15 April 2021
How King’s College London is enabling a shift in the prevention and treatment of tooth decay worldwide.
Latest update 22/04/2022
How King's College London is enabling a shift in the prevention and treatment of tooth decay worldwide.
Dental caries (tooth decay) is the most prevalent disease globally and constitutes a major challenge across the life-course of a person. Although perceived by many as a disease of childhood, the risk of caries continues into adulthood, and tooth decay is now an increasing problem for the elderly and vulnerable. Indeed, untreated tooth decay in permanent teeth was ranked number 1 across all diseases by the Global Burden of Disease Study.
A global burden
Estimated to affect 2.8 billion people worldwide, tooth decay influences people in a variety of profound ways. It can cause recurring pain – both acute and chronic. It can lead to infection and the need for complex, on-going, and expensive rehabilitation. Suffering from tooth decay can severely compromise the ability to speak, smile, taste, eat and convey emotions through facial expressions, with confidence and without pain.
King’s College London researchers have recognised deficiencies in the traditional ways that caries have been diagnosed and managed, such as treating the symptoms rather than the cause. Serially removing excessive tooth structure with repeated fillings often leads to sub-optimal long-term health outcomes.
A change has been needed from the traditional surgical care model – with a focus on only drilling and filling cavities - towards comprehensive, minimally interventive, preventive dental medicine – aiming to control early-to-late-stage caries over the life-course of a person.
The Global Collaboratory for Caries Management
The Global Collaboratory for Caries Management was launched in 2013 by King’s College London as a global oral health initiative, intended to drive policy, health systems and dental practice towards a more modern preventive approach to caries management.
Over the last 9 years the King’s-led initiative has evolved into an international umbrella group leading the paradigm shift towards comprehensive preventive dental medicine. The impact of its activities has seen the major changes in the prevention and treatment of tooth decay worldwide.
A recent caries-focused issue of the British Dental Journal, has outlined (over eight separate articles on international collaborations in the caries ecosystem around the Global Collaboratory) both the breadth and depth of the impact achieved by the research of King’s and its partners. One paper uses caries as an exemplar for showing how long-term implementation collaborations leading to multifaceted impacts can help achieve King’s Vision 2029 and “make the world a better place”.
ICDAS, ICCMS™ and CariesCare International
A key focus is on the implementation into both policy and clinical practice of two international systems:
- For caries detection and assessment, the ICDAS (International Caries Detection and Assessment System)
- For clinical management, the related ICCMS™ (International Caries Classification and Management System)
King’s researchers showed that combining assessment of caries severity and activity supports improved diagnosis and clinical decision making. This research devised a novel, rational clinical framework for integrating the available knowledge on judging both caries severity, and current lesion activity assessment, providing a coherent clinical strategy for dentists and their teams.
Staging the severity - ICDAS
The researchers at King’s developed novel methods to clinically “stage” the severity of caries. The visual and radiographic scoring systems for dentists were developed by careful study of the correlations between clinical and histological assessments of a series of lesions in extracted human teeth. They provide a simple numerical score which has allowed dentists to differentiate early, mid-, or late-stage disease for each tooth surface. The scoring systems were incorporated as key features into the International Caries Detection and Assessment System (ICDAS), which has now been used in published studies hundreds of times by researchers from all around the world. It has recently been adopted by the ISO as the international standard for caries detection and assessment.
Clinical management - ICCMS™
The Global Collaboratory, working with international dental colleagues, developed the ICCMS™, the International Caries Classification and Management System (https://www.iccms-web.com/ ). The ICCMS™ takes the research findings and assembles them into a coherent format for clinicians. The evidence and robust methodology have since changed international clinical guidance from the FDI World Dental Federation on caries management for dentists worldwide.
The FDI is the international representative body for more than 1 million dentists, setting policy and clinical guidelines for the profession. In 2015 they commissioned a white paper on caries management which highlighted the King’s research, the ICDAS system and the ICCMS™ guidance for caries detection and management. This was distributed to all National Dental Associations globally as best practice, and in 2019 a formal FDI Policy Statement was released supporting the shift in caries management, following the concepts of the ICCMS™.
CariesCare International - ICCMS™ in dental practice
A King’s-led team responded to feedback from general dentists that they needed a more “practice-friendly” format of ICCMS™, hosting two workshops reaching a broad group of 44 authors from 17 countries through 8 Co-chairs, to produce CariesCare International, a version of ICCMS™ specifically tailored for everyday practice. The resulting ‘CariesCare Practice Guide’ was published in the British Dental Journal in September 2019 and was one of the journal’s most downloaded papers for that entire year.
A recent British Dental Journal paper charts the journey from ICDAS to CariesCare International taking caries evidence into clinical practice.
The Alliance for a Cavity-Free Future (ACFF)
Integrating clinical and public health strategies for caries control for dentists and their professional organisations, the ACFF is a global charity based within King’s with the aim to promote local and global action that delivers comprehensive caries prevention and management (https://www.acffglobal.org/ ). The ACFF brings together action to address the eight separate “puzzle pieces” which need to align to secure a Cavity-Free Future.
Actively disseminating the Global Collaboratory’s systems and initiatives, the ACFF has formed collaborations between dentists, public health professionals and local government to promote local health projects in over 50 countries. The successful partnerships built around the single-issue of moving towards a Cavity-Free future has seen the sharing of locally adapted materials to deliver integrated clinical and public health strategies for caries control. The charity also communicates its work to 194 Chief Dental Officers around the world. There are now 29 Chapters in ACFF, the latest one being the UK Chapter launched in October 2021.
Informing Public Health Policy
Through the Global Collaboratory, King’s-led research and synthesis linked individual and population level caries prevention interventions to inform public health policy making. They recognised that, for the Global Collaboratory for Caries Management to make significant global changes to caries care, they would need to bring together the implementation of the ICCMS™ and integrated public health strategies to facilitate a paradigm shift in models of care and payment.
To foster the process, King’s and the Alliance for a Cavity-Free Future hosted three ‘Dental Policy Labs’ where crucial groups were brought together to co-create solutions to complex policy challenges. The labs have led to significant impact, particularly in the economic arena.
The second policy lab included French representation from the largest dental trade union in France. Intensive work in the 18 months following the lab saw a legislation developed that will test the use of the payment model in France for dental care developed in the policy lab. The model will see new payment systems for dentists to ensure that caries prevention and control is properly rewarded, in addition to Minimally Interventive (MI) restorative caries care.
The third policy lab looked at moving towards oral and dental health through partnership with a broad range of stakeholders including Industry. A recent initiative arose from the third Lab. This has developed into the ACFF Task Force for Making Cavities History, a broadly-based group of 35 leading experts from 20 countries. They co-created global health policies to accelerate Making Cavities History worldwide in a way which is both compatible with the developing global WHO Oral Health Agenda and which can also be adapted locally.
Shaping and delivering Corporate Social Responsibility activity with a global organisation
King’s and the ACFF have also shaped the Colgate company’s strategic approach to corporate social responsibility in the caries space by working together to control caries in many countries and providing strategic advice as well as policy insights.
Dental caries is the most prevalent disease globally. Building on a portfolio of King’s College London research, the King’s-led Global Collaboratory for Caries Management has evolved into an international group, leading the shift towards comprehensive preventive dental medicine.