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Guideline Summary
Guideline Title
Guideline on caries-risk assessment and management for infants, children and adolescents.
Bibliographic Source(s)
American Academy of Pediatric Dentistry (AAPD). Guideline on caries-risk assessment and management for infants, children and adolescents. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2011. 8 p. [63 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatric Dentistry (AAPD). Policy on use of a caries-risk assessment tool (CAT) for infants, children and adolescents, revised 2006. Chicago (IL): American Academy of Pediatric Dentistry (AAPD).

This guideline was republished in 2011.

Scope

Disease/Condition(s)

Dental caries

Guideline Category
Management
Risk Assessment
Clinical Specialty
Dentistry
Intended Users
Dentists
Health Care Providers
Physicians
Guideline Objective(s)
  • To assist clinicians with decisions regarding treatment based upon caries risk and patient compliance
  • To educate healthcare providers and other interested parties on the assessment of caries risk in contemporary pediatric dentistry and aid in clinical decision making regarding diagnostic, fluoride, dietary, and restorative protocols
Target Population

Infants, children and adolescents

Interventions and Practices Considered
  1. Dental caries risk assessment including mutans streptococci levels and radiographs
  2. Clinical management protocols including fluoride, diet, sealants, and restorations
Major Outcomes Considered
  • Level of risk
  • Incidence of caries

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

This guideline is an update of American Academy of Pediatric Dentistry's (AAPD’s) "Policy on Use of a Caries-risk Assessment Tool (CAT) for Infants, Children, and Adolescents, Revised 2006" that includes the additional concepts of dental caries management protocols. The update used electronic and hand searches of English written articles in the medical and dental literature within the last 10 years using the search terms "caries risk assessment," "caries management," and "caries clinical protocols." From this search, 1,909 articles were evaluated by title or by abstract.

Number of Source Documents

Information from 75 articles was used to update this document.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The oral health policies and clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) are developed under the direction of the Board of Trustees, utilizing the resources and expertise of its membership operating through the Council on Clinical Affairs (CCA).

Proposals to develop or modify policies and guidelines may originate from 4 sources:

  1. The officers or trustees acting at any meeting of the Board of Trustees
  2. A council, committee, or task force in its report to the Board of Trustees
  3. Any member of the AAPD acting through the Reference Committee hearing of the General Assembly at the Annual Session
  4. Officers, trustees, council and committee chairs, or other participants at the AAPD's Annual Strategic Planning Session

Regardless of the source, proposals are considered carefully, and those deemed sufficiently meritorious by a majority vote of the Board of Trustees are referred to the CCA for development or review/revision.

Once a charge (directive from the Board of Trustees) for development or review/revision of an oral health policy or clinical guideline is sent to the CCA, it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a policy or guideline. All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field. Members may call upon any expert as a consultant to the council to provide expert opinion. The Council on Scientific Affairs provides input as to the scientific validity of a policy or guideline.

The CCA meets on an interim basis (midwinter) to discuss proposed oral health policies and clinical guidelines. Each new or reviewed/revised policy and guideline is reviewed, discussed, and confirmed by the entire council.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published analyses were not reviewed.

Method of Guideline Validation
Comparison with Guidelines from Other Groups
Peer Review
Description of Method of Guideline Validation

Once developed by the Council on Clinical Affairs (CCA), the proposed policy or guideline is submitted for the consideration of the Board of Trustees. While the board may request revision, in which case it is returned to the council for modification, once accepted by majority vote of the board, it is referred for Reference Committee hearing at the upcoming Annual Session. At the Reference Committee hearing, the membership may provide comment or suggestion for alteration of the document before presentation to the General Assembly. The final document then is presented for ratification by a majority vote of the membership present and voting at the General Assembly. If accepted by the General Assembly, either as proposed or as amended by that body, the document then becomes the official American Academy of Pediatric Dentistry (AAPD) oral health policy or clinical guideline for publication in the AAPD's Reference Manual and on the AAPD's Web site.

Recommendations

Major Recommendations
  1. Dental-caries risk assessment, based on a child's age, biological factors, protective factors, and clinical findings, should be a routine component of new and periodic examinations by oral health and medical providers. Tables 1, 2, and 3 in the original guideline document incorporate available evidence regarding these factors/findings into tools for assessing levels of risk, whereas the tables below are examples of caries management protocols.
  2. While there is not enough information at present to have quantitative caries-risk assessment analyses, estimating children at low, moderate, and high caries risk by a preponderance of risk and protective factors will enable a more evidence-based approach to medical provider referrals, as well as establish periodicity and intensity of diagnostic, preventive, and restorative services.
  3. Clinical management protocols, based on a child's age, caries risk, and level of patient/parent cooperation, provide health providers with criteria and protocols for determining the types and frequency of diagnostic, preventive, and restorative care for patient specific management of dental caries.

Example of a Caries Management Protocol for 1-2 Year Olds

Risk Category Diagnostics Interventions Restorative
Fluoride Diet
Low risk
  • Recall every 6-12 months
  • Baseline mutans streptococci (MS)α
  • Twice daily brushing
Counseling
  • Surveillance×
Moderate risk
parent engaged
  • Recall every 6 months
  • Baseline MSα
  • Twice daily brushing with fluoridated toothpasteβ
  • Fluoride supplementsd
  • Professional topical treatment every 6 months
Counseling
  • Active surveillance of incipient lesions
Moderate risk
parent not engaged
  • Recall every 6 months
  • Baseline MSα
  • Twice daily brushing with fluoridated toothpasteβ
  • Professional topical treatment every 6 months
Counseling, with limited expectations
  • Active surveillance of incipient lesions
High risk
parent engaged
  • Recall every 3 months
  • Baseline and follow up MSα
  • Twice daily brushing with fluoridated toothpasteβ
  • Fluoride supplementsd
  • Professional topical treatment every 3 months
Counseling
  • Active surveillance of incipient lesions
  • Restore cavitated lesions with interim therapeutic restorations (ITR)¢ or definitive restorations
High risk
parent not engaged
  • Recall every 3 months
  • Baseline and follow up MSα
  • Twice daily brushing with fluoridated toothpasteβ
  • Professional topical treatment every 3 months
Counseling, with limited expectations
  • Active surveillance of incipient lesions
  • Restore cavitated lesions with interim therapeutic restorations¢ or definitive restorations

Example of a Caries Management Protocol for 3-5 Year Olds

Risk Category Diagnostics Interventions Restorative
Fluoride Diet Sealantsλ
Low risk
  • Recall every 6-12 months
  • Radiographs every 12-24 months
  • Baseline MSα
  • Twice daily brushing with fluoridated toothpaste¥
No Yes
  • Surveillancex
Moderate risk
parent engaged
  • Recall every 6 months
  • Radiographs every 6-12 months
  • Baseline MSα
  • Twice daily brushing with fluoridated toothpaste¥
  • Fluoride supplementsd
  • Professional topical treatment every 6 months
Counseling Yes
  • Active surveillance of incipient lesions
  • Restoration of cavitated or enlarging lesions
Moderate risk
parent not engaged
  • Recall every 6 months
  • Radiographs every 6-12 months
  • Baseline MSα
  • Twice daily brushing with fluoridated toothpaste¥
  • Professional topical treatment every 6 months
Counseling, with limited expectations Yes
  • Active surveillance of incipient lesions
  • Restoration of cavitated or enlarging lesions
High risk
parent engaged
  • Recall every 3 months
  • Radiographs every 6 months
  • Baseline and follow up MSα
  • Brushing with 0.5% fluoride (with caution)
  • Fluoride supplementsd
  • Professional topical treatment every 3 months
Counseling Yes
  • Active surveillance of incipient lesions
  • Restoration of cavitated or enlarging lesions
High risk
parent not engaged
  • Recall every 3 months
  • Radiographs every 6 months
  • Baseline and follow up MSα
  • Brushing with 0.5% fluoride
  • Professional topical treatment every 3 months
Counseling, with limited expectations Yes
  • Restore incipient, cavitated, or enlarging lesions

Example of a Caries Management Protocol for >6 Year Olds

Risk Category Diagnostics Interventions Restorative
Fluoride Diet Sealantsλ
Low risk
  • Recall every 6-12 months
  • Radiographs every 12-24 months
    Twice daily brushing with fluoridated toothpasteµ
No Yes
  • Surveillancex
Moderate risk
patient/parent engaged
  • Recall every 6 months
  • Radiographs every 6-12 months
  • Twice daily brushing with fluoridated toothpasteµ
  • Fluoride supplementsd
  • Professional topical treatment every 6 months
  • Counseling
Yes
  • Active surveillance of incipient lesions
  • Restoration of cavitated or enlarging lesions
Moderate risk
patient/parent not engaged
  • Recall every 6 months
  • Radiographs every 6-12 months
  • Twice daily brushing with toothpasteµ
  • Professional topical treatment every 6 months
  • Counseling, with limited expectations
Yes
  • Active surveillance of incipient lesions
  • Restoration of cavitated or enlarging lesions
High risk
patient/parent engaged
  • Recall every 3 months
  • Radiographs every 6 months
  • Brushing with 0.5% fluoride
  • Fluoride supplementsd
  • Professional topical treatment every 3 months
  • Counseling
  • Xylitol
Yes
  • Active surveillance of incipient lesions
  • Restoration of cavitated or enlarging lesions
High risk
patient/parent not engaged
  • Recall every 3 months
  • Radiographs every 6 months
  • Brushing with 0.5% fluoride
  • Professional topical treatment every 3 months
  • Counseling, with limited expectations
  • Xylitol
Yes
  • Restore incipient, cavitated, or enlarging lesions

Legends for tables above

α Salivary mutans streptococci bacterial levels.

β Parental supervision of a "smear" amount of toothpaste.

x Periodic monitoring for signs of caries progression.

d Need to consider fluoride levels in drinking water.

Careful monitoring of caries progression and prevention program.

¢ Interim Therapeutic Restoration.

¥ Parental supervision of a "pea sized" amount of toothpaste.

λ Indicated for teeth with deep fissure anatomy or developmental defects.

μ Less concern about the quantity of toothpaste.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated for each recommendation.

Content of the present caries management protocol is based on results of clinical trials, systematic reviews, and expert panel recommendations that give better understanding to, and recommendations for, diagnostic, preventive, and restorative treatments. The radiographic diagnostic guidelines are based on the latest guidelines from the American Dental Association (ADA). Systemic fluoride protocols are based on the Centers for Disease Control and Prevention (CDC) recommendations for using fluoride. Guidelines for the use of topical fluoride treatment are based on the ADA's Council on Scientific Affairs' recommendations for professionally applied topical fluoride, the Scottish Intercollegiate Guideline Network (SIGN) guideline for the management of caries in pre-school children, a Maternal and Child Health Bureau Expert Panel, and the CDC's fluoride guidelines. Guidelines for pit and fissure sealants are based on ADA's Council on Scientific Affairs recommendations for the use of pit-and-fissure sealants. Guidelines on diet counseling to prevent caries are based on 2 review papers. Guidelines for the use of xylitol are based on the American Academy of Pediatric Dentistry (AAPD) oral health policy on use of xylitol in caries prevention, a well-executed clinical trial on high caries-risk infants and toddlers, and 2 evidence-based reviews. Active surveillance (prevention therapies and close monitoring) of enamel lesions is based on the concept that treatment of disease may only be necessary if there is disease progression, that caries progression has diminished over recent decades, and that the majority of proximal lesions, even in dentin, are not cavitated.

When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Accurate risk assessment and management of dental caries in infants, children, and adolescents

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

Risk assessment procedures used in medical practice normally have sufficient data to accurately quantitate a person's disease susceptibility and allow for preventive measures. Even though caries-risk data in dentistry still are not sufficient to quantitate the models, the process of determining risk should be a component in the clinical decision making process.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Academy of Pediatric Dentistry (AAPD). Guideline on caries-risk assessment and management for infants, children and adolescents. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2011. 8 p. [63 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2002 (revised 2010; republished 2011)
Guideline Developer(s)
American Academy of Pediatric Dentistry - Professional Association
Source(s) of Funding

American Academy of Pediatric Dentistry

Guideline Committee

Council on Clinical Affairs

Composition of Group That Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Council members and consultants derive no financial compensation from the American Academy of Pediatric Dentistry for their participation and are asked to disclose potential conflicts of interest.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatric Dentistry (AAPD). Policy on use of a caries-risk assessment tool (CAT) for infants, children and adolescents, revised 2006. Chicago (IL): American Academy of Pediatric Dentistry (AAPD).

This guideline was republished in 2011.

Guideline Availability

Electronic copies: Available from the American Academy of Pediatric Dentistry Web site External Web Site Policy.

Print copies: Available from the American Academy of Pediatric Dentistry, 211 East Chicago Avenue, Suite 700, Chicago, Illinois 60611.

Availability of Companion Documents

The following is available:

  • Overview. American Academy of Pediatric Dentistry 2010-11 definitions, oral health policies, and clinical guidelines. Chicago (IL): American Academy of Pediatric Dentistry; 2010. 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Pediatric Dentistry Web site External Web Site Policy.

In addition, sample caries risk assessment forms for both dentists and other health care providers for children of varying ages are available in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on December 30, 2010. The information was verified by the guideline developer on May 9, 2011. The information was republished by the guideline developer in 2011 and updated by ECRI Institute on October 20, 2011.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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