Present and Future Approaches For The Control of Caries: Kenneth J. Anusavice, PH.D., D.M.D
Present and Future Approaches For The Control of Caries: Kenneth J. Anusavice, PH.D., D.M.D
Present and Future Approaches For The Control of Caries: Kenneth J. Anusavice, PH.D., D.M.D
A
lthough we have known for many years that responses from forty-two of fifty-five dental schools
caries is an infectious disease, the manage- on the threshold required for surgical intervention,
ment of early and late stages of the disease Yorty and Brown19 reported that only 30 percent of
are still treated identically on state and regional den- responding schools allowed teeth to be restored to
tal board exams and in dental practices, and treat- satisfy clinical requirements and competencies when
ment decisions for caries management vary consid- radiographs indicated evidence of enamel lesions. At
erably among practicing dentists.1-9 Early lesions 70 percent of the responding schools, restorations
provide evidence of caries activity, which can be ar- were not indicated until the lesions were classified
rested and the tooth surfaces remineralized through either as being in the outer third of dentin (D1) (55
appropriate treatment. However, because some cli- percent), the middle third of dentin (D2) (10 percent),
nicians are not confident of their ability to detect early or the inner third of dentin (D3) (5 percent). Also, 81
lesions, to arrest the disease, and to remineralize dem- percent of the forty-two respondents reported hav-
ineralized enamel, restorations are often placed in- ing a formal caries risk training program for
dependent of the radiographic depth of the lesion. predoctoral dental students. Thirty-six percent of
Other clinicians practice minimally invasive dentistry thirty-nine schools have caries risk assessment re-
and monitor early lesions after initial treatment to quirements for graduation, and 38 percent of the
ensure that the caries activity is arrested and that the schools require caries risk assessment for clinical
enamel can be remineralized.10-18 Thus, there is con- competencies. Multiple new or active caries lesions
siderable variability in caries detection, caries activ- were given as the most commonly used criterion for
ity assessment, caries risk assessment, the best treat- classification of a patient at high risk.
ment options for high-risk patients, decisions on However, a 2001 survey of requirements on
when and how to treat teeth with carious lesions, and state and regional board exams indicates that estab-
the best method for monitoring disease. lished clinicians responsible for dental board exami-
A shift in emphasis appears to have occurred nations still allow enamel lesions to be restored.1 Ap-
in dental schools toward assessment of caries risk, proximately 72 percent of the states allowed teeth
modern management of the disease, and delayed res- with lesions either in the outer half of enamel (E1)
toration until the probability of cavitation has in- or inner half of enamel (E2) lesion to be restored.
creased to a critical threshold level. Based on survey About 37 percent of these states allowed teeth with
Figure 2. The size of a carious lesion along the DEJ (smaller vertical bar) is related to the size of outer enamel lesion
(larger vertical bar).
80 Permanent Teeth
60
40.9
40 28.3
20 10.5
2 0 2.9
0
Outer 1⁄2 Inner 1⁄2 Outer 1⁄2 Inner ⁄2
1
Lesion Severity
Figure 3. Percent cavitation of proximal surfaces of primary and permanent teeth as a function of lesion severity
Fluoride Toothpaste
Marinho et al.30 performed a search of the (p<0.0001), indicating that 1.6 children need to brush
Cochrane Oral Health Group’s Trials Register (2000) with a fluoride toothpaste (rather than a nonfluoride
plus several other databases on randomized or quasi- toothpaste) over three years to prevent one DMFS in
randomized controlled trials with blind outcome as- populations with an annual caries increment of 2.6
sessment to analyze comparative caries prevention DMFS. In populations with an annual caries incre-
data for fluoride toothpaste with placebo in children ment of 1.1 DMFS, 3.7 children will need to use a
up to sixteen years during at least one year. The fluoride toothpaste for three years to avoid one
pooled DMFS (decayed, missing, and filled tooth DMFS. They concluded that the benefits of fluoride
surfaces) prevented fraction was 24 percent toothpaste are firmly established.
60
46 46
40
40 33
24 26
21
20
0
FG TP FR V1 V V2 CHX SEAL
FG=fluoride gel; TP=fluoride-containing toothpaste; FR=fluoride rinse; V1=fluoride varnish for primary teeth; V=all fluoride
varnish applications; V2=fluoride varnish for permanent teeth; CHX=all chlorhexidine applications; SEAL=pit and fissure
sealant
radiation caries but did not permit remineralization combination of the antimicrobial and fluoride var-
to occur. The four topical applications with a fluo- nishes more effectively reduced the caries increment
ride gel and daily rinses with an 0.05 percent sodium for the maxillary incisors. The investigators specu-
fluoride solution were inadequate to prevent radia- lated that this was partly caused by an inhibiting ef-
tion caries. fect of the antimicrobial varnish in an area with low
Ogaard et al.51 conducted a randomized pro- oral clearance of fluorine ions and partly by an in-
spective clinical study with 220 patients scheduled hibiting effect of the varnish on mutans streptococci
for fixed orthodontic therapy to test the hypothesis (ms).
that application of Cervitec: antimicrobial varnish, Tenovuo et al.52 demonstrated that if mothers
which contained 1 percent chlorhexidine plus 1 per- with ms levels higher than 105 CFU/mL were given
cent thymol (Ivoclar Vivadent, Schaan, 1 percent chlorhexidine-0.2 percent sodium fluoride
Liechtenstein) in combination with Fluor Protector gel treatments twice a year for three years (Group 1),
(Ivoclar Vivadent, Schaan, Liechtenstein), a varnish the primary teeth of their children (from age one to
containing 5 percent difluorosilane (Group 1) was four years) would have less colonization by ms and
significantly more effective in reducing white spot they would have fewer lesions than the children of
lesions on the facial surfaces than application of the mothers with high ms counts (>105 CFU/mL) who
fluoride varnish alone (Group 2). The antimicrobial did not receive the combined gel treatment (Control
varnish significantly reduced the number of mutans Group 2). In the total study population of 151 chil-
streptococci in plaque during the first forty-eight dren, 16 percent, 42 percent, and 54 percent of the
weeks of treatment. This result was not associated children were colonized by ms by the ages of two,
with significantly fewer white spot lesions on the three, and four years, respectively. Most children
facial surfaces compared with the group receiving were colonized only by S. mutans, but two had both
only the fluoride varnish application. However, the S. mutans and S. sobrinus, and two had only S.