Pitts NB (ed): Detection, Assessment, Diagnosis and Monitoring of Caries.

Monogr Oral Sci. Basel, Karger, 2009, vol 21, pp 144–148

Background Level Care

N.B. Pitts
Dental Health Services and Research Unit, University of Dundee, Dundee, UK

Abstract
The framework enabled by the International Caries Detection and Assessment System to allow
appropriate, patient-centred caries management includes a frequently encountered scenario in
which a comprehensive assessment of the teeth and the patient reveals no lesions in need of active
preventive or operative care. The issue addressed here is: what background care is appropriate for
patients attending a dental practice for routine caries care who, at present, appear to have no active
or progressing caries lesions? It is proposed that, in addition to the use of criteria for lesion extent,
treatment planning systems should also express the results of lesion assessments in terms of back-
ground level care (BLC), preventive treatment options and operative treatment options. The specific
treatment options recommended for specific lesions and patients will depend upon a variety of
other factors, including lesion activity, monitoring lesion behaviour over time and a range of other
prognostic factors. Over recent decades, there has been comparatively little focus on appropriate
BLC in a general practice setting. There are a range of issues around the need to support caries pre-
vention and health maintenance from a behavioural and patient-focussed perspective. Even if a
patient is deemed to be at low risk of future caries at a particular examination, there is a need for
maintenance care. Intrinsic issues which need to be managed for both patients and their caries
lesions in this patient group are: (1) the possibility of a change in caries risk status and (2) the impact
of incorrect lesion assessments/diagnoses. Copyright © 2009 S. Karger AG, Basel

The framework enabled by the International Caries Detection and Assessment

System (ICDAS) to allow appropriate, patient-centred caries management – based on
the application of best current evidence and practice – which is outlined in the chap-
ter by Pitts and Richards [this vol., pp. 128–143] includes a frequently encountered
scenario in which a comprehensive assessment of the teeth and the patient reveals no
lesions which are apparently in need of active preventive or operative care. The issue
addressed in this chapter is: what background care is appropriate for people attending
a dental practice for routine caries care who, at present, appear to have no active or
progressing caries lesions?
A review of categorizing caries by the management option some 14 years ago
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[1] identified a range of systems and classifications used by clinicians (as well as
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epidemiologists and clinical research workers) to subdivide carious lesions into differ-
ent grades. These systems were based on the depth of the lesion and/or the presence/
absence of macroscopic cavitation. In order to improve upon the meaningfulness and
comparability of such systems (in the light of increasing knowledge about the disease
process, lesion behaviour and caries management options), the authors then proposed
an iceberg metaphor for caries detection and a new system of categorization that dif-
ferentiates between lesions which normally require operative intervention and those
which do not. They proposed that, in addition to the use of any conventional criteria
for lesion extent, diagnostic and treatment planning systems should also allow the
results of lesion assessments to be expressed in terms of (1) lesions for which appro-
priate non-invasive preventive care is advised and (2) lesions for which operative care
is advised.
Over the intervening years, this nomenclature has been in use in a number of coun-
tries, while in Scandinavia a similar ‘non-operative care/operative care’ dichotomy
has also been used extensively. With further international harmonization through
the work of the ICDAS Committee [2], in a treatment planning context, these two
types of clinical management option are increasingly now referred to as preventive
treatment options and operative treatment options – for details see the chapters by
Longbottom et al. [this vol., pp. 149–155 and 156–163] and Ricketts and Pitts [this
vol., pp. 164–173 and 174–187].
A further review of the impact on planning appropriate care of ‘diagnostic tools
and measurements’ some 12 years ago [3] represented the iceberg metaphor for
understanding caries detected at different diagnostic thresholds and also determining
the differing management options appropriate for the care of different types of active
and inactive lesions. In this system, for patients with no obvious caries or no active
lesions, no active care was advised. As this term has, in some quarters, stimulated
debates about giving the impression of a dental practice failing to look after regularly
attending patients by providing preventive maintenance care, it has been superseded
by the term ‘background level care’ (BLC).

Current Caries Classification by Management Option

Figure 1 shows the way in which the iceberg metaphor is now presented with ICDAS
caries detection codes on the front face of the caries ‘cube’ of modern caries mea-
surement [4] providing the stages of lesion extent that can be generally subdivided
into BLC, preventive treatment options and operative treatment options. The spe-
cific treatment options recommended for specific lesions in specific patients will
depend upon a variety of other factors, including assessing lesion activity, monitor-
ing lesion behaviour over time (fig. 1) and a range of other prognostic and patient-
related factors [for further details, see the chapter by Pitts and Richards, this vol., pp.
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128–143].
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Background Level Care 145

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 Assessing lesion activity
ur
by a point-in-time estimate
h avio
b e
ICDAS activity codes
s i on
le e
o r ing er tim
Is this lesion active today?
n it ov eC
Mo Tim
4
Detecting lesion extent B de
me Co
Ti
ICDAS
Code
e3 d e0
6 Operative treatment
Co
d Co
eA
detection
codes lesions into pulp option
Tim 2
+ clinically detectable 0 de
Codes
2 de Co
lesions in dentine 4, 5
de Co
+ clinically detectable Code
Co
‘cavities’ limited to enamel 3 2
Preventive treatment
2 de
+ clinically detectable enamel Codes
option
de Co
lesions with ‘intact’ surfaces 1, 2 Co
+ lesions detectable only with additional
diagnostic aids
d e2
+ subclinical initial lesions in a dynamic state of
Co
Background
progession/regression level care

Fig. 1. The caries cube: relating the detection of lesion extent, assessment of lesion activity and
monitoring of lesion behaviour over time.

Background Level Care

Over recent decades there has been comparatively little focus on specifying appropri-
ate BLC in a general practice setting. While there is a short-term health economic
temptation to simply say that ‘no treatment is needed’ and therefore patients do not
need to be seen, there are also a range of issues around the need to support caries
prevention and health maintenance from a behavioural and patient-focussed per-
spective. Even if a patient is deemed to be at low risk of future caries at a particular
examination, there is a need for maintenance care. This is well documented in the
treatment of periodontal disease with specific hygiene and maintenance phases of
treatment. However, in clinical caries care this approach is less well described and
evaluated. Secondary prevention and treatment of dental caries should focus on the
management of the caries process over extended time periods for individual patients,
with a minimally invasive, tissue-preserving approach [5].
The caries status of an individual patient has to be assessed in a holistic sense in
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parallel with the current risk status for both periodontal disease and oral mucosal
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146 Pitts
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lesions, particularly when assessing recall intervals [6]. The other intrinsic issues
which need to be managed for both patients and their caries lesions in this group
are (1) the possibility of a change in caries risk status and (2) the impact of incorrect
lesion assessments/diagnoses. These issues should be seen in the context of a con-
tinuing cycle of comprehensive oral health assessments for new patients, followed by
serial oral health reviews in continuing care [6, 7].

The Possibility of a Change in Caries Risk Status

A minority of, but still some, patients who have been classified as having a low caries
risk will inevitably develop new caries lesions over time. This may either be because
of a misclassification of risk status [see the chapter by Twetman and Fontana, this vol.,
pp. 91–101] or because their risk category has genuinely changed over time. Changes
in salivary flow as a consequence of new or changed medications are a classic example
of this sometimes silent shift in risk status.

The Impact of Incorrect Lesion Assessments/Diagnoses

Some individual patients are very well controlled in terms of not developing either
active lesions or new caries. In these cases, the dentist need not do anything above
reinforcing general preventive advice in a personalized way, while maintaining vigi-
lance for any changes in risk status. However, the clinical diagnosis of dental caries is
a complex process, involving the steps of detection, assessment and frequently moni-
toring, and is not an exact science, even for the diligent practitioner. Inherent defi-
ciencies with current lesion detection methods [see the chapters by Topping and Pitts,
this vol., pp. 15–41, and Neuhaus et al., this vol., pp. 42–51 and 52–61] can impact
upon planning the care of individuals by allowing false-negative diagnoses of hidden
occlusal dentine lesions and approximal cavities on the one hand, whilst generating
some false-positive diagnoses on sound surfaces leading to inappropriate decisions to
restore on the other [3].
BLC should be relevant to the patient, the type of dental practice, the health system
under which the practice operates as well as the setting and country in which care is
delivered. Essentially BLC should provide maintenance and monitoring of preventive
caries control between routine visits [see the chapter by Clarkson et al., this vol., pp.
188–198]. This care should be provided in the knowledge that there is a possibility
that a patient’s caries risk status may change and that some lesion assessments and
diagnoses may be incorrect.
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Background Level Care 147

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Research and Implementation Considerations

The adoption of the additional nomenclature of BLC (as well as preventive and opera-
tive treatment options), over and above lesion detection and activity codes, together
with this approach to planning personalized caries care, should aid communications
between the different groups of staff involved in caries detection, assessment, diag-
nosis and monitoring within the clinical practice domain. The system will also assist
communication between patient and dental team and links from practice to research,
education and public health.
BLC supports long-term, personalized caries prevention and health maintenance
from a behavioural, risk management and patient-focussed perspective.

References
1 Pitts NB, Longbottom C: Preventive care advised 5 Selwitz RH, Ismail AI, Pitts NB: Dental caries.
(PCA)/operative care advised (OCA) – categorising Lancet 2007;369:51–59.
caries by the management option. Community Dent 6 National Collaborating Centre for Acute Care,
Oral Epidemiol 1995;23:55–59. National Institute for Clinical Excellence (NICE):
2 ICDAS – International Caries Detection and Ass- Dental recall – recall interval between routine dental
essment System. www.icdas.org. examinations: methods, evidence and guidance.
3 Pitts NB: Diagnostic tools and measurements – Royal College of Surgeons of England, London,
impact on appropriate care. Community Dent Oral October 2004. www.nice.org.uk/CG019fullguideline.
Epidemiol 1997;25:24–35. 7 Hally JD, Pitts NB: Developing the first dental care
4 Pitts NB: Modern concepts of caries measurement. J pathway: the oral health assessment. Primary Dent
Dent Res 2004;83(spec iss C):43–47. Care 2006;12:117–121.

N.B. Pitts
Dental Health Services and Research Unit, University of Dundee
Mackenzie Building, Kirsty Semple Way
Dundee DD2 4BF (UK)
Siriraj Medical Library, Mahidol University

Tel. +44 1382 420067, Fax +44 1382 420051, E-Mail [email protected]
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148 Pitts
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