Overtreatment in caries management? a literature review perspective and recommendations for clinicians

Discussion

Considerable variation exists between dentists on their treatment decisions regarding, among other things, the need for placing and replacing restorations.^41,42 Lesion-activity and surface integrity of the concerned tooth should guide the treatment decision.⁴³ Hence, the need arises for standardized models to ensure uniformity and objectivity in the approach to understanding the status of the caries process and managing it.

CARIOGRAM conceptualized in 1997 by Swedish and British caries researchers was initially used as an educational tool to depict the interplay of causal factors in determining caries risk.⁴⁴ Well-documented validation of the concept is available in the scientific literature and, over time, it evolved into an Internet Version which can be used by clinicians to determine an overall-risk picture of caries for their patients.⁴⁵ Risk-assessment being a key determinant of the strategy applied in caries management, the CARIOGRAM illustrates, in the form of a pie-circle diagram, whether the overall risk of an individual patient is high, intermediate or low. It also underlines those causes which make the individual at risk for caries and therefore allows the clinician to address them for caries managment. Additionally, the CARIOGRAM allows for factoring-in the clinician's judgement in the overall picture.

CAries Management By Risk Assessment (CAMBRA) first published in 2003 in the Journal of the Californian Dental Association, applies various factors (both biological as well as lifestyle factors) into a statistical model to reach a decision on the individual person's risk of caries in the future (Figure 1). Caries risk assessment is a method of determining the probability of caries incidence (that is, the number of new cavities or incipient lesions in a certain period) as well as the probability of a change in the size or activity of existing carious lesions, given that all other aetiological factors (diet, time, susceptible surface and plaque levels) remain the same.^46,47,48 Determining risk status is an essential component for caries management because it enables the clinician to determine whether to restore or monitor lesions, while determining the recall period for monitoring the progression/reversal of the lesions.

The protective factors need to be addressed in every patient, making them collectively weigh more heavily than the pathological factors (which in turn need to be mitigated) to tip the scale towards a ‘No Caries’ scenario (Figure 2). Achievement of this favourable balance forms the basis of the CAMBRA model.^32,33,49 The evidence-base supports the CAMBRA model.^38,50 Practitioners are however recommended to review their national guidelines on the usage of antibacterials like CHX/Xylitol before prescribing to patients. A sample treatment plan for a high caries risk patient has been proposed (Table 2).

From the guidelines provided by the CAMBRA model it is important to note that the assessment part and the non-surgical management of caries form the primary management strategy and the restorative intervention by the dentist in the form of sealants or composite restoration is the supplementary strategy and should be as per the ICDAS sealant protocol.

International Caries Detection and Assessment System (ICDAS) is an international standardized visual assessment tool developed in 2002 to grade an examined tooth's caries status numerically. Based on the coding that the tooth receives on visual examination, a management system International Caries Classification and Management System (ICCMS) to treat it is outlined. ICDAS II is currently being used widely by both clinicians and epidemiologists in standardizing their assessments in different settings and thereby formulating their management strategies accordingly⁵¹ (Table 3). The ICDAS employs two important elements which should be noted by clinicians, the first being that oral prophylaxis is necessary prior to visual examination of the tooth in question and second, the use of compressed air is essential to detecting early signs of caries.⁵²

However, reservations exist about feasibility of applying the ICDAS codes in a dental practice setting for treatment decisions, and this is due to the exhaustive nature of the coding system (separate criteria for root caries, coronal caries, caries adjacent to restorations, radiographic scoring and clinical correlation, etc), although it's an effective tool for researchers and epidemiologists.^53,54,55

For clinicians, a guide has been made with the categories/codes merged into 4 simple stage-based categories so that management decisions can be made easier. The management strategy takes into account also whether the lesion is Active/Inactive. The 4 merged categories have been listed in Table 4.

The ICCMS advocates a spectrum of management strategies for coronal caries, ranging from ‘Risk-based Prevention’ for ‘sound teeth’ through to ‘NOC (No Operative Care)’ in the form of ‘Resin-based sealants for Initial Active lesions’ ending in ‘TPOC (Tooth-Preserving Operative Care)’ for ‘Extensive Active and Inactive lesions’.⁴⁰

Minimally Invasive Dentistry (MID) involves the practice of minimally invasive operative caries management strategies and techniques based on a better understanding of the caries disease process. It addresses the causal factors responsible for caries rather than the symptomatic ones (cavitated lesions). It entails therefore only the minimum removal of healthy tooth structure operatively that would enable restoration of lost tissue, as well as promoting the arrest or reversal of the disease process that is caries.⁵⁶ The availability of better adhesive restorative materials and newer preparation and caries removal techniques has helped in the emergence of the MID concept.

Chemo-mechanical excavation of carious dentine, air abrasion, enzymatic digestion, ozone treatment, antibacterial therapy (fluorides, chlorhexidine, etc) are all part of the MID conceptualized techniques. Numerous clinical studies have reported good patient acceptance and the evidence base supports these treatment techniques.^57,58

Minimally invasive restorative dentistry also advocates the sealing in of caries with a fissure sealant or composite restoration, and there is considerable evidence base to suggest that caries sealed in does not progress because the microbial flora is denied fermentable carbohydrates as a substrate (an essential requirement for caries progression). This procedure will be effective only if the tooth-restoration interface is truly sealed by the restorative material that is used. Although this school of thought is a paradigm shift from the traditional school of thought (as in GV Black's teachings), the evidence base supports such a caries management philosophy. In light of the available literature, a mechanistic approach to the management of dental caries is not suggested anymore.⁴⁸ A decision algorithm has been made to assist the practitioner in making operative/non-operative decisions in managing initial carious lesions (Figure 3).

Conclusions

The following recommendations are based on the evidence from the scientific literature reviewed, including the authors' opinions towards taking caries disease management in the right direction.