More rigorous studies needed to advance emerging
     dental caries diagnostic and management strategies

  
3/28/2001  PRESS RELEASE --

The development of new diagnostic techniques to detect early stages of dental caries
(tooth decay) may give dentists more options than ever before to stop or reverse
decay using noninvasive techniques. This and other findings emerged from a Consensus
Development Conference on the Diagnosis and Management of Dental Caries Throughout
Life, convened by the National Institutes of Health on March 26-28, 2001 in Bethesda,
MD.  The conference examined the current state of dental caries research to help
health care providers and the general public make informed decisions about this
important health issue. 

Panel members reviewed an extensive collection of literature related to dental caries,
including a systematic review of the dental research literature provided by the Agency
for Healthcare Research and Quality (AHRQ). The panel also heard presentations by
experts in the field, as well as public comment. 

While water fluoridation, the use of fluoride products, dietary modification including
sugar restriction, improved oral hygiene, and regular professional care have led to
dramatic reductions in dental caries over the past 30 years, the disease remains a
major public health problem. Nearly 20 percent of children between the ages of 2 and
4 have experienced dental caries, and by the age of 17 almost 80 percent of young
people have had at least one cavity-- a late manifestation of dental caries infection.
More than two-thirds of adults between the ages of 35 to 44 have lost at least one
permanent tooth due to dental caries, and one- fourth of those aged 65 to 74 have
lost all of their natural teeth. 

Early phases of tooth decay are currently difficult to detect. While radiographs, or
x-rays, can disclose established cavities, particularly those that occur between the
teeth, they are not effective in detecting early decay, or caries in the roots of teeth.
The panel noted that the ongoing development of more sensitive diagnostic techniques
to detect dental caries in its earliest phases will pave the way for the use of
noninvasive treatment options to stop or reverse the caries process. Current data support
the following treatment options: fluorides, dental sealants; combinations of
chlorhexidine, fluoride, and sealants; and health education. 

Despite their optimism about the future of dental practice, the panel was disappointed
in the overall quality of the clinical data that it reviewed. According to the panel,
far too many studies were small, poorly described, or otherwise methodologically flawed. 

"This is not to say that the diagnostic, preventive, and restorative techniques
currently used do not work," said the panel, "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." 

Although the panel did not evaluate the evidence for the effectiveness of community
water fluoridation, they acknowledged that water fluoridation and the use of fluoridated
toothpastes are highly successful in preventing dental caries. They also determined that
there is evidence to support the use of fluoride varnishes in permanent teeth, as well as
fluoride gels, chlorhexidine gels, sealants, and chewing gum containing xylitol, a sugar
substitute. Combined interventions may be more effective in preventing caries in children. 

The panel also noted that effective dentistry requires early identification of children
at high risk for extensive caries so that they may receive early and intense preventive
intervention. Children at low risk also need to be identified to reduce unnecessary care
and expenditures. According to the evidence presented, the most consistent predictor of
caries risk in children is past caries experience. Low socioeconomic status (SES) is also
associated with higher caries rates. While some risk factors may be applicable across all
ages, others are distinctive for adult and elderly populations, such as the inability to
maintain good oral hygiene, lack of adequate salivary flow, and gum recession. 

The panel called for a major investment of research and training funds to "seize the
opportunities presented." "When solid confirmation of the effectiveness of promising new
diagnostic techniques, non-surgical treatments of non- cavitated 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." 

Panel chair Michael C. Alfano, D.M.D., Ph.D., Dean of the New York University College
of Medicine, also noted, "that for the American people to benefit from these findings,
insurance companies will need to change the way they compensate dental providers so that
the next generation of conservative therapy can be enjoyed by everyone." 

Among its recommendations, the panel called for: 

studies of dental caries in the population that collect information on natural history,
treatment, and outcomes in all age groups 

studies of diagnostic methods, including established and new devices and techniques
clinical trials of established and new treatment methods that conform to contemporary
standards of design, implementation, and analysis 

systematic research on caries risk assessment 

studies of clinical practice including effectiveness, quality of care, outcomes,
health-related quality of life, and appropriateness of care 

genetic studies to identify genes and genetic markers of diagnostic, prognostic, and
therapeutic value

The National Institute of Dental and Craniofacial Research and the NIH Office of
Medical Applications of Research sponsored the conference. Cosponsors included the
National Institute on Aging and the U.S. Food and Drug Administration. 

The full NIH Consensus Statement on Diagnosis and Management of Dental Caries Throughout
Life is available by calling 1-888-NIH-CONSENSUS (1-888-644-2667) or by visiting the NIH
Consensus Development Program Web site at http://consensus.nih.gov. (The panel's draft
statement will be posted to the Web by the evening of March 28 or morning of March 29.) 

The consensus statement is the report of an independent panel and is not a policy
statement of the NIH or the Federal Government. The NIH Consensus Development
Program was established in 1977 to resolve in an unbiased manner controversial topics
in medicine. To date, NIH has conducted 115 such conferences addressing a wide range of
controversial medical issues important to health care providers, patients, and the
general public. 

The AHRQ-supported evidence-based review, Diagnosis and Management of Dental Caries:
A Summary," is available at http://www.ahrq.gov/clinic/dentsumm.htm. Printed copies are
available for free from the AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring,
MD 20907 (tel: 800/358-9295) and by calling AHRQ InstantFAX (301) 504-2800 from a
telephone-equipped facsimile machine. 

An extensive bibliography of dental caries research papers, prepared by the National
Library of Medicine, is available in the Web at
http://www.nlm.nih.gov/pubs/cbm/dental_caries.html. 

SOURCE: National Institutes of Health