Guidance

Chapter 4: Dental caries

Updated 9 November 2021

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This publication is available at https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-4-dental-caries

This guidance is issued jointly by the Department of Health and Social Care, the Welsh Government, the Department of Health Northern Ireland, Public Health England, NHS England and NHS Improvement, and with the support of the British Association for the Study of Community Dentistry.

Delivering Better Oral Health has been developed with the support of the 4 UK Chief Dental Officers.

Whilst this guidance seeks to ensure a consistent UK-wide approach to prevention of oral diseases, some differences in operational delivery and organisational responsibilities may apply in Wales, Northern Ireland and England. In Scotland the guidance will be used to inform oral health improvement policy.

Introduction

Dental caries is one of the most prevalent non-communicable diseases nationally[footnote 1][footnote 2] and globally[footnote 3]. The disease is caused by dietary sugars that are broken down by micro-organisms in the biofilm on a tooth surface, which produces acids that, over time, demineralise tooth enamel[footnote 4][footnote 5].

The process of de- and re-mineralisation is dynamic[footnote 4]. In the early stages of the disease, dental caries can be reversed. However, when factors promoting demineralisation exceed those favouring remineralisation, dental caries progresses (unless checked) into dentine to a point where the tooth surface breaks down and ultimately a cavity forms[footnote 5].

Effective patient care involves first diagnosing the presence and recording the extent of disease, using contemporary dental caries management tools such as the International Caries Classification and Management System (ICCMS)[footnote 6], encouraging a reduction of factors that cause demineralisation, notably sugar consumption; and, enhancement of those favouring remineralisation, particularly the availability of fluoride and mineral ions. This may be achieved by a combination of preventive actions taken by patients, patient carers and healthcare professionals, supported by higher-level actions that promote policies and active change to facilitate a less cariogenic social environment.

Epidemiology

The prevalence of dental caries in children in the UK has reduced dramatically over the past 5 decades[footnote 7]. This is generally attributed to the introduction of fluoride-containing toothpaste in the early 1970s[footnote 4]. Other factors such as changed social attitudes, access to dental care, developments in preventive dental materials, together with health promoting and clinical practices have also contributed to these changes over time. Yet dental caries, which is largely preventable, remains prevalent and inequalities are marked[footnote 8].

Surveys of oral health in adults within the UK[footnote 9] suggest that there are 3 cohorts in the population:

  • the oldest cohort, who have lost all their teeth, and wear complete dentures
  • a middle cohort, who retain most of their teeth, but do so largely because of the efforts of the dental profession who have restored and maintained teeth in those who grew up before fluoride toothpaste became widely available
  • the youngest cohort, many of whom are caries-free in their early years

In the immediate future, the number of edentulous people will continue to fall. Therefore, more adults will enter older age with some or all of their natural teeth, many of which will be heavily restored. Dental caries is not just a disease of children and young people, new carious lesions can develop at any age. Dental professionals therefore need to be vigilant and take appropriate action to support all patients, irrespective of age, based on their dental caries risk.

Root caries is increasingly a cause for concern and lifelong coronal caries experience is a risk factor for root surface caries experience[footnote 10]. Root caries increases with age and amongst independently living older adults, factors such as poor plaque control, xerostomia, coronal decay and having exposed root surfaces are indicators of risk[footnote 11].

Like many common chronic lifestyle-associated diseases, the prevalence of dental caries is linked with social and economic circumstances[footnote 12][footnote 13], and ethnicity, with the prevalence of dental caries higher in some ethnic groups. It is, however, recognised that there is a complex interplay between these determinants. Whilst some of the variation in disease levels can be accounted for by deprivation (circa 41% amongst 5 year olds)[footnote 12], it is not the only risk factor and dental team members play an important role in identifying modifiable risks and helping individuals to recognise and minimise these risks, and enhance protective factors.

Dental caries risk

Assessing the level of dental caries risk for an individual patient is key to tailoring appropriate preventive care as outlined in Chapter 2: Table 1. Based on extensive research, dental caries risk assessment tools have been developed, but these can be complex and time consuming to administer. Risk identification based on a single risk or protective factor has limitations due to the multifactorial nature of dental caries. The presence of dental caries in the past is a good predictor of dental caries experience in the future, and the overall clinical judgement of a dental professional who has a general sense of an individual’s lifestyle and life-circumstances is vital[footnote 14].

Dental professionals should consider which patients are at higher risk of dental caries. People at higher risk include children presenting with tooth decay; children who have had dental caries in their primary dentition and first permanent molars and those who have been admitted to hospital for removal of their teeth; as well as certain children who are medically compromised or have a disability. Amongst adults, people with medically compromising conditions or disabilities and older adults, particularly as they become physically or cognitively impaired, are at higher risk as well as people with active caries. This includes people for whom the treatment of dental caries can be difficult or present a risk to health.

Additionally, there may be patients with specific teeth or areas of their mouth at higher risk of developing dental caries. For example, hypomineralised teeth are at increased risk of dental caries in children[footnote 15]. Also, adults with partially erupted third molars are at higher risk of developing dental caries in the impacted third molar itself or in the case of mesioangular impacted third molars, on the distal surface of the preceding second molar tooth[footnote 16][footnote 17][footnote 18][footnote 19]. These risks should be clearly identified and explained to patients.

Oral healthcare professionals should work with patients to assess their dental caries risk and support them to manage their oral health effectively as part of person-centred care.

The challenge for oral healthcare professionals is to:

  • ensure everyone receives universal preventive advice and support
  • identify those children and young people who are at higher risk of dental caries and provide additional preventive care
  • identify and provide additional support to those at higher risk in an ageing population with existing restorations, advanced prostheses and the co-morbidities that come with old age
  • identify individuals for whom dental care would be particularly difficult
  • identify specific teeth which would benefit from specific preventive action and support

Risk and protective factors

The main modifiable risk factors for dental caries are diet, consuming too much cariogenic sugar too often, and lack of optimal fluoride.

The key recommendations and good practice points to prevent dental caries are in the summary guidance (Chapter 2: Table 1) with further details in the following chapters:

Other dental caries risk and protective factors, including addressing medicine containing sugars or reducing salivary flow, placing fissure sealants, chewing sugar-free gum and using topical remineralising agents and varnishes, are addressed below.

Medicines

Liquid, chewable or soluble medications containing sugars, either provided on prescription or bought over the counter, may contribute to the frequency, and possibly volume, of an individual’s sugar intake. This presents a challenge as people who are likely to be taking long-term medications in liquid format are likely to be at increased risk of dental caries or from dental treatment that may be required, most notably children with chronic illnesses, people with special needs, or vulnerable older adults.

Children with chronic conditions such as epilepsy may require liquid medication for a long time. Frequent liquid medications can also be taken for common conditions including pain relief, infections, coughs and colds. There is some evidence that due to generic prescribing, a large proportion of the medications dispensed for possible long-term use in older adults are sugar-containing liquid oral medicines[footnote 20].

Sugar-free medicines, where available, may play an important role in the long-term care of such patients. Products that do not contain fructose, glucose or sucrose are listed as being sugar-free. Preparations containing artificial sweeteners such as hydrogenated glucose syrup, lycasin, maltitol, sorbitol or xylitol are also listed as sugar-free, since there is evidence that they are non-cariogenic[footnote 21].

Where a patient is on a long-term liquid or soluble medication that is not sugar-free, clinical teams are advised to check the British National Formulary (BNF) – NICE to determine if sugar-free alternatives are available.

Where a sugar-free version is available, the clinician should write to the patient’s general medical practitioner to ask if they can change the prescription to the sugar-free version, explaining the reason for the request.

Patients that are dentate and on long-term medication that is not sugar-free, and where sugar-free alternatives are not available, should be advised where possible to try to take medications at mealtimes. This may not be realistic if there are specific instructions such as taking medications on an empty stomach, or carers are only permitted to distribute medicines at specific times.

Parents should also be advised to discuss with pharmacists if sugar-free versions of over the counter liquid medications are available for their children.

Methadone, used in the rehabilitation of drug users, is available as a sugar-free preparation. However, the sugar-based version is most often used[footnote 22][footnote 23] due to issues of cost and practicalities. Whilst clinicians have raised concerns about the risk of developing dental caries, empirical research has not been undertaken. High-quality studies are required to assess the adverse effects of methadone on oral health[footnote 24].

It is increasingly recognised that certain medicines may reduce salivary flow, which therefore raises patient risk of developing dental caries. Again, it is helpful to discuss these issues with patients and where appropriate, liaise with their medical practitioner or specialist.

In older adults, polypharmacy leading to xerostomia is a significant risk factor for dental caries, as well as sugared oral nutritional supplements. This includes therapeutic foods which may be in milkshake type liquids which are extremely common within care homes to provide vitamins, minerals and calories to prevent further weight loss. There is a general trend towards more liquid medication, particularly in relation to end-of-life care. Analysis of recent NHS prescribing data (in England) is available online. It will not always be practical, or appropriate, to consider alternatives to these sugar-based supplements and medications because of more pressing health concerns; and, in such cases, dental professionals are encouraged to place greater emphasis on risk management using fluoride (Chapter 9).

People prescribed liquid medications are likely to be in dependent sections of the population including young children, people with special needs and older adults. Whether the use of the medication is short-term or long-term, it is vital to take their general health and wellbeing into account on prescribing these medications. The top 5 most prescribed medications in England include lactulose and morphine sulphate oral solutions, both of which contain sugar (see list of oral liquid prescribing medication). These are commonly used to manage short and long term illnesses: constipation, hepatic encephalopathy and acute or chronic pain and palliative care in older people. If the medication use is long-term, then recognition of sugar-containing oral liquid medication is important. It is important to explore with patients, and their carers or medical team, whether sugar-free options are available and can be tolerated. Alternatively it will be helpful to find ways in which the protective effects of fluoride may be optimised to manage dental caries risk and maintain the patient’s overall health.

Pit and fissure sealants

Pit and fissure sealants have been used in the prevention and control of dental caries on permanent teeth for decades[footnote 25]. A range of materials and techniques exist, with new ones continuing to emerge. Materials include resin-based, glass ionomer, polyacid-modified resin and resin-modified glass-ionomer cements.

When compared with unsealed teeth, there is moderate-certainty evidence that resin-based fissure sealants are effective in preventing and arresting dental caries for up to 48 months [footnote 26]. The evidence for glass-ionomer based sealants is inconclusive[footnote 26].

In line with the philosophy that children at increased risk of dental caries should receive additional preventive interventions, it is strongly recommended that resin-based sealants be applied on eruption of permanent teeth, particularly molar teeth, if a child is judged by the clinician to be at higher risk of dental caries.

Whilst there is limited research evidence on the benefits of proximal sealants, it would seem best practice to seal a surface if it is exposed and at risk. For example, the mesial surface of a first permanent molar may be sealed when the deciduous molar has been lost; or when a surface is exposed, whilst carrying out an interproximal restoration on an adjacent tooth.

The placement of sealants is highly technique-sensitive, with poor operative technique and/or a challenging environment affecting the retention of the sealant and therefore its success[footnote 27]. It is important to check sealants for wear, integrity and leakage at every visit and re-seal where necessary to maintain their role in caries prevention.

Sugar-free chewing gum

The use of sugar-free chewing gum (SFG) has been suggested as a dental caries-inhibiting activity. A recent systematic review provided tentative evidence that chewing SFG reduces dental caries increment compared to ‘not chewing’[footnote 28]. However, there was a considerable degree of variability in the effect and the trials included were generally of moderate quality. The review concluded that there is a need for future research to explore the acceptability and feasibility of the use of SFG as a public health intervention[footnote 28]. The National Institute for Health and Care Excellence (NICE) guidance on oral health for adults in care homes does include SFG as an option for dental caries risk management amongst dentate frail older adults in care homes[footnote 29].

Re-mineralising agents other than fluoride

Topical re-mineralising agents have been available, either on prescription from dentists or over-the-counter, for several years now. They are mainly used for patients with high dental caries risk, as an adjunct to normal therapies, including high-concentration fluoride dentifrices. It is suggested that these agents are effective in re-mineralising early enamel lesions in high risk patients[footnote 30]. Typical constituents include casein phosphopeptide (an amorphous calcium phosphate) that helps bind the re-mineralising ions to the biofilm as well as modulating biofilm pH and bacterial colonisation.

Chlorhexidine varnish

Further research in this area is required, but it may be helpful to consider chlorhexidine varnish (CHX-V) in circumstances where fluoride (Chapter 9) is not possible. There is currently limited evidence regarding the use of CHX-V for the prevention of root caries in older people and adults with xerostomia. A recent systematic review[footnote 31], involving just 3 studies, evaluated CXH-V in relation to a placebo. They reported weak evidence that CHX-V, applied by a professional to exposed roots (3 monthly application; 1% and 10%), reduces the initiation of root caries lesions and the dental caries activity of existing lesions.

Early detection and management pathways

Given that dental caries can be identified and is reversible at an early stage, lesions should be identified at an early stage and managed. There is no evidence that a specific dental recall interval influences dental caries development or progression.

The time between dental check-ups should be based on risk, as assessed by the clinician, working with patients (and where appropriate parents or guardians) and will be influenced by preventive care needed. The recall period will change across the life course[footnote 32][footnote 33], as shown in Chapter 1. For example, in children it is good practice for the recall period to be set so that they can obtain optimal prevention through treatments such as the application of fluoride varnish.

For older adults in care homes, having an oral health assessment on entry to the care home is recommended in NG48 by NICE[footnote 29], supported by access to professional care on a regular basis. Given that these people will be at higher risk of most oral diseases and conditions, shortened recall periods are likely to be the norm.

Resources

NHS Education for Scotland. Prevention and Management of Dental Caries in Children Scotland: NES; 2018 [Second Edition].

Oral health for adults in care homes NICE guideline [NG48].

NICE guidance: Dental checks: intervals between oral health reviews, Clinical guideline [CG19], National Institute for Health and Clinical Excellence; 2004. Report No. CG019.

Widget health. Easy read and communication support for healthcare and medical professionals to help patients with learning difficulties with a visit to the dentist.

References

  1. NHS Digital. Report 2: Dental Disease and Damage in Children: England, Wales and Northern Ireland. (PDF, 1.87MB) London: The Health and Social Care Information Centre; 2015 Published 19 March 2015. ↩

  2. NHS Digital. Adult Dental Health Survey 2009 – Summary report and thematic series [NS] London: The Health and Social Care Information Centre; 2011. ↩

  3. Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, and others. Global Burden of Oral Conditions in 1990-2010: A Systematic Analysis. Journal of Dental Research. 2013;92(7):592-7. ↩

  4. Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, and others. Dental Caries. Nature Reviews Disease Primers. 2017;3:17030. ↩ ↩2 ↩3

  5. Machiulskiene V, Campus G, Carvalho JC, Dige I, Ekstrand KR, Jablonski-Momeni A, and others. Terminology of Dental Caries and Dental Caries Management: Consensus Report of a Workshop Organized by ORCA and Cariology Research Group of IADR. Caries Research. 2020;54(1):7-14. ↩ ↩2

  6. ICCMS Collaboration. ICCMS: International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) – methods for staging of the caries process and enabling dentists to manage caries 2020 [updated 2020]. ↩

  7. NHS Digital. Child Dental Health Survey: England, Wales and Northern Ireland. London: The Health and Social Care Information Centre; 2015. ↩

  8. Public Health England. Inequalities in oral health in England. London: PHE; 2021 19.03.2021. Contract No.: GW-1921. ↩

  9. NHS Digital. Adult Dental Health Survey 2009, England, Wales and Northern Ireland. London: NHS Digital; 2011. ↩

  10. Thomson WM, Broadbent JM, Foster Page LA, Poulton R. Antecedents and Associations of Root Surface Caries Experience among 38-Year-Olds. Caries Research. 2013;47(2):128-34. ↩

  11. Hayes M, Da Mata C, Cole M, McKenna G, Burke F, Allen PF. Risk indicators associated with root caries in independently living older adults. Journal of Dentistry. 2016;51:8-14. ↩

  12. Public Health England. Oral health survey of 5 year old children 2019 London. 2020 (updated 19 March 2020). ↩ ↩2

  13. Public Health England. Oral health survey of 3 year old children 2020 London. 2021. ↩

  14. Fontana M, Gonzalez-Cabezas C. Evidence-Based Dentistry Caries Risk Assessment and Disease Management. Dental Clinics of North America. 2019;63(1):119-28. ↩

  15. Wuollet E, Laisi S, Alaluusua S, Waltimo-Sirén J. The Association between Molar-Incisor Hypomineralization and Dental Caries with Socioeconomic Status as an Explanatory Variable in a Group of Finnish Children. International Journal of Environmental Research Public Health. 2018;15(7). ↩

  16. Faculty of Dental Surgery. Parameters of care for patients undergoing mandibular third molar surgery. London: RCSEng; 2020. ↩

  17. Toedtling V, Coulthard P, Thackray G. Distal caries of the second molar in the presence of a mandibular third molar – a prevention protocol. British Dental Journal. 2016;221(6):297-302. ↩

  18. McArdle LW, McDonald F, Jones J. Distal cervical caries in the mandibular second molar: an indication for the prophylactic removal of third molar teeth? Update. British Journal of Oral and Maxillofacial Surgery. 2014;52(2):185-9. ↩

  19. McArdle LW, Jones J, McDonald F. Characteristics of disease related to mesio-angular mandibular third molar teeth. British Journal of Oral Maxillofacial Surgery. 2019;57(4):306-11. ↩

  20. Baqir W, Maguire A. Consumption of prescribed and over-the-counter medicines with prolonged oral clearance used by the elderly in the Northern Region of England, with special regard to generic prescribing, dose form and sugars content. Public Health. 2000;114(5):367-73. ↩

  21. European Food Standards Agency on Dietetic Products NaAN. Scientific Opinion on the substantiation of health claims related to intense sweeteners and contribution to the maintenance or achievement of a normal body weight (ID 1136, 1444, 4299), reduction of post-prandial glycaemic responses (ID 4298), maintenance of normal blood glucose concentrations (ID 1221, 4298), and maintenance of tooth mineralisation by decreasing tooth demineralisation (ID 1134, 1167, 1283) pursuant to Article 13(1) of Regulation (EC) No 1924/2006. European Food Standards Agency Journal. 2011;9:2229 [26pp]. ↩

  22. Nathwani NS, Gallagher JE. Methadone: dental risks and preventive action. Dental Update. 2008;35(8):542-4, 7-8. ↩

  23. Brondani M, Park PE. Methadone and oral health–a brief review. Journal of Dental Hygiene. 2011;85(2):92-8. ↩

  24. Tripathee S, Akbar T, Richards D, Themessl-Huber M, Freeman R. The relationship between sugar-containing methadone and dental caries: a systematic review. Health Education Journal. 2012. ↩

  25. Wright JT, Crall JJ, Fontana M, Gillette EJ, Nový BB, Dhar V, and others. Evidence-based clinical practice guideline for the use of pit-and-fissure sealants: A report of the American Dental Association and the American Academy of Pediatric Dentistry. The Journal of the American Dental Association. 2016;147(8):672-82.e12. ↩

  26. Ahovuo‐Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database of Systematic Reviews. 2017(7). ↩ ↩2

  27. NHS Education for Scotland. Prevention and Management of Dental Caries in Children Scotland. NES; 2018 [Second]. ↩

  28. Newton JT, Awojobi O, Nasseripour M, Warburton F, Di Giorgio S, Gallagher JE, and others. A Systematic Review and Meta-Analysis of the Role of Sugar-Free Chewing Gum in Dental Caries. Journal of Dental Research Clinical Translational Research. 2019:2380084419887178. ↩ ↩2

  29. NICE. Oral health for adults in care homes NG48. London: NICE; 2016. ↩ ↩2

  30. González-Cabezas C, Fernández CE. Recent Advances in Remineralization Therapies for Caries Lesions. Advances in Dental Research. 2018;29(1):55-9. ↩

  31. Meyer-Lueckel H, Machiulskiene V, Giacaman RA. How to Intervene in the Root Caries Process? Systematic Review and Meta-Analyses. Caries Research. 2019;53(6):599-608. ↩

  32. NICE. Dental recall guidelines. London: National Institute for Health and Clinical Excellence; 2004. Report No.: CG019. ↩

  33. NICE. Surveillance report 2018 – Dental checks: intervals between oral health reviews (2004) NICE guideline CG19. London: National Institute for Health and Clinical Excellence; 2018 21.06.2018. Report No.: CG019. ↩

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