1 ICCMS™ Guide for Practitioners and Educators Nigel B. Pitts, FRSE BDS PhD FDS

1 ICCMS™ Guide for Practitioners and Educators Nigel B. Pitts, FRSE BDS PhD FDS RCS (Eng) FDS RCS (Edin) FFGDP (UK) FFPH1 Amid I. Ismail, BDS, MPH, Dr. PH, MBA2 Stefania Martignon, BDS, PhD1,3 Kim Ekstrand, BDS, PhD4 Gail V. A. Douglas, BMSc, BDS, MPH, FDS, PhD, FDS (DPH) RCS5 Christopher Longbottom, BDS, PhD1 Contributing co-authors* Christopher Deery, University of Sheffield, UK Roger Ellwood, University of Manchester, UK Juliana Gomez, University of Manchester, UK Justine Kolker, University of Iowa, USA David Manton, University of Melbourne, Australia Michael McGrady, University of Manchester, UK Peter Rechmann, University of California San Francisco, USA David Ricketts, University of Dundee, UK Van Thompson, Kings College, London, UK Svante Twetman, University of Copenhagen, Denmark Robert Weyant, University of Pittsburgh, USA Andrea Ferreira Zandona, University of North Carolina, USA Domenick Zero, Indiana University School of Dentistry, USA On behalf of the Participating Authors of the International Caries Classification and Management System (ICCMSTM) Implementation Workshop, held June 2013** December 2014 1King’s College London Dental Institute, Dental Innovation and Translation Centre, Guy’s Hospital, London, UK 2Maurice H. Kornberg School of Dentistry, Temple University, Philadelphia, USA 3UNICA Caries Research Unit, Universidad El Bosque, Bogotá, Colombia 4University of Copenhagen, Denmark 5School of Dentistry, University of Leeds, UK 2 *Contact details for all authors and contributing co-authors can be found in Appendix A1. **For a list of contributors from the ICCMS™ Implementation Workshop and development meetings since, please see Appendix A2. Amid Ismail and Nigel Pitts are the co-Directors of ICDAS/ICCMS™ and are assisted by Stefania Martignon, the ICCMSTM Coordinator. Modifications, questions, and suggestions relating to the ICCMSTM Consensus Core resource document and this ICCMSTM Guide for Practitioners and Educators should be directed to Stefania Martignon (stefania.martignon@kcl.ac.uk) who also works with the current ICDAS coordinator Gail Douglas (g.v.a.douglas@leeds.ac.uk) as well as the ICDAS Coordinating Committee and the Global Collaboratory for Caries Management (GCCM), formed at King’s College London under the supervision of Professor Nigel Pitts, with the aim of initiating comparative studies of the proposed systems and evaluate the process and outcomes of its implementation. Further details can be found in the webpages www.icdas.org and www.kcl.ac.uk/sspp/kpi/projects/healthpolicy/global-caries-management.aspx. Correspondence: Stefania Martignon King’s College London Dental Institute, Dental Innovation and Translation Centre Guy’s Hospital Room 38, Tower Wing SE1 9RT, London, UK stefania.martignon@kcl.ac.uk Note: ICCMS™ is trademarked by the ICDAS Foundation in order that the International Caries Classification and Management System can remain open and available to all. Acknowledgements The Authors are indebted to the marvelous contributions made by all of the internationally mixed groups who attended the launch meeting of the Global Collaboratory for Caries Management at Kings College London in June 2013 and the many who have helped since at meetings in Liverpool, Seattle, Philadelphia, London, Capetown, Greifswald, Delhi and Tokyo to drive this initiative forward. We are also exceedingly grateful to all the Organisations and Companies who have supported this work and enabled the progress to date. A list of Supporting Organisations and Companies can be found in Appendix M. 3 TABLE OF CONTENTS Page Overview ……………………………………………………………………………………………......... 5 Introduction ……………………………………………………………………………………………… 6 1. History and Development of the ICCMSTM …………...…………...….…………………… 9 1.1 ICCMSTM’s Goals for Caries Management ……………………………….……….…………. 10 1.2 Principles for Implementing ICCMS™ …………………………………….…………………... 11 1.3 ICCMSTM Caries Management Pathway ……………………………………………………… 12 2. ICCMSTM Elements and the supporting evidence ………………………………………... 13 2.1 Element 1- History-:Patient Level Caries Risk Assessment …..…………………………... 14 2.2 Element 2- Classification: Caries Staging and Lesion Activity Assessment ..........…….. 15 2.2.1 Assessment of Caries Risk Factors Intraorally ……………………………………………….. 16 2.2.2 Staging lesions …………………………………………………………………………………… 18 2.2.2.1 Staging coronal caries lesions clinically ............................................................................. 18 2.2.2.2 Staging coronal caries lesions radiographically ………………………………….................. 20 2.2.2.3 Combining clinical and radiographic information …………………………………................. 22 2.2.2.4 Lesion activity assessment ………………………………………………………..................... 22 2.3 Element 3- Decision Making: Synthesis of information to reach Diagnoses ……..……... 24 2.3.1 ICCMS™ caries diagnosis …..……………………………………………………………......... 24 2.3 2 ICCMS™ caries risk analysis to assess likelihood of new lesions or caries progression ………………………………………………………………………………………. 25 2.4 Element 4- Management: Personalised Caries Prevention, Control & Tooth Preserving Operative Care …………………………………………………………….………………...….. 27 2.4.1 Managing a patient’s risk factors ..…………………………………………………………….. 28 2.4.2 Managing individual lesions …………………………………………………...……………….. 30 2.5 Recall interval, Monitoring and Review ……………………………………………………….. 33 3. Outcomes of Caries Management using ICCMSTM ……………………………………..... 34 4. ICCMSTM in Practice ……………………………………………………………………………. 35 5. Related Developments ………………………………………………………………………… 35 5.1 New Evidence on Current or Emerging Technology ………………………………………… 35 5.2 Research Agenda for ICCMS™ and the GCCM ……………………………………………... 36 5.3 Integrated eLearning and Data Management Software ……………………………………... 37 5.4 Implementation for ICCMS™ – GCCM ………………………………………………………... 37 References ……………………………………………………………………………………………….. 38 4 List of Tables Table 1. Risk status of the patient ……………………………………………………………………… 17 Table 2. Definition of ICCMSTM Caries categories (merged codes) ………………………………… 19 Table 3. ICDAS/ICCMS™ radiographic scoring system ……………………………………………. 21 Table 4. Combination of clinical and radiographic information ……………………………………… 22 Table 5. Characteristics of lesion activity across the ICCMSTM coronal caries stages …………… 23 Table 6. ICCMS™ caries diagnosis (staging and activity status per lesion) ………………………. 25 Table 7. ICCMS™ Caries Risk and Likelihood Matrix ………………………………………………... 25 Table 8. Managing individual lesions in permanent teeth ……………………………………………. 31 Table 9. Managing individual lesions in primary teeth ……………………………………………..… 32 List of Figures Figure 1.Identification of the ICCMS™ Practice and Education Domains relating to this Manual ………………………………………………………………………………………… 7 Figure 2. Overview of the ICCMS™ Elements and Outcomes ……………………….…………….. 8 Figure 3. The Four Elements of ICCMS™ linked by risk based recall ……………...……………… 12 Figure 4. Detailed overview of ICCMS™ Elements and their components ………………...…...... 13 Figure 5. Element 1- History- Patient-level Caries Risk Assessment …………………..………….. 14 Figure 6. Element 2- Classification: Caries Staging and Lesion Activity Assessment with Intraoral Caries Risk Factors ….…………………………………………………………….. 16 Figure 7. Element 3- Decision Making: Synthesis of information to reach Diagnoses and Risk Status ……………………………………………………………………………………. 24 Figure 8. Element 4- Management: Personalised Caries Prevention, Control & Tooth Preserving Operative Care ……………………………………...……..…………………… 27 Figure 9. Managing patient’s risk factors ……………………………………………………………… 29 Figure 10. Detailed Outcomes of Caries Management using ICCMS™ ……………..………..…... 34 List of Boxes Box 1. Patient level caries risk factors …………………………………………………….….……….. 15 Box 2. Intraoral level caries risk factors ……………………………………………………….………. 16 List of Appendices Appendix A: List of Contributing and Participating Authors ….……………………………..…..….. 47 Appendix B: Scottish Intercollegiate Guidelines Network’s (SIGN) Grading of the Evidence ….. 50 Appendix C: Patients’ caries risk factors. A consideration ………………………………………….. 51 Appendix D: Full Definition of ICCMS™ Caries categories (merged codes) ………..................... 54 Appendix E: Root caries: Staging of lesions clinically, activity assessment and management options …………………………………………………………………...… 55 Appendix F: Some considerations on Caries Associated with Restorations or Sealants (CARS) and Non carious changes ………………………………………..….. 58 Appendix G: Evidence considerations for managing patients’ risk factors ………………….…….. 60 Appendix H: Level of evidence for individual lesions’ interventions ………………………….……. 62 Appendix I: New Evidence on Current or Emerging Technology ……………………………..…… 63 Appendix J: Glossary for key words …………………………………………………………….…….. 64 Appendix K: ICCMSTM Caries Staging Photographs and Radiographs …………………………… 66 Appendix L: ICCMS™ Clinical Case Example ……………………………………………………..... 77 Appendix M: Supporters of ICCMS™ and the Global Collaboratory for Caries Management ….. 84 5 Overview The aim of this Guide is to describe the structure and facilitate the implementation of the International Caries Classification and Management System (ICCMS™), which the authors propose to be used in the daily handling of our patients for caries prevention and management and also in the teaching undertaken at dental schools around the world. The ICCMS™ is a health outcomes focused system that aims to maintain health and preserve tooth structure. Staging of the caries process and activity assessment is followed by risk-adjusted preventive care, control of initial non-cavitated lesions, and conservative restorative treatment of deep dentinal and cavitated caries lesions. There are four elements in the ICCMS™, the two key aspects are:  Classification - Caries Staging & Activity Assessment: this comprises (i) staging of caries lesion severity (‘initial’/’moderate’/’extensive’) and (ii) caries activity assessment (likelihood of progression or arrest/reversal of lesions: ‘active’/’inactive’). [Note that during the intraoral assessment phase information is also collected on oral risk factors; e.g. oral hygiene, dry mouth]  Management - Personalised Caries Prevention, Control & Tooth Preserving Operative Care: The dental team, together with the patient, devise a Personalised Caries Care Plan to manage the caries risk status of the patient as well as managing caries lesions appropriately. (i) Management of the risk status is based on both home care advice, as well as clinical activities; those with low risk getting general information on how to maintain teeth as sound, those with moderate and high risk with increasing focus on behaviour changes and short periods between recalls to the clinic. (ii) The management of the lesions is related to the diagnosis of the individual lesions: ‘initial’ active lesions in general are managed with non-operative care (NOC) whilst moderate/extensive lesions are in general managed operatively with tooth preserving operative care (TPOC). In order to devise an optimal Personalised Caries Management Plan, two other elements are also needed (please note that the chronological sequence and the method of integration of patient and clinical information may vary according to local preferences):  History - Patient-level Caries Risk uploads/Management/ iccms-guide-full-guide-with-appendices-uk.pdf

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