EARLY CARIES DETECTION
Recently, progress has been made in understanding caries detection with conservative management of demineralization.
Now More Than Ever!
Margaret I. Scarlett, DMD; Stephen H. Abrams, DDS; Lori Trost, DMD
Recently, progress has been made in understanding caries detection with conservative management of demineralization. Frank cavitation occurs later in the dynamic process of dental caries, while detection of caries at a very early stage of development has many potential benefits. These include remineralization of tooth structure and containing lesion size.
In 1999, the Second Indiana Conference on Early Caries addressed other potential benefits:
1. Reducing lesion progression to cavitation
2. Preserving natural tooth structure
3. Reducing lifetime treatment costs
4. Maintaining natural occlusion
5. Enhancing aesthetics of natural tooth enamel
In May 2003, the Third Indiana Conference on Early Detection of Dental Caries focused on the latest trends in detection, diagnosis, and management of early caries. Chaired by Dr. George Stookey, distinguished professor emeritus of the Indiana University School of Dentistry, attendees were guided through an update on ICDAS (International Caries Detection and Assessment System),1 a new system for describing the scale of progression of caries. Challenges include developing parameters for clinical trials of these devices along with educating dental professionals, the public, and the government on the benefits of early caries detection.
The conference examined new systems for early detection of caries. Methods of detection were wide-ranging: ultrasonic waves, polarized optical coherence tomography, photothermal and laser luminescence, fiber optics, confocal microscopy, and infrared thermographic imaging. Many devices used infrared or near infrared lasers for tooth examination. Some methods appeared to be more accurate than current visual or radiographic methods.
New and emerging systems for early caries detection were highlighted, including DIFOTI, QLF, and DIAGNOdent. While each method has limitations, when used in combination with traditional detection, early carious lesions and demineralized lesions can be categorized for prevention or treatment.2 Assessment of caries risk has improved with customized approaches for prevention, such as fluoride or antibacterial therapy based on risk and, when necessary, minimally invasive treatment.3,4
The evidence for the impact of new detection methods cannot be assessed without expensive and time-consuming randomized clinical trials (RCTs). In addition, the binary system of measuring caries (caries/none) is insufficient for new diagnostic measures,5 and the current DMFT is similarly insufficient. Clinical trials are expensive and lengthy because of the large number of subjects needed in populations with low caries incidence followed over long periods of time — up to two years — to detect changes.
Early detection of dental caries will shift the approach to management of this infectious disease process. Surgical intervention (the placement of restorations) will not be the optimal method for treatment; rather, the preferred approach will be a customized one based on early detection, with application of pharmacologic agents (for example, fluoride), and controlling causal agents (for example, bacteriologic agents and home care). Challenges facing dentistry include the development of new, accurate devices and reimbursement aligned with emerging science. Re-education of the public and government will be necessary for understanding novel approaches to management of dental caries. Detection and management of early carious lesions will necessitate both an investment in technology and training by the profession. Refinement of techniques will maximize ability to prevent caries, utilizing restorations only when absolutely necessary to control active demineralization and dentinal decay.6 Education of the public concurrent with public and private reimbursement systems is essential for progress.
1 Pitts, NB. "Review of the ICW-CCT meeting — The importance of early detection and the philosophy and approach of ICDAS," in Early Caries Detection III Proceedings of the 6th Annual Indiana Conference, May 2003, Stookey, GK, editor, in press.
2 Ewoldsen N and Scarlett M. Caries detection and intervention. Woman Dentist Journal March/April 2003.
3 Featherstone JDB, Adair SM, Anderson MH, Berkowitz RJ, Bird WF, Crall JJ. Et (2003) Caries management by risk assessment: consensus statement, April 2002. California Dental Association (CDA) Journal; 31, 257-269.
4 Featherstone JDB. The caries balance: contributing factors and early detection. CDA, 2003, Vol. 31, No. 2, pages 129 – 133.
5 ten Bosch, J, J., "Validation: what do we mean and how can it be done?" in Early Caries Detection III Proceedings of the 6th Annual Indiana Conference, May 2003, Stookey, GK, editor, in press.
6 Stookey, GK. "Early caries detection — future considerations" in Early Caries Detection III Proceedings of the 6th Annual Indiana Conference, May 2003, Stookey, GK, editor, in press.
Margaret I. Scarlett, DMD Dr. Scarlett is the managing editor of Woman Dentist Journal. An accomplished clinician, scientist, and lecturer, she is retired from the Centers for Disease Control and Prevention. You may contact Dr. Scarlett at email@example.com.
Stephen H. Abrams, DDS Dr. Abrams is a partner in a group practice in Toronto, Canada. He is collaborating on the development of a laser-based system for caries diagnosis. He founded Four Cell Consulting which provides advice to dental manufacturers. Contact him at dr.abrams firstname.lastname@example.org.
Lori Trost, DMDDr. Trost created the Center for Contemporary Dentistry in Columbia, Ill., in 1989. Her practice is known for being in the technological forefront. She is a member of the ADA and AGD and consults for 3M ESPE's "Council for Innovative Dentistry." You can reach Dr. Trost at email@example.com.