Everyone Is Talking About Caries Risk — Are You?

Managing dental caries is one of the most talked about — and written about — challenges facing practitioners who treat children. Although differences exist between private practice settings, public health clinics, and the larger, expanding networks of corporate dentistry offices, it all starts with an evaluation of caries risk.

Whether clinicians are using a caries risk assessment tool or just having a discussion with parents or caregivers, the etiologic factors that predispose children to dental caries are as varied as the kids themselves. What we do know, however, is that 25% of the nation’s children have 80% of the lesions — and health care providers need a tool that will lead to predictive algorithms that allow clinicians to propose individualized prevention protocols.

The American Academy of Pediatric Dentistry (AAPD) recommends caries risk determination as a critical component of the clinical decision- making process. In clinical use, caries risk assessment (CRA):

• Fosters treatment of the disease process, instead of treating the outcome of the disease
• Provides an understanding of the disease factors for a specific patient, and aids in individualizing preventive discussions
• Individualizes, selects and determines the frequency of preventive and restorative treatment
• Anticipates caries progression or stabilization¹

Tools for CRA factor in variables that cause disease directly (e.g., plaque and poor oral hygiene), are predictive of a child developing disease (e.g., socioeconomic status and/or orthodontic brackets), and are known protective factors (e.g., fluoride and regular dental visits). Tooth, bacteria and diet — the trilogy of the past — are being replaced by an understanding of the relationship between ecological and socioeconomic influences, such as ethnicity, education, and even the communities in which children live. Buried in early childhood caries causality are also newly identified parental influences relating to “governing the child’s proximate environment with parenting styles that sometimes endorse adaptive or maladaptive health attitudes, beliefs and behaviors.”² This includes associations between dental caries and sociodemographic factors, such as feeding practices, behaviors, oral health, attitudes, knowledge and beliefs, single-parent families, between-meal snacking, daily oral hygiene, toothbrushing skills and regular dental visits.²

It’s important to bear in mind that past caries experience is the result of disease — not the cause of it.³ Caries diagnosis (including lesion location) is critical in predicting caries risk. Even the presence of noncavitated white spot lesions is a sure indicator of high caries risk. If left untreated, these can progress to cavitated enamel and dentin lesions. This puts the patient on the highway to pulpal involvement and magnification of the high-risk environment.

Clinical caries detection methods are dependent on multiple factors — some as obvious as fluoride’s effect on the anatomy, opacity and texture of enamel. It challenges the interpretation and usefulness of the dental radiograph and other commercially available caries detection technologies.4 This raises questions about the ability of CRA tools to reliably predict caries, and prompted discussions of the validity of current prediction models.³ The AAPD Pediatric Oral Health Research and Policy Center (POHRPC) is in its third year of research exploring oral health promotion in primary care. It seeks to identify common risk factors that can be incorporated into more effective screening tools. The AAPD POHRPC is further looking to validate risk assessment tools through its retrospective analysis of data from 1700 patients at Nationwide Children’s Hospital in Columbus, Ohio. Based on defined influential variables, this innovative predictive model is designed to forecast the probability of a caries-related outcome.⁵

Clinicians use these tools to evaluate caries risk — but, more importantly, to discuss preventive measures and treatment with patients. At its core, CRA encourages oral health professionals and primary caregivers to drive the conversation about how to eliminate risk factors that contribute to caries.

Of course, no discussion of CRA is complete without addressing coding and reimbursement — especially when using caries detection methods and motivational interviewing at the time of the visit. A new CDT code, D0600, is intended to provide a nonradiographic means of quantifying and monitoring progression of early lesions, and recording structural changes in enamel, dentin and cementum. The new code has been added to the existing codes:

• D0601: CRA and documentation, with a finding of low risk (using recognized assessment tools)
• D0602: CRA and documentation, with a finding of moderate risk (using recognized assessment tools)
• D0603: CRA and documentation, with a finding of high risk (using recognized assessment tools)

For billing purposes, remember that existence of a CDT code does not mean the procedure is endorsed by any entity, or covered or reimbursed by a particular dental plan. It does, however, provide an association and justification of prevention modalities specific to a child’s caries risk evaluation.

Now is the time to evolve beyond the simplicity of the “no cavity club” mentality. Instead, oral health professionals can provide praise, stickers and prizes to kids in the “caries risk-factor-free club.” In my pediatric dental practice, CRA has proven remarkably effective in “getting the caries discussion going.”

In light of this shift in care, will CRA help change the conversation in your practice, too?

REFERENCES

1. American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children and adolescents. AAPD Reference Manual. 2016;38:142–149.
2. Hooley M, Skouteris H, Boganin C, Satur J, Kilpatrick N. Parental influence and the development of dental caries in children aged 0–6 years: a systematic review of the literature. J Dent. 2012;40:873–885.
3. Tellez M, Gomez J, Pretty I, Ellwood R, Ismail AI. Evidence on existing caries risk assessment systems: are they predictive of future caries? Community Dent Oral Epidemiol. 2013;41:67–78.
4. Tranæus S, Shi XQ, AngmarMB. Caries risk assessment: methods available to clinicians for caries detection. Community Dent Oral Epidemiol. 2005;33:265–273.
5. Frese W, Nowak A, Royston L, et al. Caries Risk Factors for Primary Care Providers Based on Shared Determinants of Health. Available at: aapd.org/assets/1/7/ Denta Quest-RE.pdf. Accessed January 17, 2017.

From Decisions in Dentistry. February 2017;3(2):12–13.