Obvious caries lesions may be seen on simple visual clinical examination.2 Tactile methods, e.g., the use of an explorer or ball-tipped dental probe, provide adjunctive information on evidence of enamel roughness and softening of dentin, although there are concerns about the potential, when the probe is used under force, for iatrogenic damage to the enamel surface and promotion of caries progression.2, 6 Radiographs, e.g., bitewings, can detect lesions on contacting approximal surfaces;2 however, this method has varying sensitivity and specificity, depending on the stage of the lesion.7
Newer Detection Technologies
CDT 2017 contains a code8 that enables dentists to document techniques for detection and diagnosis of decay without the use of ionizing radiation. This code, titled “nonionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum,” anticipates that the dentist delivering the procedure will determine the equipment and protocol best suited for the patient.
Examples of detection technologies for which this code might be applicable are laser fluorescence, transillumination or a combination of noncontacting modulated laser luminescence and photothermal radiometry. Devices may have specific applications for which their technology may be especially well suited or they may have more broad utility.
The 2015 ADA CSA Report on the ADA Caries Classification System (CCS, discussed below) notes that evidence-based adjunctive aids to detect caries lesions, such as fluorescence-based techniques or other light-based caries diagnostic tools, are “emerging and, as they are developed, clinically tested and validated, they may contribute to a more precise placement of caries lesions within the ADA CCS categories.”9
Classification and Risk Assessment Systems
Risk assessment is a valuable tool for the prevention and management of dental caries. Dentistry has entered an era of personalized care in which targeting care to individuals or groups based on their risk has been advocated. There are many risk tools and models in the literature. Some examples are provided in the following section.
The International Caries Detection and Assessment System is an evidence-based, preventively oriented strategy that classifies the visual appearance of a lesion (i.e., detection, whether or not disease is present), characterization/monitoring of the lesion once detected (i.e., assessment), and culminates in diagnosis.10 The system is scored on clean, dry teeth and cautions against using sharp explorers or probes in order to prevent iatrogenic damage to the tooth.10
The classification criteria, and associated estimates of caries activity, are based upon the histological extension of lesions spreading into tooth tissue.11 The scores are on a 7-point rating scale, as follows:
1 to 2
Clinically detected “intact” enamel lesions (initial stage decay)
3 to 4
Clinically detectable early, shallow, or microcavitations (moderate decay)
5 to 6
Clinically detectable late or deep cavitations (extensive decay)
The International Caries Classification and Management System™ (ICCMS™) takes the results of the ICDAS classification and translates them into a risk-assessed caries management system individualized for the patient.11
The key elements of ICCMS11
- Initial patient assessments (collecting personal and risk-based information through histories and systematic data collection);
- Lesion detection, activity, and appropriate risk assessment (detection and staging of lesions, assessment of caries activity, and caries risk assessment);
- Synthesis and decision making (integrating patient-level and lesion-level information); and
- Clinical treatments (surgical and nonsurgical) with prevention (ensuring that the treatment planning options available are prevention oriented and include nonsurgical options whenever appropriate).
ADA CCS9 incorporates the ICDAS and other classification systems into a broader classification system that also incorporates radiographic presentation of the approximal surface and the clinical presentation. The ADA CCS is conducted on clean teeth, using compressed air, adequate lighting, and a rounded explorer or ball-end probe. Radiographs should also be available. The ADA CCS is designed to include both noncavitated and cavitated lesions and to “describe them by clinical presentation without reference to a specific treatment approach.” In addition, the ADA CCS—contrasted with some caries classification systems—links “clinical lesion presentation to radiographic findings and provides an approach to identify, when possible, caries lesion activity over time.”
ADA Caries Risk Assessment forms12, 13 categorize a patient’s overall risk of developing caries, based on history and clinical examination. The forms are designated for patients ages 0 to 6 years14 and older than 6 years.13 Characteristics that place a patient at high caries risk include:
- Sugary Foods or Drinks: Bottle or sippy cup with anything other than water at bedtime (ages 0 to 6 years) or frequent or prolonged between meal exposures/day (ages >6 years)
- Eligible for Government Programs: WIC, Head Start, Medicaid or SCHIP (ages 0 to 6)
- Caries Experience of Mother, Caregiver and/or other Siblings: Carious lesions in the last 6 months (ages 0 to 14 years)
- Special Health Care Needs: developmental, physical, medical or mental disabilities that prevent or limit performance of adequate oral health care by themselves or caregivers (ages 0 to 14 years)
- Chemo/Radiation Therapy (ages >6 years)
- Visual or Radiographically Evident Restorations/Cavitated Carious Lesions: Carious lesions or restorations in last 24 months (ages 0 to 6 years)
- Noncavitated (incipient) Carious Lesions: New lesions in the last 24 months (ages 0 to 6 years)
- Cavitated or Noncavitated (incipient) Carious Lesions or Restorations (visually or radiographically evident): 3 or more carious lesions or restorations in last 36 months (ages >6 years)
- Teeth Missing Due to Caries: Any (ages 0 to 6 years) or in the past 36 months (ages >6 years)
- Severe Dry Mouth (Xerostomia; ages >6 years) or Visually Inadequate Salivary Flow (ages 0 to 6 years)