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Caries classification system under study

ADA convenes panel

What will the future look like in terms of how dentists classify and treat caries?

That question was the focus of the ADA Caries Classification Conference, held Aug. 20-21 at ADA Headquarters, where stakeholders gathered to discuss the development of a new, enhanced system for classifying the entire range of caries as a disease process and the impact on patient care.

"There is a scientific and clinical necessity for the profession to examine this issue at this time," said Dr. John Kuehne, director of research and laboratories at the ADA and lead conference organizer. "Practitioners, researchers, epidemiologists and others are discussing the shortcomings of the current classification system and the need to address more complex issues, such as demineralization and remineralization, the extent of a lesion's activity or inactivity, how we approach disease management, the use of chemotherapeutics, as well other proposed classification systems that are under consideration."

The conference, led by the Division of Science and the Council on Scientific Affairs in collaboration with other ADA councils, gave clinicians, leaders in public health dentistry, researchers, academics, third-party payers and ADA staff the task of finding common ground for developing a relatively universal classification system.

"Our understanding of caries and how best to prevent and manage it has been hampered by the use of classification systems that do not assess the full scope of changes in tooth structure that is caused by disease process," said Dr. Amid Ismail, professor of cariology, restorative sciences and endodontics, University of Michigan School of Dentistry. "The panel developed a plan to propose for discussion a Harmonized International-American Caries Classification System that will enable dental providers to assess early and advanced carious lesions and provide appropriate care tailored to the severity of the caries lesion and the risk status of a patient."

Added Dr. Kuehne, "The ADA was aware of ongoing discussions at national and international levels within various areas of dentistry that concerned caries research, diagnosis and coding, access to care and early preventive or intervention options as well as reimbursement issues. As each group tended to see and discuss the issue from slightly different perspectives, it became increasingly evident that we needed to find the consensus and explore together potential advantages as well as obstacles to implementation before we try to propose a solution. It was very important to us that these things be discussed together if we are going to have something that is truly successful and effective."

During the two-day program, participants discussed current trends and patterns of caries; the International Caries Detection and Assessment System and its relevance to today's dental practice; the components of the proposal for a new restorative treatment system; the electronic health record and diagnostic/treatment codes and their relation to caries classification; and how the various communities of interest can create a comprehensive classification system that will improve patient care and treatment outcomes.

Dr. Bruce Dye, a U.S. Public Health Services Dental Epidemiology Officer for the Centers for Disease Control and Prevention and National Center for Health Statistics, said he was pleased with the ADA's effort to "move forward the discussion on integrating emerging with current concepts in cariology diagnosis and treatment that is useful across a broad spectrum of dental practice in the U.S."

Conference participants acknowledged that one of the challenges in updating a century-old classification system is to meet the needs of today's practitioner and patient by creating one that is simple to use, but that also addresses the calls for increasingly discriminating diagnosis.

"Dentistry is really ready for something like this," said Dr. Domenick Zero, associate dean for research and director of the Oral Health Research Institute at Indiana University School of Dentistry. "Over my 30-year career as a cariologist, I've never seen so much interest in the field. I really think more and more practicing dentists are ready to manage dental caries at the early stages of the disease process before it progresses to more advanced lesions requiring restoration. We hope as a consequence of this ADA-initiated effort we will be able to provide dentists with the diagnostic tools they need."

Drs. Ismail and Dye were among the conference's presenters. Other speakers were Dr. Nigel Pitts, president of the European Organization for Caries Research (ORCA), and Dr. Wyatt R. Hume, provost and executive vice president for Academic and Health Affairs at the University of California.

Many of the discussion exercises deliberately paired up different stakeholders with each other. In one exercise, the group constructed a mind map, which incorporated all of the different aspects discussed about the current classification system so that participants could see where ideas and concerns overlapped.

"My take home message was that moving forward is going to require more discussion and buy-in from a number of differing interest groups," Dr. Dye said.

The CSA plans to submit a supplemental report to the 2008 House of Delegates to summarize the findings from the conference.

"All the right players were in the room," said Dr. Larry Herwig, chair of the ADA Council on Communications, "and we made some great strides toward updating Dr. G.V. Black's classification system that now seems outdated. The convening of this conference highlights the ADA's commitment to leading the profession and improving health care in the 21st century."

Dr. Black noted in 1910, in The Dental Brief, that "studies of caries should be continuously made."

When he first proposed a classification in "Operative Dentistry" in 1908, knowledge of the disease and treatment options were limited. Since then, dentists have learned more about the disease process and more conservative interventions are now possible.

At the August conference, participants focused on six major areas:

  • Education of new dentists;
  • Research supporting effectiveness;
  • Practical applicability;
  • Technology boom;
  • Evidence-based dentistry;
  • Change.

"I learned tremendously from this workshop," said Christine Wu, Ph.D, director of cariology research in the pediatric dentistry department at University of Illinois at Chicago College of Dentistry. "As a researcher and educator, with five years experience as an administrator at UIC, I was able to look at the problem from different angles. I was able to listen to input and comments from participants from different dental constituencies, (academia, industries, dental practitioners, educators, researchers, etc.) and get a global view of the current status and future needs of the caries classification system. The interactions and exchange of knowledge among us were most valuable."