featherstone JD, Domejean-Orliaguet S, Jenson L, et al: Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc 2007;35:703-707, 710-13
11. Doméjean S, White JM, Featherstone JD: Validation of the CDA CAMBRA caries risk assessment--a six- year retrospective study. J Calif Dent Assoc 2011;39:709-715
12. Demarco FF, Correa MB, Cenci MS, et al: Longevity of posterior composite restorations: not only a matter of materials. Dent Mater 2012;28:87-101
13. Goodacre CJ, Vernal G, Rungcharassaeng K, et al: Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31-41
14. Dreizen S, Brown LR, Daly TE, et al: Prevention of xerostomia-related dental caries in irradiated cancer patients. J Dent Res 1977;56:99-104
