April 2019

C O N T I N U I N G
eBOOK
E D U C A T I O N • 2 C E U

DIAGNOSIS AND TREATMENT

Medical Management of Dental Caries

Joel H. Berg, DDS, MS

SUPPORTED BY AN UNRESTRICTED GRANT FROM PARKELL • Published by AEGIS Publications LLC 2019
 C O N T I N U I N G E D U C A T I O N • 2 C E U

Medical Management of Dental Caries

Joel H. Berg, DDS, MS

ABSTRACT
This article covers some of the most up-to-date information regarding emerging technologies in dental caries detection and risk assessment. It explains how the under-
standing of dental caries as a disease has changed over the years and how the approach to caries management has evolved. It also suggests further developments that
are needed. The article discusses different levels of invasiveness involved in treating caries. Silver diamine fluoride is given a special focus.

LEARNING OBJECTIVES
•D
 escribe methods of risk assessment for • Evaluate the use of silver diamine fluoride • Review restorative interventions that are
dental caries. and other agents to treat caries lesions. compatible with managing caries.

S
everal major trends in dentistry that are connected to caries
management will affect everyone in the profession over
the next several years. The largest of these trends is con-
solidation, or the growth of large group dental practices.
This phenomenon has been occurring over the last 1 to 2
decades and appears to be continuing at a steady rate of growth.
Another trend is in technology integration and the use of “big data”
to perform clinical analyses and predict clinical outcomes. Attempts
have been made to use such data to provide direction to clinicians in
caring for patients; today, however, the data and analyses have been
used mainly by third-party payers to assess the likelihood of success
of one particular form of treatment versus another. It is believed by
this author that the use of big data will improve the quality of care.
However, this technology will not ultimately be useful until the most
effective outcome measures have been determined for the success
of various treatments. Additionally, various payer system changes
have occurred and will continue to occur. These include the trend
towards managed care in compensation systems, which provides
compensation for the necessary elements of time to counsel patients
and other factors needed to promote health as opposed to just treat-
ing results of disease.1 This trend, as well as the other topics in this
paragraph, are major issues but will not be discussed further in the
present paper. The trend that could change the profession more than
anything else is what is often referred to as “medical management
of oral disease” or “medical management of dental caries.”
DENTAL CARIES OVERVIEW
Rather than waiting for the disease dental caries to manifest itself
in the need for restorative dentistry, medical management of caries
implies that it will be managed as a chronic disease, such as dia-
betes, periodontal disease, and other chronic conditions. With this
concept, there is a focus on prevention and recognition that caries
manifests itself significantly in some patients, and not others; there-
fore, there is more concentration on interceptive practices, health
outcomes, and improving quality of life by mitigating the effects
of the disease through aggressive management.2-4
Restorative dentistry is the major part of dental practice in terms
of procedures and is the most common type of surgery performed
on humans. Even G.V. Black, the father of modern restorative den-
tistry, who developed cavity classifications for the use of amalgam
restorations, was, in his own words, “saddened” that he was unable
to prevent caries disease and that, particularly in children, the disease
often progressed to a state where it needed to be managed through
restorative dentistry. He described this as a necessity of dental care

DISCLOSURE: The author received an honorarium for the webinar program on which this article is based.

2 COMPENDIUM EBOOK APRIL 2019

 C O N T I N U I N G E D U C A T I O N • 2 C E U
because the disease could not be detected in the early stages, when addition to these important interventions, the concept of reducing
aggressive intervention might be more useful. G.V. Black himself risk factors for patients by differentiating patients into various risk
used silver nitrate as a way to treat caries lesions when they could categories based on ever-improving risk assessment tools has been
be visualized clinically.5 introduced. Approaches can now be targeted more effectively for
The gross domestic consumption of dentistry in the United States those in need of more aggressive medical management relative to
is approximately $115 billion a year. The vast majority of this, ap- those who do not.
proximating 70% of the total dollars, is spent related to treating the However, a new concept in caries risk evaluation and caries man-
results of dental caries.6 This includes most restorative dentistry, agement is needed. Demineralization of tooth structure resulting in
much of prosthodontics, much of endodontics, and much of what is cavitation from dental caries occurs over time. Structural changes
termed esthetic dentistry performed because of the need to restore are not reversible at a certain point, and that is when restorative
teeth that were broken down due to the caries process. dentistry must be undertaken. This accounts for the vast majority of
Most of what professional product manufacturers make and most dental treatments. If detection tools were available that were very
of what dentists perform in their practices is done to treat the effects specific at an earlier stage before cavitation, small lesions could be
of dental caries instead of the disease itself. Pediatric dentists often detected before cavitation, and intervention could be more aggres-
see the manifestations of caries in the most severe forms, including sive with medicinal therapeutics as they become available. Unfor-
facial cellulitis, which can present with children at a very young tunately, there are no clinically tested specific diagnostic tests that
age in the emergency department of a hospital as a life-threatening could identify such lesions.12
condition that must be treated immediately.7 A useful diagnostic device for detecting caries at its earliest point
The caries management continuum (Figure 1) has been devel- in time would be sensitive and specific. In addition to being gener-
oped to indicate the level of invasiveness of caries lesions. On the ally reliable, it would be reliable between examiners and with the
left side of this continuum are microbial control treatments and sal- same examiner using the device at different points in time.
ivary control treatments. On the far right of this continuum is tra- Devices have been developed or are being developed for the pur-
ditional operative dentistry. In between are less-invasive forms of pose of caries detection at an earlier phase, with the intent that re-
treatment, such as remineralization therapies, resin infiltration, and storative dentistry could be avoided in some instances and medicinal
the newly introduced silver diamine fluoride, along with the next therapeutic treatments provided instead. Some of the technologies
stage of intervention: minimally invasive restorative dentistry, which deployed toward this end employ chemical signature techniques,
has been the trend for some time, and defect-specific glass-iono- fluorescence techniques, topography scanning techniques, and pho-
mer/resin composite combinations that are less invasive in nature.8 tothermal methods. The chemical signature technique takes advan-
tage of the fact that when the bacterial biofilm progresses into tooth
CARIES RISK ASSESSMENT structure as it demineralizes, it leaves compounds called porphyrins
Risk assessment tools are also developing rapidly. However, most that can be detected by their fluorescent signature. This fluorescence,
dental caries risk assessment tools are highly sensitive but not spe- when visualized and measured through computer analytic technol-
cific. There too many false positives. Therefore, it is nearly impossi- ogy, can show the depth and extent of caries lesions at a very early
ble to determine exactly which patients will manifest with the most stage. By deploying this technology of fluorescence measurement
aggressive forms of caries disease and which will not.9-11 It would into devices, the caries lesions can be mapped in a noninvasive
be more desirable to have a specific risk assessment tool that could form and at an early stage. As improved medicinal therapeutics are
precisely predict who will manifest with the disease or who is most developed, they could be used to attenuate, halt progression of, or
likely to manifest so that aggressive interventions could be provid- otherwise stop a cavity, even before it forms. Topographical devices
ed for those patients. Such aggressive intervention for large num- can do a better job of providing good visualization to the clinician
bers of patients, many of whom will not manifest with the disease, by scanning the surface using better frequencies of light.13
is not cost-effective and takes away from the concept of effective Photothermal techniques are deployed in at least one product
managed care and medical management of disease. currently and have significant potential for early detection of car-
The focus of dentistry has shifted from treating the results of ies lesions. Using infrared radiation to measure the conductivity of
dental caries to prevention of the disease itself. This shift began heat through a tooth is a good analog to demineralization of tooth
to occur largely when fluoridation came into the water supplies structure. As these various technologies are better deployed into
and fluoride toothpaste came into the mouths of patients. Now, in devices and as they are tested with clinical outcome studies with a
concentration on being more sensitive and specific, it is likely that
a successful device will be developed that can be more predictive
Caries  Management  Con4nuum of caries.14-20
Likely the most important and largest area of discovery related to
Level  of  invasivity   dental caries taking place today is in the realm of plaque biofilms.21,22
For well over two decades, it has been known that analyzing the
role of plaque is not a simple task; the thought that streptococci and
lactobacilli are uniquely responsible for the progression of dental
•  Microbial  control •  Remineraliza4on •  MI  restora4ve •  Tradi4onal  opera4ve  
caries is not accurate or precise. It is now known that the complex
•  Salivary  control • 
• 
Resin  infiltra4on
Silver  diamine  fluoride
•  Defect-­‐specific  GI  or    
resin
den4stry
biofilm of the mouth that contains over 500 unique species of bac-
terial organisms is a system where different bacteria interact with
1
one another in the same way that the organs of the human body in-
FIG 1. Caries management continuum. MI = minimally invasive, GI = glass-ionomer. teract through hormones and other signaling methods. In fact, the

3 COMPENDIUM EBOOK 1   APRIL 2019

 C O N T I N U I N G E D U C A T I O N
signaling between bacteria is quite complex. Elucidation of this
complex structure of intra-biofilm communication is occurring at
a rapid rate in laboratories all around the world. It is believed that
the growth of laboratory science technology in determining how
to predict which bacteria communicate with which others, as well
as how to interrupt these chemical signals, will achieve effective
results for developing medicinal products that could be used for
treating caries. Specific drugs that might be developed to attenu-
ate acid production in caries could be part of the future of discov-
ery wherein caries could be treated in a medical model scenario in
the same way that many chronic diseases are treated medically and
not just surgically.
SILVER DIAMINE FLUORIDE
Silver diamine fluoride, the first treatment of dental caries offered
as a “drug” in the dental office 2 years ago, is an important inter-
vention.21-25 Silver diamine fluoride must be applied fully on the
lesion, and it must access the full extent of the lesion. Therefore,
although it is effective in halting progression of caries lesions after
being cavitated, non-cavitated lesions cannot be presented with the
liquid silver diamine fluoride, so it is not able to halt progression
of non-cavitated lesions. Perhaps delivery systems will become
available to inject silver diamine fluoride or other agents into par-
tially cavitated or non-cavitated lesions so that the powerful effect
of halting lesion progression could take place in small lesions as
well. In the meantime, silver diamine fluoride will be a useful ad-
junct to treatments, particularly for very young children; in some
cases it can delay the need for restorative care, especially to delay
restorative care under sedation or general anesthesia.
CONCLUSION
It is encouraging that the use of silver diamine fluoride has become
widespread in dental care for children, as well as for adults who have
small areas of existing restorations that have become further decayed
or who are undergoing medical treatments that make them more
susceptible to dental caries progression. Additionally, the fact that
dental disease is now being looked at as a chronic disease, and then
potentially treated as such, is an exciting development for dentistry.
ABOUT THE AUTHOR
Joel H. Berg, DDS, MS
Professor Emeritus, Department of Pediatric Dentistry, Universi-
ty of Washington School of Dentistry, Seattle, Washington
Queries to the author regarding this course may be submitted to
authorqueries@aegiscomm.com.
REFERENCES
1. Park SY, Kim SH, Kang SH, et al. Improved oral hygiene care
attenuates the cardiovascular risk of oral health disease: a pop-
ulation-based study from Korea. Eur Heart J. 2018. doi: 10.1093/
eurheartj/ehy836.
2. Rubin MS, Nunez N, Quick JD, Edelstein BL. A survey of US
early childhood caries programs: findings and recommenda-
tions. J Public Health Dent. 2018. doi: 10.1111/jphd.12302.
3. Fernando S, Kumar S, Bakr M, et al. Children’s untreated decay
is positively associated with past caries experience and with
current salivary loads of mutans streptococci; negatively with
self-reported maternal iron supplements during pregnancy: a
multifactorial analysis. J Public Health Dent. 2018. doi: 10.1111/
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jphd.12301.
4. Zhang X, Lu E, Stone SL, Diop H. Dental cleaning, community
water fluoridation and preterm birth, Massachusetts: 2009-2016.
Matern Child Health J. 2018. doi: 10.1007/s10995-018-2659-y.
5. Wolff MS, Allen K, Kaim J. A 100-year journey from GV Black
to minimal surgical intervention. Compend Contin Educ Dent.
2007;28(3):130-134.
6. Blum IR, Özcan M. Reparative dentistry: possibilities and
limitations. Curr Oral Health Rep. 2018;5(4):264-269.
7. Allareddy V, Nalliah RP, Haque M, et al. Hospital-based emer-
gency department visits with dental conditions among children
in the United States: nationwide epidemiological data. Pediatr
Dent. 2014;36(5):393-399.
8. Berg JH, Bresler JA, Killian CM. How should care at an early
age/medical management of dental caries be handled? Com-
pend Contin Educ Dent. 2018;39(9):604-607.
9. Fontana M, Eckert GJ, Keels MA, et al. Predicting caries in
medical settings: risk factors in diverse infant groups. J Dent
Res. 2018. doi: 10.1177/0022034518799080.
10. Dima S, Wang KJ, Chen KH, et al. Decision tree approach to
the impact of parents’ oral health on dental caries experience
in children: a cross-sectional study. Int J Environ Res Public
Health. 2018;15(4):692.
11. Kraljevic I, Filippi C, Filippi A. Risk indicators of early child-
hood caries (ECC) in children with high treatment needs. Swiss
Dent J. 2017;127(5):398-410.
12. Pretty IA, Ekstrand KR. Detection and monitoring of early
caries lesions: a review. Eur Arch Paediatr Dent. 2016;17(1):13-25.
13. Brouwer F, Askar H, Paris S, Schwendicke F. Detecting sec-
ondary caries lesions: a systematic review and meta-analysis.
J Dent Res. 2016;95(2):143-151.
14. Guideline on caries-risk assessment and management for
infants, children, and adolescents. Pediatr Dent. 2016;38(6):142-
149.
15. Mills C, Patel P. Adopting caries risk assessment in all practice
environments. Gen Dent. 2016;64(4):66-72.
16. Avila WM, Pordeus IA, Paiva SM, Martins CC. Breast and bot-
tle feeding as risk factors for dental caries: a systematic review
and meta-analysis. PLoS One. 2015;10(11):e0142922.
17. Opal S, Garg S, Jain J, Walia I. Genetic factors affecting dental
caries risk. Aust Dent J. 2015;60(1):2-11.
18. Kutsch VK. Dental caries: an updated medical model of risk
assessment. J Prosthet Dent. 2014;111(4):280-285.
19. Young DA, Featherstone JD. Caries management by risk as-
sessment. Community Dent Oral Epidemiol. 2013;41(1):e53-e63.
20. Young DA, Kutsch VK, Whitehouse J. A clinician’s guide
to CAMBRA: a simple approach. Compend Contin Educ Dent.
2009;30(2):92-94.
21. Horst JA. Silver fluoride as a treatment for dental caries. Adv
Dent Res. 2018;29(1):135-140.
22. Gao SS, Zhao IS, Duffin S, et al. Revitalising silver nitrate for
caries management. Int J Environ Res Public Health. 2018;15(1).
doi: 10.3390/ijerph15010080.
23. Wright JT, White A. Silver diamine fluoride: changing the
caries management paradigm and potential societal impact. N
C Med J. 2017;78(6):394-397.
24. Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver
diamine fluoride for dental caries management in children and
adolescents, including those with special health care needs.
Pediatr Dent. 2017;39(5):135-145.
25. Chibinski AC, Wambier LM, Feltrin J, et al. Silver diamine
fluoride has efficacy in controlling caries progression in pri-
mary teeth: a systematic review and meta-analysis. Caries Res.
2017;51(5):527-541.
APRIL 2019
 CONTINUING EDUCATION QUIZ 2 Hours CE Credit

Medical Management of Dental Caries

Joel H. Berg, DDS, MS

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/cceddentalcaries

ENTER PROMO CODE: CCEDMMDC

1. So far, big data and analyses have been used mainly: 6. Most dental caries risk assessment tools are highly:
A. for analysis of cariogenic microflora. A. sensitive but not specific.
B. for analysis of the most successful anticariogenic strategies. B. specific but not sensitive.
C. by third-party payers to assess the likelihood of success of one C. sensitive and specific.
particular form of treatment versus another. D. neither sensitive nor specific.
D. by university researchers seeking out a more accurate public
health caries model. 7. 
A useful diagnostic device for detecting caries at its earliest
point in time would be:
2. 
Medical management of caries implies that: A. g
 enerally reliable.
A. it will be managed as a chronic disease. B. reliable between examiners.
B. it will be managed as an acute disease. C. reliable for the same examiner using the device at different
C. it will be managed as a public health nuisance. points in time.
D. dentists have not clearly understood the caries process and D. All of the above
how to treat it properly.
8. 
Likely the most important and largest area of discovery
3. What is the most common type of surgery performed on related to dental caries taking place today is in the realm of:
humans? A. regenerative medicine.
A. appendectomy B. plaque biofilms.
B. tonsillectomy C. genetic variations in the host biology.
C. restorative dentistry D. remineralization techniques.
D. skin lesion removal
9. It is now known that the complex biofilm of the mouth
4. What percent of the $115 billion dollars of gross domestic contains over how many unique species of bacterial
consumption of dentistry is spent related to treating organisms?
the results of dental caries? A. 50
A. 10% B. 100
B. 30% C. 200
C. 50% D. 500
D. 70%
10. Silver diamine fluoride must be applied:
5. The caries management continuum has been developed to: A. on 25% of the lesion to be effective.
A. help insurance companies set fee reimbursement schedules. B. on 33% of the lesion to be effective.
B. help dentists establish appropriate fee schedules. C. on 50% of the lesion to be effective.
C. indicate the level of invasiveness of caries lesions. D. fully on the lesion.
D. explain previously unknown effects of caries on the human
dentition.

Course is valid from 4/1/2019 to 4/30/2022. Participants must attain

a score of 70% on each quiz to receive credit. Participants receiving
a failing grade on any exam will be notified and permitted to take one AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA CERP is a service
of the American Dental Association to assist dental professionals in identifying quality
Approval does not imply acceptance
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their accumulated credits, and are urged to contact their own state of dentistry. Concerns or complaints about a CE provider may be directed to the provider dentistry or AGD endorsement. The
or to ADA CERP at www.ada.org/cerp. current term of approval extends from
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1/1/2017 to 12/31/2022.
Provider #: 209722.

5 COMPENDIUM EBOOK APRIL 2019

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