12

Dental Caries
Norman Tinanoff

CHAPTER OUTLINE

Consequences of Dental Caries

Epidemiology of Dental Caries
Primary Teeth
Permanent Teeth
Dental Caries Factors
Enamel
Caries Microbiology
Preventing Dental Caries
Education and Changing Oral Health Behaviors
Diet
Tooth Brushing
Optimally Fluoridated Water
Fluoride Supplements
Professionally Applied Topical Fluorides
Antimicrobials
Sealants
Caries Risk Factors
Previous Carious Experience
 Dietary Factors
Microbiologic Factors
Maternal Factors
Visible Plaque
Enamel Developmental Defects
Socioeconomic Status
Care Pathways for Caries Management

Dental caries is perhaps the most prevalent chronic disease The

outcome of the disease is dental decay The disease is the result of a
complex interaction between acid producing tooth adherent
bacteria and fermentable carbohydrates Over time the acids in the
dental plaque may demineralize enamel and dentin in the fissures
and the smooth surfaces of the tooth The earliest visual sign of
dental caries is the so called white spot lesion If demineralization
continues the surfaces of the white spot will cavitate resulting in a
cavity However if the demineralization environment is reduced or
eliminated white spot lesions may remineralize and not progress
Risk for caries includes factors such as high numbers of cariogenic
bacteria high frequency sugar consumption inadequate salivary
flow insufficient fluoride exposure poor oral hygiene and poverty
The approach to caries prevention should be based on patient
centered and evidence based practices regarding the reduction of
risk factors and increase in preventive factors Caries management
if overt disease is present should be focused on assessment of
patient compliance and whether the disease will continue to
progress as well as tissue preserving approaches

Consequences of Dental Caries

The seriousness and societal costs of dental caries in children are
enormous Dental caries is still a major public health problem in
high income countries and is increasing in many low and middle
income countries The consequences of dental caries often include
high treatment costs loss of school days pain causing diminished
ability to learn hospitalizations and emergency room visits
disabilities and even death reduced oral health related quality of
life and other problems such as being ashamed to smile and
problems eating
Although practitioners deal with children in dental pain
periodically there are few studies of the epidemiology of children s
dental pain One study of Head Start children in Maryland reported
that of children with caries complained of a toothache and
cried because of a toothache With regard to objective data for
hospital visits due to dental problems in children the Texas
Children s Hospital in Houston reported emergency room
dental visits for children less than years of age between and
of which were for nontraumatic dental problems A
California study of emergency department visits showed that the
rate for preventable visits for children under years of age was
per in and per in With regard to the
cost of dental care a national study of children under age found
that dental care was per year in That cost now is
considerably higher due to medical inflation By any estimate
dental caries has a major effect on children s quality of life physical
health and family and societal costs

Epidemiology of Dental Caries

Primary Teeth
Information from the National Health and Nutrition Examination
Survey NHANES has been used to follow changes in dental caries
prevalence in US children This national study is more reliable than
other surveys because of its large sample size national
representativeness and careful standardization of examiners
Furthermore because these surveys include socioeconomic factors
insights can be derived regarding the prevalence of dental caries
and its treatment in US children at various income levels Studies
conducted between and have shown a consistent
relationship of dental caries prevalence with poverty levels in the
United States with those that are near poor or poor often having
twice the caries prevalence found in nonpoor children Also of
interest was that there was found a consistent increase in caries
prevalence in children in all socioeconomic levels in the years
between surveys Table Therefore one can conclude that in
general poverty has a major impact of caries prevalence in
children but the reasons for the effect has not been determined and
may be related to preventive behaviors and diet

TABLE 12.1
US Prevalence of Dental Caries in the Primary Dentition of
Children, 2 to 8 Years Old by Poverty Status and Survey Years

NHANES NHANES
years Poor
Near poor
Nonpoor
years Poor
Near poor
Nonpoor
Poor = 0% to 99% of federal poverty level.
Near poor = 100% to 199% of federal poverty level.
Nonpoor = >200% of poverty level.
NHANES, National Health and Nutrition Examination Survey.
Data from Dye BA, Tan S, Smith V, et al. Trends on oral health status: United States,
1988–1994 and 1999–2004. National Center for Health Statistics. Vital Health Stat.
2007 11(248 :1–92.

Another important finding from examining NHANES data in

to year old children over quarter of a century is the remarkable
shifts in decay and filled teeth over time This national data show
that mean number of decayed tooth surfaces was constant over the
years except for the and surveys
Remarkably the survey reported an approximately
reduction from the previous survey Also of great interest is that
even though the survey showed a large reduction in
mean decayed teeth the number of filled teeth proportionally
increased Fig The large reduction in dental caries and the
large increase in filled surfaces may indicate greater access to care
for to year old children
 FIGURE 12.1 Decayed and filled primary tooth
surfaces (DFS for children ages 2 to 5 in the United
States between 1988 and 2012. Dark bars represent
mean decayed tooth surfaces light bars represent
mean filled tooth surfaces. (Modified from Dye BA, Hsu K-L, Afful J.
Prevalence and measurement of dental caries in young children. ediatr Dent.
2015 37:200–216.

In the United States many studies of caries prevalence in

preschool populations often are derived from convenience samples
of Head Start and Women Infant and Children WIC populations
that may be greatly different from national data Fig is an
overview of US epidemiologic studies of caries prevalence between
and that shows higher caries prevalence from selected
state populations than from the three national studies NHANES
and The greater caries
prevalence from state surveys is probably due to lower
socioeconomic status of the state samples e g Head Start WIC
children compared with national samples that are generalizable to
the whole US population The greater variability of prevalence in
these state studies also is probably due to the many local factors
that may have influence on caries prevalence in the different
locations such as water fluoridation access to care and
socioeconomic levels One should recognize that national
surveillance survey data might not reflect the caries prevalence of
specific population of interest

FIGURE 12.2 Caries prevalence of US studies of

children under age 6, listed chronically between 1988
and 2012. Left-hand column shows dates that study
was conducted, location, and publication date.
NHANES, National Health and Nutrition Examination
Survey. (Unpublished data from Alkuhl H, Tsai YJ,
Tinanoff N, 2017.

Permanent Teeth
From the NHANES survey it is apparent that caries
prevalence also remains high in permanent teeth of US children
This most current survey found that children aged to had a
caries prevalence of in their permanent teeth and children
aged to had a prevalence of Approximately of
children aged to had untreated dental caries in the permanent
teeth The high caries prevalence at age to years old is
remarkable since the permanent teeth generally start erupting
around age With regard to the association of race ethnicity and
dental caries in permanent teeth the survey found that
caries was highest in Hispanic to year old children
compared to for non Hispanic white children and for non
Hispanic Asian children
The dental caries prevalence also was found to be high in
adolescents with of the to year olds and in to
year olds having experienced dental caries in their permanent
teeth With regard to untreated dental caries of children aged
to had untreated caries and of children aged to had
untreated caries As these epidemiologic studies of both primary
and permanent teeth show dental caries experience is still highly
prevalent in children of all ages with a large percentage of teeth
with caries not having treatment

Dental Caries Factors

Enamel
The earliest macroscopic evidence of a dental carious lesion is
known as a white spot lesion Such lesions are best seen after the
tooth surface is cleaned and air dried These lesions form in areas of
plaque accumulation such as in occlusal fissures on interproximal
surfaces and the gingival thirds of teeth The enamel at the white
spot stage is hard and the surface may or may not be rougher than
surrounding areas not affected by demineralization Fig

FIGURE 12.3 White spot lesions on the gingival third of

primary incisors.
 A white spot lesion indicates that there already has been
considerable loss of enamel in the affected area due to
demineralization from acids derived from bacterial metabolism If
demineralization of the white spot continues the surface will
cavitate resulting in a cavity However if the demineralization
environment is reduced or eliminated white spot lesions may
remineralize Evidence of remineralized white spot lesions is
indicated by the lesions not enlarging as well as lesions no longer
on the gingival margin as the tooth erupts Fig

FIGURE 12.4 Arrested white spot lesions on primary

central incisors, suggested by lesions at a distance
from the gingival margin.

Thin ground sections of teeth visualized by polarized light

microscopy illustrate the process of demineralization and
remineralization often associated with white spot lesions Fig
The outermost microns of the white spot lesion often is called the
surface zone This area on ground section appears relatively intact
but may be more porous that sound enamel The surface zone
remains relatively intact due to remineralization from calcium
phosphate and fluoride in saliva Subjacent to the surface zone is
the body of the lesion which is the most demineralized part of the
lesion It has a pore volume of to and is visualized as dark
brown with polarizing microscopy due to this loss of enamel If the
lesion continues to progress the surface zone will develop small
defects allowing acids to more rapidly diffuse below the surface If
a demineralizing environment continues the surface enamel will be
undermined and a cavitation will occur Once cavitation occurs
bacteria can readily invade the underlying dentin and are less likely
to be affected by preventive treatments

FIGURE 12.5 Thin ground section of a white spot

lesion visuali ed with polari ed light microscopy. The
body of the lesion is dark due to the larger pore volume
produced by deminerali ation. The surface is intact
and perhaps more dense due to reminerali ation.
(Courtesy Dr. J. Wefel.

There is a certain amount of uncertainty regarding treatment of

white spot lesions because as mentioned before these lesions may
be progressing arrested or remineralizing Besides clinical findings
to help determine activity of these initial lesions there has been a
movement to use caries risk assessment tools to assess potential
progression of caries for individual teeth and for individuals
details later in this chapter If a lesion is considered active then
the management goal should be an individualized patient approach
to reduce the cariogenic environment by affecting the patient s diet
and acid forming bacteria as well as evidence based preventive
measures such as fluoride and sealants

Caries Microbiology
The understanding of the microbiology of dental caries has
progressed with the general field of microbiology The specific
plaque hypothesis proposed by Loesche considered that only
certain bacterial species were responsible for disease With the
development of microbial media specifically for oral streptococci
species such as mitis salivarius bacitracin kanamycin agar
investigators conducted numerous studies that showed strong
association of the so called Streptococcus mutans S mutans with
dental caries prevalence and incidence S mutans was believed to
contribute to caries because of their ability to adhere to tooth
surfaces produce copious amounts of acid and survive and
continue metabolism at low pH conditions With the advent of
DNA techniques the bacteria that was previously described as S
mutans was actually a group of several species mutans streptococci
MS that included the species S mutans S sobrinus S cricetus and
S rattus Importantly the species S mutans is the most common in
man with over of adults harboring this bacterium followed by
S sobrinus that is found in to of individuals Since most
clinical studies and evaluations used in dental practice identify and
quantitate these streptococci by semi selective media that cannot
distinguish between S mutans and S sobrinus it is most appropriate
to refer to the findings from cultural techniques as the group of
bacteria i e MS
The ecological plaque hypothesis proposed in advanced the
understanding of bacterial cariogenicity by identifying how MS
relate to other bacteria in the plaque biofilm It was shown that low
pH values in dental plaque because of frequent sugar consumption
leads to alterations in tooth adherent biofilm favoring bacteria that
can survive and thrive in acidic conditions Thus the acid
production by bacteria not only is a key factor to tooth
demineralization but it also affects the microbial composition of
plaque Because MS are resistant to acid conditions and can
continue to metabolize in low pH environments they have a
competitive advantage over other plaque bacteria and
consequently will numerically become a more dominant species in
low pH dental plaque environments
Recent advances in molecular biology allow further
understanding of the factors involved in the cariogenicity of dental
plaque Techniques such as S rRNA gene sequencing reveal a
complex host bacterial community interaction that does not fit the
single microbial pathogenicity model developed from culturing
bacteria with selective media Molecular methods still support the
concept that MS is a key pathogen in dental caries and that
frequent carbohydrate consumption selects bacteria that are more
acidogenic and aciduric However molecular biology reveals the
complexity of the biofilm by identifying other bacteria that may be
associated with caries e g Lactobacillus species Veillonella
Actinomyces Bifidobacterium Scardovia Fusobacterium Prevetella
Candida etc and gives further understanding of the contribution
and interaction of bacterial community members in disease and in
health
Molecular genetics techniques such as DNA fingerprinting and
ribotyping also have increased the understanding of early
colonization of children with MS These studies show strong
evidence that mothers are the primary source of MS colonization of
their children The exact method of transmission is not known but
it is suspected to be due to close maternal child contact and sharing
of food and utensils Colonization with MS at an early age is an
important risk factor for early caries initiation Studies have shown
that the earlier MS is detected in children the higher the caries
experience
Addressing the management of dental caries as a microbial
disease assists in individualizing patient care based on a patient s
level of cariogenic microorganisms Furthermore knowledge of the
microbiology allows understanding of the caries mechanisms
including frequent sugar consumption that results in low plaque
pHs that foster demineralization as well as allowing MS to have a
competitive advantage over less cariogenic microorganisms

Preventing Dental Caries

Education and Changing Oral Health
Behaviors
Educational programs to prevent or reduce the incidence of dental
caries may involve written material or conversations with parents
or child to reduce high frequency sugar consumption brushing
teeth twice daily with fluoridated toothpaste or participate in
frequent professional visits However outcomes suggest that
educational programs improve knowledge yet only have a
temporary effect on plaque levels and have no discernible effect on
caries incidence Despite these limitations oral health education
continues to be an important component of preventive dental
programs
The technique of motivational interviewing MI to change health
behaviors has shown effectiveness in improving uptake of
educational messages altering oral health behaviors brushing
visiting the dentist diet management and decreasing dental
caries The MI approach attempts to understand patient s
expectations beliefs perspectives and concerns about changing
their health behaviors and the counseling is calibrated to the
patient s level of readiness to change Counseling is nonjudgmental
without coercion or premature suggestions of change options
Patients are given the autonomy to make their own decisions about
change

Diet
Due to the high prevalence of dental caries as well as childhood
obesity more attention is now being devoted to the amount of
sugar sweetened foods and beverages children consume daily
With regard to dental caries simple sugars e g sucrose glucose
and fructose readily facilitate growth and metabolism of MS and
other acidogenic and acid tolerating bacteria species With frequent
sugar consumption the bacteria that are attached to the teeth
produce acid that will reduce the pH of the environment and
produce tooth demineralization Fruit juices fruit flavored drinks
and soft drinks have a substantial cariogenic potential because of
their high sugar content and their frequent consumption between
meals
Since national and international organizations have
developed recommendations for daily sugar consumption that
address obesity and dental caries risk in children Their
recommendation for children ages to is that added sugar should
be less than of daily calorie consumption or approximately
g sugar To put the recommendations on sugar consumption
into perspective one must understand that the amount of sugar in
products commonly consumed often exceeds the daily
recommendation Table lists the sugar content of several foods
and beverages commonly consumed by children at recommended
serving sizes

TABLE 12.2

Examples of Sugar Content in Foods and Beverages Commonly Consumed by

Children

Foods and Beveragesa Grams of Sugar

Sports drink oz
Soda oz
orange juice oz
Chocolate milk oz
Yogurt with fruit g
Juice drink oz
Ice cream g
Children s cereal g
Cookies g
a
Suggested serving si e on package.
Note: 24 g of sugar equals 6 teaspoons of sugar, or 96 calories.
From Tinanoff N, Holt K. Children's sugar consumption: obesity and dental caries.
ediatr Dent. 2017 39(1 :12–13.

From Table it is apparent that certain foods and beverages

particularly beverages that children consume often have
substantial quantities of sugar In many cases consuming just one
ounce drink is close to the daily sugar consumption
recommendation for children To reduce the risk of dental caries
and obesity in children health professionals and parents should be
aware of the sugar content of processed foods and beverages as
well as current daily sugar consumption recommendations
Additionally dental professionals need to become more engaged in
identifying children who have high sugar consumption and
provide dietary information or referral for dietary counseling

Tooth Brushing
The role of tooth brushing in the prevention of tooth decay has long
been considered self evident Yet there is little evidence to support
the notion that tooth brushing per se reduces caries The
relationship between individual oral hygiene status and caries
experience is weak and instructional programs designed to reduce
caries incidence by promoting oral hygiene have failed However
there is convincing evidence for the decay preventing benefit of
tooth brushing when used with a fluoride containing toothpaste
To prevent fluorosis from excessive swallowing of toothpaste
children under age should brush with a smear of fluoridated
toothpaste and children over years should brush with a pea sized
amount To maximize the beneficial effect of fluoride in the
toothpaste teeth should be brushed twice daily and rinsing after
brushing should be kept to a minimum or eliminated altogether

Optimally Fluoridated Water

Community water fluoridation is the most equitable and cost
effective method of delivering fluoride to all members of most
communities Water fluoridation at the level of to mg
fluoride ion L ppm F was introduced in the United States in the
s Since fluoride from water supplies is now one of several
sources of fluoride the Department of Health and Human Services
in recommended not to have a fluoride range in community
water supplies but rather recommended the lower limit of ppm
F In some countries such as the United States where the majority
of food and drink processing is done in cities with optimally
fluoridated water supplies children living in low fluoride areas
also receive some of the benefits of fluoridated water from
consumption of processed foods This has been termed the halo
effect and is believed to be a major factor in caries reduction in
children residing in nonfluoridated areas

Fluoride Supplements
Fluoride supplements were introduced in the late s to give
anticaries benefits to populations that resided in areas where
optimally fluoridated water was not available Fluoride
supplementation programs were based on the premise that the
cariostatic effect of fluoride was predominately systemic rather than
topical and that systemic doses of fluoride should be equivalent to
those ingested from optimally fluoridated water Summaries of
trials of the effect of systemic fluoride supplements on dental caries
showed a to caries reduction in primary teeth where the
age of initiation was years or younger trials and a to
reduction in permanent teeth trials However one must be
cautious of the conclusions of these investigations since they were
reported at a time of much greater caries incidence than the present
and methods and analysis of some studies weaken confidence in
the findings
The dose of fluoride supplements has varied over the years and
generally has been adjusted downward to reduce the risk of
fluorosis The Centers for Disease Control and Prevention in
further recommended that fluoride supplements be administered
only to children at high risk for dental caries and stated that for
children under age practitioners and parents should weigh the
risks for caries with and without fluoride supplements versus the
potential for enamel fluorosis Thus current recommendations for
fluoride supplementation are based on fluoride content of the
water the child s age and the child s caries risk Table

TABLE 12.3
Current Fluoride Supplement Schedulea

FLUORIDE CONCENTRATION IN COMMUNITY DRINKING

WATER
Age Ppm Ppm Ppm
months None None None
 months mg day None None
years
years mg day mg day None
years mg day mg day None
a
Only for children at high caries risk.27
Modified from American Academy of Pediatric Dentistry, Council on Clinical Affairs.
Guideline on fluoride therapy 2014.
http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy1.pdf. Accessed
August 25, 2017.

Irrespective of efficacy there are issues associated with

administration of fluoride supplements that make supplementation
not the first line approach for caries prevention in preschool
children Concerns with fluoride supplementation include
children whether living in a fluoridated or nonfluoridated area
ingest sufficient quantities of fluoride from toothpaste beverages
and foods parents of high risk children often do not comply with a
fluoride supplement regimen and many practitioners prescribe
fluoride supplements without testing the child s water supply for
fluoride content and without considering the caries risk status of a
child

Professionally Applied Topical Fluorides

Until recently the agents for professionally applied fluoride
treatments were sodium fluoride varnish NaF ppm F
and acidulated phosphate fluoride APF ppm F gel
These products have been shown to be effective in numerous
clinical trials in children and adults although some of the evidence
is from studies conducted to years ago Fluoride varnish has
superseded the traditional fluoride gel treatments because of ease of
use and its safety due to single dose dispensers The efficacy of
fluoride varnish in primary teeth when used at least twice a year
has been reported in at least four randomized controlled trials
Products now come in dispensers of either or mL of
varnish corresponding to or mg fluoride respectively
Other topical fluoride products such as sodium fluoride
mouthrinse ppm F and brush on gels pastes e g NaF
ppm F also have been shown to be effective in reducing
dental caries in permanent teeth
Silver diamine fluoride SDF is a topical fluoride that contains
 weight volume w v fluoride and to w v silver
The reaction of SDF with exposed dentin structure reportedly
results in calcium fluoride deposits on the tooth surface and a
deposition of silver phosphate layer Silver like other heavy metals
has an antimicrobial effect with substantivity As a result the
caries disease process may arrest soon after application The black
stained dentin after treatment with SDF has been associated with
arrested caries Proponents of SDF suggest that it be applied twice
yearly to be an effective interim therapy in reducing caries risk in
primary teeth As of there are only five studies with control
groups examining the efficacy of SDF limiting the evidence that
clinicians have for using SDF in managing caries

Antimicrobials
Some antimicrobial agents such as chlorhexidine iodine
probiotics and xylitol have been proposed to reduce dental caries
by suppressing acidogenic and acid tolerating bacteria species
adherent to teeth One comprehensive systematic review found that
most antimicrobials produced a moderate reduction in cariogenic
bacterial levels following their topical use but bacterial regrowth
occurs and new carious lesions developed once the treatment has
ceased particularly in high risk children There also is evidence of
a suppression of MS in new mothers and perhaps reducing MS
acquisition in their children however the long term effect of caries
reduction in the children is lacking Another systematic review
examined the effect of xylitol in reducing dental caries it found that
xylitol had a small effect on reducing dental caries and studies
were of low quality making the preventive action of xylitol
uncertain

Sealants
Numerous reports have shown that dental sealants are safe and
highly effective in preventing pit and fissure caries in primary and
permanent teeth reducing dental caries by over after to
year follow up With regard to evidence of effectiveness a
Cochrane review found that sealants placed on the occlusal surfaces
of permanent molars in children and adolescents reduces dental
caries up to months when compared to no sealant Studies
incorporating recall and maintenance have reported sealant success
levels of to after or more years After placement
sealants greatly reduce the number of viable bacteria in the covered
fissures including S mutans and lactobacilli Thus sealants may
effectively seal a sound fissure as well as minimize the progression
of noncavitated fissure carious lesions
There are reviews and clinical trials that have evaluated
techniques for placement of sealants One review has shown that
teeth cleaned prior to sealant application with a toothbrush
prophylaxis exhibited a similar or higher success rate compared to
those sealed after handpiece prophylaxis In addition there is
limited and conflicting evidence to support mechanical preparation
with a bur prior to sealant placement and is not recommended

Caries Risk Factors

Caries risk assessment has the goal of estimating the incidence of
caries i e the number of new cavitated or incipient lesions during
a certain time period or the likelihood that there will be a change in
the size or activity of lesions already present Even though caries
risk data in dentistry still are not sufficient to quantitate the models
the process of determining risk should be a necessary component in
the clinical decision making process
The process of determining risk gives the provider and the
patient an understanding of the disease factors anticipates if there
will be caries progression or stabilization and aids in determining
the intensity of preventive procedures and recall intervals Caries
risk assessment models currently involve a combination of factors
including previous caries experience diet microflora maternal
factors plaque and enamel defects as well as social cultural and
behavioral factors Tables and

TABLE 12.4
Caries Risk Assessment for 0- to 5-Year-Olds

High Moderate Low

Factors
Risk Risk Risk
 Biological
Mother primary caregiver has active caries Yes
Parent caregiver has low socioeconomic status Yes
Child has between meal sugar containing snacks or Yes
beverages per day
Child is put to bed with a bottle containing natural or added Yes
sugar
Child has special health care needs Yes
Child is a recent immigrant Yes
Protective
Child receives optimally fluoridated drinking water or Yes
fluoride supplements
Child has teeth brushed daily with fluoridated toothpaste Yes
Child receives topical fluoride from health professional Yes
Child has dental home regular dental care Yes
Clinical Findings
Child has decayed missing filled surfaces Yes
Child has active white spot lesions or enamel defects Yes
Child has elevated mutans streptococci levels Yes
Child has plaque on teeth Yes
Modified from American Academy of Pediatric Dentistry, Council on Clinical Affairs
Guideline for caries-risk assessment and management of infants, children and
adolescents 2014.
http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment7.pdf.
Accessed August 25, 2017. Copyright 2016–2017 by the American Academy of
Pediatric Dentistry, reproduced with permission.

TABLE 12.5
Caries Risk Assessment for Children Over Age 6 Years

High Moderate Low

Factors
Risk Risk Risk
Biological
Patient is of low socioeconomic status Yes
Patient has between meal sugar containing snacks or Yes
beverages per day
Patient has special health care needs Yes
Patient is recent immigrant Yes
Protective
Patient receives optimally fluoridated drinking water Yes
Patient brushes teeth daily with fluoridated toothpaste Yes
Patient receives topical fluoride from health professional Yes
Additional home measures e g xylitol MI paste Yes
antimicrobial
Patient has dental home regular dental care Yes
Clinical Findings
Patient has interproximal lesions Yes
Patient has active white spot lesions or enamel defects Yes
Patient has low salivary flow Yes
Patient has defective restorations Yes
 Patient wearing an intraoral appliance Yes
Modified from American Academy of Pediatric Dentistry, Council on Clinical Affairs.
Guideline for caries-risk assessment and management of infants, children and
adolescents 2014.
http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment7.pdf.
Accessed August 25, 2017. Copyright 2016–2017 by the American Academy of
Pediatric Dentistry, reproduced with permission.

Previous Carious Experience

One of the best predictors of future caries is previous caries
experience Children under the age of with a history of dental
caries should automatically be classified as being at high risk for
future decay However the absence of caries is not a useful caries
risk predictor for infants and toddlers because even if these
children are at high risk there may not have been enough time for
carious lesion development Since white spot lesions are the
precursors to cavitated lesions they will be apparent before
cavitations These white spot lesions are most often found on
enamel smooth surfaces close to the gingiva

Dietary Factors
There is abundant epidemiologic evidence that dietary sugars
especially sucrose are a factor affecting dental caries prevalence
and progression The intensity of caries in children may be due to
frequency of sugar consumption High frequency sugar
consumption enables repetitive acid production by cariogenic
bacteria that are adherent to teeth Daily consumption of sugar
containing drinks especially during the night and daily sugar
intake have been shown as independent risk factors in the
development of caries

Microbiologic Factors
MS are most associated with the dental caries process and key to
the understanding of caries in preschool children MS contribute to
caries formation with their increased ability to adhere to tooth
surfaces produce copious amounts of acid and survive and
continue metabolism at low pH conditions Preschool children with
high colonization levels of MS have greater caries prevalence as
well as a much greater risk for new lesions than those children with
low levels of MS Additionally colonization with MS at an early
age is an important factor for early caries initiation

Maternal Factors
Colonization of the oral cavity with MS in children is generally
regarded as a result of transmission of these organisms from the
child s primary caregiver No definitive modes have been
confirmed but the burden of MS in the mother from dental caries
the economic level of the family as well as the feeding practices
and health habits that allowed salivary transfer from mother to
infants have been suggested Also parents history of abscessed
teeth has been found to be a predictor of their child s urgent need
for restorative treatment

Visible Plaque
Studies demonstrate a correlation between visible plaque on
primary teeth and caries risk One study found that of the
children are correctly classified as to caries risk solely based on the
presence or absence of visible plaque Most interesting is a study
of children aged to months that found a positive
correlation between the baseline MS and plaque regrowth
suggesting that the presence of plaque on the anterior teeth of
young children is related to MS colonization The potential for
visible plaque to be an accurate predictor of caries risk and MS
colonization in young children is encouraging since this screening
method is relatively easy

Enamel Developmental Defects

Lack of enamel maturation or the presence of developmental
structural defects in enamel may increase the caries risk in
preschool children Such defects enhance plaque retention increase
MS colonization and in severe cases the loss of enamel enables
greater susceptibility to tooth demineralization A strong
correlation is found between the presence of enamel hypoplasia and
high counts of MS Enamel defects in the primary dentition are
most associated with pre peri or postnatal conditions such as low
birth weight and the child s or mother s malnutrition or illness

Socioeconomic Status
Despite the consistent evidence demonstrating the importance of
socioeconomic status on caries risk there is limited understanding
of the underlying mechanisms that account for these disparities
Nevertheless there is consistent evidence to support a strong
association between socioeconomic status as represented by
income and caries prevalence Preschool children from low income
families are more likely to have caries In addition children with
immigrant backgrounds have three times higher caries rates than
nonimmigrants

Care Pathways for Caries

Management
Care pathways also called clinical pathways protocols care paths
and evidence based care are tools used to guide management of
complex health care decisions in medicine since the s Care
pathways assist in clinical decision making by providing criteria
regarding diagnosis and treatment that lead to recommended
courses of action They are based on evidence from current peer
reviewed literature and the considered judgment of expert panels
These pathways are updated frequently with new technologies and
emerging evidence In dentistry care pathways can individualize
and standardize decisions concerning the management of caries
based on a patient s risk levels age and compliance with
preventive strategies Such protocols should yield greater
probability of success and better cost effectiveness of treatment
than less standardized treatment
Current dental caries care pathways are based on results of
clinical trials systematic reviews national guidelines and expert
panel recommendations The care pathways shown in Tables
and are from the Guidelines of the American Academy of
Pediatric Dentistry AAPD and reflect radiographic protocols
from the American Dental Association ADA and fluoride
protocols based on the Centers for Disease Control and
Prevention American Dental Association and the Scottish
Intercollegiate Guideline Network Protocols for pit and fissure
sealants are based on the ADA s and AAPD s recommendations for
the use of pit and fissure sealants Active surveillance prevention
therapies and close monitoring of enamel lesions is based on the
concept that treatment of disease may only be necessary if there is
disease progression that caries progression has diminished over
recent decades and that the majority of interproximal
radiographic enamel lesions are not cavitated

TABLE 12.6
Example of a Care Pathway for Caries Management for a 3- to 5-
Year-Old Child

INTERVENTIONS
Risk
Diagnostics Fluoride Diet Sealantsf Restorative
Category
Low risk Recall every Twice daily No Yes
months brushing with Surveillanceb
fluoridated
Radiographs toothpastee
every
months
Baseline MS
Moderate Recall every Twice daily Counseling Yes Active
risk months brushing with surveillanced
Parent fluoridated of incipient
engaged Radiographs toothpastee lesions
every Fluoride Restoration
months supplementsc of cavitated
Baseline Professional or enlarging
MSa topical treatment lesions
every months
Moderate Recall every Twice daily Counseling Yes Active
risk months brushing with with limited surveillanced
Parent fluoridated expectations of incipient
not Radiographs toothpastee lesions
engaged every Professional Restoration
months topical treatment of cavitated
Baseline every months or enlarging
MSa lesions
High risk Recall every Brushing with Counseling Yes Active
Parent months fluoride with surveillanced
engaged caution of incipient
Radiographs Fluoride lesions
 every supplementsc Restoration
months Professional of cavitated
Baseline topical treatment or enlarging
and follow every months lesions
up MSa
High risk Recall every Brushing with Counseling Yes Restore
Parent months fluoride with with limited incipient
not caution expectations cavitated or
engaged Radiographs Professional enlarging
every topical treatment lesions
months every months
Baseline
and follow
up MSa
a
Salivary mutans streptococci bacterial levels.
b
Periodic monitoring for signs of caries progression.
c
Need to consider fluoride levels in drinking water.
d
Careful monitoring of caries progression and prevention program.
e
Parental supervision of a “pea-si ed amount of toothpaste.
f
Indicated for teeth with deep fissure anatomy or developmental defects.
MS, Mutans streptococci.
Modified from American Academy of Pediatric Dentistry, Council on Clinical Affairs.
Guideline for caries-risk assessment and management of infants, children and
adolescents 2014.
http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment7.pdf.
Accessed August 25, 2017. Copyright 2016–2017 by the American Academy of
Pediatric Dentistry, reproduced with permission.

TABLE 12.7
Example of a Care Pathway for Caries Management for a Child
Over 6 Years Old

INTERVENTIONS
Risk Category Diagnostics Fluoride Diet Sealantsd Restorative
Low risk Recall every Twice daily No Yes
months brushing with Surveillancea
fluoridated
Radiographs toothpastee
every
months
Moderate risk Recall every Twice daily Counseling Yes Active
Patient parent months brushing with surveillancec
engaged fluoridated of incipient
Radiographs toothpastee lesions
every Fluoride Restoration
months supplementsb of cavitated
Professional or enlarging
 topical lesions
treatment
every months
Moderate risk Recall every Twice daily Counseling Yes Active
Patient parent months brushing with with limited surveillancec
not engaged fluoridated expectations of incipient
Radiographs toothpastee lesions
every Professional Restoration
months topical of cavitated
treatment or enlarging
every months lesions
High risk Recall every Brushing with Counseling Yes Active
Patient parent months fluoride Xylitol surveillancec
engaged Fluoride of incipient
Radiographs supplementsb lesions
every Professional Restoration
months topical of cavitated
treatment or enlarging
every months lesions
High risk Recall every Brushing with Counseling Yes Restore
Patient parent months fluoride with limited incipient
not engaged Professional expectations cavitated or
Radiographs topical Xylitol enlarging
every treatment lesions
months every months
a
Periodic monitoring for signs of caries progression.
b
Need to consider fluoride levels in drinking water.
c
Careful monitoring of caries progression and prevention program.
d
Indicated for teeth with deep fissure anatomy or developmental defects.
e
Less concern about the quantity of toothpaste.
Modified from American Academy of Pediatric Dentistry, Council on Clinical Affairs.
Guideline for caries-risk assessment and management of infants, children and
adolescents 2014.
http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment7.pdf.
Accessed August 25, 2017. Copyright 2016–2017 by the American Academy of
Pediatric Dentistry, reproduced with permission.

It is known that traditional surgical intervention of dental caries

restores the tooth structure but does not stop the disease process
Additionally many lesions do not progress or with preventive
treatment lesions may arrest Therefore the principle of active
surveillance i e preventive measures along with monitoring
signs of arrestment or progression may be indicated for the
management of some lesions in patients that will be compliant with
preventive procedures Active surveillance as part of decisions in
care pathways will promote patient centered decisions based on an
individual s risk and success of preventive interventions Fig
 FIGURE 12.6 Active surveillance: Serial radiographs,
13 months apart, showing no caries progression on the
proximal surfaces of mandibular molars. Parents
complied by brushing the child's teeth twice daily with
fluoridated toothpaste.

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