Science in the News
Data Shows Caries Progression Prevention Can Work for Those Who Stick with It
December 11, 2015
- Dental caries is a chronic disease process that involves an interaction between a tooth surface, oral bacteria, dietary sugars and salivary factors.
- Management of the disease process through regular oral hygiene practices, i.e. use of fluoridated toothpaste, professionally applied fluoride varnish, sealants, and reduced consumption of dietary sugars has been effective in preventing the incidence of new caries lesions.
Swan-song for dental fillings? If it sounds too good to be true…
A follow-up of a randomized controlled clinical trial of the Caries Management System in Australia is getting a lot of media attention with catchy titles like “Goodbye to dental fillings? ‘No-drill’ techniques can treat tooth decay just as well, study finds”. What is this magical intervention that supposedly eradicates the need for dental fillings?
Spoiler alert, the Caries Management System is only ‘no-drill’ for management of early caries lesions, such as those in ICDAS 1 or 21 or labeled ‘initial’ in the ADA Caries Classification System.2 So it is inaccurate to conclude that adoption of this approach will mean an end of dental fillings. It is worth recognizing that a non-surgical approach to caries lesions management is a component of all approaches to caries classification.
The key point of this study is that caries, as a disease process, can and should be managed to prevent cavitated lesions that require restoration. Prior to cavitation, there is opportunity to arrest or reverse the demineralization process and avoid the need to restore the tooth. In general, this can be accomplished with good oral hygiene by the patient, e.g., twice daily brushing with toothpaste containing fluoride, daily flossing or other method effective for cleaning between teeth, and limiting ingestion of sugary foods and drinks, as well as regular visits to the dentist for procedures such as sealing susceptible pits and fissures on molar teeth. Active surveillance by a dentist is also necessary to monitor progression or regression of lesions using visual and radiographic methods. It is important to note that caries lesions progress at different rates, which underscores the importance of regularly assessing caries risk for each patient. It is also important to remember that caries progression is more rapid in primary teeth. This is because enamel in primary teeth is thinner, thus, once cavitated, progression into dentin can occur in 6-12 months unless preventive interventions are implemented.
The Caries Management System (CMS) is a set of protocols designed to help prevent caries incidence and arrest existing noncavitated lesions, thus helping to prevent progression to cavities and subsequent need for restorative treatment. It aims to do this via patient behavior change and nonsurgical clinical treatment of noncavitated lesions. The frequency of the nonsurgical clinical care (which consists for example of fluoride varnish applications to noncavitated lesions and sealants used preventatively and therapeutically) depends on an individual patient’s caries risk. High risk patients are those who present with caries; medium-risk patients present with ICDAS stage 3 lesions or approximal lesions where lesion depth is confined to the outer third of dentine as shown in bitewing radiographs; and low risk patients have radiolucencies of lesser depth or with clinical signs of less than ICDAS stage 3 lesions.
A multicenter randomized trial of the CMS protocols, in which 22 Australian dental practices were randomized to provide either CMS protocols or standard care to patients, showed that after 2 years, patients on the CMS protocols had 31% lower caries incidence and 21% less DMFT(Decayed/Missing/Filled Teeth) increment than patients randomized to receive standard care3. This month, researchers reported follow-up results of the trial 7 years after baseline4. Compared to the three year trial, this follow-up analysis is limited in that researchers were unable to monitor caries lesion incidence or several potential moderating or confounding factors (such as patients’ current health status, current sources of exposure to fluoride or dietary habits) in the post-trial period. Additionally, seven years after baseline the attrition of patients (88.5% in CMS arm, 64% in standard care arm) and dental practices (60% in CMS arm, 22% in standard care arm) was high and differential by study arm, which suggests that the results of this study may be subject to bias and should be cautiously interpreted. This severe attrition also limited the statistical power of tests of differences between practices. Nevertheless, there was sufficient power to evaluate effectiveness of the protocol at the patient level. The post-trial analysis found that patients assigned to the CMS protocol had significantly lower mean DMFT increments at 3, 5, and 7 years after baseline assessment. Three years after patients were first assessed, the adjusted mean DMFT increment was 3.99 among CMS patients and 5.44 among standard care patients; this 37.7% difference was statistically significant (p-value: 0.006). Five years after baseline, the difference between CMS and standard care mean DMFT increments was 25.8% (mean increment: 4.95 and 6.67 respectively, p-value: 0.001). Seven years after baseline, the difference between CMS and standard care patients’ mean DMFT increments was 29.2% (mean increment: 6.13 and 8.66 respectively, p-value: <0.0001).
The original three year trial of the CMS protocols demonstrated the efficacy of nonsurgical, preventive treatment for caries control. The post-trial results demonstrate that the benefits of the CMS protocols can be maintained for up to seven years. If patients engage in the prescribed oral hygiene practices, are regularly monitored and receive preventive treatment, restorative interventions can be avoided and tooth structural integrity preserved.
- Pitts NB, Ekstrand KR, Foundation I. International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) - methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 2013;41(1):e41-52.
- Young DA, Novy BB, Zeller GG, et al. The American Dental Association Caries Classification System for clinical practice: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(2):79-86.
- Curtis B, Evans RW, Sbaraini A, Schwarz E. The Monitor Practice Programme: is non-invasive management of dental caries in private practice effective? Aust Dent J 2008;53(4):306-13.
- Evans RW, Clark P, Jia N. The Caries Management System: are preventive effects sustained postclinical trial? Community Dent Oral Epidemiol 2015.
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