CLINICAL PROTOCOL

Australian Dental Journal 2009; 54: 381389 doi: 10.1111/j.1834-7819.2009.01165.x

The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for children and adolescents
RW Evans,* PJ Dennison*
*Faculty of Dentistry, The University of Sydney, New South Wales.

ABSTRACT
The application of the Caries Management System (CMS) for children and adolescents follows the rationale underlying the application of the CMS for adults. Briey, the CMS is a 10-step, risk-based, non-invasive strategy to arrest and remineralize early lesions and to enhance caries primary prevention. The method for assessing each patients diet, plaque distribution, and signs of caries as shown in bitewing radiograph images, follows the protocols for adults. Protocols presented here relating to caries risk assessment, lesion diagnosis and management, and patient recall are specic for children and adolescents. Fundamentally, non-cavitated lesions in primary and especially permanent teeth are managed: (1) professionally by preservative non-invasive means, including uoride varnish and sealants; and (2) daily home toothbrushing using uoride toothpaste where the aim is to arrest lesion progression so that restorations will not be necessary. Monitoring of lesions through the review of clinical signs and bitewing images is the means for assessing caries activity. For those who fail to respond to advice to reduce cariogenic exposures and continue to develop new lesions at a steady or increased rate, a more intensied programme is required; their higher risk status is conrmed and treatment follows the corresponding protocol.
Keywords: Dental caries, children and adolescents, evidence-based care, non-invasive management, risk assessment. Abbreviations and acronyms: CARS = caries associated with restorations or sealants; CMS = Caries Management System; DEJ = dentinoenamel junction; ECC = early childhood caries; ICDAS = International Caries Detection and Assessment System. (Accepted for publication 16 January 2009.)

INTRODUCTION The application of the Caries Management System (CMS) for children and adolescents follows the rationale underlying the application of the CMS for adults.1 Research undertaken by the authors has shown that general dental practitioners adapted well to the CMS protocols for adults and benets to patients were substantial.2,3 Need for complementary CMS for children and adolescents The implementation of water uoridation in Australia and elsewhere and the widespread use of uoride toothpaste has contributed to a marked decline in caries risk. Despite this reduction, dental caries remains prevalent in the community and some children and
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adolescents are affected much more severely than others while a minority remain at extreme risk.46 Early childhood caries (ECC) is a signicant problem for which the main determinants are oral hygiene status, night-feeding with a sweetened beverage, bacterial infection, and enamel defects.79 However, this condition can also be managed. Dental research has led to the development, for professional use, of efcacious primary preventive caries measures and secondary preventive non-invasive measures that can arrest noncavitated caries lesions and lead to their remineralization. In spite of this, these measures have not been utilized efciently by the dental profession, perhaps because remuneration systems do not encourage their use or possibly because dentistry developed as a branch of surgery and hence protocols that would deliver noninvasive care have not been formulated or demanded hitherto.10 The CMS for children and adolescents
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RW Evans and PJ Dennison proposed here overcomes this barrier to efcient practice. The protocols may be delivered in any clinical setting without the need to invest in new technology. THE CARIES MANAGEMENT SYSTEM Briey, the CMS is a 10-step non-invasive strategy to arrest and remineralize early lesions and to enhance caries primary prevention (Table 1). The governing principle is that caries management must include consideration of: (a) the patient at risk; (b) the status of each lesion; (c) patient management; (d) clinical management; and (e) monitoring. These considerations are dealt with separately below. The patients oral care plan is developed according to a set of protocols which refer to only those non-invasive interventions that are well supported by a strong evidence base. This approach is designed to impact on two key determinants of oral health: individual health behaviours and professional dental care.11 This system is not directly concerned with the management of cavitated lesions other than their diagnosis and by noting their need for operative care. The method for assessing each patients diet, plaque distribution, saliva ow, and signs of caries as shown in bitewing radiograph images, follows the protocols for adults to which the reader is referred.1 Similarly, the charting of plaque scores, bitewing ndings, and the details of caries risk and lesion extent and severity, that are discussed with patients or their parents during the case presentation, are recorded as illustrated for adults. On the other hand, protocols presented here relating to caries risk assessment, lesion management, topical uoride application, and patient recall are specic for children and adolescents. The patient at risk of caries The case history and clinical examination provides an overview of tooth morphology and unfavourable exposures to potential caries risk protective factors, namely: plaque, frequency of sucrose intake, and uoride.12 The risk status of each patient is determined at the completion of the clinical assessments. Assessment of plaque distribution, diet, and uoride exposure Fluoride exposure is determined from the dental history. The assessments of plaque distribution and diet are conducted according to the protocols for adults.1 If permanent rst molars and incisors have not yet erupted, the plaque distribution on the primary molars and incisors is assessed and recorded instead. The status of each lesion The clinical signs of caries are examined and classied according to the consensus reached by the Co-ordinating Committee of the International Caries Detection and Assessment System (ICDAS II)13 whereas signs revealed from the bitewing radiographic survey are classied according to CMS protocol described for adults.1 Clinical examination The ICDAS II criteria (Table 2) refer to six clinical presentations, three of which relate to increasingly progressive stages of the enamel lesion (coded 1 to 3) and three to the increasingly progressive stages of the dentine lesion (coded 4 to 6). The teeth should be cleaned prior to inspection, if necessary using a rubber cup. For inspection, the teeth are rst viewed when wet. White and brown spot demineralized lesions on smooth surfaces or those centred within pits ssures and evident when wet, are assigned Code 2. On the other hand, white or brown spot lesions that only become visible following ve seconds of air drying with the triple syringe are assigned Code 1. Clearly, demarcated black or brown stains at the base of pits ssures should not be assigned ICDAS II Code 2 in the absence of evidence of enamel demineralization. However, if it is judged that a large stain obscures such evidence, then Code 2 is justied. White or brown spot lesions that, upon air drying, are disclosed to be associated with enamel breakdown are assigned Code 3. Code 4 is reserved for the blue or grey shadows from dentine that
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Table 1. Ten-step summary of the Caries Management System

1 2 3 4 5 6 Diet assessment Plaque asssment Bitewing radiographic survey Diagnosis and caries risk assessment Preparation of oral care plan Case presentation at which patient is informed about: Dental caries s Arrest s Reversal Natural repair (Remineralization) s Prevention s Number and status of current lesions s Role of dental practitioner in caries management s Role of home care in caries prevention s Current caries risk status Result of diet assessment and recommendatons Oral hygiene coaching Clinical management Topical uoride application (both professional and home care) Sealant or GIC application Monitoring of plaque control and treatment outcomes at each visit Recall programme tailored to caries risk status

7 8

9 10
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Caries management for children and adolescents Table 2. The International Caries Detection and Assessment System (ICDAS II) criteria for smooth, pit ssure surfaces, and CARS*
When wet, surfaces may reveal Normal apearance White or brown spot lesions Code 2 or 3? A shadow from dentine plus minus enamel loss Code 4 Cavitation with exposed dentine Code 5 Extensive cavitation Code 6

Code 0 or 1? But drying for 5 seconds exposes Nothing else Code 0 White or brown spot lesions Code 1

Nothing else Code 2 Enamel loss Code 3

*Caries along restorations and sealants. Note that a non-carious defect along a restoration or sealant margin would be coded 0.

are visible through the enamel, either with or without signs of enamel breakdown. Enamel breakdown is conrmed using the WHO CPI probe which is slid across the suspect surface. If the ball-end of this probe drops into a hard-based recess, enamel breakdown is conrmed. But if the ball-end drops out of sight into a soft-based cavity, i.e, into dentine, the lesion is assigned Code 5. Frank cavities, disclosing a clearly visible dentine base, are assigned Code 6. Signs of caries associated with restorations or sealants (CARS) are coded similarly, but note that non-

caries marginal defects are assigned Code 0 as for normal appearance. With CARS, Code 3 is assigned when enamel breakdown along the margin of the restoration or sealant is judged to be caries induced or when caries induced breakdown is judged to have occurred within or alongside an existing non-caries defect. The ICDAS II codes are entered into an enlarged odontogram that allows for surface specic recording and may, therefore, enable ready reference for monitoring purposes (Fig 1). Oral care decisions reached on

Fig 1. Odontogram for entering diagnostic and oral care data.

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RW Evans and PJ Dennison the basis of inputs from the ICDAS II and the bitewing data are also entered on odontogram. Bitewing radiographic survey The assessment of bitewing images and the system for recording the ndings follows the adult protocols. Bitewing radiographic signs coded C1 and C2, respectively (Tables 5 and 6) are radiolucencies that do not extend deeper than the outer half of the enamel thickness or the dentino-enamel junction (DEJ), whereas a radiolucency that is perceived to extend just beyond the DEJ is coded C3. Radiolucencies that are conned, respectively, within or beyond the outer one-third of the dentine depth are coded C4 and C5. Assessment of the patients caries risk status As for adults, the assessment of the caries risk of children and adolescents is determined solely on an analysis of the severity and extent of their presenting clinical and radiographic signs and not from epidemiologic-type considerations of their histories of either favourable or unfavourable exposures to caries risk factors. The specic criteria used with reference to both the ICDAS II and radiographic codes in order to determine caries risk in young children who have a primary dentition only or in older children and adolescents who have mixed or permanent dentitions are presented in Tables 3 and 4. Initially, only two risk categories are assigned; low risk and at-risk. Patient management The management plan for patients follows the adult protocols. Case presentation and oral care planning During the case presentation, the details of the clinical ndings and discussion relating to oral care planning are put forward, as for adults, with reference to the Tooth Decay information leaet.1 This serves as the principal patient educational material; it highlights the need for home care toothbrushing and provides a basis for obtaining informed consent from parents concerning the implementation of the oral care plan for their children.14 Diet advice and oral hygiene coaching The value of consuming uoridated water should be emphasized. On the other hand, bottle feeding of

Table 3. Criteria for caries risk for a child who has a primary dentition only
Caries risk Low New patient dmfs = 0 ICDAS II codes < 2 No radiolucencies No sites with Plaque Index = 3 dmfs > 0 Demineralized enamel ICDAS II codes > 1 C1 or greater radiolucencies Recall patient < 1 new lesion per year* and no progression of existing lesions 1 new lesion per year* and or progression of existing lesions Any site with Plaque Index = 3 in cases where dmfs = 0 > 1 new lesion per year*

At-risk

At-risk High

Any site with Plaque Index = 3 in cases where dmfs = 0 Not assigned to new patient

*... on approximal surfaces as diagnosed by bitewing scores C1 or greater or else on other surfaces diagnosed as ICDAS II code 2 or greater.

Table 4. Criteria for caries risk for a child who has a mixed or permanent dentition
Caries risk Low New patient dmfs + DMFS = 0 ICDAS II codes < 2 No radiolucencies No sites with Plaque Index = 3 No hypomineralized or hypoplastic 6s or 7s dmfs > 0 Demineralized enamel ICDAS II codes > 1 or greater C1 or greater radiolucencies Any site with Plaque Index = 3 in cases where dmfs + DMFS = 0 dmfs + DMFT = 0 but 6s or 7s are hypomineralized or hypoplastic Not assigned to new patient Recall patient < 1 new lesion per year* and no progression of existing lesions

At-risk

1 new lesion per year* and or progression of existing lesions Any site with Plaque Index = 3 in cases where dmfs + DMFS = 0 dmfs + DMFT = 0 but 6s or 7s are hypomineralized or hypoplastic > 1 new lesion per year*

At-risk High

*...on approximal surfaces as diagnosed by bitewing codes C1 or greater or on other surfaces diagnosed as ICDAS II code 2 or greater.
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Caries management for children and adolescents sugar-containing drinks and the use of a pacier dipped in honey or other sweetened products should be discouraged. After the age of 12 months, bottle feeding should be discontinued and all uids should then be given by cup. Sugary foods should not be encouraged, especially at bedtime. Otherwise, the principles of diet control for dental caries follow those which apply to adults. A soft toothbrush may be used to clean toddlers teeth but uoride toothpaste should not be used before the age of 18 months to reduce the risk of toothpaste ingestion. Only an adult should dispense a small pea sized amount of toothpaste to be used by preschool children and their brushing should be supervised and assisted. Preschool children should be encouraged to spit, not swallow, the toothpaste. Since brushing anothers teeth is a complex manoeuvre, an appropriate method for brushing teeth should be demonstrated to parents. Clinical and home care management The risk-based caries management options are: preventive, preservative (non-invasive) and operative (invasive). Fundamentally, non-cavitated lesions in primary and especially permanent teeth are managed by preservative non-invasive means detailed in Tables 5 and 6 where the aim is to arrest their progression so that a restoration will not be necessary.15 Only cavitated lesions whose bases extend into dentine, or those so presumed to be cavitated in the absence of direct conrmation, are to be managed operatively. The criteria to be followed for determining which lesions, visible only as bitewing images, warrant operative intervention and restoration are also shown in Tables 5, 6 and 7. For less advanced pit ssure lesions showing enamel breakdown, the most conservative and effective means of treatment is resin-based sealant application (or a GIC sealant as an interim measure when there are concerns about moisture control), both to eliminate the plaque trap and to arrest further progression.1618 Noncavitated lesions are managed by home care measures to control plaque, principally by twice daily toothbrushing using uoride toothpaste, thereby arresting lesion progression. In addition, the combination of professionally applied topical uoride varnish1923 and home use of uoride toothpaste22 (Tables 7 and 8) is necessary to ensure that the natural repair process of remineralization is accelerated and thus to outweigh the effects of any remaining cariogenic challenge.24 The application of topical uoride described here relates to the non-invasive secondary preventive treatment of non-cavitated lesions. However, more importantly, professional applications of topical uoride and home use of uoridated toothpaste are, in addition, the means of primary prevention for caries. The application of uoride varnish on newly erupted ssured surfaces facilitates enamel maturation. Monitoring Patients are recalled at regular intervals12,25 (Table 9), determined on the basis of their caries risk status, for monitoring caries activity and toothbrushing

Table 5. Protocol for the management of lesions in primary teeth diagnosed clinically (ICDAS II) or from bitewing radiographic images in relation to children
Lesion code ICDAS II 12 3 Bitewing 46 C1 C2 C3 C4 C5 Management Apply uoride varnish to arrest and remineralize active lesions and to maintain arrested lesions Restore only if associated bitewing radiolucency extends deeper than C3 otherwise apply resin-based sealant or protect with GIC and review in 6 months (bitewings) Restore Do not restore apply topical uoride and monitor Do not restore apply topical uoride and monitor Do not restore without further consideration Restore now only if tooth is not due to exfoliate* Restore now only if tooth is not due to exfoliate*

C1

C2

C3

C4

C5

Further consideration of C3 surfaces

Do not restore within 12 months of exfoliation* Restore if shadow is evident below marginal ridge Otherwise separate tooth to conrm cavitation and restore only if cavitated Implement preventive stategy to: arrest active lesions remineralize lesions maintain arrested lesions preserve rst molars (take particular care)

*Clue less than of root remains.

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RW Evans and PJ Dennison Table 6. Protocol for the management of lesions in permanent teeth diagnosed clinically (ICDAS II) or from bitewing radiographic images in relation to children and adolescents
Lesion code ICDAS II 12 34 5 6 C1 C2 C3 C4 C5 Management Apply uoride varnish to (1) arrest and remineralize active lesions and (2) maintain arrested lesions Restore with UCSR* only if associated radiolucency extends deeper than C4 otherwise apply resin-based sealant and review in 6 months (bitewings) Restore with UCSR* Restore Do not restore apply topical uoride and monitor Do not restore apply topical uoride and monitor Do not restore apply topical uoride and monitor Do not restore without further consideration Restore now

Bitewing

C1

C2

C3

C4

C5

Further consideration of C4 surfaces

If possible, separate teeth and restore only if cavitated is revealed If not possible to separate, restore only if radiolucency extends fully 1/3 through dentine Otherwise, do not restore because it is more likely than not that the approximal surface: is not cavitated and lesion progression could be arrested or has already arrested Implement preventive stategy to: arrest active lesions remineralize lesions maintain arrested lesions

*Ultra-conservative sealed restoration.

Table 7. Topical uoride protocol for professional care of children and adolescents
Caries risk Low Fluoride varnish (Duraphat) 5% NaF (22 600 ppm) and GIC (Fuji 7) Apply varnish to occlusal surfaces of all newly erupted primary and permanent molars If not drinking fluoridated water, apply varnish to occlusal surfaces of all molar teeth at each recall If not using fluoride toothpaste, apply varnish to occlusal surfaces of all molar teeth at each recall Apply varnish or GIC (e.g., Fuji 7) to occlusal and approximal surfaces of newly erupted primary and permanent molars Apply varnish to surfaces with lesions (clinical and radiographic) and the respective apparently sound surfaces on homologous teeth at every treatment session, then Application as above at each review and recall appointment until patient becomes low risk. Fluoride gel 1.23% NaF (12 300 ppm) Not to be used under the age of 10 For age groups 10 and above: At recall appointments to maintain lesion arrest

At-risk

Not to be used under the age of 10 For age groups 10 and above: At recall appointments instead of varnish (for whatever reason)

competence, and for oral hygiene coaching and the re-application of topical uorides. Caries activity In relation to motivated parents or patients who follow the home care regimens, caries activity, and therefore, risk of new lesions can reduce sharply; risk status is adjusted accordingly. For those who, for whatever reason, fail to respond to advice to reduce cariogenic exposures and therefore continue to develop new lesions at a steady or increased rate, a more intensied programme is required; their higher risk status is conrmed and treatment follows the corresponding protocol.
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The monitoring of lesions through the review of clinical signs and bitewing images is the means for assessing caries activity. At recall appointments, radiolucencies on new bitewings are compared with those of earlier series. Lesions under review that are not accessible to visual inspection should be radiographed after six months, but not earlier, to gauge activity status.26 When it is judged that lesions have arrested, yearly radiographic review is recommended. For screening purposes, children and adolescents who are assessed as low risk should be scheduled for bitewings annually. It may be suggested that 18 or 24 months is a preferable interval for low risk individuals but risk status can change and caries initiation and progression can be swift; it is better,
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Caries management for children and adolescents Table 8. Topical uoride protocol for home care of children and adolescents
Caries risk Age Toothbrushing with uoride toothpaste No fluoride toothpaste Twice daily use 400 ppm toothpaste (smear small pea size only) If not drinking fluoridated water, twice daily use 1000 ppm toothpaste (smear small pea size only). Twice daily use 1000 ppm toothpaste (pea size) Twice daily use 400 ppm toothpaste (smear small pea size only) Twice daily use 1000 ppm toothpaste (smear small pea size only) Twice daily use 1000 ppm toothpaste (pea size) Fluoride rinse 0.05% NaF (neutral) (220 ppm) for one minute Not to be used Not to be used Not to be used Chlorhexidine 0.2% CHX Not applicable

Low

Before 18 months 18 months to 5 yrs 18 months to 5 yrs

617 years At-risk Before 18 months 18 months to 5 yrs 617 years 1017 years At-risk high 1017 years

Not to be used Not to be used Not to be used No use before age 10 Once daily at a separate time from toothbrushing Once daily at a separate time from toothbrushing Not applicable

If caries incidence is > 1 new lesions per year or see below,* then twice daily use 5000 ppm toothpaste (pea size)

Once daily before bedtime

*Patients with hyposalivation, or who have active lesions on anterior teeth, or who have active lesions on buccal surfaces of posterior teeth.

Table 9. Recall protocol for children and adolescents

Caries risk Low At-risk ... where evidence is: ICDAS II codes > 1 Monitoring lesion activity and patient behaviour 12 months after rst visit Note: Oral hygiene review and coaching at each visit 3-monthly until lesion progression has arrested, i.e., evidence of (1) no extension of demineralization or (2) that GIC sealant remains intact Note: Oral hygiene review and coaching at each visit 3-monthly for (1) F varnish and (2) oral hygiene monitoring until lesion progression has arrested and patient is reclassied as low risk Note: Oral hygiene review and coaching at each visit One week following rst visit to review and coach tooth brushing competence Then one month later for same Bitewing survey At rst visit Then every 12 months At rst visit Then every 6 months until patient is classied as low risk At rst visit Then every 6 months until patient is classied as low risk

At-risk ... where evidence is: Bitewing codes > C2 for primary teeth > C3 for permanent teeth At-risk ... where only evidence is: Sites with Plaque Index = 3

therefore, to err on the side of caution and screen annually. Fluoride exposure As far as professional care is concerned for patients who remain at-risk, the priority is to: (a) impress on the need for regular attendance for professional applications of uoride varnish; (b) use a higher concentration uoride toothpaste at home; and (c) use ssure sealants in an increased attempt to arrest and remineralize lesions and, therefore, reduce as much as possible any need to intervene operatively to deal with cavities.
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Plaque distribution At each and every appointment, the plaque distribution and overall Plaque Index (PI) score is recorded. Ongoing oral hygiene coaching at each visit, review of serial ndings, and linkage of oral hygiene with other aspects of grooming increases the self-esteem and condence of children and adolescents. Dietary carbohydrate exposure Diets change as children get older. Dental practitioners need to be alert to sudden changes in caries risk and be
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RW Evans and PJ Dennison prepared to discover the reason for such changes. In such cases it will be necessary to investigate betweenmeal snacking patterns and caution against overexposure to cariogenic dietary items. DISCUSSION Enamel lesions assigned ICDAS II Code 1 are not considered to indicate a higher than low risk caries rating mainly because they may not be diagnosed reliably; it would not be meaningful or useful to rate a majority of individuals as at-risk on this basis. In a uoridated community, small uorotic signs might also be mistakenly assigned Code 1 and these should denitely not contribute, inadvertently, to indicate an increased caries risk. Caries risk, as designated in Tables 3 and 4 is a classication based on clinical signs which is, nonetheless, an indirect but pragmatic measure of disease risk. More broadly, risk of disease is an epidemiologic question and entails an analysis of many contributing exposures and conditions.2729 However, for a given diseased individual it is not possible to identify a specic combination of risk factors which may be presumed as causative and, therefore, the assignment of risk should not be dictated by measures of one or more specic factors, e.g., sugar exposure. On the other hand, it is important for patients to understand something about their risk status. Thus, exposure to known factors should be explored in an attempt to discover the likely cause of their situation as a prelude to a discussion on how they might control this risk. White uorotic ecks tend to manifest predominantly at sites where enamel is thicker than elsewhere, i.e., along ridges and on cusps but not within the depths of pits and ssures. Fluorosed enamel ridges within the ssure system may be distinguished as a sign of non-caries origin since the enamel at the ssure base would appear normal and translucent. The caries lesion initiates beneath plaque at the base of the pit ssure, not along its marginal ridge, and appears within a clean and dry ssure as an area of white or brown enamel that has lost its translucency due to its demineralized state. It is, of course, possible that a caries lesion may develop in a ssure which is bordered by a uorosed ridge. In this case, the differential diagnostic sign for caries remains as the loss of enamel translucency at the ssure base. The thickness of enamel in deciduous teeth is less than on corresponding sites of permanent teeth and hence is associated with increased risk of cavity extension into dentine, at which stage risk of pulp exposure associated with operative intervention is elevated. The risk of pulp damage in deciduous teeth is minimized by following a less conservative approach than that proposed for permanent teeth. In the absence of direct conrmation of cavity extension to dentine in
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deciduous teeth, operative intervention is indicated on the basis of either the combination of ICDAS II Code 3 and an associated bitewing radiolucency coded greater than C3, or on an approximal surface which has an associated bitewing radiolucency coded greater than C3. In conclusion, it is worth emphasizing that preventive strategies aim not only to avert disease initiation and arrest lesion progression but to reduce the need for restorations for, as Mjor et al.30 pointed out, The decision to place the rst restoration in a previously unrestored surface is a crucial event in the life of a tooth, because a permanent restoration, in the true sense of the term permanent, does not exist. REFERENCES
1. Evans RW, Pakdaman A, Dennison PJ, Howe ELC. The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for adults. Aust Dent J 2008;53:8392. 2. Sbaraini A, Evans RW. Caries risk reduction in patients attending a caries management clinic. Aust Dent J 2008;53: 340348. 3. Curtis B, Evans RW, Sbaraini A, Schwarz E. The Monitor Practice Programme: is non-invasive management of dental caries in private practice effective? Aust Dent J 2008;53:306313. 4. Evans RW, Hsiau ACY, Dennison PJ, Patterson A, Jalaludin B. Water uoridation in the Blue Mountains reduces risk of tooth decay. Aust Dent J 2009;54:368373. 5. Broadbent JM, Thomson WM, Poulton R. Trajectory patterns of dental caries experience in the permanent dentition to the fourth decade of life. J Dent Res 2008;88:6972. 6. Lee M, Dennison PJ. Water uoridation in 5- and 12-year-old children from Canterbury and Wellington. N Z Dent J 2004;100: 1015. 7. Ismail AI. Determinants of health in children and the problem of early childhood caries. Pediatr Dent 2003;25:328333. 8. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health 2004;21(Suppl):7185. 9. Gussy MG, Waters EG, Walsh O, Kilpatrick NM. Early childhood caries: current evidence for aetiology and prevention. J Pediatr Child Health 2006;42:3743. 10. Clarkson JE, Turner S, Grimshaw JM, et al. Changing clinicians behaviour: a randomized controlled trial of fees and education. J Dent Res 2008;87:640644. 11. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Inuences on childrens oral health: a conceptual model. Pediatrics 2007;120: e510e520. 12. Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369: 5159. 13. International Caries Detection and Assessment System (ICDAS) Coordinating Committee. Criteria Manual: International Caries Detection and Assessment System (ICDAS II), 2005. URL: http:// www.icdas.org. Accessed October 2007. 14. Vallejos-Sanchez AA, Medina-Solis CE, Maupome G, CasanovaRosado JF, Minaya-Sanchez M, Villalobos-Rodelo JJ. Sociobehavioural factors inuencing tooth-brushing frequency among schoolchildren. J Am Dent Assoc 2008;139:743749. 15. Brown JP, Dodds MWJ. Prevention strategies for dental caries. In: Capelli DP, Mobley CC. Prevention in clinical oral health care. St Louis, Missouri: Mosby Elsevier, 2008:196212.
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16. Balevi B. The management of incipient or suspicious occlusal caries: a decision-tree analysis. Community Dent Oral Epidemiol 2008;36:392400. 17. Beauchamp J, Caueld PW, Crall JJ, et al. Evidence-based clinical recommendations for the use of pit and ssure sealants: a report of the American Dental Association Council on Scientic Affairs. J Am Dent Assoc 2008;139:257268. 18. Grifn SO, Oong E, Kohn W, Vidakovic B, Gooch BF, CDC Dental Sealant Systematic Review Work Group: Bader J, Clarkson J, Fontana MR, Meyer DM, Rozier RJ, Weintraub JA, Zero DT. Effectiveness of sealants in managing caries lesions. J Dent Res 2008;87:169174. 19. ten Cate JM, Buijs MJ, Chaussain Miller C, Exterkate RAM. Elevated uoride products enhance remineralization of advanced enamel lesions. J Dent Res 2008;27:943947. 20. Stecksen-Blicks C, Renfors G, Oscarson ND, Bertstrand F, Twetman S. Caries-preventive effectiveness of a uoride varnish: a randomised controlled trial in adolescents with xed orthodontic appliances. Caries Res 2007;41:455459. 21. Weintraub JA, Ramos-Gomez F, Jue B, Shain S, Hoover CI, Featherstone JDB, Gansky SA. Fluoride varnish efcacy in preventing early childhood caries. J Dent Res 2006;85:172176. 22. Australian Research Centre for Population Oral Health. The use of uorides in Australia: guidelines. Aust Dent J 2006;51:195199. 23. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD002279. DOI: 10.1002/14651858.CD002279. 24. Featherstone JDB. Dental caries: a dynamic disease process. Aust Dent J 2008;53:286291. 25. Beirne P, Clarkson JE, Worthington HV. Recall intervals for oral health in primary care patients. Cochrane Database Systematic Reviews 2007; Issue 4. 26. American Dental Association, US Food and Drug Administration. Guidelines for prescribing dental radiographs. 2004. URL: http:// www.ada.org. Accessed January 2009. 27. Bader JD, Perrin NA, Maupome G, Rush WA, Rindal BD. Exploring the contributions of components of caries risk assessment guidelines. Community Dent Oral Epidemiol 2008;36:357 362. 28. Ismail AI, Sohn W, Tellez M, Willem JM, Betz J, Lepkowski J. Risk indicators for dental caries using the International Caries Detection and Assessment System (ICDAS). Community Dent Oral Epidemiol 2008;36:5568. 29. Kidd EAM, Nyvad B. Caries control for the individual patient. In: Fejerskov O, Kidd EAM, eds. Dental caries: the disease and its clinical management. Oxford: Blackwell Munksgaard, 2003:303 312. 30. Mjor IA, Holst D, Eriksen HM. Caries and restoration prevention. J Am Dent Assoc 2008;139:565570.

Address for correspondence: Professor RW Evans Faculty of Dentistry The University of Sydney C24A, 1 Mons Road Sydney NSW 2145 Email: w.evans@dentistry.usyd.edu.au

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