Australian Dental Journal 2009; 54: 381–389

CLINICAL PROTOCOL
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. Briefly, 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 patient’s 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 specific for children and
adolescents.
Fundamentally, non-cavitated lesions in primary and especially permanent teeth are managed: (1) professionally by
preservative non-invasive means, including fluoride varnish and sealants; and (2) daily home toothbrushing using fluoride
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 intensified programme is required; their higher risk status is confirmed 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 = dentino-
enamel junction; ECC = early childhood caries; ICDAS = International Caries Detection and Assessment System.
(Accepted for publication 16 January 2009.)

adolescents are affected much more severely than others

INTRODUCTION
while a minority remain at extreme risk.4–6 Early
The application of the Caries Management System childhood caries (ECC) is a significant problem for
(CMS) for children and adolescents follows the ratio- which the main determinants are oral hygiene status,
nale underlying the application of the CMS for adults.1 night-feeding with a sweetened beverage, bacterial
Research undertaken by the authors has shown that infection, and enamel defects.7–9 However, this condi-
general dental practitioners adapted well to the CMS tion can also be managed. Dental research has led to
protocols for adults and benefits to patients were the development, for professional use, of efficacious
substantial.2,3 primary preventive caries measures and secondary
preventive non-invasive measures that can arrest non-
cavitated caries lesions and lead to their remineraliza-
Need for complementary CMS for children and
tion. In spite of this, these measures have not been
adolescents
utilized efficiently by the dental profession, perhaps
The implementation of water fluoridation in Australia because remuneration systems do not encourage their
and elsewhere and the widespread use of fluoride use or possibly because dentistry developed as a branch
toothpaste has contributed to a marked decline in caries of surgery and hence protocols that would deliver non-
risk. Despite this reduction, dental caries remains invasive care have not been formulated or demanded
prevalent in the community and some children and hitherto.10 The CMS for children and adolescents
ª 2009 Australian Dental Association 381
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RW Evans and PJ Dennison

proposed here overcomes this barrier to efficient fluoride application, and patient recall are specific for
practice. The protocols may be delivered in any clinical children and adolescents.
setting without the need to invest in new technology.
The patient at risk of caries
THE CARIES MANAGEMENT SYSTEM
The case history and clinical examination provides an
Briefly, the CMS is a 10-step non-invasive strategy to overview of tooth morphology and unfavourable expo-
arrest and remineralize early lesions and to enhance sures to potential caries risk ⁄ protective factors, namely:
caries primary prevention (Table 1). The governing plaque, frequency of sucrose intake, and fluoride.12
principle is that caries management must include The risk status of each patient is determined at the
consideration of: (a) the patient at risk; (b) the status completion of the clinical assessments.
of each lesion; (c) patient management; (d) clinical
management; and (e) monitoring. These considerations
Assessment of plaque distribution, diet, and fluoride
are dealt with separately below. The patient’s oral care
exposure
plan is developed according to a set of protocols which
refer to only those non-invasive interventions that Fluoride exposure is determined from the dental
are well supported by a strong evidence base. This history. The assessments of plaque distribution and
approach is designed to impact on two key determi- diet are conducted according to the protocols for
nants of oral health: individual health behaviours and adults.1 If permanent first molars and incisors have
professional dental care.11 This system is not directly not yet erupted, the plaque distribution on the primary
concerned with the management of cavitated lesions molars and incisors is assessed and recorded instead.
other than their diagnosis and by noting their need for
operative care.
The status of each lesion
The method for assessing each patient’s diet, plaque
distribution, saliva flow, and signs of caries as shown in The clinical signs of caries are examined and classified
bitewing radiograph images, follows the protocols for according to the consensus reached by the Co-ordinat-
adults to which the reader is referred.1 Similarly, the ing Committee of the International Caries Detection
charting of plaque scores, bitewing findings, and the and Assessment System (ICDAS II)13 whereas signs
details of caries risk and lesion extent and severity, that revealed from the bitewing radiographic survey are
are discussed with patients or their parents during the classified according to CMS protocol described for
case presentation, are recorded as illustrated for adults. adults.1
On the other hand, protocols presented here relating
to caries risk assessment, lesion management, topical
Clinical examination
The ICDAS II criteria (Table 2) refer to six clinical
presentations, three of which relate to increasingly
Table 1. Ten-step summary of the Caries Management
progressive stages of the enamel lesion (coded 1 to 3)
System
and three to the increasingly progressive stages of
1 Diet assessment the dentine lesion (coded 4 to 6). The teeth should
2 Plaque asssment be cleaned prior to inspection, if necessary using a
3 Bitewing radiographic survey
4 Diagnosis and caries risk assessment rubber cup.
5 Preparation of oral care plan For inspection, the teeth are first viewed when wet.
6 Case presentation at which patient is informed about: White and brown spot demineralized lesions on smooth
• Dental caries
s Arrest
surfaces or those centred within pits ⁄ fissures and
s Reversal ⁄ Natural repair (Remineralization) evident when wet, are assigned Code 2. On the other
s Prevention
hand, white or brown spot lesions that only become
s Number and status of current lesions
s Role of dental practitioner in caries management
visible following five seconds of air drying with the
s Role of home care in caries prevention triple syringe are assigned Code 1. Clearly, demarcated
s Current caries risk status
black or brown stains at the base of pits ⁄ fissures should
• Result of diet assessment and recommendatons
7 Oral hygiene coaching not be assigned ICDAS II Code 2 in the absence of
8 Clinical management evidence of enamel demineralization. However, if it is
• Topical fluoride application (both professional and judged that a large stain obscures such evidence, then
home care)
• Sealant or GIC application Code 2 is justified. White or brown spot lesions that,
9 Monitoring of plaque control and treatment outcomes upon air drying, are disclosed to be associated with
at each visit enamel breakdown are assigned Code 3. Code 4 is
10 Recall programme tailored to caries risk status
reserved for the blue or grey shadows from dentine that
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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 ⁄ fissure
surfaces, and CARS*
When wet, surfaces may reveal…
Normal apearance White or brown A shadow Cavitation Extensive
spot lesions from dentine with exposed cavitation
plus ⁄ minus dentine
enamel loss
Code 0 or 1? Code 2 or 3? Code 4 Code 5 Code 6

But drying for 5 seconds exposes…

Nothing else Nothing else

Code 0 Code 2
White or brown spot lesions Enamel loss
Code 1 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 caries marginal defects are assigned Code 0 as for
signs of enamel breakdown. Enamel breakdown is normal appearance. With CARS, Code 3 is assigned
confirmed using the WHO CPI probe which is slid when enamel breakdown along the margin of the
across the suspect surface. If the ball-end of this probe restoration or sealant is judged to be caries induced or
drops into a hard-based recess, enamel breakdown is when caries induced breakdown is judged to have
confirmed. But if the ball-end drops out of sight into a occurred within or alongside an existing non-caries
soft-based cavity, i.e, into dentine, the lesion is assigned defect.
Code 5. Frank cavities, disclosing a clearly visible The ICDAS II codes are entered into an enlarged
dentine base, are assigned Code 6. odontogram that allows for surface specific recording
Signs of caries associated with restorations or seal- and may, therefore, enable ready reference for moni-
ants (CARS) are coded similarly, but note that non- toring purposes (Fig 1). Oral care decisions reached on

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

ª 2009 Australian Dental Association 383
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RW Evans and PJ Dennison

the basis of inputs from the ICDAS II and the bitewing to determine caries risk in young children who have
data are also entered on odontogram. 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
Bitewing radiographic survey
categories are assigned; low risk and at-risk.
The assessment of bitewing images and the system
for recording the findings follows the adult proto-
Patient management
cols. Bitewing radiographic signs coded C1 and C2,
respectively (Tables 5 and 6) are radiolucencies that The management plan for patients follows the adult
do not extend deeper than the outer half of the protocols.
enamel thickness or the dentino-enamel junction
(DEJ), whereas a radiolucency that is perceived to
Case presentation and oral care planning
extend just beyond the DEJ is coded C3. Radiolu-
cencies that are confined, respectively, within or During the case presentation, the details of the clinical
beyond the outer one-third of the dentine depth are findings and discussion relating to oral care planning
coded C4 and C5. are put forward, as for adults, with reference to the
Tooth Decay information leaflet.1 This serves as the
principal patient educational material; it highlights
Assessment of the patient’s caries risk status
the need for home care toothbrushing and provides a
As for adults, the assessment of the caries risk of basis for obtaining informed consent from parents
children and adolescents is determined solely on an concerning the implementation of the oral care plan for
analysis of the severity and extent of their presenting their children.14
clinical and radiographic signs and not from epidem-
iologic-type considerations of their histories of either
Diet advice and oral hygiene coaching
favourable or unfavourable exposures to caries risk
factors. The specific criteria used with reference to The value of consuming fluoridated water should be
both the ICDAS II and radiographic codes in order 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 New patient Recall patient

Low • dmfs = 0 • < 1 new lesion per year*

• ICDAS II codes < 2 and no progression of existing lesions
• No radiolucencies
• No sites with Plaque Index = 3
At-risk • dmfs > 0 • 1 new lesion per year*
• Demineralized enamel – ICDAS II codes > 1 and ⁄ or progression of existing lesions
• C1 or greater radiolucencies • Any site with Plaque Index = 3 in cases
where dmfs = 0
At-risk – High • Any site with Plaque Index = 3 in cases where dmfs = 0
• Not assigned to new patient • > 1 new lesion per year*

*... 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 New patient Recall patient

Low • dmfs + DMFS = 0 • < 1 new lesion per year*

• ICDAS II codes < 2 • and no progression of existing lesions
• No radiolucencies
• No sites with Plaque Index = 3
• No hypomineralized or hypoplastic 6s or 7s
At-risk • dmfs > 0 • 1 new lesion per year*
• Demineralized enamel – ICDAS II codes > 1 or greater • and ⁄ or progression of existing lesions
• C1 or greater radiolucencies
• Any site with Plaque Index = 3 in cases where • Any site with Plaque Index = 3 in cases
dmfs + DMFS = 0 where dmfs + DMFS = 0
• dmfs + DMFT = 0 but 6s or 7s are hypomineralized • dmfs + DMFT = 0 but 6s or 7s are
or hypoplastic hypomineralized or hypoplastic
At-risk – High • Not assigned to new patient • > 1 new lesion per year*

*...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 pacifier criteria to be followed for determining which lesions,
dipped in honey or other sweetened products should visible only as bitewing images, warrant operative
be discouraged. After the age of 12 months, bottle intervention and restoration are also shown in Tables 5,
feeding should be discontinued and all fluids should 6 and 7. For less advanced pit ⁄ fissure lesions showing
then be given by cup. Sugary foods should not be enamel breakdown, the most conservative and effective
encouraged, especially at bedtime. Otherwise, the means of treatment is resin-based sealant application (or
principles of diet control for dental caries follow a GIC sealant as an interim measure when there are
those which apply to adults. concerns about moisture control), both to eliminate the
A soft toothbrush may be used to clean toddler’s plaque trap and to arrest further progression.16–18 Non-
teeth but fluoride toothpaste should not be used before cavitated lesions are managed by home care measures to
the age of 18 months to reduce the risk of toothpaste control plaque, principally by twice daily toothbrushing
ingestion. Only an adult should dispense a small pea using fluoride toothpaste, thereby arresting lesion pro-
sized amount of toothpaste to be used by preschool gression. In addition, the combination of professionally
children and their brushing should be supervised and applied topical fluoride varnish19–23 and home use of
assisted. Preschool children should be encouraged fluoride toothpaste22 (Tables 7 and 8) is necessary to
to spit, not swallow, the toothpaste. Since brushing ensure that the natural repair process of remineraliza-
another’s teeth is a complex manoeuvre, an appropri- tion is accelerated and thus to outweigh the effects of
ate method for brushing teeth should be demonstrated any remaining cariogenic challenge.24
to parents. The application of topical fluoride described here
relates to the non-invasive secondary preventive treat-
ment of non-cavitated lesions. However, more impor-
Clinical and home care management
tantly, professional applications of topical fluoride and
The risk-based caries management options are: pre- home use of fluoridated toothpaste are, in addition, the
ventive, preservative (non-invasive) and operative means of primary prevention for caries. The application
(invasive). Fundamentally, non-cavitated lesions in of fluoride varnish on newly erupted fissured surfaces
primary and especially permanent teeth are managed facilitates enamel maturation.
by preservative non-invasive means detailed in Tables 5
and 6 where the aim is to arrest their progression so that
Monitoring
a restoration will not be necessary.15 Only cavitated
lesions whose bases extend into dentine, or those so Patients are recalled at regular intervals12,25 (Table 9),
presumed to be cavitated in the absence of direct determined on the basis of their caries risk status,
confirmation, are to be managed operatively. The 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 Management

ICDAS II 1–2 • Apply fluoride varnish to arrest and remineralize active lesions and to maintain
arrested lesions
3 • 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)
4–6 Restore
Bitewing C1 Do not restore – apply topical fluoride and monitor
C2 Do not restore – apply topical fluoride and monitor
C3 Do not restore without further consideration
C4 Restore now only if tooth is not due to exfoliate*
C5 Restore now only if tooth is not due to exfoliate*

C1 C2 C3 C4 C5
Further consideration • Do not restore within 12 months of exfoliation*
of C3 surfaces • Restore if shadow is evident below marginal ridge
• Otherwise separate tooth to confirm cavitation and restore only if cavitated
• Implement preventive stategy to:
– arrest active lesions
– remineralize lesions
– maintain arrested lesions
– preserve first molars (take particular care)

*Clue – less than ½ of root remains.

ª 2009 Australian Dental Association 385
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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 Management

ICDAS II 1–2 • Apply fluoride varnish to (1) arrest and remineralize active lesions and (2) maintain
arrested lesions
3–4 • Restore with UCSR* only if associated radiolucency extends deeper than C4 otherwise
apply resin-based sealant and review in 6 months (bitewings)
5 • Restore with UCSR*
6 • Restore
Bitewing C1 Do not restore – apply topical fluoride and monitor
C2 Do not restore – apply topical fluoride and monitor
C3 Do not restore – apply topical fluoride and monitor
C4 Do not restore without further consideration
C5 Restore now

C1 C2 C3 C4 C5
Further consideration • If possible, separate teeth and restore only if cavitated is revealed
of C4 surfaces • 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 fluoride protocol for professional care of children and adolescents
Caries risk Fluoride varnish (Duraphat) 5% NaF (22 600 ppm) and GIC (Fuji 7) Fluoride gel 1.23% NaF (12 300 ppm)

Low • Apply varnish to occlusal surfaces of all newly erupted Not to be used under the age of 10
primary and permanent molars
• If not drinking fluoridated water, apply varnish to For age groups 10 and above:
occlusal surfaces of all molar teeth at each recall • At recall appointments to maintain lesion arrest
• If not using fluoride toothpaste, apply varnish to
occlusal surfaces of all molar teeth at each recall
At-risk • Apply varnish or GIC (e.g., Fuji 7) to occlusal and approximal Not to be used under the age of 10
surfaces of newly erupted primary and permanent molars
• Apply varnish to surfaces with lesions (clinical and For age groups 10 and above:
radiographic) and the respective apparently sound surfaces • At recall appointments instead of varnish (for
on homologous teeth at every treatment session, then whatever reason)
• Application as above at each review and recall appointment
until patient becomes low risk.

competence, and for oral hygiene coaching and the The monitoring of lesions through the review of
re-application of topical fluorides. clinical signs and bitewing images is the means for
assessing caries activity. At recall appointments,
radiolucencies on new bitewings are compared with
Caries activity
those of earlier series. Lesions under review that are
In relation to motivated parents or patients who follow not accessible to visual inspection should be radio-
the home care regimens, caries activity, and therefore, graphed after six months, but not earlier, to gauge
risk of new lesions can reduce sharply; risk status is activity status.26 When it is judged that lesions have
adjusted accordingly. For those who, for whatever arrested, yearly radiographic review is recommended.
reason, fail to respond to advice to reduce cariogenic For screening purposes, children and adolescents who
exposures and therefore continue to develop new are assessed as low risk should be scheduled for
lesions at a steady or increased rate, a more intensified bitewings annually. It may be suggested that 18 or
programme is required; their higher risk status is 24 months is a preferable interval for low risk
confirmed and treatment follows the corresponding individuals but risk status can change and caries
protocol. initiation and progression can be swift; it is better,
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Caries management for children and adolescents

Table 8. Topical fluoride protocol for home care of children and adolescents
Caries risk Age Toothbrushing with fluoride Fluoride rinse 0.05% Chlorhexidine
toothpaste NaF (neutral) (220 ppm) 0.2% CHX
for one minute

Low Before 18 months • No fluoride toothpaste • Not to be used • Not applicable

18 months to 5 yrs • Twice daily use 400 ppm • Not to be used
toothpaste (smear ⁄ small pea size
only)
18 months to 5 yrs • If not drinking fluoridated • Not to be used
water, twice daily use 1000 ppm
toothpaste (smear ⁄ small pea size
only).
6–17 years • Twice daily use 1000 ppm • Not to be used
toothpaste (pea size)
At-risk Before 18 months • Twice daily use 400 ppm • Not to be used • Not applicable
toothpaste (smear ⁄ small pea size
only)
18 months to 5 yrs • Twice daily use 1000 ppm • Not to be used
toothpaste (smear ⁄ small pea size
only)
6–17 years • Twice daily use 1000 ppm • No use before age 10
toothpaste (pea size)
10–17 years • Once daily at a
separate time from
toothbrushing
At-risk – high 10–17 years • If caries incidence is > 1 new • Once daily at a • Once daily
lesions per year or see below,* separate time from before bedtime
then twice daily use 5000 ppm toothbrushing
toothpaste (pea size)

*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 Monitoring lesion activity and patient behaviour Bitewing survey

Low • 12 months after first visit • At first visit

• Note: Oral hygiene review and coaching at each visit • Then every 12 months
At-risk ... where evidence is: • 3-monthly until lesion progression has arrested, i.e., • At first visit
ICDAS II codes > 1 evidence of (1) no extension of demineralization or (2) that
GIC sealant remains intact
• Note: Oral hygiene review and coaching at each visit • Then every 6 months until
patient is classified as low risk
At-risk ... where evidence is: • 3-monthly for (1) F varnish and (2) oral hygiene monitoring • At first visit
Bitewing codes until lesion progression has arrested and patient is reclassified
> C2 for primary teeth as low risk
> C3 for permanent teeth • Note: Oral hygiene review and coaching at each visit • Then every 6 months until
patient is classified as low risk
At-risk ... where only evidence is: • One week following first visit to review and coach tooth
Sites with Plaque Index = 3 brushing competence
• Then one month later for same

therefore, to err on the side of caution and screen

Plaque distribution
annually.
At each and every appointment, the plaque distribution
and overall Plaque Index (PI) score is recorded.
Fluoride exposure
Ongoing oral hygiene coaching at each visit, review of
As far as professional care is concerned for patients serial findings, and linkage of oral hygiene with other
who remain at-risk, the priority is to: (a) impress on the aspects of grooming increases the self-esteem and
need for regular attendance for professional applica- confidence of children and adolescents.
tions of fluoride varnish; (b) use a higher concentration
fluoride toothpaste at home; and (c) use fissure sealants
Dietary carbohydrate exposure
in an increased attempt to arrest and remineralize
lesions and, therefore, reduce as much as possible any Diets change as children get older. Dental practitioners
need to intervene operatively to deal with cavities. 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 deciduous teeth, operative intervention is indicated
such cases it will be necessary to investigate between- on the basis of either the combination of ICDAS II
meal snacking patterns and caution against overexpo- Code 3 and an associated bitewing radiolucency coded
sure to cariogenic dietary items. greater than C3, or on an approximal surface which
has an associated bitewing radiolucency coded greater
than C3.
DISCUSSION
In conclusion, it is worth emphasizing that preventive
Enamel lesions assigned ICDAS II Code 1 are not strategies aim not only to avert disease initiation and
considered to indicate a higher than low risk caries arrest lesion progression but to reduce the need for
rating mainly because they may not be diagnosed restorations for, as Mjor et al.30 pointed out, ‘‘The
reliably; it would not be meaningful or useful to rate a decision to place the first restoration in a previously
majority of individuals as at-risk on this basis. In a unrestored surface is a crucial event in the life of a
fluoridated community, small fluorotic signs might also tooth, because a permanent restoration, in the true
be mistakenly assigned Code 1 and these should sense of the term ‘permanent’, does not exist’’.
definitely not contribute, inadvertently, to indicate an
increased caries risk.
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