Caries-risk Assessment and Management for Infants, Children and Adolescents

Caries-risk Assessment and Management for Infants, Children, and Adolescents

you can look up the pdf in this link BP_CariesRiskAssessment (1)

Purpose
The American Academy of Pediatric Dentistry recognizes that caries-risk assessment and management protocols, also called care pathways, can assist clinicians with decisions regarding treatment based upon child’s age, caries risk, and patient compliance and are essential elements of contemporary clinical care for infants, children, and adolescents. These recommendations are intended to educate healthcare providers and other interested parties on the assessment of caries risk in contemporary pediatric dentistry and aid in clinical decision-making regarding evidence- and risk-based diagnostic, fluoride, dietary, and restorative protocols.

Methods
This document was developed by the Council on Clinical Affairs and adopted in 20021 and last revised in 2014. To update this best practices document, an electronic search of systematic reviews/meta-analyses or expert panels was conducted from 2012 to 2018 using the terms: caries risk assessment, diet, sealants, fluoride, radiology, non-restorative treatment, active surveillance, caries prevention. There were four systematic reviews that informed this update on caries risk assessment.3-6 There were 10 systematic reviews and clinical practice guidelines that inform this update on care pathways for caries.7-16 When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians.

Background
Caries-risk assessment
Risk assessment procedures used in medical practice generally have sufficient data to accurately quantitate a person’s disease susceptibility and allow for preventive measures. However, in dentistry there still is a lack of sufficiently validated multivariate screening tools to determine which children are at a higher risk for dental caries.5,6 Nevertheless, caries-risk assessment:

1. fosters the treatment of the disease process instead of treating the outcome of the disease.

2. allows an understanding of the disease factors for a specific patient and aids in individualizing preventive discussions.

3. individualizes, selects, and determines frequency of preventive and restorative treatment for a patient.

4. anticipates caries progression or stabilization.

Caries-risk assessment models currently involve a combination of factors including diet, fluoride exposure, a susceptible host, and microflora that interplay with a variety of social, cultural, and behavioral factors. Caries-risk assessment is the determination of the likelihood of the increased incidence of caries (i.e., the number of new cavitated or incipient lesions) during a certain time period9 or the likelihood that there will be a change in the size or activity of lesions already present. With the ability to detect caries in its earliest stages (i.e., non-cavitated or white spot lesions), health care providers can help prevent cavitation.
Caries risk indicators are variables that are thought to cause the disease directly (e.g., microflora) or have been shown useful in predicting it (e.g., life-time poverty, low health literacy) and include those variables that may be considered protective factors. The most commonly used caries risk indicators include presence of caries lesions, low salivary flow, visible plaque on teeth, high frequency sugar consumption, presence of appliance in the mouth, health challenges, sociodemographic factors, access to care, and cariogenic microflora. Protective factors in caries risk include a child’s receiving optimally-fluoridated water, having teeth brushed daily with fluoridated toothpaste, receiving topical fluoride from a health
professional, and having regular dental care.

Some issues with the current risk indicators include past caries experience is not particularly useful in young children and activity of lesions may be more important than number of lesions. Low salivary flow is difficult to measure and may not be relevant in young children.17 Frequent sugar consumption is hard to quantitate. Socio-demographic factors are just a proxy for various exposures/behaviors which may affect caries
risk. Predictive ability of various risk factors across the life span and how risk changes with age have not been determined. Furthermore, genome-level risk factors may account for substantial variations in caries risk. Risk assessment tools can aid in the identification of reliable predictors and allow dental practitioners, physicians, and other non-dental health care providers to become more actively involved in identifying and referring high-risk children. Tables 1 and 2 incorporate available evidence into practical tools to assist dental practitioners, physicians, and other non-dental health care providers in assessing levels of risk for caries development in infants, children, and adolescents. As new evidence emergences, these tools can be refined to provide greater predictably of caries in children prior to disease initiation. Furthermore, the evolution of caries-risk assessment tools and care pathways can assist in providing evidence for and justifying periodicity of services, modification of third-party involvement in the delivery of dental services, and quality of care with outcomes assessment to address limited resources and work-force issues.

Care pathways for caries management
Care pathways are documents designed to assist in clinical decision-making; they provide criteria regarding diagnosis and treatment and lead to recommended courses of action.8 The pathways are based on evidence from current peer-reviewed literature and the considered judgment of expert panels, as well as clinical experience of practitioners. Care pathways for caries management in children aged 0-2 and 3-5 years old were first introduced in 2011.18 Care pathways are updated frequently as new technologies and evidence develop. Historically, the management of dental caries was based on the notion that it was a progressive disease that eventually destroyed the tooth unless there was surgical/restorative intervention. Decisions for intervention often were learned from unstandardized dental school instruction and then refined by clinicians over years of practice.
It is now known that surgical intervention of dental caries alone does not stop the disease process. Additionally, many lesions do not progress, and tooth restorations have a finite longevity. Therefore, modern management of dental caries should be more conservative and includes early detection of non-cavitated lesions, identification of an individual’s risk for caries progression, understanding of the disease process for that individual, and active surveillance to apply preventive measures and monitor carefully for signs of arrest or progression.

Care pathways for children further refine the decisions concerning individualized treatment and treatment thresholds based on a specific patient’s risk levels, age, and compliance with preventive strategies (Tables 3 and 4). Such clinical pathways yield greater probability of success, fewer complications, and more efficient use of resources than less standardized treatment.8

Content of the present caries management protocol is based on results of systematic reviews and expert panel

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