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Several major trends in dentistry that are connected to caries management will affect everyone in the profession over the next several years. The largest of these trends is consolidation, or the growth of large group dental practices. This phenomenon has been occurring over the last 1 to 2 decades and appears to be continuing at a steady rate of growth. Another trend is in technology integration and the use of "big data" to perform clinical analyses and predict clinical outcomes. Attempts have been made to use such data to provide direction to clinicians in caring for patients; today, however, the data and analyses have been used mainly by third-party payers to assess the likelihood of success of one particular form of treatment versus another. It is believed by this author that the use of big data will improve the quality of care. However, this technology will not ultimately be useful until the most effective outcome measures have been determined for the success of various treatments. Additionally, various payer system changes have occurred and will continue to occur. These include the trend towards managed care in compensation systems, which provides compensation for the necessary elements of time to counsel patients and other factors needed to promote health as opposed to just treating results of disease.1 This trend, as well as the other topics in this paragraph, are major issues but will not be discussed further in the present paper. The trend that could change the profession more than anything else is what is often referred to as "medical management of oral disease" or "medical management of dental caries."
Dental Caries Overview
Rather than waiting for the disease dental caries to manifest itself in the need for restorative dentistry, medical management of caries implies that it will be managed as a chronic disease, such as diabetes, periodontal disease, and other chronic conditions. With this concept, there is a focus on prevention and recognition that caries manifests itself significantly in some patients, and not others; therefore, there is more concentration on interceptive practices, health outcomes, and improving quality of life by mitigating the effects of the disease through aggressive management.2-4
Restorative dentistry is the major part of dental practice in terms of procedures and is the most common type of surgery performed on humans. Even G.V. Black, the father of modern restorative dentistry, who developed cavity classifications for the use of amalgam restorations, was, in his own words, "saddened" that he was unable to prevent caries disease and that, particularly in children, the disease often progressed to a state where it needed to be managed through restorative dentistry. He described this as a necessity of dental care because the disease could not be detected in the early stages, when aggressive intervention might be more useful. G.V. Black himself used silver nitrate as a way to treat caries lesions when they could be visualized clinically.5
The gross domestic consumption of dentistry in the United States is approximately $115 billion a year. The vast majority of this, approximating 70% of the total dollars, is spent related to treating the results of dental caries.6 This includes most restorative dentistry, much of prosthodontics, much of endodontics, and much of what is termed esthetic dentistry performed because of the need to restore teeth that were broken down due to the caries process.
Most of what professional product manufacturers make and most of what dentists perform in their practices is done to treat the effects of dental caries instead of the disease itself. Pediatric dentists often see the manifestations of caries in the most severe forms, including facial cellulitis, which can present with children at a very young age in the emergency department of a hospital as a life-threatening condition that must be treated immediately.7
The caries management continuum (Figure 1) has been developed to indicate the level of invasiveness of caries lesions. On the left side of this continuum are microbial control treatments and salivary control treatments. On the far right of this continuum is traditional operative dentistry. In between are less-invasive forms of treatment, such as remineralization therapies, resin infiltration, and the newly introduced silver diamine fluoride, along with the next stage of intervention: minimally invasive restorative dentistry, which has been the trend for some time, and defect-specific glass-ionomer/resin composite combinations that are less invasive in nature.8
Caries Risk Assessment
Risk assessment tools are also developing rapidly. However, most dental caries risk assessment tools are highly sensitive but not specific. There too many false positives. Therefore, it is nearly impossible to determine exactly which patients will manifest with the most aggressive forms of caries disease and which will not.9-11 It would be more desirable to have a specific risk assessment tool that could precisely predict who will manifest with the disease or who is most likely to manifest so that aggressive interventions could be provided for those patients. Such aggressive intervention for large numbers of patients, many of whom will not manifest with the disease, is not cost-effective and takes away from the concept of effective managed care and medical management of disease.
The focus of dentistry has shifted from treating the results of dental caries to prevention of the disease itself. This shift began to occur largely when fluoridation came into the water supplies and fluoride toothpaste came into the mouths of patients. Now, in addition to these important interventions, the concept of reducing risk factors for patients by differentiating patients into various risk categories based on ever-improving risk assessment tools has been introduced. Approaches can now be targeted more effectively for those in need of more aggressive medical management relative to those who do not.
However, a new concept in caries risk evaluation and caries management is needed. Demineralization of tooth structure resulting in cavitation from dental caries occurs over time. Structural changes are not reversible at a certain point, and that is when restorative dentistry must be undertaken. This accounts for the vast majority of dental treatments. If detection tools were available that were very specific at an earlier stage before cavitation, small lesions could be detected before cavitation, and intervention could be more aggressive with medicinal therapeutics as they become available. Unfortunately, there are no clinically tested specific diagnostic tests that could identify such lesions.12
A useful diagnostic device for detecting caries at its earliest point in time would be sensitive and specific. In addition to being generally reliable, it would be reliable between examiners and with the same examiner using the device at different points in time.
Devices have been developed or are being developed for the purpose of caries detection at an earlier phase, with the intent that restorative dentistry could be avoided in some instances and medicinal therapeutic treatments provided instead. Some of the technologies deployed toward this end employ chemical signature techniques, fluorescence techniques, topography scanning techniques, and photothermal methods. The chemical signature technique takes advantage of the fact that when the bacterial biofilm progresses into tooth structure as it demineralizes, it leaves compounds called porphyrins that can be detected by their fluorescent signature. This fluorescence, when visualized and measured through computer analytic technology, can show the depth and extent of caries lesions at a very early stage. By deploying this technology of fluorescence measurement into devices, the caries lesions can be mapped in a noninvasive form and at an early stage. As improved medicinal therapeutics are developed, they could be used to attenuate, halt progression of, or otherwise stop a cavity, even before it forms. Topographical devices can do a better job of providing good visualization to the clinician by scanning the surface using better frequencies of light.13
Photothermal techniques are deployed in at least one product currently and have significant potential for early detection of caries lesions. Using infrared radiation to measure the conductivity of heat through a tooth is a good analog to demineralization of tooth structure. As these various technologies are better deployed into devices and as they are tested with clinical outcome studies with a concentration on being more sensitive and specific, it is likely that a successful device will be developed that can be more predictive of caries.14-20
Likely the most important and largest area of discovery related to dental caries taking place today is in the realm of plaque biofilms.21,22 For well over two decades, it has been known that analyzing the role of plaque is not a simple task; the thought that streptococci and lactobacilli are uniquely responsible for the progression of dental caries is not accurate or precise. It is now known that the complex biofilm of the mouth that contains over 500 unique species of bacterial organisms is a system where different bacteria interact with one another in the same way that the organs of the human body interact through hormones and other signaling methods. In fact, the signaling between bacteria is quite complex. Elucidation of this complex structure of intra-biofilm communication is occurring at a rapid rate in laboratories all around the world. It is believed that the growth of laboratory science technology in determining how to predict which bacteria communicate with which others, as well as how to interrupt these chemical signals, will achieve effective results for developing medicinal products that could be used for treating caries. Specific drugs that might be developed to attenuate acid production in caries could be part of the future of discovery wherein caries could be treated in a medical model scenario in the same way that many chronic diseases are treated medically and not just surgically.
Silver Diamine Fluoride
Silver diamine fluoride, the first treatment of dental caries offered as a "drug" in the dental office 2 years ago, is an important intervention.21-25 Silver diamine fluoride must be applied fully on the lesion, and it must access the full extent of the lesion. Therefore, although it is effective in halting progression of caries lesions after being cavitated, non-cavitated lesions cannot be presented with the liquid silver diamine fluoride, so it is not able to halt progression of non-cavitated lesions. Perhaps delivery systems will become available to inject silver diamine fluoride or other agents into partially cavitated or non-cavitated lesions so that the powerful effect of halting lesion progression could take place in small lesions as well. In the meantime, silver diamine fluoride will be a useful adjunct to treatments, particularly for very young children; in some cases it can delay the need for restorative care, especially to delay restorative care under sedation or general anesthesia.
Conclusion
It is encouraging that the use of silver diamine fluoride has become widespread in dental care for children, as well as for adults who have small areas of existing restorations that have become further decayed or who are undergoing medical treatments that make them more susceptible to dental caries progression. Additionally, the fact that dental disease is now being looked at as a chronic disease, and then potentially treated as such, is an exciting development for dentistry.
About the Author
Joel H. Berg, DDS, MS
Professor Emeritus, Department of Pediatric Dentistry, University of Washington School of Dentistry, Seattle, Washington
Queries to the author regarding this course may be submitted to authorqueries@aegiscomm.com.
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