Principles and care pathways for caries management in children: IAPD Rome forum

Abstract

The traditional approaches to the treatment of dental caries have focused on repairing the consequences of the caries process, the lesions, rather than addressing the disease process itself. Advances in the understanding of caries microbiology, de-/remineralization cycling, risk/susceptibility assessment, staging of lesion activity/severity, non-surgical/micro-/minimally invasive procedures and public health interventions are fundamentally changing the landscape of caries management. To facilitate the global adoption of contemporary caries management for children, international experts were convened as part of an International Association of Paediatric Dentistry (IAPD) forum in Rome, in November 2022. This expert panel met for a one-day pre-conference workshop to discuss and consider principles of cariology and care pathways to improve oral health for individuals and healthcare systems. The topics discussed included advances in the science of cariology, advances in caries management, improving oral healthcare systems and teaching caries management. Such advances are especially important for children's oral health because of the value of establishing early preventive behaviours (including caregivers), difficulties of performing procedures in young children and inequalities/inequities in children's oral health care. The topics were presented over the two-and-a-half-day congress, and the feedback was collected. This position paper presents the summarized evidence collated by the expert panel and the IAPD Board of Directors.

The concept of ‘caries management pathways’ in contrast to ‘dental treatment plans’ is critical to the contemporary person-focused management of dental caries, since clinical pathways yield a greater probability of success, fewer complications and more efficient use of resources.¹⁸ An example of clinical caries management was suggested by Ismail and others in 2015 that emphasized the following: (1) staging lesion severity and activity; (2) assessing patient's caries risk/susceptibility status; (3) synthesizing data leading to diagnosis; (4) comprehensive caries care planning including prevention, non-operative management and tooth-preserving operative management; and (5) evaluating outcomes including further management and recall frequency.¹⁹

Primary caries management/prevention for children should begin before the initiation of disease. The evidence-based pillars for primary prevention are twice-daily toothbrushing using a fluoride-containing toothpaste, limited intake of free sugars^{20, 21} and dental sealants where necessary.²² If primary prevention fails, secondary prevention needs to target early carious lesions with advances in minimally invasive strategies, such as professionally applied fluoride and high-fluoride (1.1% NaF) toothpaste for children over age six.²³ Advanced cavitated lesions may be less likely to be arrested, thus requiring operative approaches. In addition to the many advances in caries management, it is important that they conform to SDM, patient preferences, local/regional standards and government/healthcare policy regulations.

Pulp therapy in the primary dentition aims to preserve the teeth until they exfoliate naturally. In young permanent dentition, pulp therapy aims to preserve pulp sensibility and allow root development to continue. For both primary and permanent teeth, selective caries removal is an advance in caries management to prevent pulp exposures by excavating to hard dentine on the peripheral walls of deep lesions while leaving leathery (or in some cases, soft dentine) on the pulp floor.²⁴ There is a fundamental need to increase oral health providers' awareness of selective caries removal techniques for the management of deep carious lesions.

The advanced knowledge of oral health care for children compels the movement from a surgical care model to an oral health outcome model. This transformation has consequences for the way the profession is educated, integrated across a dental school's curricula and how students' learning and competencies are assessed/evaluated.^{40, 41} Person-focused, evidence-based cariology curriculum frameworks have been developed and adapted to different parts of the world for use in dental education.^{42, 43} Approaches to implement health outcome model will need to include the training and calibrating of oral health educators on evidence-based caries management; integrating caries management with other disciplines; and establishing clinical competencies in patient assessment, behavioural science and caries management. The oral health outcome model will prepare new practitioners for the future, which includes patients at the centre of preventive oral health management.

NT initiated a panel to advance the principles and care pathways. MB, VD, MF, NI, HK, SL, NP, FS, ST and KV contributed to the initial drafts. All authors reviewed and critically revised the manuscript drafts. All authors read and approved the final manuscript.

No authors claim any conflicts of interest with this manuscript.