Medical Management of Dental Caries: “Be a Knife Doctor and a Pill Doctor”

Introduction

When thinking about managing dental caries as a disease, and not just the outcomes, one might look to a health network, to see how they characterize the management of that disease, as they would with other health conditions. If you were to look at the Mayo Clinic as a source, you would find this description of how to manage dental caries1.

“Regular checkups can identify cavities and other dental conditions before they cause troubling symptoms and lead to more-serious problems. The sooner you seek care, the better your chances of reversing the earliest stages of tooth decay and preventing its progression. If a cavity is treated before it starts causing pain, you probably won’t need extensive treatment.

Treatment of cavities depends on how severe they are and your particular situation. Treatment options include:

Fluoride treatments. If your cavity just started, a fluoride treatment may help restore your tooth’s enamel and can sometimes reverse a cavity in the very early stages. Professional fluoride treatments contain more fluoride than the amount found in tap water, toothpaste and mouth rinses. Fluoride treatments may be liquid, gel, foam or varnish that’s brushed onto your teeth or placed in a small tray that fits over your teeth.

Fillings. Fillings, also called restorations, are the main treatment option when decay has progressed beyond the earliest stage. Fillings are made of various materials, such as tooth-colored composite resins, porcelain or dental amalgam that is a combination of several materials.
Crowns. For extensive decay or weakened teeth, you may need a crown – a custom-fitted covering that replaces your tooth’s entire natural crown. Your dentist drills away all the decayed area and enough of the rest of your tooth to ensure a good fit. Crowns may be made of gold, high strength porcelain, resin, porcelain fused to metal or other materials.

Root canals. When decay reaches the inner material of your tooth (pulp), you may need a root canal. This is a treatment to repair and save a badly damaged or infected tooth instead of removing it. The diseased tooth pulp is removed. Medication is sometimes put into the root canal to clear any infection. Then the pulp is replaced with a filling.

Tooth extractions. Some teeth become so severely decayed that they can›t be restored and must be removed. Having a tooth pulled can leave a gap that allows your other teeth to shift. If possible, consider getting a bridge or a dental implant to replace the missing tooth”.¹

It is noteworthy, that there are very few other human conditions/diseases where the focus of the effort starts mainly with “surgery”.²

Premise

Dental caries is the most prevalent disease in humans. It affects nearly all in their lifetime. Yet, even with this exceptionally high prevalence, the disease itself is rarely effectively treated.³ Rather, we generally wait for the outcomes of the disease in the form of needing to carry out various and often extensive forms of restorative dentistry. This “need” to wait and only late in the game perform restorative treatments is primarily due to the fact that we cannot see caries lesions clinically, or radiographically until such time that the lesions are cavitated. At the stage of cavitation, the caries lesions do require restorative intervention. (Fig. 1) We become a “knife doctor”.⁴

Fig. 1

Over the last decade, various technologies have evolved which will eventually allow us to treat caries medically and not only surgically. In our counterpart profession of medicine, there are two distinct types of providers. There are those who pursue “medical” careers, and those who choose surgical careers. In dentistry we are both–“knife doctors and pill doctors”. Yet, we have not been able to manifest the “medical” part of dental caries disease treatment because of the lateness of detection of the lesions. Although we are strong and engaging in empirical prevention the form of using fluoride products, encouraging appropriate diets, and engaging in proper oral hygiene, (Fig. 2) we cannot entirely prevent the manifestations of dental caries due to its “invisible” state at the early stages.⁵

Fig. 2

The idea of a caries management continuum has been described in previous publications.⁶ This continuum discusses the fact that at the earliest stage, one should look at every aspect of the caries process. Caries is a disease caused by biofilm acid production which begins to demineralize the tooth surface, usually subsurface, prior to cavitation. This acid production and disease production coincides with various opportunities to treat the disease if the disease process could be identified on a localized basis before cavitation. Although there are interventions available in vitro at various early stages of lesion formation, these interventions cannot be deployed clinically because the clinical detection of the lesion at that early stage is not possible. We therefore resort to late identification, and therefore relatively late treatment on the continuum6 in the form of restorative dentistry.⁷

Caries Risk Assessment

The necessary but not sufficient conditions to become a “Pill Doctor” as much as a “knife doctor” is via the use of various caries risk assessment tools.^5,8

We have been exposed to an array of caries risk assessment tools over the last decades. Most of the used tools to date are of the questionnaire, health screening variety. Many of these are outstanding and sensitive tools for the identification of who may be at risk for future caries lesions. These tools provide a platform upon which we can have a discussion with our patients regarding the elements of risk, and to try to engage in risk mitigation. However, the downside of the existing risk assessment tools is that although they are “highly sensitive”, they are not “specific” enough⁹. They detect far too many patients deemed to be at high-risk of experiencing future caries lesions who are not in actuality at high-risk. This is a critical point, because the ability to predict quickly and precisely who is actually at risk, is the main component of medical management of dental caries, that is not entirely possible today.

Caries Risk Scanning Devices

We look forward to the development of scanning devices which could more specifically and sensitively identify the future risk of caries lesions in both children and adults at an early stage. Technology-based tools assessment tools with specific outcome metrics related to likely “cavity experience in the future” could become validated determinants of risk. These devices might examine the “potential acid production” of a patient when challenged with sucrose, in order to describe the individual patient’s biofilm, and could serve as a predictor of future cavity experience10. (Fig. 3) By having a technology that is shown to be predictive, one can deploy various “medical” or “pill doctor” treatments that would ultimately avoid restorative dentistry. (Fig. 4)

Fig. 3

Fig. 4

Treatments that are Medical (“Pill Doctor”)

Such medical treatments include the use of silver diamine fluoride or fluoride itself^11-14. Another discussed “medical” treatment that does not require surgical intervention is resin infiltration. We should be discussing saliva much more often and its impact on caries prevention and management. The fact that we talk little about saliva and its importance in caries prevention and management has impaired our ability to do more medical management, merely by monitoring the patient’s saliva flow and consistency. We could look at viscosity of the saliva at each examination appointment as well as the estimated salivary volume. One can characterize these two aspects of saliva and determine if there has been a change.

There is “plain old fluoride” which if applied to early caries lesions that were identified with evolving technologies might halt the progression of these lesions, with technology assisted demonstrable results.^15-17 Indeed, it is clear that many have attempted to develop peptides and other molecules which could mitigate acid production or turn off acid production by interfering with the chemical communication pathways within the biofilm. Such interventions might take place in various form of pharmaceuticals, such as those which currently disrupt human biochemical pathways. With the rapid pace of technology development in the applications of well-established molecular biological techniques applied to the oral biofilm, it is this author’s opinion that we will soon be in an era where we can actually treat biofilms medically, based on their potential for inducing large amounts of caries lesions.

Other forms of caries treatments

In addition to fluoride and other pharmacological agents that might be developed once we can establish/visualize demineralization in the early stages of the caries lesion process, we can also begin to use a variety of naturally occurring minerals which might halt or slow the progress of early caries lesions. This will bring great value to the medical management of dental caries.

Discussion and Conclusions:

Most of what we do in dentistry is related to restorative dentistry. Most endodontics, most prosthodontics and most of general dentistry practice is related to the late stages of caries activity (Figs. 5 & 6) that were not detected at a very early stage. With the cost of restorative dentistry being a major part of all dental expenditures, we can imagine the possibilities by implementation of medical management into the dental profession. This will precisely require attention to caries risk with a “metric” in the same way that metrics have allowed us to manage common chronic diseases such as diabetes, where HgA1C is a predictive metric. Therefore, it is the belief that technologies which can specifically assess both the risk and the progression of caries lesions in early stage will guide us into a host of pathways to treat caries lesions medically. It is distinctly possible that dentistry could evolve from an only surgical management of disease to a medical model of managing disease as the Flexner Report did for Medicine in the early 20th century.¹⁸

Fig. 5

Fig. 6

In a recent publication in Nature International Journal of Oral Science, Cheng et al19 describe that “Dental Caries is a kind of chronic oral disease that greatly threatens human beings’ health.” They further state that “a system of caries prevention and management is established based on dental caries diagnosis and classification”.

As far back as 1994 and perhaps even earlier, another leading expert, Edelstein,²⁰ described the need to have medical management of dental caries. He was right then, as others were before him, yet his vision preceded the science and technology to support his recommendations. That has all changed.

Oral Health welcomes this original article.

References

1. https://www.mayoclinic.org/diseases-conditions/cavities/diagnosis-treatment/drc-20352898
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19. Lei Cheng, Lu Zhang, Lin Yue, Junqi Ling , Mingwen Fan, Deqin Yang , Zhengwei Huang , Yumei Niu, Jianguo Liu , Jin Zhao, Yanhong Li, Bin Guo Zhi Chen and Xuedong Zhou International Journal of Oral Science (2022) 14:17.
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About the Author

Joel Berg is a consultant in the dental industry and practices Pediatric Dentistry part-time in the Phoenix area. He is former Dean at the University of Washington School of Dentistry. He is a Past-President of the American Academy of Pediatric Dentistry and a Past-President of the American Academy of Esthetic Dentistry.

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