EPIDEMIOLOGY OF

DENTAL CARIES

Dr: ARHEIAM AL AWAMI

BDS, MSc, DDPH RCS (Eng.), PhD (UK)
To understand epidemiology, it is important to
understand the definitions of the following terms:

• Prevalence: This is the proportion of individuals

with disease (cases) in a population at a specific
point in time.
• Incidence: This is the number or proportion of
individuals in a population who experience new
disease during a specific time period.
• Trends: These are the changes or differences in
the prevalence or incidence of disease with respect
to time, location, or socioeconomics
 Global distribution

◼ For most of 20th century dental caries

pattern was :

◼ High prevalence → developed countries.

◼ Low prevalence → underdeveloped countries.

◼ So it is called the disease of civilization

By the late of 20th century dental caries
pattern was changing into two ways:

◼ Sharp rising in caries

prevalence in
developing countries
especially urban areas.
◼ Marked reduction
among children and
young adults in
developed countries.
◼ This was attributed
to:
➢ Dietary changes
➢ Fluorides
➢ Preventive programs
 Untreated caries in permanent teeth remained the most prevalent health condition
across the globe in 2010, affecting 2.4 billion people, and untreated caries in deciduous
teeth was the 10th most prevalent condition, affecting 621 million children worldwide.
 Some terminology

◼ Risk factor: It is an exposure or attribute

associated with increased probability of
disease occurrence .

◼ Demographic risk factor: An attribute or

exposure that increase probability of disease
occurrence that can not be modified.

◼ Risk marker: an exposure or attribute

associated with increased probability disease
occurrence and is not part of causal chain.
 Sociodemographic
Status

Saliva
•Buffer capacity
•Composition
•Flow rate
Education Antibacterial
Agents Income
Tooth Protein

Dental Sealants

Diet Sugars
Fluoride •Amount •Clearance rate
•Composition Caries Time •Frequency
•Frequency

Behavior
•Oral hygiene Ca
•Snacking Chewing Gum Bacteria P04
In
Biofilm Dental
Insurance
Coverage
Plaque pH
Microbial Species

Knowledge/ Selwitz RH, Ismail AI,

Oral Health
Literacy Pitts NB. Dental caries.
Lancet 2007 369: 51-59
 Demographic risk factors

◼ Age

◼ Gender

◼ Race and ethnicity

◼ Socio-economic status

◼ Familial and genetic distribution

 Age

◼ The mean DMFT scores increase with age

◼ Children → restoration

◼ Adult → missing

◼ In past →childhood disease

◼ Now →life time disease

Prevalence (proportion) and number of incident cases of untreated caries in 1990 (light
line) and 2010 (dark line) with 95% uncertainty intervals by age.
We have also identified that the burden of untreated caries is shifting from
children to adults. We hypothesized that the prevalence peak at age 25 y
represents a delay in caries development, possibly due to promoting oral health
to schoolchildren and then neglecting this aspect of health in adult life just after
leaving school. Untreated caries is now peaking later in life, at adulthood rather
than childhood. The current assumption—that the current low levels of caries in
childhood will continue throughout the life course—may be incorrect.
 Gender

◼ DMFT in females higher than males

◼ Possible reasons
❖ Earlier eruption
❖ More dental visits

Race
◼ Early studies→ non European races show more resistance to
caries.

◼ Now → concept of racial difference has been faded.

◼ It is the result of environment.

 Socio-economic status
(SES)

◼ SES is inversely related to the status of many

diseases.

◼ Low SES have higher values of Decayed and

Missing but low values of Filled teeth

◼ Fluoride reduce disparities

 Familial and genetic pattern

Bad teeth run in families

➢ Familial tendency has been reported

➢ Inheritance of pit and fissures pattern and

arch form

➢ Similarity in dietary and oral hygiene habits

➢ Bacterial transmission
 Environmental risk factors

◼ Diet and nutrition

◼ Teeth

◼ Saliva

◼ Climatological factor

◼ Fluoride
 Diet and nntrition

◼ Diet: total oral intake of food and drink to

provide nourshiment and energy

◼ Nutrition: it’s the absorption and

metabolism of nutrients.

◼ Diet can effect caries locally by acting as a

substrate for cariogenic bacteria.

◼ Nutrition effect teeth systematically only

during teeth development period.
The systemic effect of diet on dental
caries

◼ Undernutrition is associated with hypoplasia of enamel which

increases caries susceptibility
◼ Undernutrition results in salivary gland atrophy, reduced salivary
flow rate, and reduced buffering capacity—these factors increase
caries susceptibility
◼ Deficiency of vitamin D is associated with enamel hypoplasia and
increased caries risk
◼ Undernutrition results in delayed shedding of the primary teeth
and delayed eruption of the permanent teeth. This may
influence the caries prevalence at a given age
◼ In undernourished populations where there is exposure to
sugars in the diet, caries prevalence is higher than expected
from observations in well-nourished populations
 Diet

Diet have clear influence on caries

prevalence and severity
◼ Refined carbohydrate specially sugars are major
aetiological factor

◼ Without dietary sugars, dental caries will not occur.

◼ Flour and starches are not usually decay-causing, but

when starch is used in conjunction with sugar, i.e. in
cookies and so on, the potential for caries increases.
Evidence for a relationship between diet
and dental caries comes from different
types of studies

• Human intervention studies (clinical trials)

• Human observational studies
• Animal experiments
• Plaque pH studies
• Enamel slab experiments
• Incubation studies
Epidemiological studies of the sugars/caries
relationship

• A positive relationship exists between per capita sugar availability

and DMFT at age 12 years
• A marked increase in the prevalence and severity of dental caries
has been observed in populations who move away from their
traditional way of eating and adopt a westernized diet, high in
sugars
• Sub-groups of the population who habitually consume a high sugars
diet have been shown to have higher levels of dental caries
compared to the general population
• Sub-groups of the population who habitually consume a low sugars
diet have been shown to have lower levels of dental caries
compared with the general population
Epidemiological studies of the sugars/caries
relationship

• Caution is needed when interpreting the findings of cross-

sectional studies that have compared diet to levels of dental
caries at one time point, since caries develops over time. It may
be the diet several years previous which is responsible for
current disease levels
• Studies with a longitudinal design, that measure diet and relate
it to change in levels of dental caries over time provide stronger
evidence
• Human intervention studies provide the strongest evidence for
an association between diet and diseases, however, these are
difficult to conduct from an ethical and logistic point of view
Vipeholm study (Gustafsson et al. 1954)

The Vipeholm study was conducted shortly after the Second World
War in an adult mental institution in Sweden between 1945 and
1953.The study investigated the effects of consuming sugary foods of
varying stickiness (i.e. different oral retention times) and at different
times throughout the day on the development of caries by
measuring caries increment in subjects who consumed (1) refined
sugars with a slight tendency to be retained in the mouth at meal
times only (e.g. sucrose solution, chocolate) (2) refined sugars with a
strong tendency to be retained in the mouth at meal times only (e.g.
sweetened bread) (3) refined sugars with a strong tendency to be
retained in the mouth, in between meals (e.g. toffee). The subjects
were divided into 6 groups (and two groups were subdivided into
male and female)
Main conclusions of the Vipeholm study
• Sugar intake, even when consumed in large
amounts, had little effect on caries increment if it
was ingested up to a maximum of four times a day
at mealtimes only
• Consumption of sugar in-between meals was
associated with a marked increase in dental caries
• The increase in dental caries activity disappears on
withdrawal of sugar-rich foods
• Dental caries experience showed wide individual
variation
• The risk is greater if the sugar is in sticky form.
The Turku sugar studies
A second important intervention study was the Turku study. This was a controlled longitudinal study carried
out in Finland in the 1970s (Scheinin and Makinen 1975). The study investigated the effect of almost total
substitution of sucrose in a normal diet with either fructose or xylitol on caries development, but evidence
from the control group can be used as indirect evidence for the impact of sugar on the development of caries.
Three groups of subjects (n = 125 in total) aged 12–53 years, with 65% being in their twenties, consumed a
diet sweetened with either sucrose, fructose, or xylitol for a period of 25 months and dental caries increment
was monitored blind at six-month intervals by one person throughout the study and both carious cavities and
precavitation lesions were monitored

An 85% reduction in
dental caries was
observed in the
xylitol group who
had removed sugar
from their diet.
 Caries in ancient man

◼ The extent of dental decay seen in ancient people

depended upon their diet and dental hygiene - just as
it does today.

◼ Low caries incidence in the ancient man was

mainly due to diet which was:

◼ 1. natural diet(un refined)

◼ 2. coarse and not full prepared or cooked

◼ 3. low in carbohydrates
 Cariogenic Potential

Any food that contains sugars or other readily

fermentable carbohydrates can be
metabolized by cariogenic bacteria in plaque
to produce acid (acidogenic). However, the
cariogenic potential of this food will depend
on:

◼ Clearance time

◼ Consistency

◼ Frequency
 Other factors affecting the
cariogenic potential of food
◼ Predominant bacterial flora
◼ Flow rate and buffering capacity of saliva
◼ Fluoride availability
◼ Individual immune factors
◼ Remember:

◼ Dental caries is a multifactorial

disease
 Cleansing and protective food:

◼ There was thinking that chewing a fibrous

food (apple, carrot, celery) will clean plaque
from tooth surfaces and thus prevent caries.
◼ But researches have shown that chewing
fibrous foods does not remove plaque.
◼ One food with reported protective factors is
cheese; there is evidence in humans to
show that finishing a meal with cheese
reduces the acidity of plaque and therefore
its cariogenicity.
 Fluoride and trace elements

◼ Fluoride in water and some food.

◼ Calcium carbonate(total water hardness),
inverse relation with caries
◼ Trace elements:
◼ Found in water and food
◼ Selenium increase caries when consumed
during development period.
 Saliva

◼ Dilution

◼ Buffering

◼ Antibacterial , antifungal; effect

◼ Caries increase with xerostomia.

 Climatological factors

◼ Sunshine : inverse relationship

◼ Temperature: vary the caloric requirement

and water intake.

◼ Relative humidity: higher correlation than

other climate factors.
 Role of tooth size,
morphology & composition
◼ Various aspects of resistance of tooth to
dental caries:

1- Shape & size of tooth

2- Physical characteristics of enamel

(defective/rough)

3- chemistry of enamel

determinants of tooth resistance

 Root caries:

◼ Root caries is strongly associated with the loss of

periodontal attachment.

◼ An important risk factor is:

◼ multiple medications among the elderly that can promote
xerostomia. (salivary diminution)

◼ History of coronal caries.

◼ low-fluoride communities.

◼ Smokers.

◼ Prevalence of root caries tends to be inversely related to the

number of teeth remaining.
ROOT CARIES
 Nursing caries
◼ Primary teeth, 1-3 years old.

◼ More prevalent in low SES

◼ Prevention based on education.

 Early childhood caries
-ECC

◼ Early Childhood Caries is defined as the presence of one or more

decayed (non-cavitated or cavitated lesions), missing (due to caries)
or filled tooth surfaces in any primary tooth in a preschool-age child
between birth and 71 months of age. The term "Severe Early
Childhood Caries" refers to "atypical" or "progressive" or "acute" or
"rampant" patterns of dental caries.

38
Early childhood
caries -ECC

• ECC is a highly prevalent global disease.

• ECC is a noncommunicable disease of
medical, social and economic importance.
• ECC risk factors are linked to family
lifestyle and community norms.
• Prevention and control of ECC require a
primary health-care approach.

39
40
41
 Early
childhood
caries in
Benghazi
Arheiam and his colleagues (2011) found lower mean dmft among children attending private
schools (a proxy for children with high socio-economic status). This was corroborated by the
findings of Ballo et al (2016) who showed a negative correlation between family income and
severity of early childhood caries (Figure 3).

3.98
4

3.5
3.15

2.5 2.26
2.08
1.98
2

1.5 1.27

0.5 0.08 0

0
filling missing decayed dmft

Private Nursery State-run Nursery

 Hidden Caries or Mis-Diagnosis?
✓ When no lesion is detected by visual examination, but
radiographic methods reveal a lesion into the dentin.
✓ Noted in several reports in the 1980’s and 90’s (changes in
histopathology of disease, slower progression, increased use of
fluoride). Most studies at that time (that report a criteria) use
cavitation as a threshold for caries.

✓ Prevalence: Ranges from 3% to

50% of lesions only detected on
radiographs, usually 8-15% in
adolescent population (Ricketts
et al, 1997)
✓ Hidden caries does not seem to be a major problem when the
clinical caries diagnostic criteria include non-cavitated
diagnoses (Machiulskiene et al., Caries Res 1999)
 Caries Management

Arheiam Al awami
BDS, MSc, PhD (UK) , DDPH (RCSEng.)
ICCMS

◼ The mission of the International Caries Classification

and Management System (ICCMS™) is a holistic way of
caries prevention and control through a comprehensive
assessment and personalised caries care plan.
◼ This is in order to:
❖ prevent new lesions from appearing
❖ prevent existing lesions from advancing further
❖ preserve tooth structure with non-operative care at more initial stages
and conservative operative care at more extensive caries stages

46
◼ Theinternational trend in caries management is to move
away from the surgical model (to excise and replace
diseased tooth tissue) towards a preventive approach
aiming to control the initiation and progression of the
disease process over a person’s lifetime
 The International Caries
Classification and
Management System is a
health outcomes
focused system that
DETECT
aims to maintain health
and preserve tooth
& Assess
structure. It uses a
simple form of the ICDAS
Caries Classification Caries Staging & Activity
model to stage caries
severity and assess (CLASSIFICATION &
lesion activity in order to
derive an appropriate,
INTRA-ORAL RISK)
personalised,
preventively based, risk-
adjusted, tooth
preserving Management
Plan.
DETERMINE DECIDE
Patient-level Caries Risk
ICCMS™4D Personalised Care Plan:
Caries Management Patient & Tooth Levels

(DECISION MAKING)
(HISTORY)

Risk-based
Recall
interval
DO
Appropriate Tooth
& Patient
Preserving Caries
Prevention & Control
Interventions
(MANAGEMENT)
 ICCMS™ Caries Categories
1 DETERMINE Patient Level Caries Risk 2.1 DETECT & ASSESS Sound Initial Active Initial Inactive
First/distinct
Caries Staging & visual changes in
enamel (ICDAS
Patient-level Risk Factors Activity Status 1& 2)

The International Caries

‒ Head and Neck Radiation No evidence
Moderate Active Moderate Inactive Enamel
Classification and
‒ Dry mouth of visible breakdown/
‒ Inadequate OH practices caries after 5- underlying
Management System is a
health outcomes
focused system that
‒
‒
Deficient exposure to topical Fluoride-
High frequency/amount of sugar
DETECT second air-
drying (ICDAS
0)
dentine shadow
(ICDAS 1 & 2)
aims to maintain health
and preserve tooth ‒
consumed
Symptomatic-driven attendance
& Assess Extensive Active Extensive Inactive
Distinct cavity with
structure. It uses a
simple form of the ICDAS
‒
‒
Socioeconomic Status/Access barriers
Mothers high DMF (caries experience)
Note: Where available
combine with
11 visible dentine
(ICDAS 5 & 6)
Caries Classification Risk factors in red will always classify an
Caries Staging & Activity radiographs.
model to stage caries individual as high caries risk.
severity and assess (CLASSIFICATION & 2.2 ASSESS Intra-Oral Risk Factors
lesion activity in order to
derive an appropriate,
INTRA-ORAL RISK) Intra-Oral Risk Factors
personalised, ‒ Hypo-salivation/Dry mouth
preventively based, risk-
‒ PUFA- Dental Sepsis
Risk
adjusted, tooth
preserving Management
‒ Caries experience factors in
Plan.
‒ Thick plaque red will
always
‒
DETERMINE DECIDE > biofilm retention classify an

DO Appropriate
4 Prevention &
Preservation Interventions
Management at the patient level
Homecare
2-day toothbrushing
[≥1,000 ppm F-]
Motivational engagement: improve oral
ICCMS™4D ‒ individual
Exposed root surfaces as high
caries risk.
Patient-level Caries Risk Personalised Care Plan:
Caries Management Patient & Tooth Levels
DECIDE on a
3 Personalised
(DECISION MAKING)
(HISTORY)
Care Plan
Clinical Interventions/Approaches
hygiene & reduce free sugars
Risk-based
Recall
interval
DO Tooth & surface level Patient level

Improve oral-health Professional cleaning ICCMS™ Caries Diagnosis

Appropriate Tooth
behaviour Sealing
F- mouthrinse 2-4/year-F- varnish/gel/ solution & Patient ICCMS™ Sound
Modifying hyposalivation Preserving Caries ICCMSTM Initial Active/Inactive
Interval recalls: 1-3 m in high-, 3-6 m in
moderate-, 6-12 m in low likelihood Prevention & Control ICCMSTM Moderate Active/Inactive
Interventions
ICCMSTM Extensive Active/Inactive
(MANAGEMENT)
Management of individual lesions
Non-Operative Care- Control Tooth-Preserving Operative Care
Management of individual Management at the patient
Fluoride varnish, gel, toothpaste (+ Tooth-preservative restorations
Oral Hygiene) Step-wise excavation / Pulp Preserving restorations active lesions level
Sealing (resin-based, GI, infiltrants) Sealing / Hall Technique / ART
Mechanical biofilm removal
 Early Caries Detection

▪ The Value of early detection:

– is the ability to then control the
disease process in order
– to contain, arrest, or
remineralize lesions in order
– to avoid or delay the burdens
and costs associated with a
spiral of restoration and re-
restoration
Terminology

There is a consensus to separate out three key terms:

 lesion detection (which implies an objective method of
determining whether or not disease is present)
 lesion assessment (which aims to characterise or
monitor a lesion, once it has been detected)
 caries diagnosis (which should imply a human
professional summation of all available data)

Pitts N B and Stamm J. ICW-CCT Statements. J Dent Research 2004 83C: 125-128.
The concept of caries diagnosis

 Means: comprehensive assessment of all patient

information by a dentist
 So, it involves more than merely detecting an enamel
and/or dentine carious lesion.
 In other words, it is a broader evaluation that considers
all caries risk factors directly contributing to the caries
risk of the individual is an essential part of the process

Pitts N B and Stamm J. ICW-CCT Statements. J Dent Research 2004 83C: 125-128.
There is a wide range of caries detection
methods and tools
• Ideal caries measurement methods should:
– accurately capture any signs of the caries process at
any given point in time,
– be able to monitor different levels of de/remineralisation
– differentiate product effects in terms of lesion initiation
and lesion behaviour (progression, arrest and/or
regression)
• Choice of measurement methods depends on :-
– The type of investigation
– Nature of information required
– Ability to reproduce the findings
Caries Detection Threshold

• Diagnostic level that

determines what is
diagnosed as caries or
caries free
• It varies according to
the reason of caries
detection
– Dental office
– field survey
– clinical research projects
 The “iceberg of dental caries”

D
4 P&OCA
les ion s in to p u lp Preventive & Operative Care Advised

+ clin ica lly d etecta b le D 3

les ion s in d en tin e

+ clin ica lly d etecta b le D

2
"ca vities " lim ited to en a m el
P CA
+ clin ica lly d etecta b le en a m el D Preventive Care Advised
les ion s with “in ta ct” s u r fa ces 1

+ les ion s d etecta b le on ly with tr a d ition a l

d ia gn os tic a id s

+ s u b -clin ica l in itia l les ion s in a d yn a m ic s ta te of B LC

p r ogr es s ion / r egr es s ion Background Level Care
NB Pitts 2006©
Caries diagnostic thresholds- WHO
• The term “caries free” is frequently used when
referring to data reported at the D3 (caries into
dentin only) diagnostic threshold.
• This conveys the mistaken impression that there is
no disease present in an individual or population,
even though large no.s of carious lesions
recognized and scored by dentists and researchers
as dental caries in the enamel are present.
Initial caries

57
Initial caries

58
Cavitated

59
60
61
62
Caries detection in field surveys

• Clinical Indices are commonly used

• An index is a method of measuring or recording a disease
or condition from established criteria

Properties of an ideal index

Validity: must measure what it is intended to measure
Reliability: consistent across time and examiners
Clarity, simplicity and objectivity
Quantifiability: amenable to statistical analysis
Sensitivity: able to detect small shifts in the condition
Acceptability: no burden on individuals
DMFT/S is the most common caries index

DMF
Decayed due to caries (D or d) untreated
disease

Missing due to caries (M or m) treated disease

Filled due to caries (F or f)
Upper case = permanent dentition
Lower case = primary dentition

DMFT = no. of decayed, missing and filled teeth

(Klein and Palmer 1938)

DMFS = no. of decayed, missing and filled

surfaces
Oral health clinical indices - dental caries
• Scoring dmft/DMFT
A score of 1 is given to each D, M or F tooth
Scores usually expressed as D + M + F = total
DMFT
For individuals the max possible score is 32 DMFT
and 20 dmft
For communities, mean dmft/DMFT is calculated
Limitations of the DMFT/S index
• It has no denominator, and as such, does not
reflect how many teeth are at risk.
• It has little meaning unless age is attached.
• It is irreversible (score only increases with time).
• It gives equal weight to missing, untreated
decayed, and well-restored teeth or tooth surfaces.
• The DMFS overestimates true caries level as not
all surfaces in a missing tooth were decayed.
• Only assesses restorative care (and not extns)
• Fissure sealants, may not know why placed
Limitations of the DMFT/S index
• It can overestimate caries experience in teeth with
“preventive restorations”.
• It assumes that missing and filled teeth were once
carious. Teeth may be missing for other reasons.
• It measures extent not severity.
• It is of little use for estimating treatment needs.
• It does not reflect functional state or perceived
health.
• It cannot be used to assess root caries.
Recording as per WHO oral health survey

0 = sound
1 = decayed
2 = filled with decay
decayed
3 = filled with no decay
4 = missing tooth, as a result of caries
5 = permanent tooth missing for any other reason
6 = fissure sealant
7 = bridge abutment
8 = unerupted
T = trauma
Sound
• No evidence of treated or untreated clinical caries.
• The stages of caries that precede cavitation, as well as
other conditions similar to the early stages of caries, are
excluded because they cannot be reliably diagnosed.
• Thus, teeth with the following defects, in the absence of
other positive criteria, should be coded as sound:
– white or chalky spots;
– discoloured or rough spots;
– stained pits or fissures in the enamel that catch the explorer but do
not have a detectably softened floor, undermined enamel, or
softening of the walls;
– dark, shiny, hard, pitted areas of enamel in a tooth showing signs
of moderate to severe fluorosis.
• All questionable lesions should be coded as sound.
Decay
• Caries is recorded as present when a lesion in a
pit or fissure, or on a smooth tooth surface, has a
detectably softened floor, undermined enamel or
softened wall.
• A tooth with a temporary filling should also be
included in this category.
• On approximal surfaces, the examiner must be
certain that the probe has entered a lesion.
• Where any doubt exists, caries should not be
recorded as present
 From: Figure 1: 2003 terminology for dental decay (caries)

established decay decay into

obvious decay
dentine
experience
(%d3mft/D3MFT)
Unseen
dentine
decay

Unseen excludes all

early stage decay Visible enamel decay enamel enamel lesions
Decay

very early
Sub-clinical decay
stage decay
International Caries Detection and
Assessment System (ICDAS)
• ICDAS (the International Caries Detection and Assessment System) is a
new approach for coding and recording the six stages of caries severity,
varying from initial changes visible in enamel to frank cavitation in
dentine.
• The essential feature of ICDAS is the subdivision of stages of the
continuum of dental caries into a variable number of discrete and
predicable categories based upon the histological extent of the lesion
• within the tooth
International Caries Detection and
Assessment System (ICDAS)
• 0 Sound
• 1 First Visual Change in enamel
Code 0 Code 1 Code 2 Code 3
• 2 Distinct Visual Change in enamel
• 3 Localized enamel breakdown
• 4 Underlying dentine shadow
• 5 Distinct cavity with visible dentine
• 6 Extensive cavity with visible dentine

Code 4 Code 5 Code 6

There is a wide range of caries detection
methods and tools
• Ideal caries measurement methods should be valid
and reliable:
– accurately capture any signs of the caries process at
any given point in time,
– be able to monitor different levels of de/remineralisation
– differentiate product effects in terms of lesion initiation
and lesion behaviour (progression, arrest and/or
regression)
• Choice of measurement methods depends on :-
– The type of investigation
– Nature of information required
– Ability to reproduce the findings
Validity

The validity of a test can be assessed by its:

 Sensitivity: the ability of a test to identify correctly those
who have the disease.
 Specificity: the ability of a test to identify correctly those
who do not have the disease.
 The true disease status of individuals must be known
prior to calculation.
 A gold standard test is the best test available, but it is
often invasive or expensive.
Reliability

There are two types of reliability:

 Intra-examiner reliability: the degree to which
one examiner gets similar results in multiple
examinations on the same individual cases.
 Inter-examiner reliability: the degree to which
different examiners classify the same cases in
the same way.
Visual Examination
• Most widely used method, in dental offices, in clinical
research and in epidemiological studies.
n Quick, cheap and easy.
Should be performed on a dry, clean tooth, with good light,
with a mirror.
Useful on all surfaces and on all types of caries.
The basis of most other detection, and most often
compared to new methods.
Standard on occlusal, smooth surface and root caries.
Mostly dichotomous decisions: presence or absence.
Usually no quantification of lesions and therefore difficult to
monitor lesions.
 Probes?

Use a BLUNT probe, proper lighting, dry, clean

teeth and sharp eyes
Explorers are not recommended as they
may produce traumatic defects.

Ekstrand et al., 1987

Ball-ended
MAGNIFICATION
Correct and appropriate magnification will enhanced quality and
comfort.
To be used during MI diagnosis & treatment using hand
instruments.
Assist in maintaining correct working distance
Radiographs
• Radiographs are the most used detection aid using
the bitewing technique.
• Detect proximal caries lesions that cannot be
detected in the visual inspection.
• The use of radiographs is more sensitive than
clinical inspection for:
– detecting approximal lesions and for
– occlusal lesions in dentin,
– for estimating depth of the lesion, and
– for monitoring lesion behavior
BUT……. in occlusal surfaces
• When an occlusal lesion is detected on a bitewing
radiograph, the lesion may have already reached
the middle third of dentine
• Moreover, radiography cannot distinguish between
active and arrested lesions and sometimes
between non-cavitated and cavitated lesions
• It has been suggested that temporary tooth
separation can offer to clinicians the ability of
determining if the lesion is active/inactive,
cavitated/non-cavitated
• The most common caries detection method is the
combination of visual-tactile examination
supplemented by bitewing radiography
Fiber-optic transillumination (FOTI)

• based on the phenomenon of light scattering to increase

contrast between normal and carious enamel.
• Sound enamel is comprised of modified hydroxyapatite
crystals that are densely packed, ‘producing an almost
transparent structure.
• Dentine appears orange, brown, or grey underneath enamel
and this can help in the discrimination between enamel or
dentine lesions
Quantitative light-induced fluorescence QLF
• QLF is a diagnostic aid for detection, quantification and
monitoring of early enamel demineralisation.
• QLF operates on the principle of enamel autofluorescence,
detecting and quantifying the loss of fluorescence
associated with demineralisation
•
Early lesion detection with green
fluorescence
The technique is based on the principle of the excitation of the dentine with blue
light (370 nm) and would make it to fluoresce into yellow-green region. When a
lesion is present, an increase of light scattering makes appear the lesion as
dark spots on a bright green background.

E D
QLF in Vivo System

Light

CCD camera Dental mirror

with Filter
Acquisition software
QLF
The reliability of the QLF
• The reliability of the QLF in vivo appears to be excellent for
the quantification of initial caries lesions on smooth surfaces
• QLF has shown good sensitivity in vivo. However, the
specificity is sometimes compromised due to the
confounding factors.
• Correlations of up to 0.82 have also been reported for QLF
metrics and lesion depth
• QLF has also shown the ability to detect and quantify
changes of mineral content and size of lesions by
demonstrating a dose response between F and non-F
dentifrices in short term clinical trials
Red Laser fluorescence
• In 1998, Hibst & Gall showed that exposing a tooth
surface to red light (638– 655nm) can help
differentiate between sound and carious tissue
because fluorescence intensity caused by
excitation in caries lesions exceeds that of healthy
tissue.
• Red emission light as well as infrared fluorescence
excitation radiation are less absorbed and
scattered by enamel than light of shorter
wavelength.
• Red light penetrates deeper in the tooth material,
and it is therefore possible to detect fluorescence
even from carious dentine under visibly sound
enamel.
Red Fluorescence: how
• When bacteria have colonized the biofilm, plaque,
tartar or lesion, they produce metabolic products.
• Some of these fluoresce red (>600 nm). This signal
is much brighter than the yellow/green
fluorescence.
• The red fluorescence is therefore a measure of the
local bacterial activity and a measure of the threat
the location poses.
Red Fluorescence: how

E D
Examples of bacterial activity
DIAGNOdent®
• Consists of a laser diode as the excitation
lights source (655nm, 1 mW peak power)
and a photo diode combined with a long pass filter
(transmission > 680nm) as the detector.
• The red laser excitation light (λ = 655nm) is
transmitted through an optical fibre on the tooth.
• A bundle of 9 fibres arranged concentrically
around the excitation light fibre transports light for
detection.
• The emitted fluorescence, as well as back-
scattered ambient light is collected through one tip
and passed in ascending fibres to a photo-diode
detector.
• To discriminate the fluorescence from ambient light, the
laser diode is modulated. By amplifying only the
modulated portion of the signal, the ambient light is
suppressed.
• The signal of the fluorescence is finally processed and
presented on the display as digits between 0 and 99. A
reading is provided on a digital display accompanied by
an audible tone.
The tip of Diagnodent pen
• There are different shapes of tips for the hand piece.
• A tapered tip A has been designed for detection of fissure
caries and tip B for smooth surfaces.
• In order to collect fluorescence from the maximum
extension of carious lesions on occlusal surfaces, the tip
must be tilted and turned around the site to be measured.
This ensures that the tip picks up fluorescence from the
slopes of the fissure walls, where the caries process is
believed to start. The acoustic signal with increasing digits
helps the examiner to find the site of the maximum
fluorescence value.
• the surfaces must be plaque-free, and the probe must be
rotated in all directions to obtain the highest reading.
Reading guidelines
• There are guidelines provided by the manufacturer
(KaVo 1998a3, b4, 1999, 2001, and 2002) and
researchers (Lussi et al. 1999, 2001, Shi et al.
2000, and Pereira et al. 2001) for cut-off points of
the laser fluorescence readings referring to
respective degree of dental caries status and
giving guidelines for clinical procedures
Infra-Red
Fluorescence:
Diagnodent®
Values Interpretation Recommendation

0-13 Sound no treatment

14-20 Enamel lesion preventive treatment

>20 Dentin Lesion preventive or restorative treatment

depending upon risk
>30 Dentin Lesion restorative treatment

Lussi et al, 2001

 Caries Prevention

1 2 3

Reduce the Increase the Augment

pathogenic resistance of salivary
potential of tooth factors
dental plaque structure to
caries attack
◼ This should be done while
managing risk factors
through all of the
elements in the caries
management cycle and
recalling patients at
appropriate intervals, with
periodic monitoring and
reviewing.

103
Element 1- Caries Risk Assessment

104
Element 1- Caries Risk Assessment

◼ ICCMS™ embraces the CAMBRA (Caries Management by Risk

Assessment) philosophy for risk assessment.

◼ Some other examples of caries risk assessment methods are listed

below:
❖ Cariogram
❖ ADA
❖ University of Michigan / University of Indiana
❖ University of North Carolina
❖ Dundee Risk Assessment Model
❖ Caries Management book’ risk form
❖ The ICCMS risk factors

105
 Saliva
Microbial
Colonization

SES,
Oral Hygiene,
Caries
Diet
Experience

Behavior
 Sociodemographic
Status

Saliva
•Buffer capacity
•Composition
•Flow rate
Education Antibacterial
Agents Income
Tooth Protein

Dental Sealants

Diet Sugars
Fluoride •Amount •Clearance rate
•Composition Caries Time •Frequency
•Frequency

Behavior
•Oral hygiene Ca
•Snacking Chewing Gum Bacteria P04
In
Biofilm Dental
Insurance
Coverage
Plaque pH
Microbial Species

Knowledge/ Selwitz RH, Ismail AI,

Oral Health
Literacy Pitts NB. Dental caries.
Lancet 2007 369: 51-59
Patient level caries risk factors

108
Element 2- Caries Staging and Lesion Activity

109
In a systematic review, Zero et al. concluded that for caries prediction in permanent
teeth in adults, past caries experience was the best predictor, followed by education
and marital status, probably because these factors influenced attitudes towards oral
health.

110
111
112
Element 2- Caries Staging and Lesion Activity

113
Element 2- Caries Staging

◼ The staging of caries lesions involves two

steps of the caries diagnosis process:

◼ Lesion detection (which implies an objective

method of determining whether or not caries
disease is present)

◼ Lesion assessment (which aims to

characterise or monitor a lesion once it has
been detected).

114
International Caries Detection and
Assessment System (ICDAS)
• ICDAS (the International Caries Detection and Assessment System) is a
new approach for coding and recording the six stages of caries severity,
varying from initial changes visible in enamel to frank cavitation in
dentine.
• The essential feature of ICDAS is the subdivision of stages of the
continuum of dental caries into a variable number of discrete and
predicable categories based upon the histological extent of the lesion
• within the tooth
International Caries Detection and
Assessment System (ICDAS)
• 0 Sound
• 1 First Visual Change in enamel
Code 0 Code 1 Code 2 Code 3
• 2 Distinct Visual Change in enamel
• 3 Localized enamel breakdown
• 4 Underlying dentine shadow
• 5 Distinct cavity with visible dentine
• 6 Extensive cavity with visible dentine

Code 4 Code 5 Code 6

Element 2- Lesion activity

◼ The scientific definitions and characteristics of active

and inactive lesions have been d described as:

◼ An Active Lesion is considered to have a greater

likelihood of transition (progress, arrest or regress)
than an inactive lesion (there is an increase in dynamic
activity in terms of mineral movement).

◼ An Inactive (arrested) Lesion is considered to have a

lesser likelihood of transition than an active lesion
(there is less movement of mineral and the lesion stays
at the same stage of severity.)

119
Element 2- Lesion activity

120
Element 3- Decision Making (Diagnosis)

121
Element 3- Decision Making (Diagnosis)

122
Element 3- Decision Making (Diagnosis)

The current caries status at the patient level synthesises whether or not there are
any active lesions (sound and/or inactive caries), whether active lesions at the
patient level are initial stage caries, or whether active lesions at the patient level
are at a moderate and/or extensive stage of severity.

123
Element 4- Management:

◼ After defining the individual patient’s likelihood risk status and

the diagnosis for each lesion, we can plan personalised caries
prevention, control & tooth preserving operative care

◼ The Personalised Comprehensive Caries Care Plan involves and

interconnects:
❖ Managing patient’s likelihood for new caries and/or progression
❖ Managing individual caries lesions, with caries related treatment
when they are active and defining different options according to
their severity and taking into account if the dentition is primary or
permanent for coronal caries.

◼ The Management Element Includes:

❖ Preventing New Caries
❖ Non-Operative Care of lesions (NOC) (Control)
❖ Tooth Preserving Operative Care of lesions (TPOC),
124
Element 3- Management:

125
Element 4- Managing a patient’s risk factors

◼ The patient’s caries risk factors management plan is tailored at

the individual level and involves actions to protect sound tooth
surfaces from developing new caries lesions, and all current
active and inactive lesions from progressing.

◼ It aims to lower the risk status of the patient when moderate or

extensive, and to maintain if low.

◼ A preventive plan should address both homecare and clinical

interventions/approaches adjusted to the caries risk likelihood
status of each patient.

◼ The intensity of the intervention is cumulative

126
127
Dear (Patient X),
Congratulations, you have been assessed at low risk for future dental decay. We want to
help you stay that way. You will find that you will be able
to maintain your current level of oral health if you do the following:
■ Brush twice daily with an over-the-counter fluoride-containing toothpaste.

■ Review with us your dietary and oral hygiene habits and receive oral hygiene instructions. If

good, continue with your existing dietary and oral

hygiene habits unless there is a change in status, such as new medications.
■ Get a thorough professional cleaning as needed for your periodontal health. We will be

happy to provide these cleanings for you.

■ Return for a caries recall exam (when requested) in six to 12 months to re-evaluate your

current caries risk.

■ Have new bitewing radiographs (X-rays) taken about every 24 to 36 months to check for

cavities.
■ Consider using xylitol gum/candies and over-the-counter fluoride rinse (0.05 percent

sodium fluoride) instead of regular gum/candy or mouthwash.

■ Get fluoride varnish after teeth cleanings, base line bacterial test, sealants if your dentist

recommends it. You may or may not need this. It

depends on your oral conditions.
■ Other recommendations:

128
Dear (Patient Y),
You have been assessed to be at moderate risk for new dental decay in the near future
because you have (fill in the blank). We want you to move
into a safer situation to avoid new decay in the future. Here are some ways to accomplish
this goal:
■ Review your dietary and oral hygiene habits with us and receive oral hygiene instructions.
■ Brush twice daily with an over-the-counter fluoride-containing toothpaste, following the
oral hygiene instruction procedures you have been
given.
■ Purchase an over-the-counter fluoride rinse (0.05 percent sodium fluoride, e.g. Fluorigard
or ACT) and rinse with 10 ml (one cap full) once or
twice daily after you have used your fluoride toothpaste. Continue daily until your next
dental exam.
■ Get a thorough professional cleaning from us as needed for your periodontal health.
■ Chew or suck xylitol-containing gum or candies four times daily.
■ Return when requested for a caries recall exam in four to six months to re-evaluate your
progress and current caries risk.
■ Get new bitewing radiographs (X-rays) about every 18-24 months to check for cavities.
■ Get a fluoride varnish treatment every four to six months at your caries recall exams.
■ You may also need a base line bacterial test and sealants (depending on your situation
and condition).

129
Dear (Patient Z),
Our assessment reveals you are at a high risk of having new dental decay in the
near future because you have (fill in the blank). We want to help
you to move to a safer situation to avoid new decay if at all possible. We strongly
recommend the following:
■ Complete a caries bacterial test with us today (as a base line before antibacterial
therapy). We will have the results of this test in three days.
■ Complete a saliva flow measurement to check for dry mouth. This is a very simple
test that we will do today as part of the bacterial assessment.
■ Review with us your dietary and oral hygiene habits and receive instructions on
both. The most important thing is to reduce the number of
between-meal sweet snacks that contain carbohydrates, especially sugar.
Substitution by snacks rich in protein, such as cheese, will also help
as well as the xylitol gum or candies described below.
■ Brush twice daily with a high fluoride toothpaste, either Control RX or Prevident
Plus toothpaste (5,000 parts per million fluoride). We will
provide some for you today. This is to be used twice daily in place of your regular
toothpaste.

130
■ Rinse for one minute, once a day with a special antibacterial mouthrinse we will
provide for you today. It is called Peridex or Periogard and
has an active ingredient called chlorhexidine gluconate at 0.12 percent. You should
use this once daily just before bed at night (10 ml for one
minute), but only for one week each month. You must use this at least one hour
after brushing with the 5,000 ppm fluoride toothpaste.
■ Have the necessary restorative work done, such as fillings or crowns, as needed,
in a minimally invasive fashion.
■ Suck or chew xylitol candies or gum four times daily. You can obtain supplies from
us today or we can help you buy these elsewhere.
■ Get sealants applied to all of the biting surfaces of your back teeth to keep them
from being reinfected with the bacteria that cause dental
decay. We will be happy to do this for you.
■ Return when requested for a caries recall exam in three to four months to re-
evaluate your progress and current caries risk.
■ Participate in another caries bacterial test at your caries recall exam or earlier to
compare results with your first visit. This will allow us to
check whether the chlorhexidine is working satisfactorily.
■ Allow us to review your use of chlorhexidine and Control RX/Prevident and oral
hygiene at that visit.
■ Get a thorough professional cleaning as needed for your periodontal health.
■ Get new bitewing radiographs (X-rays) about every six to 18 months to check for
cavities.
■ Get a fluoride varnish treatment 131
Element 4- Managing Individual Lesions

◼ The Management Element Includes:

❖ Preventing New Caries
❖ Non-Operative Care of lesions (NOC) (Control)
❖ Tooth Preserving Operative Care of lesions (TPOC),

◼ The levels of clinical management recommended for active

lesions are defined as follows:
❖ MInitial: Initial caries management stage (Non-Operative care (NOC) -
control)
❖ MModerate: Moderate caries management stage (in general TPOC)
❖ MExtensive: Extensive caries management stage (in general TPOC)

◼ For sound surfaces and inactive lesions, risk-based prevention is

recommended.

◼ Surgical restorative interventions are only

used as a last resort. 132
Element 4- Managing Individual Lesions

133
134
◼ With respect to Caries Associated with
Restorations or Sealants (CARS) ICCMSTM
recommends to either seal or repair defective
or carious margins wherever possible. This
also applies to defective or lost fissure
sealants, which require maintenance/ repair
only.

135
 The International Caries
Classification and
Management System is a
health outcomes
focused system that
DETECT
aims to maintain health
and preserve tooth
& Assess
structure. It uses a
simple form of the ICDAS
Caries Classification Caries Staging & Activity
model to stage caries
severity and assess (CLASSIFICATION &
lesion activity in order to
derive an appropriate,
INTRA-ORAL RISK)
personalised,
preventively based, risk-
adjusted, tooth
preserving Management
Plan.
DETERMINE DECIDE
Patient-level Caries Risk
ICCMS™4D Personalised Care Plan:
Caries Management Patient & Tooth Levels

(DECISION MAKING)
(HISTORY)

Risk-based
Recall
interval
DO
Appropriate Tooth
& Patient
Preserving Caries
Prevention & Control
Interventions
(MANAGEMENT)
 ICCMS™ Caries Categories
1 DETERMINE Patient Level Caries Risk 2.1 DETECT & ASSESS Sound Initial Active Initial Inactive
First/distinct
Caries Staging & visual changes in
enamel (ICDAS
Patient-level Risk Factors Activity Status 1& 2)

The International Caries

‒ Head and Neck Radiation No evidence
Moderate Active Moderate Inactive Enamel
Classification and
‒ Dry mouth of visible breakdown/
‒ Inadequate OH practices caries after 5- underlying
Management System is a
health outcomes
focused system that
‒
‒
Deficient exposure to topical Fluoride-
High frequency/amount of sugar
DETECT second air-
drying (ICDAS
0)
dentine shadow
(ICDAS 1 & 2)
aims to maintain health
and preserve tooth ‒
consumed
Symptomatic-driven attendance
& Assess Extensive Active Extensive Inactive
Distinct cavity with
structure. It uses a
simple form of the ICDAS
‒
‒
Socioeconomic Status/Access barriers
Mothers high DMF (caries experience)
Note: Where available
combine with
11 visible dentine
(ICDAS 5 & 6)
Caries Classification Risk factors in red will always classify an
Caries Staging & Activity radiographs.
model to stage caries individual as high caries risk.
severity and assess (CLASSIFICATION & 2.2 ASSESS Intra-Oral Risk Factors
lesion activity in order to
derive an appropriate,
INTRA-ORAL RISK) Intra-Oral Risk Factors
personalised, ‒ Hypo-salivation/Dry mouth
preventively based, risk-
‒ PUFA- Dental Sepsis
Risk
adjusted, tooth
preserving Management
‒ Caries experience factors in
Plan.
‒ Thick plaque red will
always
‒
DETERMINE DECIDE > biofilm retention classify an

DO Appropriate
4 Prevention &
Preservation Interventions
Management at the patient level
Homecare
2-day toothbrushing
[≥1,000 ppm F-]
Motivational engagement: improve oral
ICCMS™4D ‒ individual
Exposed root surfaces as high
caries risk.
Patient-level Caries Risk Personalised Care Plan:
Caries Management Patient & Tooth Levels
DECIDE on a
3 Personalised
(DECISION MAKING)
(HISTORY)
Care Plan
Clinical Interventions/Approaches
hygiene & reduce free sugars
Risk-based
Recall
interval
DO Tooth & surface level Patient level

Improve oral-health Professional cleaning ICCMS™ Caries Diagnosis

Appropriate Tooth
behaviour Sealing
F- mouthrinse 2-4/year-F- varnish/gel/ solution & Patient ICCMS™ Sound
Modifying hyposalivation Preserving Caries ICCMSTM Initial Active/Inactive
Interval recalls: 1-3 m in high-, 3-6 m in
moderate-, 6-12 m in low likelihood Prevention & Control ICCMSTM Moderate Active/Inactive
Interventions
ICCMSTM Extensive Active/Inactive
(MANAGEMENT)
Management of individual lesions
Non-Operative Care- Control Tooth-Preserving Operative Care
Management of individual Management at the patient
Fluoride varnish, gel, toothpaste (+ Tooth-preservative restorations
Oral Hygiene) Step-wise excavation / Pulp Preserving restorations active lesions level
Sealing (resin-based, GI, infiltrants) Sealing / Hall Technique / ART
Mechanical biofilm removal
 Example

Patient information:

Male, 25 years old, he lives in

Elsinnore, Denmark (ppm F in the
water supply = 0.3ppm)

Chief medical and dental

complaints:
“I have problems with food impaction
and have not been to the dentist in
the last 3 years 138
Element 1- Risk Assessment

139
Element 1- Risk Assessment

140
Element 2- Caries Staging and Lesion Activity
Assessment plus Intraoral Caries Risk Factors

141
Element 2- Caries Staging and Lesion Activity
Assessment plus Intraoral Caries Risk Factors

Several coronal caries lesions were detected and staged as Initial,

Moderate or Extensive in a number of surfaces by means of the
ICCMS™ visual scoring system. Lesions were further assessed as
Active or Inactive was further assessed in each lesion.
142
Element 2- Caries Staging and Lesion Activity
Assessment plus Intraoral Caries Risk Factors

143
Element 3- Decision Making: Synthesis and
Diagnosis

144
Element 3- Decision Making: Synthesis and
Diagnosis

145
Element 3- Decision Making: Synthesis and
Diagnosis

146
Element 4- Management:

Managing a patient’s risk factors

◼ Home care
❖ Instruction in tooth brushing and flossing
❖ Tooth brushing 2/day ≥ 1,450 ppm F- dentifrice
❖ General Behaviour Modification in Oral Health:
❖ Diet counselling: stop /reduce the use of sugar in the coffee
❖ Diet counselling: reduce the number of in-between meals

◼ Clinical Interventions/ approaches

❖ Motivational reinforcement and One-to-one dietary intake interventions
❖ F- Varnish four times per year
❖ Recalls every 3 months where professional cleaning and local treatment
with fluoride is done on active lesions

147
148
Element 4- Management:
Managing Individual Lesions
◼ 38 Occlusal-Distal: NOC /
TPOC
❖ Stepwise excavation /
Extraction
◼ 37 Mesial, Buccal: NOC
❖ Oral hygiene instructions
❖ Fluoride varnish
◼ 36 Occlusal-Distal: TPOC
❖ Restoration
◼ 35 Distal: NOC
❖ Oral hygiene instructions
❖ Fluoride varnish
◼ 47 Mesial-Occlusal: TPOC
❖ Restoration
◼ 48 Occlusal, Buccal
❖ Extraction
149
150