Is the factor modifiable?
Having a high predictive value for further lesion development
(Previous restorations, carious lesions from early demineralization to deep lesion that may have a pulpal involvement)
Neither by the dental practitioner nor by the patient
Directly linked to the onset of the disease
Bad oral hygiene
(Low frequency, absence of regular use of fluoridated agent)
By the patient after professional advice and recommendations
Toothbrushing at least twice a day with a fluoridated toothpaste at a concentration and amount adapted to age and caries risk status
Frequent consumption of carbohydrates
By the patient after professional advice and recommendations, coupled with substitution with non-cariogenic sweeteners such as xylitol
Decreased saliva flow
(Temporary due to medication or permanent due to head and neck irradiation)
Neither by the dental practitioner nor by the patient. Additional aggressive antibacterial therapy and pH control (sodium bicarbonate) are essential for these patients
Deep pits and fissures
Sealant placement by a dental professional
High cariogenic bacteria count
By the patient after professional advice and recommendations using proven antibacterial therapy
(Factors of plaque retention and stagnation)
The patient should follow professional advice and recommendations in terms of oral hygiene
Appliances (orthodontic and prosthodontic)
(Factors of plaque retention and stagnation)
The patient should follow professional advices and recommendations in terms of oral hygiene and high-concentration fluoride therapy
Stopping or even counterbalancing the pathological factors
Good saliva function
No need for change
Remineralizing and antibacterial agents
No need for change except for high and extreme risk when aggressive fluoride therapy and antibacterial therapy are needed
Disease indicators include the variables directly related to caries experience that, regardless of age, is a reflection of caries activity, past or present. These are primarily clinical observations that indicate the presence of disease, rather than the factors that caused it. Caries experience is determined by the presence of existing lesions (from early non-cavitated lesions to deep dentin carious lesion close to the pulp), restorations, and missing teeth due to caries. Active carious lesions have a strong predictive value and are a very strong indicator of future carious lesions, even without considering other factors. In preschool children, we need to consider not only the child’s caries experience but also the presence of cavitated active lesions among the parents, the caregivers, and the siblings.
Pathological factors are directly linked to the onset of the disease; they include inadequate oral hygiene (low frequency of toothbrushing, absence of regular use of fluoridated agent), inadequate oral environment (decreased saliva flow, high count of cariogenic bacteria), and frequent consumption of carbohydrates. More recently, a genetic component has been identified but is so far impossible to assess clinically in adults (Vieira et al. 2014). In young children some additional factors have to be noted, such as unfavorable eating habits linked to prolonged breastfeeding; prolonged use of a “sippy cup” containing milk, juice, or a sweetened beverage; or sleeping with a bottle that contains liquids other than water. During the first year, the predictive value of salivary counts of mutans streptococci and lactobacilli is higher than at later ages.
Protective factors include the biological and therapeutic components involved in stopping or even counterbalancing the pathological factors. These include remineralizing and antibacterial agents such as fluoride, calcium phosphate, chlorhexidine, hypochlorite, silver diamine fluoride, and agents currently in development or that will be developed in the future. Unfortunately, some pathological factors cannot be easily corrected by the dental professional, such as decreased saliva flow due to some antihypertensive drugs, mood-altering medications, and numerous other medications that have hyposalivatory side effects in some people. Increased efforts by the patient himself/herself and the use of aggressive fluoride therapy and antibacterial therapy are needed to overcome the high caries challenge in these cases.
More important than the risk level determination (low/high in the French Haute Autorité de Santé (Haute Autorité de Santé 2005) recommendations or low/moderate/high/extreme in CAMBRA (Featherstone et al. 2007)) is the specific identification of the pathological and protective factors in order to plan customized preventive strategies adapted to individual needs and ability of compliance; a customized preventive plan aims to counterbalance individual pathological factors by strengthening individual protective factors. These procedures have been validated by outcomes assessments in thousands of patients demonstrating the ability of CAMBRA CRA to identify high- and extreme-risk patients with between 70 and 90 % success (Doméjean et al. 2011; Chaffee et al. 2015a, b).
Omitting to consider the CRA is nowadays unethical; indeed, despite the lack of consensus (Tellez et al. 2013), it has been shown that traditional restorative strategies have no effect of the bacterial count and the carious process itself (Featherstone et al. 2012; Elderton 1992, 1996). Moreover, baseline CRA helps both the practitioner and the patient to objectively understand the evolution of the carious process through follow-up and regular CRA (Lapidos et al. 2016).
19.1.3 Strategies for Prevention
Numerous strategies are available and can be used alone or in combination according to the individual need and individual CRA of each patient. As seen in the previous chapter, dental caries is characterized by demineralization of tooth tissues at lowered pH following bacterial fermentation of dietary carbohydrates. Thus essential components of the caries prevention and management are related to preventing the early colonization of infants by cariogenic bacteria as well as the control of the diet in terms of frequency of ingestion of fermentable carbohydrates (such as glucose, sucrose, fructose, or cooked starch), the inhibition of bacterial metabolism, and other strategies preventing demineralization and/or enhancing the remineralization to counterbalance the drop of pH following carbohydrates intake.
The following paragraphs discuss prevention strategies including education (prevention of the early contamination and dietary counseling), dental sealants, fluoridated agent, and non-fluoridated agents.
Preventing Early Colonization
It is critical to consider an infant oral care program in the context of a participating pair or mother-and-child dyad, which includes comprehensive maternal perinatal oral healthcare, counseling, and treatment (Ramos-Gomez et al. 2012). Indeed, caries is a transmissible, infectious disease and generally, colonization of mutans streptococci (MS) in the oral cavity of children is the result of transmission of these organisms from the child’s primary caregiver; numerous studies showed that a direct relationship exists between MS levels in adult caregivers and that of caries prevalence in their children. Factors influencing colonization include frequent sugar exposure in the infants and habits that allow salivary transfer from mother/caregiver to infants. Maternal factors, such as high levels of MS, poor oral hygiene, low socioeconomic status, low education level, and frequent snacking, increase the risk of bacterial transmission to her infant (Tinanoff et al. 2002; Seki et al. 2006; Douglass et al. 2008; da Silva Bastos Vde et al. 2015).
In the light of these facts, dental professionals must recognize the essential role a mother/caregiver plays in ensuring her child’s oral health (Albino and Tiwari 2016). Improving expectant mothers’ and caregiver’s oral health by reducing pathogenic bacteria levels in their own mouths will delay the acquisition of oral bacteria and the development of early childhood caries in their children, and an effective perinatal program should institute practices such as therapeutic interventions and lifestyle modification counseling both during pre- and postpartum to reduce maternal MS and lactobacilli levels (Ramos-Gomez et al. 2012). Education aims also to inform the mother/caregiver of simple items such as using the same spoon may lead into early contamination.
Although the relationship between the presence of plaque and caries is not as clear as with gingivitis, there is clear evidence that the presence of plaque makes teeth more at risk of caries (Zenkner et al. 2013). It is illusionary to think that toothbrushing even combined with flossing results in a perfect plaque removal; nevertheless regular disruption of biofilm has been shown to play a key role in maintaining oral health in general and in caries prevention in particular. Effective toothbrushing depends on a number of factors including motivation, knowledge, and manual dexterity. Classically, toothbrushing is recommended at least twice a day (after breakfast and at bedtime); frequency can be increased according to the patient need (in case of orthodontic appliances favoring plaque stagnation and retention) and compliance. Emphasis has to be on frequency of the toothbrushing more than on the technique, as there is no consensus yet on the effectiveness of different methods/techniques; nevertheless, the Bass method is the most popular (Muller-Bolla and Courson 2013). For young patients, toothbrushing has to be supervised by an adult (for better plaque removal and to avoid ingestion of fluoride toothpaste). Manual toothbrushing is the method with the better cost-effectiveness ratio; nevertheless, powered (or “electric”) toothbrushes were shown to provide a significantly better plaque removal in both short and long terms. Dental floss must be used once a day (Yaacob et al. 2014; Re et al. 2015). Other tooth-cleaning tools, like waxed dental floss, dental picks, sticks, mini-brushes, oral irrigator (with low water pressure), may be useful to optimize plaque removal in proximal areas (Berchier et al. 2008; Slot et al. 2008). Toothpaste and toothbrushing cannot be considered separately; even though toothbrushing without fluoride toothpaste helps improve oral hygiene and gingival health, it has no caries-preventive effect.
Frequent snacking is not only strongly associated with increased risk of dental caries progression, but also with type 2 diabetes and obesity. Snacking has gained an increasing role as a risk indicator for caries development (Lingström et al. 1994). Energy-dense, low-nutrient-dense foods are often characterized by a high content of added sugar, but several modern snack products such as chips (crisps), popcorn, and shrimp crackers, while not sweet, are still potentially cariogenic due to their content of extensively hydrolyzed starch (Lingström et al. 2000, 2003). Moreover, sweetened and flavored beverage consumption has increased dramatically over the past decades in most of the industrialized countries and particularly in the USA with carbonated soft drinks being consumed the most frequently and most often by children, teens, and young adults (Reddy et al. 2015). It is interesting to notice that different snacking patterns have been reported based on household income: individuals with income at or below the poverty line in the USA more frequently consumed potato chips, fried potatoes, whole milk, and fruit drinks, whereas those with higher incomes consumed more grain-based salty snacks, fruits, skim milk, soft drinks, coffee, and tea (Johansson et al. 2010).
The type and frequency of carbohydrates consumed is of major importance when dealing with caries prevention (Peres et al. 2016); but other important dietary factors are consistency and degree of retention.
Dietary counseling should aim at reducing both the amount and the frequency of carbohydrate intake (Table 19.2).
Dietary advice for patients
Identify the fermentable carbohydrates
Fermentable carbohydrates can be found in various forms in food. Some foods can be rich in sugar without having a sweet taste.
The sugar content may be verified on the nutrition facts label.
Many foods (chips, cereals, etc.) contain cooked starch, which has a high cariogenic potential
Have 3 or 4 meals per day
Avoid snacking between meals
Take time for a real breakfast which may be the most important meal (25 % of the total calorie intake per day)
If snacking is necessary or cannot be stopped, choose some sugar-free food
Avoid drinking or eating sweetened foods all day long (better to consume them during the meals)
22.214.171.124 Dental Sealants
Dental sealants were introduced in the 1960s. Their caries-preventive effect in the pits and fissures of mainly the occlusal tooth surfaces has been well described for high caries risk (Ahovuo-Saloranta et al. 2013). Although studies have utilized first permanent molars, by extension, the results indicate that sealants are effective and should also be recommended for second permanent molars and premolars. While most of the studies and recommendations target children and adolescents, dental sealants also represent an effective preventive measure in adult patients on lifelong therapies capable of producing a number of systemic and oral complications, including xerostomia, which may increase caries susceptibility (Gore 2010).
Comparison of dental sealants to fluoride varnish showed contradictory results; a 2010 literature review presented some evidence toward the superiority of sealants in the prevention of occlusal carious lesions (Hiiri et al. 2010), when the results of a randomized controlled trial with parallel groups concluded that they are all effective in preventing pit and fissure carious lesions in permanent molars (Liu et al. 2012).
Deep pits and fissures have been clearly related to caries risk in occlusal surfaces, and in this case sealants are strongly recommended.
Dental sealants have also been proposed for proximal lesions; it seems that they are rarely used due to the difficulties to access the lesion (need for orthodontic separator); resin infiltration, with a simplified clinical protocol, may be as effective as dental sealant for such lesions (Martignon et al. 2012).
Apart from the indication for primary prevention, dental sealants have also been shown to be an effective noninvasive management strategy for non-cavitated carious lesions and defective restorations (Holmgren et al. 2014).
126.96.36.199 Fluoridated Agents
Fluoride has been used for over 70 years in caries prevention and remains the cornerstone of modern noninvasive dental caries prevention and management based upon a large body of scientific evidence demonstrating its effectiveness. However, the evidence is still evolving and varies for different modes of delivery. Even though systemic fluoride methods were originally designed to promote caries protection by ingestion, anticaries benefits are delivered primarily through topical effects due to the direct contact of fluoride with the tooth surface and penetration of the plaque and enamel of dentin, especially into carious lesions. Obviously fluoride topical effects occur prior to ingestion, but also the beneficial effects can be partly explained by the ingested fluoride that returns to the oral cavity via the saliva (Sampaio and Levy 2011). Thus, the effect of fluoride is local – topical – on the tooth surface and inside precavitated or cavitated lesions: inhibiting bacterial acid production, stopping enamel demineralization, enhancing remineralization (repair), and improving enamel resistance to future acid attacks. The evidence for these fluoridation methods and corresponding products varies from very strong to weak, so that the choice of the most suitable fluoride strategy depends on many factors, including the evidence of effectiveness, the setting, and the resources available in each country or community. Effective fluoride products are available in some countries but not others, and high-concentration fluoride products are not available in numerous countries, making fluoride therapy for high-risk individuals very difficult. Fluorides are safe and effective if applied at recommended levels. However, exposure to higher-than-recommended levels of fluoride during tooth development (between birth and four years of age) may cause dental fluorosis (Fédération Dentaire Internationale 2015)
Fluoride toothpaste sold without restriction over the counter is currently the most widespread fluoride delivery method for individuals and the evidence for its caries-preventive effect in both primary and permanent dentitions is strong (Fédération Dentaire Internationale 2015; Marinho et al. 2003a, b, 2004a, b; Marthaler 2003). Recommendations concern all patients whatever the age and the WHO states that, for public health, based on scientific evidence, every effort must be made to develop affordable fluoridated toothpastes for use in developing countries (Petersen and Lennon 2004). Moreover, its use in combination with water or salt fluoridation is safe.
Recommendations have to be adjusted according to age and risk level. Thus most of the current recommendations consider concentration of fluoride as well as the amount must be adjusted to age (a smear of toothpaste for children up to 3 years old and a pea-size amount after 3 years of age, for example, for the recent recommendations edited by the Scottish Intercollegiate Guidelines Network), particularly for young children to prevent from fluorosis (from fluoride swallowing and ingestion) whom require supervised toothbrushing by an adult (parents, caregivers) (Scottish Intercollegiate Guidelines Network 2014). Moreover, in order to maximize the topical effect of the fluoride toothpastes, patients should be encouraged to spit out excess toothpaste and not rinse with water after brushing. It has to be noted that fluoride toothpaste at a concentration below 1,000 ppm has not been demonstrated to be effective in caries control. In Europe, toothpaste now commonly contains 1,450 ppm fluoride in some form, whereas in other countries they tend to be at 1,000 ppm F.
More recently, toothpaste combining fluoride (1,450 ppm) and arginine (1.5 %) has been developed and studied toward its potential caries-preventive effect, assuming that arginine as an alkali-generating substrate could further counter the acid accumulation within the oral biofilm and thus serves as a promising approach to caries prevention and management. In vitro results showed that the combinatory application of fluoride and arginine has a potential synergistic effect in maintaining a healthy oral microbial equilibrium and thus represents a promising ecological approach to caries management (Zheng et al. 2015). In vivo results support the conclusion that dentifrices containing 1.5 % arginine, an insoluble calcium compound, and 1,450 ppm fluoride may provide significantly greater protection against caries lesion cavitation, in a low to moderate caries risk population, than dentifrices containing 1,450 ppm fluoride alone (Kraivaphan et al. 2013; Li et al. 2015) (Table 19.3).
Manual or powered toothbrusha
Fluoride toothpaste (see below)
At least twice a day:
At bedtime (no eating no drinking (except water) after bedtime brushing)
Approximately every 2 months maximum
The evidence indicates that, for preventing caries in children and adolescents, toothpastes of at least 1,000 ppm fluoride should be used. From 1,000 ppm fluoride, there is a dose-response relationship for caries prevention that should be taken into account when advising children from 3 to 6 years old at high risk for caries. For younger children, consideration should be given, when brushing with concentrations greater than 1,000 ppm fluoride, to their risk of developing mild fluorosis; a risk-benefit decision needs to be discussed with parents/guardians.
For high-risk patients presenting with non-cavitated carious lesions (aged over 6 years) or high-risk patients having root caries lesions (when roots are exposed), toothpaste with 5,000 ppm fluoride has been shown to be superior for caries control compared to 1,450 ppm F toothpaste (Nordstrom and Birkhed 2010; Ekstrand et al. 2013; Srinivasan et al. 2014).
The most commonly used and evaluated concentration of fluoride in varnish vehicles is 22,600 ppm (Marinho et al. 2002a, 2003a, 2004a, b, 2013; Twetman 2015b). Its use for high-caries-risk patient is recommended at least 2 times per year (maximum 4 times per year). Fluoride varnish is a delivery system easily used by a dental practitioner or another trained professional (e.g., dental hygienists, dental therapists, pediatricians) whatever the age of the patient (even for infants) by bypassing the risk of ingestion and thus the risk of fluorosis. Several systematic reviews and meta-analysis on the topics have been published describing the effectiveness of fluoride varnishes (Marinho et al. 2002a, 2003a, 2004a, b, 2013; Twetman 2015b).
Fluoride varnishes have also their indications in the field of secondary prevention for non-cavitated carious lesion (one application per week during 6 to 8 weeks up to remineralization).
They are indicated for moderate or high-caries-risk patients older than 6 years, as the young patient is not able to spit out the fluoride solution; when prescribed for children, an adult must supervise their use (Scottish Intercollegiate Guidelines Network 2014). Fluoride mouthwashes have been shown to have a clear caries prevention effect in the absence of daily fluoride toothpaste use; nevertheless, there were inconsistent results when viewed against the background of fluoride toothpaste use (Marinho et al. 2003a, c, 2004a, b; Twetman 2015b).
The effectiveness of fluoride gels as caries-preventive agents has been reported in both deciduous and permanent teeth (Marinho et al. 2002b, 2003a, 2004a, b, 2015). They are indicated for high-caries-risk patients aged 6 years. High-concentration fluoride gels (≥12,300 ppm) may be applied in disposable trays, which fit loosely over the teeth. Several guidelines recommend the alternative use of fluoride gels to fluoride varnish, but there is no clinical evidence in favor of one or the other. Some other recommendations, such as in Scotland (Scottish Intercollegiate Guidelines Network 2014) or Australia (Australian Dental Association 2012), recommend their use only in the absence of fluoride toothpaste. The European Association of Paediatric Dentistry (EADP) (European Association of Paediatric Dentistry 2009) or the New Zealand Guidelines Group (Ministry of Health New Zealand 2009) recommend that the patient should sit in upright position, should not swallow, and must be allowed to expectorate freely after application (teeth should be wiped at the end of the session with gauze; refrain from eating or drinking for 20–30 min after application). In general, fluoride gels are less recommended than fluoride varnishes; this may be explained by the limitation due to age but also by the limited distribution at professional concentrations (≥12,300 ppm) in some countries like in France, for example, and the additional cost represented by the individualized tray.
Comparison of the Caries-Preventive Effectiveness of One Form of Topical Fluoride Intervention with Another
A literature review published in 2004 proposed to assess the caries-preventive effect of one fluoridated topical agent to another. It concluded that fluoride toothpastes in comparison to mouthrinses or gels appear to have a similar degree of effectiveness for the prevention of dental caries in children in permanent teeth. It also reported that there was no clear suggestion that fluoride varnish is more effective than mouthrinses; moreover, the evidence for the comparative effectiveness, on temporary teeth, of fluoride varnishes and gels and mouthrinses and gels is inconclusive; nevertheless, a tendency of a superior effect of fluoride varnish is suggested (Marinho et al. 2004a).
Another literature review from the same team compared the caries prevention effectiveness of two topical fluoride agents combined with one of them alone, and it appears that mouthrinses, gels, or varnishes used in addition to fluoride toothpaste achieve a modest reduction in caries compared to toothpaste used alone (the prevented fraction was increased about 10 %) (Marinho et al. 2004b).
Slow-Release Fluoride Devices
Slow-release fluoride devices (e.g., slow-dissolving fluoride-releasing glass beads) have been more recently proposed for the prevention, the arrest, or the reversal of the progression in both temporary and permanent teeth carious lesions. So far, there is insufficient evidence to determine whether slow-release fluoride devices (such as glass beads) help reduce dental decay (retention of the beads is a problem) (Chong et al. 2014).
Fluoride Tablets, Drops, Chewing Gums, and Lozenges
The prescription of fluoride supplements like tablets, drops, chewing gums, and lozenges is subordinated by several factors: the patient age, his/her individual caries risk level, the level of fluoride in drinking water, and the determination of dietary fluoride (in order to prevent intake of excess fluoride) (European Association of Paediatric Dentistry 2009). A 2011 literature review and meta-analysis showed that fluoride supplements are associated with a caries increment reduction when used in permanent teeth versus no other preventive fluoride treatment. The preventive effect was not significantly different when fluoride supplements were compared to other fluoridated topic agents. Unfortunately, many of the studies included in the cited review had been conducted at a time when topical fluorides were not widely used suggesting that there is a lack of evidence from the review to make actual good recommendations because, at the present time, the effect of fluoride supplements in children using fluoride toothpastes on a regular basis would probably be limited (Tubert-Jeannin et al. 2011).
Furthermore, when the fluoride supplements were compared with the use of topical fluorides (toothpastes, varnishes, rinses) or with the use of other preventive measures (xylitol lozenges), there was no differential effect (Table 19.4).
The different fluoridated topic agents and their effectiveness (when compared to a placebo or the absence of treatment) – prevented fraction recorded in randomized clinical trials (based on D(M)FS and d(m)fs increment during follow-up)
Frequency of use
Prevented fractionb (CI 95 %)
(Walsh et al. 2010)
(at least two times)
No evidence of effectiveness
23 % (19–27 %)
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