Recently there has been growing emphasis on caries management by risk assessment (CAMBRA), designed as the medical approach to diagnosing and treating the caries disease. New technologies have been developed to help identify patients at risk for the disease, and these include chairside tests of saliva, plaque, and biofilm activity or ATP bioluminescence, such as Saliva-Check (GC America, www.gcamerica.com) and CariScreen (CariFree®, www.carifree.com). Additionally, new technologies have emerged to better identify individual lesions and activity on teeth. These technologies include transillumination, laser fluorescence, and imaging devices such as DIAGNOdent (KaVo Dental, www.kavousa.com), Caries I.D.™ (DENTSPLY Professional, www.cariesid.com), DIFOTI®, Spectra, SOPROLIFE (Acteon, www.soprolife.com), and the recently introduced CarieScan Pro (us.cariescan.com).
Providing better sensitivity and specificity than dental explorers and radiographs, when added to visual inspection, these new technologies provide the dentist with an improved ability to identify early stages of the disease and individual lesions. On a daily basis, all dentists are faced with the challenge of identifying and diagnosing dental caries with accuracy and consistency. These new technologies represent a giant leap forward.
The challenge for practitioners and the profession today is consistency and predictability. Mostly this is a historical issue. Dentistry traditionally diagnosed dental caries, ignoring the disease process itself; and using visual inspection, a sharp explorer, and radiographs, identified lesions and then classified them based on where they were located or what type of restoration would be used. This historical system does not lend itself to predictability and reproducibility. While the dental profession has done a commendable job of implementing evidence-based care into daily practice, the profession as a whole is handicapped by the lack of a better system, dental diagnostic codes, and the lack of treatment-outcome–based care.
A growing frustration for the public is that they can visit three different dentists and come away with three different diagnoses and opinions. Adding new technologies for caries diagnosis and caries-lesion detection dramatically improves the practitioner’s ability to develop diagnostic accuracy, improved sensitivity and specificity, and consistency within their own practice, and between different practitioners. When these technologies are then added to the standardized caries classification developed by the International Caries Assessment and Detection System (ICDAS, www.icdas.org), which classifies carious lesions based on distinctly defined stages of development, a new level of diagnostic accuracy and consistency emerges. Dentists now have the ability to evaluate and purchase these technologies and easily add them into their practices, improving their own patient care.
Practitioners can improve the predictability of their treatment outcomes by adding the emerging philosophy (ie, CAMBRA) and caries-detection technologies to their current systems. Recognizing and addressing the disease process in patients by using a simple caries risk-assessment form, dentists can develop a treatment plan for correcting the biofilm disease by examining the patient’s specific risk and protective factors. Numerous caries risk-assessment forms are available. The practitioner can direct patients back to a healthy stable condition, and this will provide long-term predictability to their restorative care.
Adding a disease risk assessment or biometric technology will give the practitioner the additional benefit of baseline data, and the ability to monitor the patient’s therapeutic progress. By adding the ICDAS lesion classification and caries lesion-detection technology, the practitioner now has the ability to accurately and consistently identify and describe lesions at distinct stages, and recommend evidence-based care appropriate for each individual lesion. This will provide significantly improved consistency, predictability, and patient satisfaction and confidence.
There are two recommendations for implementing any changes into an active dental practice: have the entire team involved and keep it simple. It is no different for caries-detection technologies, and keeping this in mind will make implementation smoother and more successful. It is important to have everybody understand why the change is important and the benefit it provides in terms of patient care.
CAMBRA represents a huge philosophical shift, and it requires the support of every team member. They need to feel competent and confident in discussing these issues with patients and comfortable in routinely using caries risk-assessment forms. The addition of new diagnostic technologies and chairside tests requires them to learn a few new skills. The ICDAS lesion-classification system is steadily gaining use and will require the entire team to understand this simple system and the evidence-based treatment recommendations for each stage.
Caries detection technologies are simple to use and easily integrated into routine oral examinations. Practitioners are commonly using these technologies during re-care examinations in the hygiene operatory, but they are portable and can be used anywhere. As with any behavioral change, it takes some time to implement a new system, but dental practices are finding this new level of accuracy in diagnosing and treating dental caries personally satisfying and rewarding.
About the Author
V. Kim Kutsch, DMD