Evidence-Based Caries, Risk Assessment, and Treatment

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Dental caries is a dietary and host-modified biofilm disease process, transmissible early in life that, if left untreated, will cause destruction of dental hard tissues. If allowed to progress, the disease will result in the development of caries lesions on tooth surfaces, which initially are noncavitated (eg, white spots), and eventually can progress to cavitation. The “medical model,” where the etiologic disease-driving agents are balanced against protective factors, in combination with risk assessment, offers the possibility of patient-centered disease prevention and management before there is irreversible damage done to the teeth. This article discusses how to use evidence supporting risk assessment and management strategies for the caries process.

Section snippets

What is evidence-based dentistry?

Evidence-based dentistry (EBD) is defined by American Dental Association (ADA) as an approach to oral health care that requires clinical decision-making based on the judicious integration of systematic assessments of clinically relevant scientific evidence relating to the patient's oral and medical condition and history; the dentist's clinical expertise; and the patient's treatment needs and preferences.1 Of the three determinants listed above, the use of current science by the clinician in the

Levels of scientific evidence: how much is enough?

Searching the existing literature to locate the best evidence and determining the quality of the evidence available is not as difficult as translating this evidence into changes in clinical guidelines. Shekelle and colleagues6 developed a process for the development of guidelines that have been used within Europe and North America. This process starts with classifying evidence. Their suggested levels of evidence classification scheme, and strength of the evidence for a clinical recommendation,

Traditional caries management: the case of minimal evidence for caries therapy

Between the years 1869 and 1915, Greene V. Black published a series of papers and texts on dental materials and preparation or restoration techniques that changed dentistry. Though many current investigators have credited or criticized these tenants for overly aggressive preparations and restorations in modern dentistry,8, 9 G.V. Black was the first dentist to propose treating dental caries using minimal intervention, based on the knowledge and materials available at that time. Therefore, Black

Caries management by risk assessment: how much evidence is needed?

In contrast to the traditional management of dental caries based on surgical restoration of tooth damage alone, current management strategies explore treating dental caries based on an individual risk assessment of the patient (because each patient presents with their own unique set of pathologic and protective factors).23, 24, 25, 26, 27, 28, 29, 30, 31 Caries management by risk assessment (CAMBRA) was developed to promote the clinical management philosophy in which the caries disease process

Obstacles for evidence: randomized, controlled caries management clinical trials

Why aren't there more randomized clinical trials on risk-based management of caries? The design and implementation of a clinical trial to detect clinically and statistically significant differences between multiple treatment interventions based on risk, is extremely expensive and time-consuming. Randomized clinical trials for dental caries on human subjects require many years for caries lesions to form and progress to cavitation, which is still the only acceptable outcome measurement. In

Summary

The methods used for treating dental caries in practice today remain largely focused on the use of surgical tooth restoration alone (ie, restorative treatment), without consistent and individualized consideration of the underlying disease process for each patient. But, there is no evidence that restorative care effectively prevents or manages the dental caries disease process. Clinical trials to provide clear evidence regarding the effectiveness of various risk-based caries interventions are

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