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Caries risk assessment (CRA) is an essential component informing clinical decision making for personalized caries management. The aim of this study was to assess the predictive validity of the CRA model used at the University of Michigan School of Dentistry. Data from patients treated in the school's adult integrated clinics between 2011 and 2014 who had a CRA documented were accessed from the electronic health record. Data extracted included caries risk category, date of reassessments, presence of caries risk indicators/factors, and treatments completed. Out of 2,449 patients who had a CRA completed in 2011, 447 had one or more reassessments at least 180 days after the initial CRA. Caries risk status was significantly associated (p0.0001) with the number of new caries-related treatments during follow-up, with significant increases (p0.01) in these needs for each caries risk level. For the 11,152 patients with a completed CRA in 2011-14, the prediction model (area under the curve=0.82) included the following risk factors significantly (p0.001) associated with increased caries experience/needs over time: stagnant plaque (OR 2.6, 95% CI 2.4, 2.9), presence of salivary risk factors (OR 2.6, 95% CI 2.2, 2.9), presence of dietary risk factors (OR 3.2, 95% CI 2.9, 3.6), lack of adequate protective factors (OR 2.1, 95% CI 1.8, 2.4), presence of conditions that affect compliance (OR 2.4, 95% CI 1.9, 3.1), and past/current caries experience (OR 23.7, 95% CI 21.1, 26.7). High risk patients were significantly more likely (p0.0001) to have restorative, extraction, or endodontic treatments completed due to caries and less likely (p0.0001) to have diagnostic procedures than low or moderate risk patients. These results suggest that the CRA model used at the dental school can help predict adult patients' future caries experience/needs.

Approaches for managing carious tissues during cavity preparations vary considerably among clinicians, which may reflect inconsistencies in the teaching of this subject by dental schools. The aims of this study were to investigate practices related to the preclinical and clinical teaching of caries removal at U.S. dental schools and the relationship between that teaching and requirements for U.S. dental licensure examinations. The electronic survey included questions about terminology, methods, instruments and materials, treatment planning, criteria for clinical exams, faculty calibration sessions, and licensure exams. The faculty members at U.S. dental schools responsible for teaching cariology were invited to participate; 54 of the 65 schools had identified a contact person at the time of the survey in October 2015. Of those 54 invited to participate, 43 completed the survey (response rate of 79.6%). Most of the respondents indicated that depth of carious lesions was a clinical determinant of the amount of carious dentin being removed in cavity preparations. Caries removal was used as a criterion in restorative clinical examinations by 95% of responding schools. Marked differences were observed regarding the criteria used for assessment and removal of carious tissues, management of deep carious lesions, and definition of "caries remaining at cavity preparations," which is considered a critical error on licensure exams. Faculty calibration sessions on caries removal were reported to occur in 65% of these schools and at different time frames. Overall, the study found a wide range of teaching practices related to caries removal. Best evidence in caries management needs to be aligned with teaching and the criteria used to calibrate faculty members and examiners.

The aim of this study was to document cariology education across Canadian dental schools. Ten faculty members who supervise cariology education at each of the ten Canadian dental schools were invited to participate in the study in 2016. An adapted version of the European Organization for Caries Research-Association for Dental Education in Europe cariology curriculum group questionnaire was used. Representatives of all ten dental schools completed the questionnaire, for a 100% response rate. In four schools, cariology and restorative dentistry were taught by the same department. Five schools had didactic/laboratory courses focusing primarily on cariology as well as a specific written curriculum. Six schools provided cariology-related hands-on workshops/laboratories before students started working with patients. In teaching cariology, seven institutions included dental hard tissues defects. The following caries detection methods were addressed didactically in cariology education: visual (10/10 total schools), tactile (9/10), International Caries Detection and Assessment System criteria (6/10), caries activity assessment (9/10), radiographic (10/10), and other detection tools (8/10). Seven schools charted activity of carious lesions in clinic. Only one school used the concept of caries risk assessment regularly in clinic. Clinical cariology teaching was carried out mostly by private dentists hired as clinical instructors (7/10) and faculty members involved in didactic cariology education (9/10). Calibration of faculty members for caries detection criteria was reported by only one school. The main concern reported by all institutions was the difficulty of implementing didactic instruction on cariology into clinical training. This study found that contemporary cariology concepts are in the process of being implemented in didactic education across Canadian dental schools, but all schools lacked appropriate integration of cariology education into clinical training. These findings suggest a need for harmonization of evidence-based cariology education in Canada.

The goal of this quality assurance study was to explore the decision making of clinical faculty members at the University of California, San Francisco School of Dentistry predoctoral dental clinic in terms of caries risk level assignment using the caries risk assessment (CRA) as part of the Caries Management by Risk Assessment (CAMBRA) concept. This research was done in part to determine if additional training and calibration were needed for these faculty members. The study tested the reliability and reproducibility of the caries risk levels assigned by different clinical teachers who completed CRA forms for simulated patients. In the first step, five clinical teachers assigned caries risk levels for thirteen simulated patients. Six months later, the same five plus an additional nine faculty members assigned caries risk levels to the same thirteen simulated and nine additional cases. While the intra-examiner reliability with weighted kappa strength of agreement was very high, the inter-examiner agreements with a gold standard were on average only moderate. In total, 20 percent of the presented high caries risk cases were underestimated at caries levels too low, even when obvious caries disease indicators were present. This study suggests that more consistent training and calibration of clinical faculty members as well as students are needed.

Caries management requires a complete oral examination and an accurate caries risk assessment (CRA). Performing Caries Management by Risk Assessment (CAMBRA) is inefficient when the caries risk level assignment is incorrect. The aim of this study was to evaluate the ability of faculty members and students at one U.S. dental school to correctly assign caries risk levels for 22 CRA cases, followed by calibration with guidelines on how to use the CRA form and a post-calibration test two months after calibration. Inter-examiner reliability to a gold standard (consensus of three experts) was assessed as poor, fair, moderate, good, and very good. Of the 162 students and 125 faculty members invited to participate, 13 students and 20 faculty members returned pre-calibration tests, for response rates of 8% and 16%, respectively. On the post-calibration test, eight students and 13 faculty members participated for response rates of 5% and 10%, respectively. Without guidelines and calibration, both faculty members and students when evaluated as one group performed only poor to fair in assigning correct caries risk levels. After calibration, levels improved to good and very good agreements with the gold standard. When faculty and students were evaluated separately, in the pre-calibration test they correctly assigned the caries risk level on average in only one-quarter of the cases (students 24.1%±13.3%; faculty 23.6%±17.5%). After calibration, both groups significantly improved their correct assignment rate. Faculty members (73.8% correct assignments) showed even significantly higher correct assignment rates than students (47.7% correct assignments). These findings suggest that calibration with a specific set of guidelines improved CRA outcomes for both the faculty members and students. Improved guidelines on how to use a CRA form should lead to improved caries risk assessment and proper treatment strategy for patients.

Students’ attitudes toward caries prevention can impact their receptivity to training and subsequent involvement in preventive services in their future practices. The aim of this study was to evaluate dental students’ opinions and knowledge regarding caries management and prevention at the University of Florida College of Dentistry. A twenty-six-item written survey instrument was administered to third- and fourth-year dental students. The response rate was 92.3 percent (72/78) for third-year and 45.5 percent (35/77) for fourth-year students. In their responses, 83 percent reported they would use chlorhexidine rinses for caries control, and 51 percent would use salivary tests for detecting cariogenic bacteria. Ninety-two percent reported they would use fluoride varnishes for caries control, and 40 percent were not sure if varnishes have associated dental or medical side effects. The majority of respondents felt that training and practice on caries prevention should be increased. Favorable responses to increasing education in preventive dentistry indicate that students may be receptive to modern caries management and prevention principles. This study suggests there is a need to update and integrate a more comprehensive caries prevention program into the predoctoral dental curriculum. Such programs should stress, in addition to actual training, the importance of prevention in students’ future practice.

Caries management by risk assessment (CAMBRA) represents a paradigm shift in the management of dental decay. It treats dental caries as an infectious disease that is curable and preventable. The science supporting CAMBRA has been present for quite some time; however, its clinical adoption, until recently, remained slow. This article analyzes the Western CAMBRA Coalition, a special collaboration of diverse groups of independent organizations based in the western region of the United States. This coalition, which has formed an interorganizational collaborative (IOC), has evolved over four years and has led to significant progress in the clinical adoption of CAMBRA. Theoretical perspectives of reasons and the conditions that drive organizations to collaborate will be applied to the CAMBRA model, concluding that IOCs offer great benefits in promoting CAMBRA as well as future innovations in dental treatments.

Research has demonstrated the validation of specific caries risk assessment (CRA) systems, but little is known about how dental practitioners assign a caries risk level to their patients. The aim of this study was to explore dental students' decision making in caries risk assignment when using the Caries Management By Risk Assessment (CAMBRA) system. Multiple correspondence analysis and chi-squared automated interaction detector analysis were performed on data collected retrospectively for a period of six years (2003-09) at the University of California, San Francisco predoctoral dental clinic. The study population consisted of 12,952 patients from six years of age through adult who received a baseline CRA during the period, were new to CAMBRA, and had not received any prior CAMBRA recommendations. The results showed variation in decision making and risk level assignment, illustrated by the range of percentages for the three scores (low, moderate, and high/extreme caries risk) when CRA was assigned for the first time. For those first-time CRAs, decision making was mainly based on four factors: cavities or caries lesions into dentin on radiograph, restorations during the last three years due to caries, visible heavy plaque, and interproximal lesions into enamel (by radiographs). This study's findings provide important data regarding one group of CAMBRA users and thus contribute to the development of knowledge about the implementation of caries risk assessment in contemporary dental practice.

This article summarizes current and potential future approaches for the management of caries. Current surveys suggest that traditional “drill, fill, and bill” dentistry is still widely practiced in the United States in spite of considerable evidence that supports a minimally invasive treatment approach. Because there is a wide variability in treatment decisions on when and how to prevent new lesions, on how to arrest the progression of existing lesions, and on when and how to place initial and replacement restorations, the findings from some studies differ significantly from the results of other studies. While fluoride treatments are known to prevent a percentage of new lesions, they do not have the ability to prevent all caries lesions. Modern management of caries entails treating patients according to risk and monitoring early lesions in tooth surfaces that are not cavitated. Although we know that the dmfs score for children is a powerful predictor of caries increment in permanent teeth of these children a few years later, this score is rarely used in private practice as a measure of risk or as a measure of treatment success. Although these modern methods for caries management offer great promise for controlling the disease, they may take decades to apply in a standardized way so that the variability in treatment is reduced. However, during the next two decades, an alternative approach to caries prevention such as replacement therapy and a caries vaccine may become available as a more consistent method of controlling this disease.

The relationship between cavity preparation extension and restoration longevity is examined through a systemic review of the available evidence on specific conservative, operative caries-management strategies. Evidence tables are provided for three specific techniques in the permanent dentition: 1) the proximal "tunnel" restoration, 2) the proximal "box-only" restoration, and 3) the preventive resin restoration. In the primary dentition, the clinical trials involving the proximal box-only restoration, most of which involved glass-ionomer materials, are reviewed. In the permanent dentition, the evidence reveals low effectiveness for "tunnel" restorations, limited but supportive results for proximal-only restorations, and generally favorable outcomes for the occlusal composite resin-sealant restoration. The weak link in the latter is the overlying fissure sealant, which requires adequate ongoing maintenance. Conservative operative strategies in the primary dentition have not been uniformly successful, and deleterious material effects dominate restoration performance. This systematic review concludes that operative conservatism per se does not guarantee increased restoration longevity and that all restorations are vulnerable to caries recurrence, material failures, and technical deficiencies. The more successful conservative strategies are expected to enhance tooth longevity, provided concomitant caries control is effective.

The aim of this review of clinical decision-making for caries management in primary teeth is to integrate current knowledge in the field of cariology into clinically usable concepts and procedures to aid in the diagnosis and therapy of dental caries in primary teeth. The evidence for this paper is derived from other manuscripts of this conference, computer and hand searches of scientific articles; and policy statements of councils or commissions of various health organizations. Current evidence regarding the carious process and caries risk assessment allows the practitioner to transcend traditional surgical management of dental caries in primary teeth. Therapy can focus on patient-specific approaches that include disease monitoring and preventive therapies supplemented by restorative therapies. The type and intensity of these therapies should be determined utilizing data from clinical and radiograph examinations as well as information regarding caries risk status; evidence of therapy outcomes; assessment and reassessment of disease activity; natural history of caries progression in primary teeth; and preferences and expectations of guardians and practitioners. Changes in the management of dental caries will require health organizations and dental schools to educate students, practitioners, and patients in evidence- and risk-based care.

Dental caries is an infectious disease of bacterial origin. The use of antimicrobial agents to reduce or eliminate the bacteria associated with caries follows the approach used to combat other infectious diseases of humans. Unfortunately, only a few dozen studies have sufficient resolving power to make inferences as to the anticaries efficacy of the antimicrobial approach to caries management. Here, we comment on the findings of the RTI/UNC review concerning antimicrobials, discuss additional findings not covered in that review, and make recommendations based upon both the available literature and from our own experience. Even though the studies published thus far are inconclusive or lack sufficient demonstration of efficacy to recommend a specific approach involving antimicrobial agents in routine clinical practice, several pieces of information from these studies suggest future avenues of investigation.

Dental caries management should be based on a comprehensive diagnosis and risk assessment to help support the most appropriate evidence-based surgical and nonsurgical treatment decisions to address both the disease process and its consequences, noncavitated and cavitated caries lesions, and their