European Journal of Dental Education ISSN 1396-5883

Caries risk assessment, diagnosis and synthesis in the context of a European Core Curriculum in Cariology
N. Pitts1, P. Melo2, S. Martignon3, K. Ekstrand4 and A. Ismail5
1 2 3 4 5

Dental Health Services & Research Unit, University of Dundee, Dundee, UK, Faculty of Dentistry, University of Porto, Porto, Portugal, Cariology Research Centre, University El Bosque, Bogota, Colombia, Department of Cariology and Endodontics, School of Dentistry, University of Copenhagen, Copenhagen, Denmark, Kornberg School of Dentistry, Temple University, Philadelphia, PA, USA

keywords caries; curriculum; cariology; caries risk assessment; detection; activity; assessment; diagnosis and synthesis. Correspondence Nigel Pitts Dental Health Services & Research Unit University of Dundee The Mackenzie Building Kirsty Semple Way Dundee DD2 4BF, UK Tel: +44 0 1382 420067 Fax: +44 0 1382 420051 e-mail: n.b.pitts@cpse.dundee.ac.uk Accepted: 29 August 2011 doi:10.1111/j.1600-0579.2011.00711.x

Abstract
This paper is part of a series outlining a European Core Curriculum in Cariology for undergraduate dental students. The European Core Curriculum in Cariology is the outcome of a process starting in 2006 and culminating in a joint workshop of the European Organization for Caries Research (ORCA) together with the Association for Dental Education in Europe (ADEE), held in Berlin from 27 to 30 June 2010. For the areas of risk assessment, diagnosis, detection, activity, monitoring and synthesis Cariology, the present paper outlines the key competencies required and the related areas in which knowledge of and familiarity with are needed for dentists graduating at the beginning of 21st century. Three major competencies were identied: Risk Assessment competent at identifying and estimating the probability for a patient of developing new caries lesions or progression of existing lesions during a specied period of time; Diagnosis competent through collecting, analysing and integrating data on signs and symptoms of dental caries and assess activity status of a lesion on a tooth surface to arrive at an identication of past or present occurrence of the disease caries; and Synthesis competent at synthesising all relevant information by combining and interpreting ndings from: risk assessment and diagnostic processes; from patients needs, preferences and best interests; and from monitoring, review and re-assessment ndings, when available. Similar competencies were identied for erosion and non-erosive wear. Issues that were felt by the working group panel to be important in this eld are discussed, as are approaches to aid curriculum implementation.

Introduction
This paper is part of a series of papers towards a European Core Curriculum in Cariology for undergraduate dental students. The European Core Curriculum in Cariology is the outcome of a process starting in 2006 and culminating in a joint workshop of the European Organization for Caries Research (ORCA) together with the Association for Dental Education in Europe (ADEE), which was held in Berlin from 27 to 30 June 2010. The foundation for teaching undergraduate students, about dental caries and how best to manage this process in a patientcentred way according to best evidence, is based on a thorough understanding of the caries process and the scientic foundation for caries risk assessment, diagnosis and synthesis. This paper focuses on this Domain of learning and clinical practice and reports discussions and deliberations owing from Work-

group II at the Berlin Workshop (Fig. 1). The Domain includes assessment of risk at both the patient and lesion level, lesion detection (including clinical visual methods and the appropriate use of detection aids) as well as the assessment of lesion activity, leading to accurate diagnoses and the monitoring of lesion behaviour over time. Synthesis of all the relevant factors can then produce an appropriate care plan for each patient. Similar logical frameworks also apply when the focus is on caries prevention and control at the group or population level.

Scope
Although this paper concentrates on cariology, the curriculum being considered also relates to dental erosion, non-erosive wear and other dental hard tissue disorders. An essential background competency for proper consideration of dental caries and these other conditions is the ability to understand the

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Fig. 1. ORCA-ADEE Workshop on the development of a European Core Curriculum in Cariology: Participants in working group II Risk Assessment, Diagnosis and Synthesis: Nigel Pitts (Chair), University of Dundee, UK; Lorraine Robinson (Co-Chair), University of Dundee, UK; Amid Ismail (Rapporteur), Temple University, USA; Joana Carvalho, University of Louvain, Belgium; Renata Chalas, University of Lublin, Poland; Tracy de Peralta, Peninsula University, UK; Kim Ekstrand, University of Copenhagen, Denmark; Carolina Ganss, University of Giessen, Germany; Stefania Martignon, University El Bosque, Colombia; Paulo Melo, University of Porto, Portugal; Klaus Neuhaus, University of Berne, Switzerland; Liisa Seppa University of Oulu, Finland; and Anne , Bjo Tveit, University of Oslo, Norway. rg

different aetiology and pathogenesis of the conditions and to make an effective differential diagnosis between the various possible conditions. It is therefore imperative at the start that all students and clinicians understand the essential differences between dental caries and disorders of the hard tissues. There is a stark contrast between caries a complex, biolm-mediated disease, which initially involves subsurface demineralisation with repeated demineralisation remineralisation cycles on the one hand, and the environmental (chemical or physical) demineralisation and loss of surface associated with erosion or wear or developmental anomalies on the other.

Methods
Workgroup II, initially called Risk Assessment, Detection, Activity and Monitoring a Synthesis, considered the scope of its task and then debated each element in turn before considering the linkages between them. The results of the deliberations were then presented incrementally to the plenary sessions at the end of each session to obtain feedback, to minimise unnecessary duplication of issues, which could more appropriately be included in other Workgroups reports, and to build rational and essential competencies for the overall curriculum (1). This present paper reports the full list of competencies designed and rened by all members of Workgroup II, as well as a number
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of the key points that emerged from the discussions at Workgroup II. The authors, as requested, have also built on these topics to present graphical materials and concepts, which they believe, from their experiences across a range of countries, will be of use in the implementation of these aspects of the core curriculum. The paper is presented to complement the results derived from a comprehensive survey of educational practices across Europe (2), the material set out in the overall core curriculum document (1), and the detailed texts set out in the companion papers on: the Knowledge base (3), Decision-making and preventive non-surgical therapy (4), Decision-making and treatment with respect to surgical intervention (5) and Evidence-based cariology in clinical and public health practice (6). The key areas directly linked to cariology Domain II by Clinical Decision-Making are the preventive non-surgical therapy of Domain III and the surgical intervention of Domain IV.

The challenges of modern, preventive, patient-centred caries control and management

The Workgroup participants concluded that the activities of caries risk assessment, diagnosis and the synthesis of the information so derived should be seen in the context of ensuring the appropriate, continuing management of dental caries and

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should be part of enabling patient-centred and shared clinical decision-making (7). This is part of a shift in treatment philosophy over recent decades, moving away from a surgical-only model of care. The newer philosophy is one in which the dentist is seen as the leader of an oral health team, acting in many instances as an oral health physician and diagnostician, but retaining the skill sets and abilities to provide high-quality surgical care when this is needed (8). The student should be prepared for this changing professional and educational environment, and the emphasis should now reect the need to acquire this broad range of equally valued competencies and not allow the traditional dominance of surgical decision-making and restorative-only care. In some cases, curricula have already changed a great deal; in others, various stages of transition are seen. There are particular challenges associated with achieving a consistent approach with part-time faculty and maintaining appropriate and up-to-date relationships with the dental licensing agencies in some countries. Other challenges identied and discussed by the Workgroup included: A Disintegrated approach in dental education in general and in these aspects of cariology in particular. This was demonstrated by many experiences voiced at the Workshop and evidenced further by data collected in the questionnaire survey of teaching (2). A more unied strategy was recommended. Communication issues: s It was felt that those responsible for teaching cariology across the areas of: caries risk assessment, detection, activity assessment, monitoring, clinical decision-making, clinical prevention and surgical caries management frequently did not communicate well between each other. Students learning experiences are made more confusing and contradictory as a direct result of this poor communication. s Poor communication was evident between those working in what were frequently silos of dental Education and Clinical Practice, Public Health and Research. s There was confusion about scientic and clinical terminology across the silos mentioned earlier. This had been partially addressed with a recently published Glossary of key terms (9), but there was felt to be continuing need for a more comprehensive and compatible dictionary for cariology. s Previous attempts to compile systematic reviews of systems for caries detection and assessment had been frustrated by the myriad differences in the methodological approaches used. The move to, where possible, harmonise caries classication and management systems to enable comparability and translation of research into practice through an International Caries Detection and Assessment System (ICDAS) (10) was supported. Departmental/specialty home: It was frequently observed that in many dental schools, there is no common departmental or specialty home for cariology. Whilst the range of teaching required across age groups is a challenge to establishing such a home, the lack of one was seen as a challenge in ensuring that teaching in caries risk assessment, diagnosis, synthesis cariology and clinical decision-making was sufcient and appropriate. Course objective: It was felt that the structure of the teaching programme should be for patient-centred management of car-

ies, rather than faculty-focused or student-focused models that have traditionally been common in dental schools. Clinical patient-centred curriculum: It was felt that the patient-centred aspects of the curriculum should be taught in all stages of dental education and not just in cariology and disorders of the heard tissues. Integration plan: It was felt that each school should develop a plan to ensure that integration of teaching and clinical management among disciplines and departments is achieved, maintained and developed. Individual integrators: These staff are needed as part of the system, not just when they become available by chance or as a result of the unplanned activities of an occasional individual. Erosion and non-erosive wear are important elements of the curriculum risk assessment, diagnosis, synthesis and clinical decision-making in these areas can be a serious challenge. Dental schools should both develop and maintain academic and clinical expertise in the areas of erosion and non-erosive wear. Table 1 below provides an overview of the nal competencies agreed by the Workgroup and the Berlin Workshop plenary for Domain II: Caries risk assessment, diagnosis and synthesis. This provides a prescription for the educational programmes needed in these areas by a modern dentist graduating in Europe at the beginning of the 21st century. Table 1 shows that across the three subject areas (caries risk assessment, diagnosis and synthesis), the curriculum species a range of requirements in the form of major competences (3), Supporting competences (8), Have knowledge of (6), and Be familiar with (2).

Discussion and approaches to aid implementation

Implementation of the core cariology curriculum, which has now been specied (1), will require careful attention to delivery of all ve of the cariology Domains identied. There needs to be, particularly, careful linkages built between the teaching and learning in (i) this Domain (caries risk assessment, diagnosis and synthesis) with (ii) clinical decision-making and (iii) the two other most closely related Domains (III and IV). Specic consideration of many issues in Domains III and IV can be found in the related papers produced by the other respective workgroups (4, 5). To complement this detail (given in these other papers on decision-making and preventive non-surgical as well as surgical therapy for caries), what follows focuses on some distinctive issues limited to Domain II. The authors have identied further resources and graphical approaches to communicate some of the complex relationships affecting the dental caries process that underpin caries risk assessment, diagnosis and synthesis. This is to aid the implementation of the core curriculum and address some of the specic challenges identied by the Domain II Workgroup.

Detection, assessment and monitoring

There is often still very considerable confusion between the various uses of the terms caries diagnosis, lesion detection and lesion assessment across departments, Universities, specialties and
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Table 1. Competencies in Domain II: caries risk assessment, diagnosis and synthesis Be familiar with Have knowledge of

Subject Risk assessment: identifying and estimating the probability for a patient of developing new caries lesions or progression of existing lesions during a specied period of time (also with regard to erosion and non-erosive wear). A varying depth of knowledge and understanding is required to collect, record and analyse reliable, valid and clinically meaningful data allowing the dentist to categorise patients into different risk categories for caries and, where applicable, for erosion and non-erosive wear 2.1 Obtaining data by selecting the appropriate risk factors/indicators if/when applicable from: patients histories comprising medical, oral, dental, social and economic aspects; oral health behaviours by taking into account oral hygiene, knowledge, preferences and self-efcacy, dietary habits and intraoral biological factors; caries experience; uoride use; systemic health; and considering new validated risk factors, as new evidence emerges 2.2 Communicating the results of risk assessment with patients or others and providing recommendations to enable patients to reduce risk of developing new caries lesions and/or progression of existing lesions in the future see Domains III and IV 2.3 Judging emerging information on risk factors and indicators Diagnosis: On graduation, the dentist must be competent at caries diagnosis through collecting, analysing and integrating data on signs and symptoms of dental caries and assess activity status of a lesion on a tooth surface to arrive at an identication of past or present occurrence of the disease caries. A similar competence is required for diagnosis of erosion and non-erosive wear 2.4 Recognising abnormal tooth tissue and differentiating between carious and non-carious hard tissue changes or anomalies. This should encompass primary and secondary lesions in both coronal and root surfaces 2.5 Collecting and recording data on the presence of different stages of the caries process (signs) and symptoms related to dental caries 2.6 Assessing activity status for different stages of the caries process 2.7 Collecting, analysing and integrating data on signs and symptoms of erosion or non-erosive wear with activity status where appropriate, to arrive at a diagnosis of the different types of erosion or non-erosive wear 2.8 Evaluating different current and emerging methods for detection and staging the caries process and assessing activity of carious lesions and use such information to contribute to making informed treatment decisions (see also Domains III and IV) 2.9 Evaluating different current and emerging methods for detection and staging of erosion or non-erosive wear and activity assessment of erosion or non-erosive wear and how to use such information to contribute to making informed treatment decisions (see also Domains III and IV) 2.101 The different types of developmental anomalies and the differentiation of these conditions from caries and erosion or non-erosive wear Synthesis: synthesising all relevant information by combining and interpreting ndings from: risk assessment and diagnostic processes; from patients needs, preferences and best interests; and from monitoring, review and re-assessment ndings, when available 2.11 Eliciting and assessing patients needs, preferences and best interests for the management of caries 2.12 Making clinical decisions incorporating, when appropriate, ndings from monitoring, review and re-assessment of caries 2.13 Erosion and non-erosive wear, synthesising all relevant ndings from histories and examinations by combining and interpreting them to enable patient-centred and shared clinical decision-making 2.14 Eliciting and assessing patients needs, preferences and best interests for the management of erosion and non-erosive wear 2.15 Making clinical decisions incorporating, when appropriate, ndings from monitoring, review and re-assessment of erosion and non-erosive wear

Supporting competences

Major competences x

x x

x x x

x x

x x x

x x

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Table 1. (Continued) Be familiar with x Have knowledge of

Subject 2.161 Treatment options: including when to refer for specialist medical and dental care, for other, rarer, disorders of dental hard tissues or medical illnesses causing dental hard tissue disorders
1

Supporting competences

Major competences

For 2.10 and 2.16, Workgroup II held the view that greater prominence might be given to elements of the differential diagnosis of various types of developmental anomalies and the differentiation of these conditions from caries, erosion or non-erosive wear (2.10) and referral decisions related to rarer disorders of dental hard tissues, or medical illnesses causing dental hard tissue disorders (2.16). However, at the plenary sessions, the consensus view across all the Workshop participants was that these subjects should be listed only as Be familiar with.

Countries. The recent international Glossary of key terms (9) considers that: l Lesion detection implies a process involving the recognition (and/or recording), traditionally by optical or physical means, of the changes in enamel and/or dentine and/or cementum, which are consistent with having been caused by the carious process. l Lesion assessment is the assessment of the characteristics of a carious lesion, once it has been detected. These characteristics may include optical, physical, chemical or bio-chemical parameters, such as colour, size or surface integrity. l Caries diagnosis should imply the human professional summation of all the signs and symptoms of disease to arrive at an identication of the past or present occurrence of the disease caries. It is also important to make clear the meaning of caries activity and monitoring (9): l Active Caries Lesion a caries lesion, from which, over a specied period of time, there is net mineral loss, i.e. the lesion is progressing. [This may be identied by either: (i) a 1-point-in-time characterisation of the lesion, using particular lesion parameters indicative of lesion progression, or (ii) a comparison, at 2 or more time points, of specic lesion parameters/characteristics when monitoring a lesion.] l Monitoring of a caries/carious lesion the assessment, over time, of one or more of the characteristics of a caries lesion to assess whether any changes have occurred in that lesion. [This can involve comparison of one or more of the characteristic(s), such as the severity or the extent or the activity of a lesion.] The ways in which caries may be detected on the basis of lesion extent, assessed in terms of lesion activity and then monitored over time, are summarised in the graphic set out as Fig. 2. The emphasis is on carefully examining clean dry teeth with sharp eyes and blunt probes/explorers.

Fig. 2. Cube representation of Lesion Detection, Activity Assessment and Monitoring Lesion Behaviour.

Patient box, whilst the diagnostic steps are grouped under the Tooth/Surface box. The information obtained is then brought together in a synthesis, combining diagnostic and prognostic steps, to produce an integrated and personalised treatment plan including elements of recall, reassessment and review.

Caries risk assessment

The core curriculum (1) species as a major competency that, on graduation, the dentist must be competent at identifying and estimating the probability for a patient of developing new caries lesions or progression of existing lesions during a specied period of time. Risk assessment is an essential component in the decision-making process for the correct prevention and management of dental caries (11). The literature reveals that there is a strong body of evidence to support that caries experience is still, unfortunately, the single best predictor for future caries development. In young children, prediction models that include a variety of risk factors seem to increase the accuracy of the prediction, whilst the usefulness of additional risk factors for prediction purposes, as measured until now in the literature, is at best questionable in schoolchildren, adolescents and adults. That is not to say these additional factors should not be assessed to help understand the strength of their associations with the disease experience in a particular patient and aid in the development of an individualised and targeted preventive and management plan (11).
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Framework for risk assessment, diagnosis and synthesis

An integrated approach to mapping a framework, in which the various elements of risk assessment, diagnosis and synthesis link together, has been widely disseminated internationally by ICDAS (7, 10). A variation of this framework is shown as Fig. 3. The risk assessment elements are grouped under the

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Fig. 3. Framework for ICDAS-enabled, patient-centred caries management.

Risk Assessment does not have to be undertaken by a single system, there are a range of contrasting strategies and forms in use. The Cariogram approach has considerable utility (11), even when used without the microbiological elements, whilst in the USA, the Caries Management By Risk Assessment (CAMBRA) groups have undertaken considerable work in awareness raising and promoting risk assessment. Recent developments have focused more on the impact of assessing the risk of a complex and biolm-mediated dynamic disease process (3), rather than the more traditional focus on specic types of bacteria. It should also be appreciated that in some cases where patients exhibit no clinical evidence of visible active caries, but the dentists risk assessment still suggests high or moderate risk for lesion development, then risk-related preventive treatment should still be planned. Students should be able to select the appropriate currently recognised risk factors/indicators and consider new validated risk factors, as new evidence emerges. They should also be adept at communicating the results of risk assessment to patients.

Diagnosis
The major competence for diagnosis on graduation (1) centres on the dentists ability to make a diagnosis (through collecting, analysing and integrating data on signs and symptoms of disease) and, in addition, assess the activity status of a lesion. The graduating dentists should also be able to collect and record data on the presence of different stages of the caries process, differentiate between carious and non-carious hard tissue changes or anomalies for primary and secondary lesions in both coronal and root surfaces and have knowledge of evaluating different current and emerging methods for lesion detection, staging the caries process and assessing activity of carious

lesions. Further details of the ICDAS approach to clinical visual lesion detection are reported elsewhere (12), as are the ICDAS approach to assessing lesion activity (13) and an alternative approach to activity assessment in younger patients developed by Nyvad et al. (14). The ICDAS system has evolved over the last 9 years. The shared vision for the International Caries Detection and Assessment System is now that: l it employs an evidence-based and preventively oriented approach, l is a detection and assessment system classifying stages of the caries process, l is for use in dental education, clinical practice, research and public health, l provides all stakeholders with a common caries language, l has evolved to comprise a number of approved, compatible formats, l supports decision-making at both individual and public health levels and l has generated the International Caries Classication and Management System ICCMS (15), to enable improved long-term caries outcomes. The system has been trade-marked merely so that it can be continued to be used as an open system promoted by the ICDAS Foundation charity. The Caries Continuum used by ICDAS extends from the extremes of caries-related sepsis and extensive decay at one end (see Fig. 4) to initial lesions, sound surfaces with health and wellness at the other end. It is important that this full extent of the stages of caries can be assessed and classied. This range of comparable information that can be collected provides for a number of different formats of caries recordings, which can be used both within and across the various dental

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The international caries detection and assessment system caries continuum Health Disease
Dental caries: The ICDAS* caries continuum (using ICDAS stages and assessment with PUFA)

2
Caries

3
Moderate

4
Caries

5
Extensive

6
Caries

PUFA
Pain/sepsis

Wellness/ Initial sound Caries prevention & control

* ICDAS is a charitable foundation committed to open access

Fig. 4. The International Caries Detection and Assessment System Caries Continuum, from health and wellness to extensive decay and sepsis.

Wardrobe of formats for use in and across applications

ICCMS practice Prevention-focussed clinical care for individual patients

ICCMS public health

Population focussed health promotion & prevention

ICCMS education Standardized and EBD cariology education

ICCMS research Population and clinical research

Fig. 5. A Wardrobe of formats for use within and across education and three other dental applications.

applications (or silos) identied earlier. Figure 5 shows the representation of the ICCMS wardrobe, from which a student (or dentists) can choose the most appropriate method for the task at hand. The curriculum should equip dental graduates to be able to understand the needs of those working in general practice, dental public health and dental research. The open wardrobe shown in Fig. 6 shows, up the centre, a series of six stages of caries corresponding to increasing histological severity of the disease (using the same codes as in Fig. 4 with + indicating an active lesion and indicating an inactive or arrested lesion). The left-hand door shows the merged codes format, in which the six caries codes have been collapsed to three, representing initial stage, moderate and extensive decay. The door on the right of the gure represents the simplied reporting tool, which allows those in public health who require a backwards-compatible simple binary measure of Obvious decay and No Obvious decay, to compute a caries estimate at this level. It should be appreciated, however, that despite WHO standards for basic methods, there are wide variations between

countries and groups as to exactly where the binary threshold is drawn. The boxes for M and F on the top of the wardrobe denote the options to compute values for the Decayed, Missing and Filled (DMF) caries index (at a range of thresholds of D in the main wardrobe) and to also have the option of capturing the PUFA index recording pulps, ulceration, stulas and abscesses.

Synthesis
The major competence for synthesis on graduation (1) centres on the dentists ability to ensure the appropriate, continuing management of dental caries to enable patient-centred and shared clinical decision-making. This is achieved through synthesising all relevant information by combining and interpreting ndings from: risk assessment and diagnostic processes; from patients needs, preferences and best interests; and from monitoring, review and re-assessment ndings, when these are available.

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ICDASs international caries classification & management system (ICCMS): The Wardrobe 2011
Comprehensive recording system

Clinical decision making - most challenging for moderate caries

Domain I The knowledge base

M
Merged codes recording system
From specied ICDAS codes

F
From 1st digit ICDAS codes

PUFA

Basic repor ng tool

(aids backwards compa bility)

Domain II Risk assessment, diagnosis and synthesis

Domain III
Caries management Decision making & preventive Non-surgical therapy

International caries classification and management system

Clinical decision making

Domain IV
Caries management Decision making & surgical therapy

6 +/ 5 +/ 4 +/ 3 +/ 2 +/
+ epi. op on to combine 1 & 2

0
Wellness/ sound

1
Initial

2
Caries

6
Caries

PUFA
Pain/ sepsis

Moderate Caries Extensive The ICDAS caries continuum

Monitoring

and

Review

Domain V Evidence-based cariology in clinical & public health practice

Fig. 7. Clinical decision-making: the most challenging stages to consider are those of moderate caries.

1+/

0
ICDAS Full code format format f
(+/ (+/) = activity status /)

ICDASs international caries classification & management system (ICCMS): synthesis to treatment plan elements
f
Initial patient caries risk assessment

ICDAS foundation

Fig. 6. ICDASs International Caries Classication and Management System (ICCMS) The Wardrobe 2011 detailing alternative formats.

Detection, activity and enhanced risk assessment

Synthesis and decision making

Synthesis is an important step in ensuring that all the various strands of information obtained from histories, examinations and special investigations are drawn together in a systematic manner and integrated for the benet of a specic patient at a specic time. The Workgroup for Domain II considered that the philosophy and guiding principles, which should drive assessment, synthesis and, later, review, should be that: l Primary prevention and secondary preventive treatment are priorities in the management of caries, whereas tertiary prevention (surgical intervention) should be used as a last resort. l Dentists are both oral health physicians and oral health surgical interventionists. Whilst clinical decision-making at the extremes of the caries continuum may be relatively straightforward, the most challenging decisions involve deciding on the most appropriate care for ICDAS code 3 and 4 lesions in specic patients with specic risk proles, see Fig. 7. Recent developments from the ICDAS Coordinating Committee working with the International Association for Dental Research (15) and the FDI World Dental Federation have generated the International Caries Classication and Management System ICCMS. This System takes the information derived from comprehensive risk assessments, histories and clinical examinations and leads, via the Synthesis step, to ve structured elements of a patient-centred treatment plan. These elements comprise primary prevention, secondary prevention, minimal surgical procedures, advanced surgical procedures and
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Clinical treatments (non-surgical & surgical, as required) with prevention

Pa ent centred

Fig. 8. ICDASs International Caries Classication and Management System (ICCMS): Synthesis to produce ve treatment plan elements.

then review, monitoring and recall. The diagram in Fig. 8 provides an outline framework for students to learn and dentists to practice modern caries management and control and is being developed further by the ICDAS Foundation. The personalised recall and review elements should be built on best practice guidelines derived from the rather limited worldwide evidence we currently have on recall frequency and oral health (16, 17). The rate of the more widespread global implementation of modern preventive caries care across countries will be inuenced by a range of factors, including: a shift in general health systems towards more holistic and preventive approaches, health systems and insurance systems paying for preventive interventions on a more balanced basis, as well as the potential impact of measures to phase down the use of dental amalgam, and other restorative materials on environmental grounds (18). Graduating dentists should be well prepared to ensure that their diagnostic and treatment planning skills are suitable to meet both present conditions and likely future changes.

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Conclusion
On graduation, the dentist must be sufciently competent at caries risk assessment, diagnosis and synthesis to ensure the appropriate, continuing prevention, control and management of dental caries and to enable patient-centred and shared clinical decision-making. They should also be ready to critically update and evolve their diagnostic, prognostic and clinical decision-making skills in cariology, erosion and non-erosive wear as new evidence and techniques emerge.

Acknowledgements
The authors are grateful to: Lorraine Robinson (Workgroup Co-Chair) and the rest of the Domain II Workgroup for their invaluable contributions particularly in generating and rening all of the competencies set out in Table 1; the overall CoChairs of the Berlin Workshop for their vision and help with this initiative; and the members of the ICDAS Coordinating Committee for being open to sharing ideas and material to assist with the implementation of aspects of the core cariology curriculum. We are also very grateful to the sponsors of this ORCA/ADEE project for enabling the entire process.

Conict of interests
Professors Pitts and Ismail are Co-chairs of the International Caries Detection and Assessment System (ICDAS) Foundation, a charity that seeks to promote evidence based and comparable systems to enable improved long-term caries outcomes; Professor Ekstrand and Dr Martignon are also members of the ICDAS Coordinating Committee.

References
1 Schulte AG, Pitts NB, Huysmans MCDNJM, Splieth C, Buchalla W. European Core Curriculum in Cariology for undergraduate dental students. Eur J Dent Educ 2011: 15 (Suppl. 1): 917. 2 Schulte AG, Buchalla W, Huysmans MCDNJM, et al. A survey on education in cariology for undergraduate dental students in Europe. Eur J Dent Educ 2011: 15 (Suppl. 1): 38. 3 Anderson P, Beeley J, Manarte Monteiro P, et al. European Core Curriculum in Cariology: the knowledge base. Eur J Dent Educ 2011: 15 (Suppl. 1): 1822.

4 Bottenberg P, Ricketts DNJ, Van Loveren C, Rahiotis C, Schulte AG. Decision-making and preventive non-surgical therapy in the context of a European Core Curriculum in Cariology. Eur J Dent Educ 2011: 15 (Suppl. 1): 3239. 5 Buchalla W, Wiegand A, Hall A. Decision-making and treatment with respect to surgical intervention in the context of a European Core Curriculum in Cariology. Eur J Dent Educ 2011: 15 (Suppl. 1): 40 44. 6 Splieth C, Innes N, Sohnel A. Evidence-based cariology in clinical and public health practice as part of the European Core Curriculum in Cariology. Eur J Dent Educ 2011: 15 (Suppl. 1): 4551. 7 Pitts NB. Introduction how the detection, assessment, diagnosis and monitoring of caries integrate with personalized caries management. Monogr Oral Sci 2009: 21: 114. 8 Pitts NB. Are we ready to move from operative to non-operative/ preventive treatment of dental caries in clinical practice? Caries Res 2004: 38: 294304. 9 Longbottom CL, Huysmans MC, Pitts NB, Fontana M. Glossary of key terms. Monogr Oral Sci 2009: 21: 209216. 10 International Caries Assessment and Detection System (ICDAS). Available at: http://www.icdas.org/index.html (accessed 22 Sept 2011). 11 Twetman S, Fontana M. Patient caries risk assessment. Monogr Oral Sci 2009: 21: 91101. 12 Topping GV, Pitts NB; International Caries Detection and Assessment System Committee. Clinical visual caries detection. Monogr Oral Sci 2009: 21: 1541. 13 Ekstrand KR, Zero DT, Martignon S, Pitts NB. Lesion activity assessment. Monogr Oral Sci 2009: 21: 6390. 14 Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Res 1999: 33: 252260. 15 Pitts N, Amaechi B, Niederman R, et al. Global oral heath inequalities dental caries task group research agenda. Adv Dent Res 2011: 23: 198200. 16 National Institute for Clinical Excellence (NICE). Clinical Guideline 19. Dental recall: recall interval between routine dental examinations. London: Department of Health, 2004. ISBN: 1-84257-801-4, Available at: http://www.nice.org.uk/CG019NICEguideline (accessed 22 Sept 2011). 17 Oral Health Assessment and Review Guidance in Brief. Scottish Dental Clinical Effectiveness Programme. Pitts NB (Guidance Development Group Chair) and the SDCEP Guidance Development Group pp 25. 2011. ISBN: 978 1 905829 11 8, Available at: http:// www.sdcep.org.uk/index.aspx?o=3079 (accessed 22 Sept 2011). 18 Pitts NB. Modern perspectives on caries activity and control. J Am Dent Assoc 2011: 142: 790792.

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