As early as 1896, G.V. Black predicted that "The day is surely coming when we will practice prevention rather than reparative dentistry." Today, more than a century later, the dental profession is finally poised to make that goal a reality.
Major advances in the science of cariology (the study of decay), have taught us that caries is a dynamic process of demineralization and remineralization of tooth structure, and that when the oral cavity is in a demineralization phase longer than a remineralization or neutral phase, the caries process will lead to cavitation, or tooth decay. Today we know that there is a balance between positive and negative factors. A patient who suffers from frequent cavities has tipped the balance of the scale to the negative side, and it is our job to re-establish a balance.
In 2006, a coalition of dental schools, the CAMBRA (Caries Management By Risk Assessment) coalition, of which NYUCD is a founding member, was formed to promote awareness of this process among both the profession and the public and to establish guidelines for finally achieving the end of cavities. The guidelines are as follows:
- oral bacteria can be modified to promote health
- patient education and informed participation are key to controlling dental caries
- remineralization of non-cavitated lesions of enamel and dentin/cementum can repair hard tissues, so that dental decay, in its earliest stages, need not lead to developing a hole in a tooth
- minimal operative intervention of cavitated lesions is key to the long-term success of restorations
- repair of defective restorations exists as a possible alternative to replacement.
CAMBRA works to highlight indicators that identify individuals as high-risk patients and therapies that can be used both at home and in the dental office to prevent or reverse caries. Risk factors include xerostomia (dry mouth), recent restorations, caries, diets high in refined carbohydrates and sugars, lack of fluoride, and frequency of eating. Beneficial treatments include sealants, fluoride applications, and prescription fluorides.
Using this new knowledge, NYUCD has implemented a formal program to identify the caries risk of every patient. Whether patients are assessed as being at low, moderate, or high risk, they are counseled and advised regarding their particular level of risk, and appropriate therapies, using the CAMBRA guidelines, are instituted. In addition, recall and re-evaluation intervals are
recommended and recorded in the patient record. Indeed, caries risk assessment and monitoring have become the accepted and required standard of care that all NYU dental students must follow.
But while knowledge of the caries process has advanced tremendously in recent years, challenges still remain. When we look at the epidemiological data, studies show that 20 percent of the population is responsible for 80 percent of the caries activity. Moreover, there is an inverse correlation between economic status and severity of this infectious disease. Some of this is due to diet and inadequate counseling, as well as to the lack of fluoridated water and inadequate access to care in many areas. Equally important is the fact that many of the preventive measures and treatments that have proven to be effective in preventing or at least significantly reducing the disease are not covered by insurance. The irony is that insurance companies will pay for surgery but not for treatment t0hat can eliminate the need for surgery. In dental terms, they will pay to "drill and fill," but not to "seal and protect."
Despite these obstacles, NYUCD is committed to educating our students to prevent disease using the most advanced therapies available, including intervention in the caries process at an early enough stage so that surgical treatment is unnecessary. As recently as 1989, it was reported that 43 percent of six-year olds in a low socioeconomic status group demonstrated a caries-free mouth while the same age group identified as high socioeconomic status were 77 percent caries-free. Re-evaluated in 1996, the same groups showed some improvement-- to 49 percent and 84 percent, respectively. Are these caries-free individuals just lucky or can this
disease actually be eliminated? Obviously, the model in place for the vast majority of high socioeconomic status children has proved to be effective. However, we need to narrow the gap even further. The end of caries is finally a real possibility, and NYUCD is working hard to make this happen.