Quality Resource Guide
l
Caries Risk Assessment and Management for Adults
2
www.metdental.com
(The International Caries Detection and Assessment
System (ICDAS) Foundation committee), formed
in 2002, developed a detailed caries detection
process based on evidence-based visual criteria to
stage dental caries severity.
3,4
The process allowed
close monitoring of changes in dental caries lesions
in a preventive-oriented framework for patient-
centered caries management. The maturation of
the process resulted in the development of the
current ICCMS.
3,4
ICCMS calls for non-cavitated
lesions that are deemed active, to not be “watched”,
but instead, be treated with non-restorative options.
The goal is to arrest lesion progression and move
the patient to a lower caries risk status.
Correctly identifying risk is paramount to a
successful treatment, as restorative treatment is
subject to failure, frequently due to caries lesions
around restorations.
5
Thus, identifying risk has two
objectives: 1) determine which are the main culprits
driving the patient’s current caries status and
2) determining the best management approach.
Evidence supports that Caries Management by
Risk Assessment (CAMBRA) leads to better
outcomes.
6,7
Introduction
Dental caries is a very complex disease that affects
most individuals during their lifetime. There are
several factors, such as diet, biofilm, and absence
of saliva among others, that contribute to the
establishment and progression of the disease.
These are known as “risk factors”. If these risk
factors are identified early and risk appropriate
management is implemented, dental caries lesions
may be prevented. Although caries preventive
efforts have historically focused on children, there
are a myriad of factors that affect adults, placing
them at higher caries risk. Identifying these risk
factors and determining an adequate management
protocol for each patient are key to a successful
outcome.
Dental caries treatment has traditionally consisted
of restoration of existing caries lesions and
placing non-cavitated lesions on “watch” (periodic
assessment). Modern management of dental caries
involves:
2
1.
Determining the caries risk status of the
patient
2.
Detecting caries lesions at an earlier stage
and assessing their activity status
3.
Making a diagnosis of whether the disease is
actually present
4.
Establishing a prognosis
5.
Applying intervention strategies focused on
preventing, arresting and possibly reversing
the caries process
6.
Restricting restorative treatment to only when
absolutely necessary
A
4D approach
(
Determine
patient’s caries risk,
Detect
and assess caries lesions,
Decide
on
a personalized treatment plan and
Do
caries
management) to personalize caries management
with the goal of maintaining health and preserving
tooth structure (
Figure 1
), has been proposed
by
the
International
Caries
Classification
and
Management
System
(ICCMS).
1,2
The
ICCMS spawned from the need to provide a
framework for caries management. A committee
Caries Risk Assessment
Several caries risk assessment (CRA) instruments
have been evaluated, predominantly on children,
but some have been more recently assessed in
adults.
8-12
Most CRA instruments have some of
these elements present:
13
•
Previous caries experience
•
Diet
•
Fluoride exposure
•
Saliva
•
Medical history
There
are
several
CRA
guidelines/systems
available.
8,10,14,15
but evidence favoring one system
over another is limited.
16
A brief questionnaire that the
patient can complete in the waiting room or be asked
by the dental assistant, can gather critical information
needed for a CRA. Practitioners should consider
incorporating a formal caries risk assessment in their
practice. Several electronic record systems have
available CRA modules. There are also several CRA
instruments applicable to adults that are available
online, either at no-cost or for a fee. Some examples
of no-cost sources include:
Figure 1
The 4-D Approach to Caries Management (ICCMS)