Dental Caries: An Update in the Age of P4 Medicine

Abstract

Dental caries is a biofilm dysfunction or dysbiosis disease of the dental biofilm characterized by prolonged periods of low pH which results in net mineral loss from the teeth. The disease initiates by acid dissolution of the enamel and eventually creates a cavitation in the enamel, followed by microbial invasion of the tooth. As the disease progresses this process may lead to eventual pulpal tissue death and necrosis and ultimately may mean the loss of the tooth or teeth. Dental caries is biofilm mediated but also host modulated. Despite all the advances in restorative dentistry, this disease remains the most common disease in mankind and the disease burden of dental caries has remained constant. New approaches based on scientific evidence challenge existing paradigms about the etiology, diagnosis and treatment strategies. In the previous century, most treatment for dental caries involved a needle and a drill. But the 21^st century ushered in a new era, with the concept of P4 Medicine reflected in a new approach to dental caries management. This paper provides the current scientific evidence of the current biofilm model of the disease, best practices for diagnosis based on risk assessment and targeted treatment strategies to the patient’s individual risk factors. The biofilm model of dental caries, rather than pathogen specific, is now understood to be a metabolic issue of the biofilm, producing an acidic environment. The major risk categories for dental caries are reduced saliva flow, dietary issues, biofilm dysfunction and genetic considerations. Treatment strategies include restorative and reparative approaches including antimicrobial, remineralization with fluoride and nano-particle hydroxyapatite, xylitol, silver diamine fluoride, and pH. Behavioral strategies include coaching the patient with routine daily hygiene and also dietary counseling. Caries risk management provides a model of care that is predictive, preventive, personalized and participatory and promises to improve patient outcomes from this disease. This paper describes the most recent best practices for this disease from diagnosis to treatment, and offers an evidenced based philosophy based on current scientific literature and clinical practices.