Curing the Silent Epidemic - CDA Foundation by gdf57j

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									             MANAGING CARIES
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                                                           Curing the Silent
                                                           Epidemic: Caries
                                                           Management in the 21st
                                                           Century and Beyond
                                                           DOUGLAS A. YOUNG, DDS, MS, MBA; JOHN D.B. FEATHERSTONE, MSC, PHD;
                                                           AND JON R. ROTH, MS, CAE


                             ABSTRACT Caries is the most prevalent disease of children and is epidemic in some
                             populations. A risk-based approach to managing caries targets those in greatest
                             jeopardy for contracting the disease, as well as provides evidence-based decisions
                             to treat current disease and control it in the future. This paper outlines key concepts
                             necessary to effectively manage and reduce caries based on the most current science
                             to date. Subsequent articles will outline a roadmap to success in curing dental caries.



AUTHORS

Douglas A. Young, DDS,       John D.B. Featherstone,       The Silent Epidemic                             disease of childhood, with a rate five times
MS, MBA, is an associate     MSC, PHD, is interim dean,
                                                                “What amounts to ‘a silent epidemic’       greater than that seen for the next most
professor, Department        University of California,
of Dental Practice,          San Francisco, School of      of oral diseases is affecting America’s          prevalent disease of childhood: asthma.
University of the Pacific,    Dentistry, and is a profes-   most vulnerable citizens: poor children,        Because dental infections are common
Arthur A. Dugoni School of   sor, Department of Pre-       the elderly, and many members of ra-            and usually nonlife-threatening in nature,
Dentistry.                   ventive and Restorative       cial and ethnic minority groups.”               the significance of dental caries in overall
                             Dental Sciences, at UCSF.
                                                                — THE SURGEON GENERAL 2000                 health has historically been minimized
                             Jon R. Roth, MS, CAE, is           U.S. Department of Health and              until recently. On Feb. 28, 2007, the
                             executive director, Cali-     Human Services, 2000 Oral Health in             Washington Post reported that a 2-year-
                             fornia Dental Association     America: A Report of the Surgeon Gen-           old Maryland boy died from untreated
                             Foundation.                   eral, Rockville, Md., U.S. Department of        tooth decay. This news received national
                                                           Health and Human Services, National             attention, not only from the dental profes-
                                                           Institute of Dental and Craniofacial Re-        sion but the public in general. Although
                                                           search, National Institutes of Health.          overall dental caries prevalence and sever-
                                                                                                           ity has been notably reduced in several




                                                           D
                                                                                                           western countries over the past couple of
                                                                        ental caries, also known as the    decades, dental caries continues to be a
                                                                        process leading to tooth decay,    major health issue in the United States.
                                                                        is the pathologic progression          The third National Health and Nutri-
                                                                        of tooth destruction by oral       tion Examination Survey (NHANES III)-
                                                                        microorganisms that can            Phase , collected data from 988 to 994
                                                           affect individuals of all ages, cultures, eth-   that indicated 50 percent of 5- to 8-year-
                                                           nicities, and socioeconomic backgrounds.        old children in the United States had ex-
                                                           In 2000, it was determined that dental          perienced caries in the primary dentition.2
                                                           caries was the most common chronic              Remarkably, when the data are examined,

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approximately 25 percent of children and        same.4 Throughout this Journal, the             tion of fermentable carbohydrates) battle
adolescents in the 5- to 7-year-old range      authors will refer to an evidence-based         protective factors (saliva and sealants,
accounted for 80 percent of the caries          disease management protocol for Car-            antibacterials, fluoride, and an effec-
experienced in the permanent teeth. These       ies Management by Risk Assessment,              tive diet).6 With the use of CAMBRA,
data indicate that dental caries contin-        or CAMBRA.5 Evidence-based dentistry,           there is evidence that early damage to
ues to be a major oral health concern in        as defined by American Dental Asso-              teeth from dental caries may be re-
children in the United States and world-        ciation Council on Scientific Affairs in          versed and the manifestations of the
wide.3 This suggests that the population        2006, is an approach to oral health care        disease perhaps prevented all together.
of individuals susceptible to dental decay      that requires the judicious integration
continues to expand with increased age.         of systematic assessments of clinically         Transitioning From Science to Practice
It is evident from numerous other studies       relevant scientific evidence relating to the         In February and March 2003, two
that dental caries continues to affect indi-                                                     issues of the Journal of the California
viduals through childhood and beyond.3                                                          Dental Association were dedicated to
     Much of the dentistry is focused on           THE CORE PRINCIPLES                          reviewing the scientific basis for CAM-
restoring the symptoms of this transmissi-                                                      BRA, culminating with a consensus
                                                supporting risk-based caries
ble bacterial infection rather than treating                                                    statement of national experts and the
its etiologic cause, the infectious cariogen-     management are decades                        production of risk assessment forms.
ic biofilm in a predominantly pathologic                                                         The California Dental Association,
                                                 old, and many practitioners
oral environment. The core principles sup-                                                      through the CDA Foundation, has made
porting risk-based caries management are          are already using this as                     these journals available to the public at
decades old, and many practitioners are                                                         www.cdafoundation.org/journal. These
                                                   their current standard
already using this as their current standard                                                    issues of the Journal present reviews
approach in patient care. Many clinicians         approach in patient care.                     of the scientific literature on the caries
still need help getting started with em-                                                        process starting with the infectious
ploying these principles in their practice.                                                     nature of the pathogenic bacterial
     This issue of the Journal provides cur-    patient’s oral and medical condition and        organisms that are part of an extremely
rent information on how to assess caries        history, with the dentist’s clinical exper-     complex biofilm community.7 These
risk, what to do as a result, and provides      tise and the patient’s treatment needs          organisms utilize fermentable carbohy-
the protocols to implement it in practice.      and preferences (www.ada.org/prof/re-           drates as an energy source and create
The articles emphasize practical sugges-        sources/pubs/jada/reports/index.asp).           small molecule acids that then enter the
tions on how these current management               Simply put, with the CAMBRA                 tooth via diffusion channels between
techniques may be efficiently incorpo-            methodology the clinician identifies the         the mineral crystals. The diffusion of
rated into a dental practice. This paper        cause of disease by assessing risk fac-         acid causes mineral loss below the tooth
will present key concepts necessary for         tors for each individual patient. Based         surface and, if the process is not halted,
the most current management of dental           on the evidence presented, the clinician        the surface will cavitate. In the case of
caries and sets the stage for subsequent        then corrects the problems (by managing         a noncavitated lesion, it is possible to
papers in this issue to cover the clinical      the risk factors) using specific treatment       halt or reverse the caries process. In
implementation of a caries management           recommendations including behavioral,           this case, using the Caries Balance, the
by risk assessment model, or CAMBRA.            chemical, and minimally invasive pro-           protective factors overcome the patho-
                                                cedures. Both the risk assessment and           logical factors and remineralization of
Caries Management by Risk                       interventions are based on the concept of       the lesion is possible and preferred.8
Assessment                                      altering the Caries Balance (see Feather-       Remineralization is the natural repair
    For more than two decades, medi-            stone, et al. this issue). The Caries Balance   process for dental caries. Several articles
cal science has suggested that physi-           is a model where pathological factors           in those Journals reviewed the individual
cians identify and treat patients by risk       (bacteria, absence of healthy saliva, and       chemotherapeutic agents such as xylitol,
rather than treating all patients the           poor dietary habits (i.e., frequent inges-      chlorhexidine, iodine, fluoride, as well

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as fluoride releasing dental materials.9-3      Why Define Terminology?                         cariogenic biofilm in the presence of
     More recently, a pivotal randomized            Changing paradigms in caries manage-       an oral status that is more pathologi-
clinical trial by Featherstone et al.           ment does not happen without global in-        cal than protective leads to the demin-
investigated CAMBRA protocols                   volvement and collaboration from several       eralization of dental hard tissues.
compared to conventional care.4 In             sources, including updating terminology            Any resulting changes, visible on the
the intervention group, patients were           to reflect new scientific advances. Existing     teeth or not, are merely symptoms of
assessed at levels of caries risk based         terminology does not always accurately         this disease process. Therefore, caries is
upon the Caries Balance described               reflect new advances in science. However,       not a hole in the tooth, cavitation, nor
previously. Depending upon their risk           new terminology is not always universally      should it be used to describe everything
status, patients were treated with              accepted as new concepts are often de-         clinically detectable. Throughout this
antibacterial therapy (chlorhexidine) to        scribed with different definitions, names,       Journal there will be clear use of other
reduce the bacterial challenge and topical                                                     descriptive terminology when referring to
fluoride (daily fluoride mouthrinse) to                                                          the symptoms of caries such as cavita-
enhance remineralization. The control                 MINIMALLY INVASIVE                       tion, carious lesions, radiographic caries,
group received examination, customary                                                          white or brown spot lesions, infected
                                                          dentistry and
preventive care and restoration as                                                             dentin, affected dentin, and so on.
needed, but no risk assessment or                     minimal intervention
chemical interventions. Results showed                                                         CAMBRA, MID, AND MI
                                                            stand for
a significant reduction of cariogenic                                                               Minimally invasive dentistry, minimal
bacteria and future carious lesions in                   much more than                        intervention, and CAMBRA are relatively
the CAMBRA test group compared to the                                                          new terms developed in response to sci-
                                                       conservative cavity
conventional care control group.4                                                             entific advances in the field. They are used
     Since the science of CAMBRA has                      preparation.                         interchangeably by some, and by others a
been well-cited in the literature, clinicians                                                  source of debate about which is the most
are increasingly placing this knowledge                                                        proper term. For example, CAMBRA does
into practice to the benefit of their            or labels. Some feel there should be glob-     not stop at prevention and chemical treat-
patients. This issue of the Journal will        ally accepted terminology, while others        ments; it includes evidence-based deci-
present ways to incorporate CAMBRA              want the freedom to apply terminology          sions on when and how to restore a tooth
into practice and will be added as a            that is more locally accepted. In any case,    to minimize structural loss. In addition,
resource to the previously mentioned            caries management by risk assessment           minimally invasive dentistry and minimal
Web site. Protocols mentioned in this           accurately describes the new paradigm of       intervention stand for much more than
Journal are suggestions based on the            treating the caries disease process and will   conservative cavity preparation. The term
best available scientific evidence to            be used throughout this Journal. Alterna-      “minimal intervention” was endorsed by
date as well as clinical practice in offices      tive terminology that has been used in         the Federation Dentaire Internationale
currently using the CAMBRA approach.            the past includes the “medical model”          in a 2002 policy statement and is globally
It is meant to be a starting point to aid       or the “modern management of caries.”          recognized.6 The terms CAMBRA and
the offices that have not yet incorporated        The limitations with these terms is that       MID are in 00 percent agreement with
CAMBRA principles. This issue also              they do not describe the disease process.      the FDI statement on minimal inter-
contains updated risk assessment forms                                                         vention. Thus, the authors support the
and procedures that should be adopted by        CARIES                                         interchangeability of all three terms and
those currently utilizing CAMBRA as the             The term caries has been used to           recognize the importance of local prefer-
changes are based upon experience to            describe a multitude of manifestations,        ences as well as global collaboration.
date. This effort will continue to be            which may lead to confusion if not
updated as new research science and             further defined.5 For purposes of this         DETECTION VERSUS DIAGNOSIS
dental products are incorporated into           Journal, caries is defined as an infectious        Defining the terms detection and di-
the dental marketplace.                         transmissible disease process where a          agnosis as it relates to dental caries is best

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done by example. Simply put, one diagno-      Arizona. Additionally, representatives       new CAMBRA groups in the Eastern and
ses the caries disease but detects carious    from research, industry, the California      Central United States have formed and
lesions. Detecting a white spot lesion, for   Dental Association Foundation, govern-       begun to meet with the same agenda
example, is not diagnosing the disease        ment, the Dental Board of California,        and principles as the Western CAMBRA
of caries because the disease process         third-party payers, and private practice     Coalition. The regional groups have agreed
involved with the lesion could be inactive    clinicians were included in the work-        to work together and collaborate with the
and the lesion could be remineralized.        ing group. The strategy for including a      newly formed ADEA Cariology Special
                                              diverse perspective of individuals was to    Interest Group where opportunities exist.
PREVENTION VERSUS MANAGING RISK               break the traditional mold where only
FACTORS                                       researchers, educators, and clinicians       Standard of Care
    Traditionally, the term “prevention”      met for their specialties. The goal was           Standard of care involves many
has become a common language term                                                          components and is more than just what
that has been blanched and simplified to                                                    a dentist does in his/her own practice,
only mean “brush and floss” and “don’t           THE TERM “PREVENTION”                      what a dental school teaches, or even
eat sugar.” That advice is historically                                                    what is published in refereed publica-
what many consider when the term is              has become a common                       tions. Standards are never static, nor is
used in the context of caries prevention.          language term that                      there always complete agreement on the
Utilizing CAMBRA archetype, manag-                                                         application. The California legal system
ing risk factors is what is done after first      has been blanched and                     defines the standard of care as what a
performing caries risk assessment. Once          simplified to only mean                   reasonably careful dentist should do
the risk factors are identified, then evi-                                                  under similar circumstances. Reason-
dence-based treatment decisions can be            “brush and floss” and                    able care weighs the benefits versus the
made to bring the balance of pathologic              “don’t eat sugar.”                    risks. If the benefits exceed the risks,
and protective factors positively back to                                                  then reasonable dentists should adopt
favor health using an array of behavioral,                                                 these standards. The public expects that
chemical, minimally invasive surgical,                                                     dentists and physicians will utilize current
and other techniques. Throughout this         to infuse new ideas into the conversa-       scientifically safe and effective practices.
issue of the Journal the term prevention      tion where no existing network for                CAMBRA procedures, as presented in
will be defined as risk factor management      sharing this information existed.            this issue of the Journal, provide a frame-
(by maximizing protective factors and             Additionally, the cross-pollination      work for providing caries management
minimizing pathological factors).             provided support from nontraditional         by risk assessment for the benefit and
                                              partners to implement changes in car-        improved dental health of the patient.
Western CAMBRA Coalition                      ies management. The coalition used           Explaining the planned treatment to the
    The Western CAMBRA Coalition              this conduit of information based on         patient and obtaining informed consent
is a unique collaboration of diverse          reciprocity so that those in the network     is, of course, necessary as part of this
groups of independent organizations.          could share information freely and           approach, as it is for any procedure. Al-
This coalition represents an interor-         confidentially in the spirit of coopera-      though the CAMBRA protocols are based
ganizational collaboration that has           tion, collaboration, and coordination for    on the best available science we have now,
evolved over four years and has led to        the common good of improving the             there is much more involved in treat-
significant progress in the clinical adop-    standard of caries management.               ment decisions other than just science.
tion of CAMBRA. The working group,                The coalition has used the World         As stated previously, the ADA definition
assembled from different aspects of the       Congress of Minimally Invasive Dentistry     of evidence-based dentistry implies that
dental profession, included unofficial        annual meeting, attended mostly by           treatment decisions should also consider
representatives of education from all         clinicians, as a venue to gather each year   the clinical expertise of the clinician and,
five California dental schools, as well as    because CAMBRA is a core value of the        most importantly, the preferences of
from Oregon, Washington, Nevada, and          WCMID (www.wcmid.com). Recently,             the fully informed patient just as much

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as the science (www.ada.org/prof/re-                                6. Featherstone JD, The caries balance: the basis for caries        14. Featherstone JDB, Gansky SA, et al, A randomized clinical
                                                                    management by risk assessment. Oral Health Prev Dent 2              trial of caries management by risk assessment. Caries Res
sources/topics/evidencebased.asp).                                  Suppl 1:259-64, 2004.                                               39:295 (abstract #25), 2005.
                                                                    7. Berkowitz RJ, Acquisition and transmission of mutans strep-      15. Young DA, Managing caries in the 21st century: today’s
Conclusions                                                         tococci. J Calif Dent Assoc 31(2):135-8, 2003.                      terminology to treat yesterday’s disease. J Calif Dent Assoc
                                                                    8. Featherstone JD, The caries balance: contributing factors        34(5):367-70, 2006.
    It is the consensus of the Western                              and early detection. J Calif Dent Assoc 31(2):129-33, 2003.         16. Tyas MJ, Anusavice KJ, et al, Minimal intervention dentistry
CAMBRA Coalition that it is best for                                9. Lynch H, Milgrom P, Xylitol and dental caries: an overview       -- a review. FDI Commission Project 1-97. Int Dent J 50(1):1-12,
the profession to position itself for the                           for clinicians. J Calif Dent Assoc 31(3):205-9, 2003.               2000.
                                                                    10. Anderson MH, A review of the efficacy of chlorhexidine
future and embrace caries management                                on dental caries and the caries infection. J Calif Dent Assoc       TO REQUEST A PRINTED COPY OF THIS ARTICLE, PLEASE
by risk assessment. This means think-                               31(3):211-4, 2003.                                                  CONTACT Douglas A. Young, DDS, MS, MBA, University of the
ing of dental caries as a disease process                           11. DenBesten P, Berkowitz R, Early childhood caries: an            Pacific, Arthur A. Dugoni School of Dentistry, 2155 Webster St.,
                                                                    overview with reference to our experience in California. J Calif    Room 400, San Francisco, Calif., 94115.
with the possibility of intervention,                               Dent Assoc 31(2):139-43, 2003.
arresting the progress of the disease,                              12. Donly KJ, Fluoride varnishes. J Calif Dent Assoc 31(3):217-9,
and even reversing it. Caries risk assess-                          2003.
                                                                    13. Weintraub JA, Ramos-Gomez F, et al, Fluoride varnish
ment should become a routine part of                                efficacy in preventing early childhood caries. J Dent Res
the comprehensive oral examination, and                             85(2):172-6, 2006.
the results of the assessment should be
used as the basis for the treatment plan.
    This issue of the Journal provides
caries risk assessment and treatment
procedures for newborns to age 5 (Ra-
mos-Gomez et al.); caries risk assessment
for age 6 through adult (Featherstone
et al.); caries management based on
risk assessment (Jenson et al.); and
dental products available for use in the
CAMBRA approach (Spolsky et al.).
    In summation, the Western CAMBRA
Coalition urges that all dentists imple-
ment CAMBRA in their practices for the
benefit of their patients and the improved
oral health of the nation. The time to do it
is now. The tools and rationale are
provided in the following pages.

REFERENCES
1. Mouradian WE, Wehr E, Crall JJ, Disparities in children’s oral
health and access to dental care. JAMA 284(20):2625-31, 2000.
2. Kaste LM, Selwitz RH, et al, Coronal caries in the primary
and permanent dentition of children and adolescents 1-17
years of age: United States, 1988-1991. J Dent Res 75 Spec No:
631-41, 1996.
3. Macek MD, Heller KE, et al, Is 75 percent of dental caries
really found in 25 percent of the population? J Public Health
Dent 64(1):20-5, 2004.
4. Anderson MH, Bales DJ, Omnell K-A, Modern management
of dental caries: the cutting edge is not the dental bur. J Am
Dent Assoc 124:37-44, 1993.
5. Featherstone JDB, et al, Caries management by risk assess-
ment: consensus statement. J Calif Dent Assoc 31(3):257-69,
2003.


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