Diagnosis and management of dental caries throughout life.

OBJECTIVE

To provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the diagnosis and management of dental caries throughout life.

PARTICIPANTS

A non-Federal, non-advocate, 13-member panel representing the fields of dentistry, epidemiology, genetics, medicine, oral biology, oral radiology, pathology, periodontics, public health, statistics, surgery, and including a public representative. In addition, 31 experts in these same fields presented data to the panel and to a conference audience of approximately 700.

EVIDENCE

Presentations by experts; a systematic review of the dental research literature provided by the Agency for Healthcare Research and Quality; and an extensive bibliography of dental caries research papers, prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience.

CONSENSUS PROCESS

Answering predefined questions, the panel drafted a statement based on the scientific evidence presented in open forum and the scientific literature. The draft statement was read in its entirety on the final day of the conference and circulated to the experts and the audience for comment. The panel then met in executive session to consider these comments and released a revised statement at the end of the conference. The statement was made available on the World Wide Web at http://consensus.nih.gov immediately after the conference. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

CONCLUSIONS

This Consensus Development Conference, the first sponsored by the NIH on dental caries, provided an excellent venue to describe the great success that has been achieved in reducing caries prevalence. More importantly, it provided a public forum to review both the strengths and weaknesses of current dental caries research and clinical procedures. Effective preventive practices, such as the use of fluoride, sugarless products, and dental sealants were reconfirmed and clinical studies to identify more conservative but more effective nonsurgical and surgical approaches are to be applauded. However, it was evident that current diagnostic practices are inadequate to achieve the next level of caries management in which noncavitated lesions are identified early so that they can be managed by nonsurgical methods. Some new and sensitive diagnostic approaches were presented to the panel, but concern was raised about the use of histological confirmation of caries presence as an appropriate gold standard. The resolution of these issues requires that surrogate markers, validated by histological confirmation, be developed. Once these surrogate markers of dental caries activity are validated, rapid advances in our understanding of the caries. In spite of optimism about the future, the panel was disappointed in the overall quality of the clinical data set that it reviewed. Far too many studies used weak research designs or were small or poorly described, and consequently had questionable validity. There was a clear impression that clinical caries research is underfunded, if not undervalued. Moreover, incomplete information on the natural history of dental caries, the inability to accurately identify early lesions and/or lesions that are actively progressing, and the absence of objective diagnostic methods are troubling. Several systematic reviews of the literature presented at the Consensus Development Conference concluded that the majority of the studies were inadequate, and it is clear that a major investment of research and training funds is required to seize the current opportunities. This is not to say that the diagnostic, preventive, and treatment techniques currently used do not work, but rather that earlier studies to support their efficacy do not meet current scientific standards. Indeed, given the dramatic improvements in reducing dental caries prevalence in the past 30 years, both consumers and health professionals should not depart from the practices which are likely to have contributed to this oral health improvement, including the use of a variety of fluoride products, dietary modification, pit and fissure sealant, improved oral hygiene, and regular professional care. In addition, pending new data, clinicians should apply both preventive and therapeutic interventions in the manner in which they have been studied. When solid confirmation of the effectiveness of promising new diagnostic techniques, nonsurgical treatments of noncavitated lesions, and conservative surgical interventions for cavitated lesions are obtained, dental health professionals and the public should embrace them rapidly in anticipation of attaining still higher levels of oral health. None of these anticipated advances will be achieved, however, in the absence of a progressive, third-party payment system that acknowledges its responsibility to compensate providers adequately to ensure that the next generation of conservative therapy can be enjoyed by the American people.