REVIEW published: 27 April 2021 doi: 10.3389/froh.2021.657518 Evidence-Based Caries Management for All Ages-Practical Guidelines John D. B. Featherstone 1*, Yasmi O. Crystal 2,3, Pamela Alston 4, Benjamin W. Chaffee 1, Sophie Doméjean 5,6,7,8, Peter Rechmann 1, Ling Zhan 4 and Francisco Ramos-Gomez 9 1 Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco, San Francisco, CA, United States, 2 Pediatric Dentistry Department, College of Dentistry, New York University, New York, NY, United States, 3 Comprehensive Pediatric Dentistry, Bound Brook, NJ, United States, 4 Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, San Francisco, CA, United States, 5 Department of Operative Dentistry and Endodontics, UFR d’Odontologie de Clermont-Ferrand, Clermont-Ferrand, France, 6 EA 4847, Clermont-Ferrand, France, 7 Université Clermont Auvergne, Clermont-Ferrand, France, 8 Service d’Odontologie, CHU Estaing, Clermont-Ferrand, France, 9 Section of Pediatric Dentistry, School of Dentistry, University of California, Los Angeles, Los Angeles, CA, United States Introduction: The purpose of the present paper is to provide step-by-step guidelines for dental healthcare providers to manage dental caries based upon caries risk assessment (CRA) for ages 0–6 years and 6 years through adult. The manuscript reviews and updates the CAMBRA (caries management by risk assessment) system which includes CRA and caries management recommendations that are guided by the assessed risk level. Caries Risk Assessment: CAMBRA CRA tools (CRAs) have been evaluated in several Edited by: clinical outcomes studies and clinical trials. Updated CAMBRA CRAs for ages 0–6 years May Lei Mei, University of Otago, New Zealand and 6 years through adult are provided. These CRAs have been refined by the addition Reviewed by: of a quantitative method that will aid the health care provider in determining the caries Jilen Patel, risk of individuals. University of Western Australia, Australia Caries Management Based Upon Risk Assessment: Guidelines for individualized Bathsheba Turton, patient care are provided based upon the caries risk status, results of clinical exams University of Puthisastra, Cambodia and responses of the patient to questions in the CRA. These guidelines are based upon *Correspondence: John D. B. Featherstone successful outcomes documented in several clinical outcomes studies and clinical trials. [email protected] The paper includes a review of successful caries management procedures for children and adults as previously published, with additional emphasis on correct use of silver Specialty section: This article was submitted to diamine fluoride (SDF) for children. The caries management plan for each individual is Oral Hygiene and Oral Health Policy, based upon reducing the caries risk factors and enhancing the protective factors with a section of the journal the additional aid of behavior modification. Beneficially altering the caries balance is Frontiers in Oral Health coupled with minimal intervention restorative dentistry, if appropriate. These methods Received: 23 January 2021 Accepted: 08 March 2021 are appropriate for the management of dental caries in all patients. Published: 27 April 2021 Keywords: caries management, caries risk assessment, dental caries, fluoride, infants and toddlers Citation: Featherstone JDB, Crystal YO, Alston P, Chaffee BW, Doméjean S, INTRODUCTION Rechmann P, Zhan L and Ramos-Gomez F (2021) Evidence-Based Caries Management Dental caries is a multifactorial, bacterially generated disease, where an unhealthy shift in the for All Ages-Practical Guidelines. oral microbiome is driven by a diet that favors frequent ingestion of fermentable carbohydrates Front. Oral. Health 2:657518. and behaviors, such as ineffective home oral hygiene practices, that allow the preservation of this doi: 10.3389/froh.2021.657518 unfavorable oral environment. In addition, other biological factors like salivary dysfunction or Frontiers in Oral Health | www.frontiersin.org 1 April 2021 | Volume 2 | Article 657518 Featherstone et al. Caries Management-Practical Guidelines factors in the environment, like low health literacy or limited risk level [3, 4, 6, 9, 11, 12, 15, 19–21].Inthispaper,weinclude the access to care, complicate the scenario; therefore, there is no use of a quantitative component with the CAMBRA CRA forms single “magic bullet” that cures dental caries [1, 2]. The disease to aid the clinician in the determination of the caries risk level. can be thought of as a balance between caries pathological and preventive factors as illustrated by the diagram in Tables 1, 2, CARIES MANAGEMENT BASED UPON [3–5]. The management of dental caries can be challenging when patients present with several caries risk factors. This is especially RISK ASSESSMENT—PRACTICAL the case for patients with special needs. GUIDELINES FOR THE HEALTH CARE Dental caries may be managed by swinging the caries balance PROVIDER toward the protective factor side and maintaining it there by reducing pathological risk factors and promoting protective Several segments of this publication are reproduced or modified factors [6]. It is now well-recognized that caries management from Featherstone et al. [3, 4], Rechmann et al. [22], and is best done on a personalized basis building upon a reliable CAMBRA guide [23] with permission of the publishers. caries risk assessment (CRA) where detailed information about the specific risk factors of a patient can be utilized not only to Definitions of Terminology for Caries Risk establish the risk of developing future caries lesions, but also to Assessment establish an effective plan to promote protective habits with the In the present publication caries risk, risk factors, protective aid of behavior modification and to tailor the periodicity of oral factors and disease indicators are defined as follows: evaluations. Assessment of caries risk for each individual patient is essential as the basis for the management of dental caries for a) Caries risk is the likelihood of the patient having new caries patients of all ages [7, 8]. lesions (active white spots, non-cavitated approximal lesions, The procedures and philosophy known as “caries cavitated lesions) in the near future. management by risk assessment” and abbreviated to CAMBRAR b) Protective factors are environmental factors, biological were published in the Journal of the California Dental factors or chemical therapy that help to swing the caries Association in 2007 and updated in 2019 for patients aged balance to caries lesion prevention or reversal. Examples are 6 years through adult [4, 9, 10], as well as for young children fluoride in drinking water, adequate saliva and the use of aged 0–5 years [3, 11] and have been utilized for over 15 years in fluoride toothpaste. the teaching clinics of the School of Dentistry at the University c) Risk factors are environmental or biological factors that of California San Francisco (UCSF) [12] and at the University contribute to the initiation or progression of caries lesions. of California Los Angeles (UCLA) School of Dentistry Pediatric Biological factors include items such as acid producing Dental Clinic, as well as several community health centers in bacteria, visible plaque on the teeth, frequent snacking on California [13, 14]. Successful management of dental caries fermentable carbohydrates. Environmental factors include requires (a) the use of a reliable CRA tool, that then leads to items such as low health literacy (Tables 1, 2). (b) the formulation of an individualized treatment plan that is d) Disease indicators are the clinically observed results of derived from the caries risk level and the information learned previous and/or ongoing dental caries destruction of the tooth during the CRA process. The overall CAMBRA method includes mineral. They do not contribute to the disease, but they are both risk assessment and caries management. direct indicators of the presence of disease in the past or at The CAMBRA CRA tool was developed over decades by the time of the observation. personnel at UCSF as described above, based upon research e) Caries lesion. In this publication the term “caries lesion” is on key factors that contribute to caries progression or reversal used throughout to describe a dental lesion (cavitated or non- on real patients over time. The tool was launched in 2003 cavitated) caused by the dental caries process. The term caries and has been updated since then based upon clinical outcomes lesion may also be referred to as a carious lesion. [3, 4, 10, 11, 15]. It provides a risk assessment form for two age ranges, namely ages 0–6 and 6 years through adult. The General Considerations for Successful CAMBRA CRA tool has been shown to be highly predictive of Caries Management future caries lesions in three different studies, totaling more than Assessment of the caries risk level for future occurrence of 20,000 patients, for the age group 6 years through adult and for caries lesions is an important first step in managing dental the age group 0–5 years [12, 16–18]. A detailed discussion of these caries and monitoring oral health improvement over time. clinical studies has been reported previously [3, 4]. CAMBRA All children should be given their first oral exam upon the CRA can confidently be used by the dental care provider to assess eruption of the first tooth or before 1 year of age to ensure the caries risk of an individual patient and