Advances in Pediatrics 64 (2017) 307–330

ADVANCES IN PEDIATRICS

Dental Caries
An Update on Dental Trends and Therapy

Allen Wong, DDS, EdD, DABSCD*, Paul E. Subar, DDS, EdD,

Douglas A. Young, DDS, EdD, MBA, MS
University of the Pacific- Arthur A. Dugoni School of Dentistry, 155 5th Street, San Francisco, CA
94103, USA

Keywords
 SDF (Silver diamine fluoride)  Prevention  Caries risk  Remineralization
 Minimal invasive  Fluoride
Key points
 Update on caries risk assessment (CRA).
 Describe the role of pediatric health care providers in oral health care with
respect to caries risk assessment (CRA).
 Draw attention to patients with special needs and oral health from youth to adult.
 A new philosophy and trend in the minimally invasive approach to dental caries
treatment.
 Dental caries is a preventable disease and all health care providers should be
able to identify and refer high and extreme caries risk patients for care.
 Dental disease that does not cause pain to the patient may be treated in a
noninvasive manner that is effective but has potential.

I
n the 2007 Advances in Pediatrics article on dental caries by Drs David Krol
and Michael Nedley, the state of the science for dental caries was well pre-
sented [1]. This article focuses on recent updates on the dental sciences
regarding caries management of particular interest to medical health care pro-
viders so that they may be fully informed of new interprofessional opportu-
nities for them to identify and treat the caries disease process and perhaps
avoid a lifetime of oral problems for those at greatest risk. A segment also dis-
cusses the medical-dental management of patients with special needs.

Disclosure Statement: The authors have no financial disclosures to report relating to products in article.

*Corresponding author. E-mail address: awong@pacific.edu

http://dx.doi.org/10.1016/j.yapd.2017.03.011
0065-3101/17/ª 2017 Elsevier Inc. All rights reserved.
308 WONG, SUBAR, & YOUNG

In the 2009 Journal of American Dentistry, a current review of the available

epidemiologic data from many countries clearly indicated that there is a
marked increase in the prevalence of dental caries. This global increase in
dental caries prevalence affects children as well as adults, primary as well
as permanent teeth, and coronal as well as root surfaces. This increase in
dental caries signals a pending public health crisis [2]. Unless a new model
is adopted, dental caries shall remain as one of the most commonly over-
looked pediatric issues. Brushing and flossing alone is not going to reduce
the dental caries rate on patients with high caries risk. At one time, dentistry
had believed that mutans streptococci and lactobacillus were the only bacteria
involved in the dental caries process; we now know that it is more complex
than just that. Dental caries is a complex multifactorial biofilm disease that re-
sults in prolonged periods of low pH in the mouth and a net mineral loss from
the teeth [3]. Acid-producing bacteria exposed to dietary carbohydrates
(including but not limited to sucrose) will produce weak organic acids in
the 3.8 to 4.8 pH range, sometimes in combination with decreased salivary
function, that can lead to a subsurface demineralization of the teeth. If the con-
dition is allowed to progress, it will eventually cause a cavitation or cavity
through the enamel layer. If left untreated it will cause damage to deeper
layers of the tooth, the tooth nerve, and possibly result in tooth loss. Pattern
recognition of the risk factors that modulate this disease will help the health
care provider halt and overcome the destruction caused by dental caries.
The factors are genetics, bacterial activity, diet, saliva, and pH. Numerous
genes are now associated with dental caries; more than 17 studies in the
past 5 years have identified 34 genes and more than 54 bacteria are now iden-
tified as potential cariogens [3].
If the risk factors are well controlled or managed, the dental caries process
can be prevented, arrested, and reversed (remineralized). The medical commu-
nity should be the first to support the concept of treating dental disease rather
than knowingly leave the disease and wait until there is irreversible damage to
the teeth, which will then require irreversible surgical restoration (which does
not treat the source of the disease). This is covered in the section under ‘‘Caries
disease information for health care providers.’’
Other areas of growing interest are for patients with special health care
needs. This population is one of the most underserved and at highest risk
for dental caries disease. Pediatric health care providers are well positioned
to help patients reduce their risk factors and avoid tooth damage and costly
treatment. Due to the health and cooperation of patients with special health
care needs, there are times when treatment needs to be performed under gen-
eral anesthesia. General anesthesia is safe in a hospital setting but has risks as
well as substantial costs.
The 2015 Centers for Disease Control and Prevention (CDC) report from
the National Center for Health Statistics describes its review of children and
adolescents from the period of 2011 to 2012. Although dental caries has
been declining in permanent teeth for many children since the 1960s, previous
DENTAL CARIES 309

findings showed caries in primary teeth for preschool children increasing from
24% to 28% between 1988 and 2004. Disparities in caries prevalence continue
to persist for some race and ethnic groups in the United States. Prevalence of
dental sealants applied to the tooth chewing surfaces to help prevent caries le-
sions has also varied among sociodemographic groups.
An example like Brookdale Hospital and Medical Center’s Prenatal Care
Assistance Program (PCAP) provides oral health education and treatment to
expectant mothers from a minority, impoverished, high-risk population. A
chart review examined dental records for 42 children of mothers who took
PCAP training versus 49 children of mothers who did not. At age 2, the chil-
dren of PCAP mothers had fewer and less severe dental caries experiences and
fewer extractions. When combining children at ages 2 and 3, results were sta-
tistically significant and clinically important. Evidence strongly suggests the
PCAP program can lead to vastly improved oral health of participants’ young
children [4].

EPIDEMIOLOGY
In 1997 and then again in 2014, the National Institutes of Health convened a
conference on early childhood caries (ECC). During the intervening time, there
have been tremendous strides made in the understanding of the pathogenesis of
ECC. ECC is now accepted to be a chronic preventable disease that has wide-
ranging quality-of-life implications, social impact, and economic implications
[5].
National dental caries incidence and prevalence information is obtained us-
ing data from the National Health and Nutrition Survey (NHANES). This sur-
vey is administered by the CDC to approximately 5000 adults and children
each year. The interview includes psychology, medical, and dental questions
along with a physical and oral examination. Findings from the NHANES sur-
vey 2011 to 2012 show a decline in caries experience for 2-year-olds to 5-year-
olds from previous NHANES surveys.
Data from NHANES 2001 to 2002 NHANES demonstrated that 15% of
children ages 2 to 5 had active decay, with 25% having had caries experience
that included having restorative dentistry. In 2003/2004 NHANES, those
numbers increased to 24% active caries, 30% active and/or filled teeth. How-
ever, by 2011/2012, the active caries percentage decreased greatly to less
than 10%, whereas decayed/filled experiences increased to 30% of those chil-
dren surveyed. The results indicated that more children had restorative
dentistry. Remaining unchanged since 1991 however, were data indicating
that almost 50% of caries in young children was due to caries in the maxillary
anterior teeth [6].

DIFFERENCES IN SUBPOPULATIONS
Although there is an overall improving trend of caries prevalence there remain
differences in caries experience between subpopulations, which is most evident
when examining race, ethnicity, and socioeconomic status.
310 WONG, SUBAR, & YOUNG

Socioeconomic status
For all children age 2 to 5 in the United States, the decayed filled surfaces (DFS)
mean was 2.15 from 1988 to 1994, 2.58 from 1999 to 2004, and remained un-
changed from 2011 to 2012. From 1988 to 2004, the mean numbers of decayed
surfaces remained unchanged; however, there was an increase in mean number
of filled surfaces. From 1999 to 2004, the mean DFS was 3 times higher for chil-
dren living in households below 200% of the federal poverty level than for
higher-income counterparts [6].

Race and ethnicity

Caries prevalence and severity are stratified when examining children of
different races and ethnicities. The NHANES from 1992 to 2002 showed caries
prevalence was 49.1% for all children ages 6 to 11. NHANES data from 1999 to
2004 demonstrated caries experience 56.12% with 37.38% untreated caries for
African American children ages 6 to 8. A study from a small county in Ala-
bama demonstrated primary tooth caries for age 6 to 11 as 61% [7].
NHANES data show that Hispanic children age 2 to 8 had a 45.7% caries
experience with 19.4% of the children having untreated decay. This compares
to 43.6% of those ages 2 to 8 of African American children and 30.5% of
non-Hispanic white children with a caries experience, and 20.5% of African
American children with untreated caries and 10.1% of untreated caries for
non-Hispanic white children (www.ced.gov/nchs/data/databrief/fs/db191).
Asian children age 2 to 8 had 35.9% dental caries experience rate with 15.9%
having untreated caries [6].
The highest rate of caries experience in the United States has been tradition-
ally found in those of Native American descent. In 1999, almost 80% of Native
American children ages 2 to 5, 91% ages 6 to 8, and 96% of 16-year-olds had
caries experience. Although there has been much improvement, Native Amer-
ican and Alaska natives continue to have the most dental caries experience ac-
cording to the 2014 NHANES. The 2014 NHANES data indicate that 75.6% of
those ages 2 to 5 have had had decay experience, with 47.1% having untreated
decay [8].
The prevalence of severe caries in minority populations, combined with ac-
cess barriers, has created a generation of vulnerable patients who tend to seek
care in hospital emergency departments. Community clinics and dental schools
provide the bulk of oral health services for those who lack access to more tradi-
tional venues for care.
According to the Agency for Health Care Research and Quality, in 2009
there were 939,482 hospital visits in the United States in which a dental condi-
tion was listed as a primary diagnosis, a 16% increase from 2006. For these
visits, dental caries was the diagnosis listed, and dental abscess listed for 63%
of inpatient stays. The rates of emergency department visits for dental-
related disease were reported to be more than twice in rural communities
than in larger cities. For ages 0 to 17, there were roughly 27,000 visits in
2009 for dental-related conditions. The bulk of these patients represent the
DENTAL CARIES 311

uninsured with 30% covered under Medicaid. There are many implications
surrounding the management of chronic dental disease in an acute care setting.
First, very few emergency departments in the United States maintain a dental
department capable of managing routine dental problems. Typically, a nurse
practitioner, physician assistant, or physician will evaluate patients who visit
the emergency department for a dental infection. The result is usually prescrip-
tions for pain and infection, then referral to a dentist for treatment. For more
severe infections, an overnight stay with more invasive care may be indicated.
The financial implications can be staggering. In 2007, dental visits to hospital
emergency departments were more than $23 million in Georgia, and $88
million in Florida in 2010 [9].

CARIES DISEASE INFORMATION FOR HEALTH CARE

PROVIDERS
Overview of the caries disease process
Dental caries is a complex, chronic, progressive, multifactorial disease interme-
diated by pathogenic factors that may lead to tooth damage (frequent exposure
to dietary carbohydrates, dry mouth, and an acid-producing biofilm capable of
fermenting carbohydrates and producing a decrease in pH) and apposing pro-
tective factors (fluoride, sealants, normal salivary flow and buffering capacity,
and products such as antibacterial agents) that may protect teeth from harm.
Acid-producing bacteria exposed to dietary fermentable carbohydrates will pro-
duce small chain organic acids that are small enough to diffuse into the tooth
subsurface causing dissolution of tooth mineral called demineralization.
Healthy saliva can help neutralize these bacterial acids and provide added cal-
cium and phosphate to diffuse back into the tooth subsurface. This process is
called remineralization. The balance (or imbalance) between these pathogenic
and protective factors determines whether there will be a net demineralization
or remineralization of the mineral in the teeth [10]. Demineralization over time
will likely result in detrimental damage to the tooth. Demineralization happens
at the molecular level where calcium and phosphate are lost from the subsur-
face and will not be visible by the naked eye in the earliest stages of deminer-
alization. However, if allowed to progress, it will eventually cause visible
changes that can be seen on the tooth. The visible changes seen on the teeth
are sometimes called caries lesions (the end result of caries disease). One of
the earliest signs of a caries lesion appear as ‘‘white-spot lesions’’ and if not ar-
rested and reversed, the weak subsurface of the tooth will eventually collapse
and form what is commonly called a ‘‘cavity’’ (more correctly called a ‘‘cavita-
tion’’) [11]. Cavity Treatment usually entails surgical removal of tooth struc-
ture and dental restoration (fillings, crowns, root canals), yet because the
cavity is only a sign of the end stages of caries disease, fillings do nothing to
treat the cause of the disease. The classic example is diabetes and heart disease.
Health care providers treat diabetes with early diagnosis and medicine. They
do not ignore the cause of the disease and wait for a diabetic ulcer to form
on the foot so they can do surgery. The same goes for treating the risk factors
312 WONG, SUBAR, & YOUNG

for heart disease (eg, hypertension, high cholesterol, obesity, smoking) and not
waiting until a bypass or a transplant is necessary. Thus, a caries risk assess-
ment (CRA) is critical to identify the risk factors and protective factors for
caries disease [12]. Once the CRA is completed, the clinician can manage
risk factors using strategies that combine oral products and behavioral change
to decrease the pathogenic risk factors and increase the protective factors. Cur-
rent dental science supports caries management by risk assessment, in which
risk factors for caries disease are identified and treated similar to the medical
approach of treating risk factors for heart disease [13]. Managing caries disease
using this medical model is a major paradigm shift for dentistry, and with its
current reimbursement model may be slow to change. Interprofessional collab-
oration with our medical colleagues will not only support adoption of this new
paradigm but also help in identifying patients at risk for dental caries and deliv-
ering caries prevention could be pivotal to reduce the burden of dental caries,
especially in those groups that suffer disproportionately from this disease
process.
Overview of interventions that modify biofilm and chemistry
Fluoride toothpaste
Over-the-counter (OTC) fluoridated toothpaste has been a good daily regimen
for low caries risk individuals, whereas higher risk patients can be prescribed a
higher concentration fluoride toothpaste. Fluoride toothpaste is an effective de-
livery approach to daily application of fluoride topically on teeth to prevent and
help remineralize carious lesions. The mechanism of action for fluoride to
decrease acid dissolution and enhance remineralization is mainly a topical effect
and there is no need for ingestion. A pea-size amount of OTC fluoride tooth-
paste for children younger than 6 years and caution on ingestion is a safe
recommendation. Fluoride is an important ion for remineralization, but accord-
ing to Cummins does not prevent pathologic factors that initiate the caries pro-
cess [14]. In a Cochrane review of 179 articles from 2002 to 2008 on fluoride
toothpaste (15 met criteria), there was strong evidence that daily use of fluoride
toothpaste has a significant caries-preventive effect in children compared with
placebo (prevented fraction 24%). The effect was boosted by supervised tooth
brushing, increased brushing frequency to twice daily, and use of a toothpaste
concentration of 1500 ppm fluoride [15]. The results reinforced the outstanding
role of fluoride toothpaste as an effective caries preventive measure in children
[15].
Fluoride gels/foam/rinses
For patients who require more fluoride, professional applications in the dental
office for fluoride gels and foam have been available. In a systematic review
from 2002 to 2014, a total of 19 articles were included (6 on fluoride mouth
rinse, 10 on fluoride gel, and 3 on fluoride foam); 6 had a low risk of bias
whereas 2 had a moderate risk. All fluoride measures appeared to be beneficial
in preventing crown caries and reversing root caries, but the quality of evidence
was graded as low for fluoride mouth rinse, moderate for fluoride gel, and very
DENTAL CARIES 313

low for acidulated fluoride foam. This review, covering the recent decade, has
further substantiated the evidence for a caries-preventive effect of fluoride
mouth rinse, fluoride gel and foam, previously established in systematic re-
views. The lack of clinical trials free from bias is, however, still a concern, espe-
cially for fluoride mouth rinses and fluoride foam. There is also a scientific
knowledge gap on the benefit and optimal use of these fluoride supplements
in combination with daily tooth brushing with fluoride toothpaste [16].
Although office-strength fluoride gels, rinses, and foams have been largely
replaced with the easier to apply and less ingested fluoride varnishes, OTC
fluoride rinses still have some benefits and can supplement patients who prefer
rinsing to increase their fluoride uptake.
Topical fluoride varnish
Most recent studies according to the American Dental Association (ADA) rec-
ommendations support fluoride varnish as being the most effective way of fluo-
ride delivery. It allows the highest concentration application of fluoride with the
least amount of possible ingestion.
For high or extreme caries risk patients, the importance of dental sealants
and fluoride varnish applications approximately 2 to 4 times a year should
be emphasized. Unfortunately, insurance companies at this time are reluctant
to cover multiple applications, but current studies recommend it according to
evidence-based information from the ADA [17,18]. According to the US Pre-
ventive Task Force 2014 report, ‘‘new evidence supports the effectiveness of
professionally applied fluoride varnish at preventing caries in higher risk chil-
dren younger than age 5 years. Research is needed to understand the accuracy
of primary care oral health examination and CRA, primary care referral to
dental care, and effect parental and caregiver/guardian educational and coun-
seling interventions’’ [19].
Fluoride varnish in many states is an acceptable therapy for primary care
providers, nurse practitioners, nurses, and trained staff. Although the literature
has clearly demonstrated that preventive care treatments, such as the applica-
tion of fluoride varnish performed in the primary care setting, improve oral
health in children, very few primary care providers include oral health services
in their well-child visits [20].
As early as 2005, a number of state Medicaid programs, including Washington,
reimburse pediatricians and other pediatric health care providers to apply fluoride
varnish to eligible patients’ teeth. Fluoride varnish can be adopted successfully into
medical practice provided that the primary care physician (PCP) and staff are
committed and open to change, and leaves participants motivated with profes-
sional dental care referral [20]. In addition, PCP involvement with fluoride varnish
provided opportunities to discuss preventive oral health with families [21].
Systemic fluoride tablets
In the 2012 Journal of Evidence-Based Dentistry, the findings of the Cochrane re-
view concluded the effect of fluoride supplements was unclear on deciduous
teeth. When compared with the administration of topical fluorides, no
314 WONG, SUBAR, & YOUNG

differential effect was observed. They rated 10 trials as being at unclear risk of
bias and one at high risk of bias, and therefore the trials provide weak evidence
about the efficacy of fluoride supplements. The use of fluoride supplements is
associated with a reduction in caries increment when compared with no fluo-
ride supplement in permanent teeth [22]. Therefore, for patients in low or no
fluoridated communities, fluoride tablets may be a benefit, especially if they
are swished in the mouth for the topical effect before swallowing. Safe dosing
is important to consider if using multiple strategies of fluoride delivery.
Xylitol
Xylitol is a naturally occurring 5-carbon sugar that is used as a sucrose substi-
tute because it is not a usable source of energy for bacteria and it is thought to
inhibit the attachment of Streptococcus mutans to the teeth (strike) [23]. That said,
the studies of xylitol have a low level of strength in evidence for caries preven-
tion. It should be reminded that it is difficult to research efficacy for a multifac-
torial disease by looking at one variable. The evidence does support its use as
an anticariogenic therapy alone but xylitol does have some effects that promote
remineralization. Xylitol in chewing gum is thought to be a good option to
stimulate salivary production just by the chewing action. Clinical studies
have also shown that xylitol consumption decreases caries incidence and re-
duces the amount of plaque [23]. Xylitol can come in various forms; more com-
mon is the xylitol gum. Other delivery systems are mints, sprays, and candies.
At the very least, xylitol chewing gum may help stimulate saliva that is neces-
sary for remineralization to occur. The dosing is from 6 to 10 g for adults and
approximately half of that for children.
Arginine
A novel technology, based on arginine, has been identified that targets dental
plaque to prevent initiation of the caries process by increasing pH. As the mech-
anisms of action of arginine and fluoride are highly complementary, a new
dentifrice, which combines arginine with fluoride, has been developed and clin-
ically proven to provide superior caries prevention [14]. Alkali production by
oral bacteria via the arginine deiminase system increases the pH of oral biofilms
and reduces the risk for development of carious lesions [24].
Silver diamine fluoride
Silver diamine fluoride (SDF) is a noninvasive treatment compound that when
applied to an active caries lesion (that has not created a dental abscess or acute
symptoms yet) will predictably arrest and remineralize the lesions after just 2 ap-
plications [25]. SDF (38% wt/vol Ag[NH3]2F, 30% wt/wt) is an inexpensive color-
less topical agent that has been used extensively outside of the United States to
treat and prevent dental caries [25]. The silver acts as an antimicrobial [26] and
the fluoride promotes remineralization with the highest fluoride concentration
of any available material. SDF became commercially available in the United
States in April 2015. It does not require local anesthesia and has minimal side ef-
fects. The solution can cause a chemical burn on soft tissue on contact but is not
DENTAL CARIES 315

permanent. The use of antibacterial effects of silver nitrate has been used in
dentistry since the 1800s, but the side effects of discoloration of teeth were not
well accepted. It is a therapy used outside of the United States as an economical
way of treating dental caries. Other countries, such as Argentina, Cuba, Brazil,
and China, began using SDF in the 1980s. SDF was recently accepted for use
in the United States as a desensitizing agent. Randomized clinical trials reported
that 2 applications of SDF to soft diseased dentin and enamel can arrest and remi-
neralize to become hard again [27–30]. The major side effect is a darkening of the
tooth where dental caries exist. It will not darken healthy tooth structure. Once
the tissue hardens (remineralizes), the tooth can be prepared and restored in a con-
ventional manner or left alone if so desired by the patient (Fig. 1).
In a 2015 review of dental literature on dental caries prevention, a total of 73
articles including clinical trials, in vitro studies, case reports, and review articles
were reviewed. Twenty-two clinical trials and in vitro studies were selected for
review. Most studies suggested use of SDF as a simple and effective caries-
arresting approach. The use of SDF and fluoride varnish is an effective combi-
nation. Fluoride varnish treatment effectively arrests caries by inhibiting
demineralization, resulting in highly significant caries reductions [31]. The
use of this SDF allows the situation to stop its progression until the patient
can tolerate the procedure and minimize the need for costly restorative options,
such as root canals, while allowing the tooth to repair itself.
Health care providers interested in offering this service should be properly
trained in the SDF protocols. The use for SDF is currently approved by the
Food and Drug Administration for dentinal sensitivity treatment and is an
off-label use for caries arrest.
Sealants
For patients with high dental caries risk and deep grooves on their chewing sur-
faces, sealants are a less-invasive therapy to prevent future cavitation. Available

Fig. 1. (A, B) Pictures of teeth darkened after SDF application. (A) Central incisors interprox-
imal lesions. (B) Molar occlusal lesion. (Courtesy of Steve Duffin, DDS, Wilsonville, Oregon;
with permission.)
316 WONG, SUBAR, & YOUNG

evidence suggests that sealants are effective and safe to prevent or arrest the
progression of noncavitated carious lesions compared with a control without
sealants or fluoride varnishes [17].
Sealants are cost-effective and often applied without any local anesthesia or
removal of natural tooth structure. There are 2 types of sealant materials in
everyday use: (1) resin-based sealant materials, which are micromechanically
bonded to the tooth that work well in cooperative patients, and (2) glass ion-
omer–based fluoride-releasing sealant materials that are chemically bonded to
the tooth and work well on uncooperative high caries risk patients. Sealants
may be used on both primary or adult teeth [17].
Filling material options: glass ionomers/composites
Restorative dentistry has evolved from amalgams (mercury/silver fillings) to-
ward a resin-based filling material (composites) and to a lesser extent glass ion-
omer–based materials. For most patients with reasonable caries risk, composite
restorations are cosmetic and appropriate. In patients who are not cooperative
or high caries risk, composites may not have the remineralization and chemical
bonding advantages of glass ionomer materials. The newer generation of glass
ionomer cement fluoride-releasing filling material is both functional and anti-
cariogenic. It is the only filling material that resists caries formation. An article
in the Journal of American Dental Association in February 2012 compared the effi-
cacy of glass ionomer versus resin sealants for a 24-month study. Sealing dur-
ing tooth eruption presents a particular challenge owing to difficulty in isolating
the tooth. Glass ionomers may be a better material for sealing partially erupted
molars [32]. Other studies suggest that the ionic exchange mechanism of the
glass ionomer material creates a strong chemical bond and makes the interface
acid resistant, whereas resin filling materials have a strong bond on the enamel
layer but are vulnerable to micro leakage over time and subsequent acid
penetration.
Caries lesion detection by the medical provider
Historically the term ‘‘caries’’ has been used to describe many different situa-
tions in dentistry. It has been used to reference both caries disease and a caries
lesion. The disease is clearly different from the lesion, thus use of the tradi-
tional single term ‘‘caries’’ by itself is extremely imprecise and confusing. To
further complicate matters, the term ‘‘caries’’ has been used to describe various
parts of the tooth that are bacterially infected, stained, white in appearance, and
actually cavitated. To solve this problem, the profession has called for more
universally accepted precise terminology. In 2015, the ADA published the
Caries Classification System (ADA CCS) [11]. This publication has 2 helpful
tables that can visually train providers simply by comparing what they see
when they look in the patient’s mouth with the tables. Fig. 2 shows all possible
appearances of the teeth at 3 different sites displaying what the tooth would
look like from healthy to all stages of caries lesion progression based on the
site where the clinician is looking. Fig. 2 shows what a sound, initial, moderate,
and advanced caries lesion would look at the chewing surface (occlusal
 DENTAL CARIES
Fig. 2. American Dental Association Caries Classification System (ADA CCS). (From Young DA, Novy BB, Zeller GG, et al. The American Dental Asso-

317
ciation Caries Classification System for Clinical Practice: A report of the American Dental Association Council on Scientific Affairs. Journal of the American
Dental Association 2015;146(2):82; with permission.)
318 WONG, SUBAR, & YOUNG

surface), in between teeth via a dental radiograph (approximal) and the visible
facial (cheek side) and lingual (tongue or palate side) surfaces. It also includes
more precise nomenclature should the clinician so choose to use it. Table 1 de-
scribes how the lesion would look if it is active (progressing) or inactive (ar-
rested). An inactive (arrested) caries lesion does not need to be treated [11].

Caries risk assessment guidelines for medical providers

CRA is the clinical process of analyzing the probability of a patient developing
new or having progression of existing caries lesions in the near future [12].
The CRA is critical to not only identify patients at greatest risk for dental
caries but also the CRA helps determine what preventive and reparative stra-
tegies can be implemented to correct the patient’s caries problem. The best pre-
dictor of future caries risk is past caries experience (caries lesions) and the use
of additional risk factors does not drastically improve prediction [33]. Howev-
er, prediction of future caries activity is not the only important outcome of a
CRA; identifying additional risk factors in the CRA process will help deter-
mine treatment strategies to arrest, reverse, or prevent the caries process.
This suggests that medical providers can become proficient at identifying the
presence of new or progressing caries lesions. These are called disease indica-
tors because they indicate the disease is present or has been present in the
recent past. The presence of just one new or progressing caries lesion is consid-
ered high caries risk and should trigger referral or treatment by the medical
provider. In addition, medical providers often see patients before they are
seen by a dentist and are in an excellent position to easily identify the 3 major
caries risk factors: (1) heavy bacterial plaque, (2) absence of saliva (dry mouth),
and (3) destructive lifestyle habits, such as poor dietary habits and/or

Table 1
Characteristics of active and inactive lesions
Caries lesion activity assessment descriptors
Likely to be
Activity assessment factor inactive/arrested Likely to be active
Location of the lesion Lesion is not in a plaque Lesion is in a plaque stagnation
stagnation area area (pit/fissure, approximal,
gingival)
Plaque over the lesion Not thick or sticky Thick and/or sticky
Surface appearance Shiny; color: brown-black Matte/opaque/loss of luster;
color: white-yellow
Tactile feeling Smooth, hard Rough enamel/soft dentin
enamel/hard dentin
Gingival status (if the No inflammation, no Inflammation, bleeding on probing
lesion is located near bleeding on probing
the gingiva)
From Ekstrand KR, Zero DT, Martignon S, et al. Lesion activity assessment. Monogr Oral Sci 2009;21:63–90;
with permission.
DENTAL CARIES 319

recreational drug use. If these risk factors are identified, they also can be
referred or treated by the medical provider.
Although many dental providers find it helpful to categorize caries risk into
4 levels (low, moderate, high, and extreme), for medical providers it may be
sufficient to simply classify patients into 2 caries risk categories (low or high).
For this to be effective in the medical environment, it must be made simple.
Look in the mouth for any new or progressing caries lesions (compare to
photos in Fig. 2). If there is even one new or progressing lesion consider
the patient high risk. Even in the absence of new or progressing caries lesions
the patient can still be at high caries risk if he or she has risk factors. Look at
the teeth for heavy plaque. Does the patient complain of a dry mouth? Does
the mouth look dry or have very thick ropey or bubbly saliva? Does the med-
ical history or social history have any evidence of destructive dietary or drug
habits? Is their medication induced xerostomia? For each risk factor identified
there should be a strategy to manage the patient toward health.

Caries management by the medical provider

In review, a careful look in the mouth will determine the presence of any dis-
ease indicators (the presence of any new or progressing caries lesions) and a
caries risk factor such as heavy plaque. Disease indicators and risk factors
are used in the CRA process to help determine caries risk level. These disease
indicators and risk factors will then determine appropriate management op-
tions. If there are any new or progressing caries lesions, the ADA CCS can
be used to determine extent and activity of the lesion. Initial lesions and
many moderate lesions are likely noncavitated caries lesions and should be
treated by the health care provider with nonsurgical remineralizing strategies
using topical fluoride, good oral hygiene, and healthy dietary habits. The
ADA recommends the following for patients at risk of developing dental caries:
2.26% fluoride varnish or 1.23% fluoride (acidulated phosphate fluoride) gel, a
prescription-strength, home-use 0.5% fluoride gel or paste, or 0.09% fluoride
mouth rinse for patients 6 years or older. Only 2.26% fluoride varnish is rec-
ommended for children younger than 6 years [18,34].
Advance lesions are by definition fully cavitated and there is no enamel stop-
ping the ingress of bacteria into deeper layers of the tooth (dentin and pulp).
For these lesions, both a nonsurgical approach that treats the risk factors
causing the disease is in order along with surgical restoration when appropriate.
There are circumstances in which restoration is not practical, such as special
needs patients, medically compromised patients, young patients, phobic pa-
tients, and patients who cannot afford comprehensive restorative procedures.
In addition, many pediatric dentists who are using SDF rather than surgical
removal of tooth structure and restoration are accomplishing the retention of
primary teeth until exfoliation without subjecting the child to needles, physical
restraints, or sedation/general anesthesia. In these cases, the option of arresting
the lesion using SDF should be considered. As a result of arresting and remi-
neralizing the caries lesion, the SDF will significantly darken and harden the
320 WONG, SUBAR, & YOUNG

lesion (but not healthy tooth structure) and informed consent regarding this
and other side effects is mandatory. The application of SDF is fairly simple:
dry the lesion with cotton and apply SDF with a small brush. Extreme care
must be taken not to get SDF on surfaces other than the caries lesion (eyes,
soft tissue, countertops), as it is not only caustic but will stain almost anything
it contacts [25].
Managing caries risk factors identified in the CRA is always a combination
of behavioral modification techniques coupled with take-home products that
you want the patient to use. The goal of dispensing products is to modify
the bacterial biofilm and chemistry to favor remineralization. For example, if
there is a high bacterial challenge as evident by heavy visible plaque seen on
the teeth, then the medical provider can reinforce improved oral hygiene
habits, and prescription antibacterial rinses [35–37] and xylitol gum or mints
[35,36,38]. If there is evidence of dry mouth (hyposalivation) then the saliva
may benefit from products designed to help neutralize acid and calcium/phos-
phatelike products to supplement mineral uptake back into the tooth [35,36,38].
Destructive lifestyle habits related to dental caries, such as poor dietary habits
or illicit drugs that can cause hyposalivation, should be dealt with in an appro-
priate manner. To be successful, all medical team members must support envi-
ronmental caries management strategies. Products must be dispensed directly
to the patients because it is highly unlikely that patients can successfully locate
and purchase these products on their own. A simplified example management
guide is presented in Table 2. For a more detailed version used by many den-
tists, see Fig. 3.
Interprofessional collaboration with medical providers
Managing dental caries disease using a collaborative care has the potential to
identify and treat the highest-risk patients early in the disease process and
perhaps avoid a lifetime of oral problems. Oral health services provided in
medical offices have demonstrated improved access and increased utilization

Table 2
Simplified caries management

Problem identified Management

Disease indicators Consider
New or progressing caries Over-the-counter fluoride toothpaste (children younger than
lesions: (white spots, cavities) 6 y) or a prescription-strength, home-use 0.5% fluoride
gel or paste (for 6 y and older), 2.26 fluoride varnish,
silver diamine fluoride, and referral to dentist
Risk factors Consider
Heavy amounts of plaque Oral hygiene instruction, xylitol products, antibacterial
rinses
Abnormal saliva consistency Xylitol gum, pH neutralization products, calcium/phosphate
(ropey, stringy, bubbly) supplements, sodium bicarbonate rinses
Destructive lifestyle habits Appropriate education, behavioral modification, and
(eg, diet, drugs) counseling
 DENTAL CARIES
Fig. 3. SAFER guidelines. (From Glassman P. A manual of hospital dentistry. 10th edition. San Francisco (CA): Author; 2012. with permission.)

321
322 WONG, SUBAR, & YOUNG

[39,40]. Most children see a medical provider numerous times before their first
birthday, yet few of these young patients see a dentist.
Medical providers are capable of engaging in preventive dental services [41]
such as oral health screening, anticipatory guidance, promotion of healthy die-
tary habits, brushing with a fluoride toothpaste, applying fluoride varnish, and
referring high caries risk patients to a dentist and perhaps prevent, arrest, or
reverse early initial lesions before there is a need for restoration. Studies have
demonstrated that fluoride varnish applied by medical care providers coupled
with oral health counseling will increase fluoride varnish utilization [42] and posi-
tively affect patient outcomes [43], especially in the low-income population [44].
Fluoride varnish and high-concentration fluoride toothpaste are attractive tools
for medical providers because they fit existing models, such as well-child visits
and community-based geriatric programs [45]; however. the introduction of
SDF provides new opportunity for medical providers with proper training to
help arrest even grossly cavitated lesions on children and adults.
Warning signs
As a health care provider, there are many opportunities to help reduce or even
prevent dental caries in children or reduce future oral complications. In addition
to the standard instruction of remembering to brush and floss, we should
remember that brushing and flossing are not the only tools for fighting tooth
decay and in fact may do very little in many susceptible high caries risk patients.
Dental disease has a multifactorial effect and even those who brush all the time
can develop dental disease. As mentioned in the ‘‘Overview of the caries disease
process,’’ it is all about the balance of minerals, pH, and reducing acid-producing
bacteria. Some patients are genetically susceptible, whereas others have a destruc-
tive biofilm and improper chemistry that has never been addressed.
In 2015, 450 pediatricians in Tennessee were surveyed on their knowledge, at-
titudes, and experience with oral health prevention, as well as willingness to incor-
porate oral prevention strategies. The response of 107 pediatricians reported most
were willing to participate in oral examinations but a minority use prevention
techniques such as fluoride varnish. The conclusion was that pediatricians receive
very little education on oral health during medical school and residency pro-
grams. Expanding oral health care access through PCPs will require adequate
training in medical school, residency, and in continuing education courses [46].
Special needs population
Patients with special health care needs are a growing population. When we
describe special needs, we are accounting for those with medical, physical,
emotional, and developmental conditions, and in some cases, a combination
of the categories. Any patient with teeth and gums is still a concern, whether
the patient is gastric tube or nasogastric tube fed. Currently, there are 2 con-
cerns that need immediate attention. One is that predoctoral education is not
well prepared to accommodate the growing need of the special needs popula-
tion. Although dental schools have introduced changes in their curricula to
improve the preparation of new graduates to provide services for patients
DENTAL CARIES 323

with special health care needs, the challenge is to provide current practitioners
with programs to ensure the treatment of patients with disabilities. Second, it is
estimated that 1 in 5 children in the United States has a disability [47].
In most cases, these patients are seen by the pediatric dentist, a specialist with
advanced training in behavioral, complex, and syndromic cases of the primary
and mixed dentition. Unless a general dentist had training from dental school
on advanced care or had completed a postdoctoral general dentistry program,
such as a General Practice Residency or Advanced Education in General
Dentistry, some dental offices may be reluctant to treat. The major concern
for all pediatric health care providers is to whom do they refer when the patient
is beyond the age of a pediatric patient.
With patients living longer due to earlier detection and treatment of medical
conditions, we have a population that is also aging. Each year thousands of
poor children with disabilities ‘‘age out’’ of dental programs that were estab-
lished to meet their needs. Most states provide minimal if any dental services
(with limited reimbursement levels) for adults within the Medicaid system [48].
The spectrum of care for the patient with special health care needs is to develop
trust and rapport to complete a thorough examination and treatment. The tech-
nique may involve multiple visits of desensitization due to the new surroundings,
equipment, noise, and environment. This additional attention requires time,
patience, and understanding from the team and parent but is not reimbursed
by insurance and could be a barrier if patient’s parent does not wish to pay.
Whether the patient is a child or an adult with special needs, an assessment
to evaluate safety in treating the patient and the appropriate number of proced-
ures is mandatory in deciding to see the patient in-office under routine care
(with or without oral sedation) versus seeing the patient in a hospital setting.
The continuum of treatment modality is shown in Fig. 4. To the left is the

Fig. 4. Continuum of patient management: pain control. (From Glassman P. A manual of hos-
pital dentistry. 10th edition. San Francisco (CA): Author; 2012; with permission.)
324 WONG, SUBAR, & YOUNG

most conservative approach and least expensive, whereas the far right would
be the more complicated cases and consequently more expensive with more po-
tential risks, such as general anesthesia.
Many patients with developmental disabilities are covered by the Medicaid
system known as Medi-cal in California. Each state has specific guidelines and
limitations as to what procedures are covered. Again, the discrepancy between
coverage of pediatric-age patients and adults varies greatly. The adult dental
coverage is often less than that of pediatric coverage and can be rather costly.
With premature tooth loss or congenitally missing teeth, the occlusion can
compromise the patient’s function or proper eruption of teeth. Thus, increasing
risk for dental caries and periodontal disease. As a reminder, primary teeth are
important for growth and development of succedaneous teeth as well as proper
mastication and speech. There are generally 20 deciduous teeth in the primary
dentition and replaced by 32 adult teeth (http://www.mouthhealthy.org/en/az-
topics/e/eruption-charts).

Hospital dentistry and general anesthesia

If an unsuccessful attempt has been made to treat the patient in a routine setting,
the options are either medical immobilization (papoose board), oral sedation, or
general anesthesia. There are no standard recommendations for hospital
dentistry or general anesthesia at this time. Certified personnel may provide gen-
eral anesthesia in hospital, surgery centers, and even private offices. Hospital
dentistry may be recommended for those patients with anxiety and mild to severe
medical conditions. Hospital dentistry includes care in a hospital for routine care,
bedside for inpatient care, or in the operating room for general anesthesia.
For some patients who are medically compromised (such as bleeding disor-
der or combative), hospital dentistry may be the safest route for treatment un-
der general anesthesia. Inpatient hospital care of patients is relatively direct,
whereas outpatient surgery presents more hurdles for insurance approval
and can be a lengthy process. Dental cases are usually scheduled as elective
care and not a benefit for medical insurance. Patients may require a statement
from their physician to their medical insurance to justify the ‘‘medical neces-
sity’’ regarding their medical diagnosis leading to general anesthesia and outpa-
tient hospital stay.
For the patient with special needs, the dental pathologies can be extensive
and numerous for those patients unable to communicate. Practitioners
providing dental care must be competent in all phases of dentistry and comfort-
able in the medical operating room setting. Dental CRA and medical risk as-
sessments are important in developing comprehensive and predictable
treatment plans [49]. Predictable dental work should not endanger patients,
require extraordinary maintenance, or potential future complications.
When possible, if a patient is to undergo general anesthesia, it would be
beneficial to have any other tests or examinations for those who cannot toler-
ated them in a routine setting. For example, in a highly active patient who may
need an electrocardiogram; laboratory tests; or eye, ear, podiatric, or obstetric/
DENTAL CARIES 325

gynecologic examination, it may be beneficial to see if coordinated care with

appropriate specialty support is available. Coordination of time and advanced
planning are essential.
Medical and anesthetic risk assessment
Medical necessity is always guided by the patient’s medical risk status and the
benefits over the potential risks of dental pathology, such as infection or possible
malignant lesion. Psychological and emotional assessments are also major factors
in recommending a patient for hospital dentistry. Often the patient with special
needs may have restrictions or anatomic concerns from developmental disabil-
ities that restrict or compromise airway anatomy or organ function.
Limitations/considerations for general anesthesia
Over time, the delivery of general anesthesia for special needs patients has
moved from dental clinics to general hospitals. The demand for dental treat-
ment for special needs patients under general anesthesia continues to increase.
Currently, there are no accepted protocols for the provision of dental treatment
under general anesthesia [50].
Parents are more willing to accept the hospital dentistry, in-office general
anesthesia, or in-office intravenous sedation choices, as it seems to become
more popular and widely accepted as options that are presented as an ‘‘efficient
method’’ for the child who is unable to cooperate. The trend for more general
anesthesia hospital dentistry procedures is increasing not only in the United
States; a 2014 article in the Journal of International Pediatric Dentistry noted in Ger-
many there was a sudden increase in oral rehabilitation for children in hospitals
[51]. It was noted that attention to reducing caries risk is important to lessen
that need. The cost of outpatient surgery is expensive and in many cases could
be avoided if prevention strategies are implemented early in the child’s devel-
opment. Although medical insurance may cover part of it, it may not cover all
of it. Not only are costs high, but it brings up the concern of challenges in get-
ting patients seen in a timely manner. Due to the increased demands, the wait-
ing times for hospital-based procedures have increased dramatically. The most
common reason for hospital dentistry remains dental caries with dental pain as
a close second. Whether in the United States or Casablanca, the trend is similar
[52]. Because many hospitals are looking at cost containment, they are limiting
their services for dental procedures due to poor reimbursement. Although the
delay in getting treatment becomes a greater issue, the dental pathologies
continue to increase in size and symptoms. In time, the only treatment for teeth
may be more extractions, which leads to a cascade effect of concerns.
Not just about teeth
Dental infections can become life-threatening if not properly treated, as in
the case of Deamonte Driver. The February 28, 2007, Washington Post article
titled ‘‘For Want of a Dentist,’’ reports the story of Deamonte Driver, a
12-year-old boy who died of a toothache (http://www.washingtonpost.com/
wp-dyn/content/article/2007/02/27/AR2007022702116.html).
326 WONG, SUBAR, & YOUNG

Deamonte suffered from some teeth that needed to be extracted, but due to
costs and delay, ended up in the emergency room. The end result was multiple
procedures, including treatment of infection spread to the brain and subsequent
death, with a cost of more than $250,000.00. In Maryland, a concerted effort to
recognize oral health with ‘‘overall health’’ is an outcome of the Deamonte
Driver tragedy. In response to the death of a young child, efforts by many part-
ners have enabled Maryland to institute oral health reforms that ensure that
low-income children remain visible and have continued access to dental
services [53].
Oral health literacy is important because low health literacy contributes to
disease that results in increased costs for all of us. Those with low health liter-
acy are usually at highest risk for oral diseases and problems [54].
Intravenous sedation/oral sedation
Another option is to provide sedation via in-office intravenous means whereby
the patient receives medication in an intravenous line but not to the point
where breathing stops. Many offices are qualified to provide in-office intrave-
nous sedation by the pediatric dentist with qualified support staff. Recently,
there have been some unfortunate cases in which the child or patient had
some complications that resulted in death. In some states, legislation is being
considered to limit this activity unless someone administers the sedation who
is trained other than the dental practitioner providing the service. The thought
process is that a patient’s medical status can quickly change while the attention
of the dentist is focused in the mouth.
Similarly, oral sedation is also a growing option and similar concern. Accord-
ing to a July 13, 2012, Huffington Post article, there were 31 child deaths over the
past 15 years. Additionally, from the period of 2007 to 2012, there were more
than 18,000 dentists who had trained over a weekend course to certify for oral
sedation. Should you recommend any person for sedation, intravenous or gen-
eral anesthesia, it is important that the patient or guardian know the experience
level and evaluate the risks carefully.

DENTAL HOME/ACCESS TO CARE (VIRTUAL HOME) OVERVIEW

Ideally, every patient has a respective ‘‘home’’ for medical and dental care.
Unfortunately, due to economics and lack of Medicaid providing dental
offices, there are challenge to finding offices to see patients. One of the stra-
tegies to help bridge the gap for those unable to get help either due to phys-
ical location distances or costs, the concept of a virtual home has recently
been adopted. Virtual homes use a dentist with trained allied support
to gather information and implement telehealth techniques via wireless
connections, including digital radiographs, photographs, and electronic
charts. The supervision of the treatment is remote and only for basic types
of procedures. Any emergency procedure or invasive procedure is to be
directed to the dentist. This concept is not available in all states but is a
growing trend.
DENTAL CARIES 327

Table 3
Dental treatment paradigm shift comparison
Surgical approach (old) Minimally invasive approach (new)
Review health history Review health history
Dental examination medication (xerostomic inducing)
Gingival probing as needed Caries risk assessment
Oral hygiene instructions/diet counseling Check saliva pH/flow/quality
Full set of radiographs initial visit Check bacterial activity
Use sharp instrument to detect soft areas Oral hygiene instructions/diet counseling
Fillings any soft area or suspicious stain treat etiology: biofilm and environment
Cleanings 2/y Dental examination (no sharp instrument but
Recall bitewing radiographs every year dry teeth, observe texture and color)
New full set radiographs every 3 y Diagnose: etiology/consider remineralize
strategy
Treat biofilm (antimicrobial)
Gingival probing as needed
Dental Cleaning
Fillings with appropriate dental material
Recall and radiographs based on caries risk

People with complex medical, physical, and psychological conditions are

among the most underserved groups in receiving dental care, and consequently
have the most significant oral health disparities of any group. The traditional
dental care delivery system is not able to deliver adequate services to these peo-
ple with ‘‘special needs’’ for a variety of reasons. New systems of care are
evolving that better serve the needs of these groups by using interprofessional

Table 4
Checklist for pediatric health provider
Check Possible
Discuss relationship of dental disease with Refer parent to dentist
parents and care providers (vertical
transmission)
Check gums for bleeding, redness, or puffiness Possible cleaning, consider systemic
problems, dentist/periodontist
Check teeth for:
Deep grooves Possible sealants
Brown, black, or white spots Possible caries. remineralize
Cavitation(s) (holes) Refer to dentist
Appropriate number for age (see eruption Refer to dentist, possible orthodontist
chart)
Crowding Refer to dentist, possible orthodontist
Check soft tissue inside mouth (lips/palate) for Possible dentist to oral surgeon
any color changes, clefts, trauma
Check facial symmetry Refer to dentist, possible orthodontist
Check dry mouth? (thick, ropey, bubbly saliva) Dentist to manage caries risk
History of snoring or obstructive sleep apnea Refer dentist for possible orthodontist
or medical management
328 WONG, SUBAR, & YOUNG

teams to reach these individuals and integrate oral health services into social,
educational, and general health systems [55].
The paradigm of treating dental disease is changing. Table 3 demonstrates
some of the minimally invasive changes proposed. The pediatric health care
provider can be an essential part of the team to help prevent dental caries.
Table 4 offers a suggested checklist.

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