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Caries Prevention and Management Chairside Guide

The goal is to reduce the impact of caries development by intervening as soon as possible to manage further tooth destruction, and reversing the caries
process in favour of remineralization. Ideally, the management of early caries lesions should involve the least invasive approach capable of preventing
disease progression and empowering the patient to improve and maintain their own oral health.

Understanding Lesion Activity Determining Caries Risk

The essential challenge is to differentiate between firstly a lesion which is active Assessing a patient’s caries risk is essential in determining the appropriate level of
today and continuing to suffer net loss of mineral, with demineralization being out of preventive care. Previous caries experience is often the best indicator but several
balance with remineralization, as opposed to a lesion of similar severity which has other factors should be considered when assessing risk.
been “switched off” and become inactive, i.e. arrested or remineralized. The clinical
and economic implications of making the correct activity assessment are profound. HIGH MODERATE LOW
3 or more incipient or cavitated 1 or 2 incipient or cavitated primary No incipient or cavitated primary or
REMINERALIZE ARREST RESTORE
primary or secondary caries lesions or secondary caries lesions in the secondary caries lesions during the
in the last 2 years last 2 years last 2 years and no change in the
Tooth
Sound loss risk factors that may increase caries

Subclinical Initial caries Moderate caries Severe caries

caries* Additional preventive measures are indicated: No additional interventions
• Patient education (oral hygene, dietary counselling) indicated
• Protective factors (fluoride, sealants, salivary stimulation)

Balancing Caries Pathological & Protective Factors

ICDAS 0 1 2 3 4# 5 6
codes Pathological Factors Protective Factors
Non-cavitated Cavitated Frequent consumption of dietary Tooth-healthy diet
sugars Fluoride toothpaste twice daily
Primary Prevention Secondary Prevention Tertiary Prevention
Non-surgical Surgical Inadequate fluoride Professional topical fluoride
Biofilm homeostatic imbalance Preventive and therapeutic
Salivary dysfunction sealants
Normal salivary function
ICDAS Distinct Distinct Extensive
First visual Localized Underlying
visual cavity with cavity with
Dental Sound change in enamel dentine
Terms enamel
change in
breakdown shadow
visible visible Demineralization Remineralization
enamel dentine dentine

ICDAS Disease Health

Detection 0 1 2 3 4# 5 6 Lesion progression Lesion arrest or regression

HIGH MODERATE LOW

*caries refer to carious lesions #
dentine shadow may require surgical treatment in some cases Caries Risk Caries Risk Caries Risk

Action Points
ACTION POINTS

 Assess lesion activity  Assess caries risk  Convert actively progressing lesions into
 Target appropriate level of intervention  Favour preventive measures arrested controlled ones

 Prevent more damage  Minimize surgical intervention  Improve patients’ oral health behaviours

The following caries risk assessment system is age-specific to account for varying risk factors throughout life
 AGE 0–5 years 6–11 years 12–17 years 18–69 years 70 years & older
• Active or previous caries lesions • Reduced salivary flow or salivary pH • Familial risk factors (educational level of parents’/sibling’s
Universal risk factors • Low socio-economic status • Poor oral hygiene oral health status)
• Frequent consumption of dietary sugars • Suboptimal fluoride exposure

• Long-term consumption of sweetened medication • Alcohol and tobacco consumption

• Obesity
• Illness or disability > dexterity and/or compliance problems • Poor oral health knowledge • Genetic background • Family framework and support network
• Information about education/school system • Mouth piercing • Desocialization: loss of hygiene concept
Caries risk assessment

(canteen, boarding school) • Drugs

• Unhealthy diet • Cariogenic diet • Taste disturbance and change in dietary

• Eating disorders habits (risk of dietary deficiencies and
increasing sugar consumption)
• Functional problems with eating
• Dietary advice balances patient needs and
expectations

1 • Increased level of dependance, reduction

in fine motor skill or possible disabilities

Post eruption of permanent teeth: • Medical history (existing condition • Medical history (general and oral health pathologies/comorbidities)
• Fixed orthodontic appliance or disability) • Polypharmacy
• Developmental dental conditions (MIH, • Wisdom teeth eruption
amelogenesis imperfecta etc.) • Mouth guard • Suboptimal restorations, dental prosthesis • Removable prosthesis history: tooth-

DISCLAIMER • Please also consult national guidelines on fluoride • In case of fluorosis risk, it is recommended to use a “smear” (equivalent to 0.1 mg F)
and dentures or implant-borne denture
• Complex existing restorations with poor
oral health

of 1000 ppm toothpaste for young children The fluoride concentrations mentioned in this guideline comply with FDI recommendations
• For all children aged 3 and above, 22,600 ppm fluoride varnish application at least twice per • In case of high caries risk, professional • Non-cavitated caries lesions: 22,600 ppm • Care-facility programme relying on
maintenance
Professional

year up to 4 times a year for high-risk children cleaning at least twice a year fluoride varnish application 4 times a year patients’ needs and abilities
• In case of high caries risk, first and second • Remineralization agents, resin infiltration • Prophylactic cleaning with removal of
• Fissure sealants should be placed upon permanent molars sealing techniques or therapeutic sealants as plaque retentive features
eruption of first permanent molars • In case of high caries risk, 22,600 ppm possible remedies • Filling of sealants and lesions by bio-active
2 fluoride varnish application every 3 months
during 1 year
• Lesions requiring restoration: preserve
tooth structure where possible; ensure
fluoride seals
• Antiseptic varnish application on purified
topical fluoride (gel/foam/varnish) surfaces with/or 22,600 ppm fluoride at
treatment is delivered after restoration least twice per year up to 4 times a year
• Seal or repair defective restorations where
possible. Replace only when necessary

• Twice daily (after breakfast and just before • Twice daily (after breakfast and just before • 2 minutes twice-daily brushing (after breakfast and just before bed) with fluoride toothpaste: do not rinse but spit
bed) supervised brushing with fluoride bed) partial supervised brushing with
RANGE OF FLUORIDE TOOTHPASTE*:
Patient & education

toothpaste (parents/guardians) fluoride toothpaste (parents/guardians)

• 1,500 ppm fluoride
RANGE OF FLUORIDE TOOTHPASTE*: RANGE OF FLUORIDE TOOTHPASTE*:
maintenance

• 6–12 months: • Low caries risk: 1,000/1,500 ppm fluoride RANGE OF FLUORIDE TOOTHPASTE*: RANGE OF FLUORIDE TOOTHPASTE*:
1,000 ppm fluoride below rice size on • High caries risk: 1,500 ppm fluoride • Up to 2,800 ppm fluoride till 16 years • Up to 5,000 ppm fluoride (upon prescription or professional recommendations)
compress or baby toothbrush from 6–10 years old & 2,500 ppm fluoride old and up to 5,000 ppm fluoride in case of very high risks
3 • 1–3 years old: from 10–12 years old (upon prescription or professional
recommendations from 16–18 years old) in In case of dry mouth or hyposalivation, sugar-free chewing gum and salivary substitutes
1,000 ppm fluoride below rice size
• 3–6 years old low caries risk: case of very high risks
1,000 ppm fluoride pea size
• 3–6 years old high caries risk: • Fluoride mouthwash, dental floss and interdental brushes, tongue brushing and specific toothbrush
1,450 ppm fluoride pea size
• Denture hygiene
• Soft tissue care
• Chlorhexidine or fluoride rinsing
RICE SIZE PEA SIZE
mouthwash at different times

2 times a year for children (please also consult European Academy of Paediatric Dentistry ALL PATIENTS: 1 time a year - High risks: 2 times a year to be adapted (please consult national guidelines for high-risk patients*)
! RECALL guidelines and national guidelines for high-risk children)