Introduction
Scientific evidence has previously established the fact that restorations do not last a lifetime.1, 2 A considerable extent of a practitioner’s professional life is spent on placing and replacing restorations. Often, clinicians encounter an individual patient whose reason for attendance is for replacement or repair, or refurbishment of existing defective restorations or requires restorations for newly cavitated lesions. This should be a cause for concern for the operator as it suggests that an uncontrolled carious process is functional in the patient’s mouth, independent of earlier restorative work. Therein, lies the importance of a caries management plan.3
What is Modern Caries Management?
Modern Caries Management (MCM) has evolved from over three decades of caries research. 4 Its goal is to arrest the dynamic caries process in the patient’s oral cavity, prevent any further cavitated/ non-cavitated lesions and restore any new or old lesions with a minimum-intervention philosophy. To explain it broadly, modern caries management operates at two levels.4 (Figure 1)
Success in management for both levels can only be obtained by mitigation of the degree of risk of caries exhibited by the patient.5 As per CAMBRA guidelines any patient with one or more cavitated lesions can be considered a high risk for caries individual.5 CAMBRA (CAries Management By Risk Assessment) or Cariogram6 are risk assessment tools developed by Western researchers for this very purpose (Figure 2).
Figure 4
Caries management team work (Suggested Model).
GDP- General Dental Practitioner, CRA-Caries Risk Assessment, HCR- High Caries Risk
Table 1
ICCMS document 2014
Table 2
High-risk for caries protocol - phases
[i] HCFPT = High Concentration Fluoride Prescription Toothpaste (2800ppm F for patients over 10 years of age and 5000ppm F for those over 16 years of
[ii] Sample treatment plan for a ‘High Caries’ risk patient (adapted from Jenson et al 2007).7 ‘High Caries’ risk: 17-year-old female, ongoing endodontic therapy of LL6; missing teeth UR6 and LR6; poor oral hygiene; UL4 and UL6 pit and fissures stained; Orthodontist recommendation for restorations in UL4, UL6.
Table 3
Highrisk for caries protocol
The key points in Oral Components management are as below
Inadequate saliva formation/ expression: A sub-normal saliva flow and function may not be expressed by the patient in the form of any symptom. It will need to be tested and addressed.8
Commercially saliva test kits are available which can be good motivational tools for the behavioral changes in the patient that are desired by the clinician.
Patients/ clinicians might not always recognize the cariogenic potential of certain foods in their daily diet and therefore a detailed analysis by a nutrition expert/dietician is needed for both parties to address.
Patients with new caries lesions or exhibiting a negative change in the size and activity of existing lesions may be regarded as having insufficient fluoride exposure.
The key points in Tooth Tissue-Level Management are as below (Table 1)(Figure 3, Figure 4):
Involves protecting existing tooth structure affected or unaffected by cavitated or non-cavitated lesions. 7
Restoring lost tooth tissue with the least invasive restorative approach. 9
Detection of a carious lesion does not automatically qualify it for a restoration. 10
A tissue-preservative approach is the first line of treatment for any clinical situation (operative or non-operative). 11
Vitality assessment is an important factor in extensive lesions and caries removal in the deepest part of the cavitated lesion is done only to remove softened and infected dentine and ensure no exposure of the vital pulp. 12
Whenever there is an associated risk of exposing the pulp, a step-wise partial caries excavation is the standard operating procedure. 12
Defective restoration margins need either sealant application or repair or refurbishment and not a replacement.
If sealants are applied then an appropriate recall system needs to be in place (based on risk assessment) to monitor for loss of sealant and subsequent maintenance/repair.
For implementing minimum intervention in restorative dentistry, early identification of caries lesions (both cavitated and non-cavitated) is important and various commercially available products are available for the preventive and restorative phases of a minimum intervention treatment plan.13
Conclusion
There has been a paradigm shift from the historic/ conventional method of caries management. 14 The interplay of factors causally responsible for dental caries is different for each individual and is assessed using CARIOGRAM and CAMBRA. The current-day approach (Operative/ non-operative) is Evidence-based, Risk-based & prevention focused (Table 2) and can be easily implemented with minimal damage to the tooth as well as tissue structure. Patients should be periodically assessed with regards to caries risk at intervals consistent with CAMBRA guidelines. (Table 3)
Opportunities exist for the educators to rethink the older concepts and teach the newer concepts in dental schools so that patients directly benefit from thirty years of caries research. Opportunities also exist for the researchers to set-up a Dental Practice Based Research Network (DPBRN) to monitor the effectiveness of caries management practices across the country.
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