ICCMS: caries management and classification Flashcards
What are the 5 keystones of ICCMS staging?
- Staging of caries lesion
- Risk assessment and classification
- Decision matrices for diagnosis
- ICCMS comprehensive patient management plan
- Outcomes of caries management using ICCMS
What are the ICDAS categories of caries?
Sound surface: ICDAS 0
Initial stage caries: ICDAS 1 and 2
Moderate stage caries: ICDAS 3 and 4
Extensive stage caries: ICDAS 5 and 6
What is ICCMS keystone 1?
Staging of caries lesion; ICDAS stages.
What is ICCMS keystone 2?
Risk assessment and classification
How are risk factors assessed in caries?
Head and neck radiation
Active caries lesion
Dry mouth
What is ICCMS keystone 3?
Combination of ICCMS diagnosis (none, initial, moderate/extensive) + risk assessment (low, moderate, and high)
Uses the first two keystones to classify the patient into a low, moderate or high
likelihood of existing lesion progression and development of new carious lesions.
What is ICCMS keystone 4?
A comprehensive patient management plan:
What recommendations are given to patients based on their risk level?
Low risk: Home care (toothbrushing 2x a day with at least 1000ppm fluoride) and clinical care (Promote healthy dietary and oral hygiene behaviours.
Medium risk: Same recommendations as for low-risk patients + daily (226 ppm F) or weekly (900 ppm F) fluoride rinses. Clinical care: preventive procedures such as sealants, fluoride varnish applied at least twice a year, 2% fluoride gel applied twice a year. Consult with other health professionals about recreational drug use or medications that reduce salivary flow.
High risk: Same recommendations as medium risk + chlorhexidine mouthrinse or varnish and fluoride applications; fluoride varnish 4 x’s per year + high concentration preventive dentifrice (5,000 ppm F) for daily use on patients 16 years or older.
What guides decisions for all restorative care?
TPOP (Tooth Preserving Operating Principles) should guide decisions for all restorative care. TPOP is a set of guides that aim to preserve tooth structure, whenever tooth structure is removed surgically. Surgical restorative interventions are only used as a last resort.
What is ICCMS keystone 5?
Outcomes of caries management using ICCMS.
What outcomes should result from patient care plans?
Patient care plans should be value focused and designed to evaluate these potential outcomes:
Health promotion: Maintaining sound teeth/free of new disease.
Disease control: Initial caries lesions/radiographically detected lesions remain unchanged or do not progress.
Patient-Centered quality metrics: Satisfaction with their dental health, risk reduction, improving oral hygiene and diet, reduction of cost of care.
What are the positives of using ICDAS classification?
ICDAS employs an evidence-based and preventitively oriented approach.
ICDAS supports decision making at both individual and public health levels which has caused ICCMS to enable improved long-term caries outcome.
What are the radiographic scoring ratings?
No radiolucency = 0
Initial stages are RA1, RA2, RA3.
RA1 is a radiolucency in outer 1/2 of enamel
RA2 is a radiolucency in the 1/2 of the enamel +/- (Enamel-Dentine Junction)
RA3 is a radiolucency limited to the outer 1/3rd of dentin
RB are moderate stages and include RB4 with radiolucency reaching the middle 1/3 of dentin.
RC are extensive stages with radiolucency reaching the pulp and with clinical cavitation.
How are likelihood matrices formed for risk categories?
Uses the first 2 categories to classify patient as a low, moderate, or high likelihood of existing lesion progression and development of new carious lesions.
● 9 cells
● Combines moderate and extensive active caries lesions into one category
● Once there is any active lesion, risk status is at least ‘moderate’
● Visual, traffic light system
● Each risk category has distinct preventative and management strategies
How are low risk patients managed?
Home care: Tooth brushing 2x a day with >1000ppm fluoride dentrifice.
Clinical care: Promote healthy dietary and oral hygiene behaviours
How are medium risk patients managed?
Home care: Same recommendations as for low risk patients + daily or weekly fluoride rinses.
Clinical care: Preventative procedures such as sealants, fluoride varnish applied at least twice a year, consult with other health professionals about recreational drug use or medications.
How are high risk patients managed?
Same recommendations as medium risk + chlorhexidine mouthrinses or varnish and fluoride applications.
How are caries managed?
Customized to the type of lesion and activity status.
What principles are followed in restorative care?
The ICCMS TPOP (Tooth Preserving Operating Principles)
What should guide patient outcomes using ICCMS?
Patient care should be value-focused and designed to evaluate these potential ourcomes:
Health promotion: Maintaining sound teeth/free of new disease
Disease control:
Initial caries lesions/radiographically detected lesions remain unchanged or do not progress
Patient centered quality metrics:
Satisfaction with their dental health, risk reduction, improving oral hygiene and diet, and reduction of cost of care
How is ICCMS keystone 2 caried out?
Risk assessment and classification:
Completed prior to oral examination
Caries risk factors are checked at the patient and intraoral level
What are the limitations of current methods for risk assessment and classification of caries?
Evidence of predictive validity of current assessment tools is weak.
What does ICCMS stand for?
The International Caries Classification and Management System
How are caries lesions classified?
Staging of caries lesion severity (initial/moderate/extensive)
Caries activity assessment (Active or inactive)
These 2 are used to form the likelihood table.
What are the aims of preventative management of caries?
Protect sound tooth structure
Stop progression of active caries
Control the disease process
Avoid initiating cycle of restoration
Preserve the tooth for as long as possible
What is low risk defined as?
No exposure to high risk factors
Low level of other risk factors (sugary snacks, oral hygiene practice, fluoride exposure)
What is moderate risk defined as?
Stage between low and high caries risk
Dentist cannot rule out that the individual is at low risk of developing caries
What is high risk defined as?
Presence of any high risk factors AND
Previous restorations, appliances
Accumulation of biofilm
Low fluoride exposure
Low socioeconomic status
Mothers/caregivers with high caries experience
What are the aims of managing carious lesions?
Manage dental caries and control activity of existing
cavitated lesions
Preserve hard tissue and retain teeth long-term
Methods for biofilm removal and control are first priority
for controlling disease in cavitated carious lesions
Cavitated lesions that are no longer able to be sealed or
cleansed are indicated for restorations
What is dental caries?
Disease resulting from ecological shift within dental biofilm,
From a balanced population of microorganisms to an
acidogenic/acidoduric and cariogenic microbiological
population
Maintained by consumption of fermentable carbohydrates
Imbalance between demineralization and remineralization
Leads to net mineral loss of dental hard tissues
How are non-cavitated lesions treated?
Biofilm removal and/or remineralization by sealing.
Smooth surface or proximal lesions are sealed with resin
What are the types of cavitated lesions?
Cleansable and non-cleansable lesions
Cleansable = managed non-restoratively via biofilm removal or remineralization
Non-cleansable = Cannot be inactivated likely to still be active and will progress.
What are the criteria for assessing the removal of carious tissue?
Primary criterion = Hardness
Secondary criterion = Moisture, colour and fluorescence, Dye stainability
These are weak recommendations, however.
What is the difference between active and arrested lesions?
Active lesions are soft and moist whereas arrested lesions are harder, dry, and darker.
How is carious tissue removed?
Several methods:
Hand excavators
Tungsten carbide burs
Ceramic burs
Air abrasion
Sonoabrasion
Chemomechanical caries tissue removal
Polymer burs
Laser removal
Which methods of caries removal are most effective?
Insufficient evidence to place any method as superior
Chemomechanical or hand excavation might reduce pain
