The Patient Perspective:
Assessment is the foundation of all care planning. Practitioner and patient work together to create a shared understanding of the patients’ current health status and their priorities. Conceiving of caries severity as a series of stages helps to identify the importance of both patient and practitioner behavior in modifying the disease process.
What it is:
Caries staging and activity assessment is the second essential step in the 4D-cycle for effective and personalised care. It builds on the knowledge acquired from the 1st D. The aim is to examine the patient carefully for caries lesions, combining this clinical assessment with information from radiographs when available. This step will involve differentiating caries lesions from other pathologies/conditions such as erosive tooth wear, developmental defects, etc., as well as noting the stage of any caries present (initial, moderate or extensive) and the activity of lesions (likely active or likely inactive). Additionally, this step considers the patient’s past caries experience (including number of restorations, state of previous restorative work, teeth extracted due to caries, and dental sepsis). Caries staging and activity assessment also helps clinical decision-making and enables the development of an individualised caries management plan.
How to conduct the caries staging and activity assessment:
The caries assessment is based on visual examination of clean teeth in combination with, where possible, a radiographic examination of posterior teeth (bite-wing x-rays). It is worth remembering that detecting smaller initial stage caries lesions may be more difficult as they develop in areas of plaque stagnation, thus removing plaque is essential. (Tables 1,2,3,4).
- Stage the severity of caries lesions. These categories based upon surface characteristics of the lesion seen clinically are linked to the histological depth of the lesion.
- Where there are radiographs, the radiographic depth of a lesion is combined with its clinical appearance to determine the stage of caries.
- Once the severity stage of a caries lesion has been determined, its activity is assessed.
Three key visual caries stages can be discriminated to help inform non-operative/operative care decisions.
Visual combined with radiographic
Radiographically, ICDAS classifies coronal caries into three key caries stages (initial, moderate and extensive). That, in combination with the visual staging, help to inform non- operative/operative care decisions.
Good practice points
• Clinical caries severity staging is fast and easy after training, which is available through the ICDAS/ICCMS webpage
• Sharp probing does not improve detection and it causes further damage to caries lesions
• Clinical caries severity staging does not require any specific device
• Remember that the radiographic images on bite-wing projections show a range of sizes of approximal lesions but are not able to reveal many occlusal lesions until they are quite extensive
• The caries staging and activity assessment should be integrated into the oral health record and, if possible, into a digital record system.
Guidance references: 1,2,3,4,5,6,7,8,9,10,22,23,24,25,26,27, 28,29,30,31,32,33,34,35,36
3rd D: DECIDE: Personalised care plan: Patient and tooth levels
1st D: DETERMINE Caries Risk