Minimal intervention dentistry II: part 2. Management of caries and periodontal risks in general dental practice

Dento-legal considerations about an MI approach

Over the years there have been many conceptual changes in how dental disease is prevented and managed. What is now the norm and standard practice was at some earlier time considered to be at best pioneering, and at its worst, heresy or negligent. When we look, for example at how we conservatively manage periodontal disease when less than a generation ago we were wielding surgical knives far more frequently than we do now, we can see how research and evidence-based dentistry has influenced our thinking. We are very much at that tipping point now with minimum intervention (MI) dentistry. This article will discuss the impact of MI dentistry from a legal viewpoint, covering such aspects as consent and record-keeping.

Baseline caries risk assessment as a predictor of caries incidence

Few studies have evaluated clinical outcomes following caries risk assessment in large datasets that reflect risk assessments performed during routine practice.

OBJECTIVES

From clinical records, compare 18-month caries incidence according to baseline caries risk designation.

METHODS

For this retrospective cohort study, data were collected from electronic records of non-edentulous adult patients who completed an oral examination and caries risk assessment (CRA) at a university instructional clinic from 2007 to 2012 (N=18,004 baseline patients). The primary outcome was the number of new decayed/restored teeth from the initial CRA to the ensuing oral examination, through June 30, 2013 (N=4468 patients with follow-up). We obtained doubly-robust estimates for 18-month caries increment by baseline CRA category (low, moderate, high, extreme), adjusted for patient characteristics (age, sex, payer type, race/ethnicity, number of teeth), provider type, and calendar year.

RESULTS

Adjusted mean decayed, restored tooth (DFT) increment from baseline to follow-up was greater with each rising category of baseline caries risk, from low (0.94), moderate (1.26), high (1.79), to extreme (3.26). The percentage of patients with any newly affected teeth (DFT increment>0) was similar among low-risk and moderate-risk patients (cumulative incidence ratio, RR: 1.01; 95% confidence interval, CI: 0.83, 1.23), but was increased relative to low-risk patients among high-risk (RR: 1.28; 95% CI: 1.10, 1.52), and extreme-risk patients (RR: 1.52; 95% CI: 1.23, 1.87).

CONCLUSIONS

These results lend evidence that baseline caries risk predicts future caries in this setting, supporting the use of caries risk assessment to identify candidate patients for more intensive preventive therapy.

CLINICAL SIGNIFICANCE

Identification of patients at greater risk for future caries helps clinicians to plan appropriate personalized care. In this study, a multifactorial approach to caries risk assessment effectively stratified patients into groups of higher or lower caries propensity. Dentists can apply risk assessment in practice antecedent to patient-tailored caries management.