211

research agendas in clinical science, health promotion/public

health, and basic science.
INTRODUCTION
T
he members of the Dental Caries Task Group of the Global
Oral Health Inequalities Research Initiative were identi-
fied on the basis of their global involvement in cariology
research and the implementation of research findings, as well
as for their expertise in caries research areas from basic to
clinical science and health services research, in evidence-
based dentistry, epidemiology, dental public health, and
health promotion.
The remit of this Task Group was to review the field to
identify:
1. global inequalities in dental caries, taking into account
inequalities within as well as between countries;
2. likely reasons to account for these oral health inequalities;
3. fundamental gaps in knowledge and understanding;
4. reasons for failure to implement at scale measures which
have been shown to be effective in clinical or laboratory
studies;
5. priorities for both basic and applied research; and
6. a five-year research agenda, which will lead to key improve-
ments in global oral health, with particular reference to
inequalities between and within countries.
The Task Group has examined implementation gaps and
articulated a research agenda to address inequalities in caries
experience and the implementation of effective caries preven-
tion strategies in a coherent way, related to the Global (Oral)
Health Promotion Agenda already being pursued by WHO and
others.
INITIAL DELIBERATIONS
The Caries Task Group began by reviewing the IADR Presidents
Address to the Miami General Session (Williams, 2009) and
the evidence and future research directions synthesized in a
2007 Lancet review paper on dental caries (Selwitz et al., 2007).
The Task Group endorsed the principles outlined by the World
ABSTRACT
The IADR Global Oral Health Inequalities Task Group on
Dental Caries has synthesized current evidence and opinion to
identify a five-year implementation and research agenda which
should lead to improvements in global oral health, with particu-
lar reference to the implementation of current best evidence as
well as integrated action to reduce caries and health inequalities
between and within countries. The Group determined that
research should: integrate health and oral health wherever pos-
sible, using common risk factors; be able to respond to and
influence international developments in health, healthcare, and
health payment systems as well as dental prevention and materi-
als; and exploit the potential for novel funding partnerships with
industry and foundations. More effective communication
between and among the basic science, clinical science, and
health promotion/public health research communities is needed.
Translation of research into policy and practice should be a pri-
ority for all. Both community and individual interventions need
tailoring to achieve a more equal and person-centered preven-
tive focus and reduce any social gradient in health.
Recommendations are made for both clinical and public health
implementation of existing research and for caries-related
N. Pitts
1
*, B. Amaechi
2
, R. Niederman
3
,
A.-M. Acevedo
4
, R. Vianna
5
, C. Ganss
6
,
A. Ismail
7
, and E. Honkala
8
1
IADR Cariology Group & Evidence-based Dentistry Network, European
Organisation for Caries Research, International Caries Detection &
Assessment System Co-Chair, European Association for Dental Public
Health Director, Centre for Clinical Innovations, University of Dundee,
The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF,
Scotland, UK;
2
IADR Cariology Group President, San Antonio, TX,
USA;
3
IADR Evidence-based Dentistry Network President, Boston,
MA, USA;
4
IADR Regional Development Program Caracas, Venezuela;
5
FDI World Dental Federation President, Rio de Janeiro, Brazil;
6
European Organisation for Caries Research President-elect, Giessen,
Germany;
7
International Caries Detection & Assessment System
Co-Chair, Temple University, Philadelphia, PA, USA; and
8
European
Association for Dental Public Health Past President, University of
Kuwait; *corresponding author, [email protected]
Adv Dent Res 23(2):211-220, 2011
Key Words
Dental caries, health inequalities, health disparities, implementation
research, translational research.
DOI: 10.1177/0022034511402016
A supplemental appendix to this article is published electronically only at
http://adr.sagepub.com/supplemental.
International & American Associations for Dental Research
Global Oral Health Inequalities: Dental Caries
Task GroupResearch Agenda
212 Pitts et al. Adv Dent Res 23(2) 2011
Health Organization (WHO) at the World Health Assembly
(Petersen, 2008), where the Member States agreed on an action
plan for oral health and integrated disease prevention. The key
points included urging member states to consider mechanisms to
provide coverage of the population with essential oral health
care, to incorporate oral health into the framework of enhanced
primary health care for chronic noncommunicable diseases, and
to promote the availability of oral health services that should be
directed toward disease prevention and health promotion for
poor and disadvantaged populations, in collaboration with inte-
grated programs for the prevention of chronic non-communica-
ble diseases. Other recommendations were for those countries
without access to optimal levels of fluoride, and which have
not yet established systematic fluoridation programs, to consider
the development and implementation of fluoridation programs,
to incorporate an oral health information system into health
surveillance plans so that oral health objectives are in keeping
with international standards, to evaluate progress in pro-
moting oral health, to strengthen oral health research and use
evidence-based oral health promotion and disease prevention to
consolidate and adapt oral health programs, to encourage the
intercountry exchange of reliable knowledge and experience of
community oral health programs, and to increase, as appropri-
ate, the budgetary provisions dedicated to the prevention and
control of oral and craniofacial diseases and conditions.
The Task Group also drew on the recently published report
of the International Conference on Novel Anti-Caries and Rem-
ineralizing Agents (ICNARA, 2009). This international confer-
ence recognized the strong evidence for the effectiveness of
fluoride in caries prevention, and evaluated the evidence and
potential of other novel anti-caries and remineralizing agents for
caries prevention and repair, with the objective of developing an
agreed multidisciplinary research agenda for the next decade.
Links between and among the IADR, WHO, and the FDI
World Dental Federation have been very important in imple-
menting research findings, as have links with the International
Caries and Detection System (ICDAS) Foundation. This chari-
table foundation has developed an evidence-based clinical car-
ies scoring system for use in dental education, clinical practice,
research, and epidemiology designed to lead to better quality
information to inform decisions about appropriate diagnosis,
prognosis, and clinical management at both the individual and
public health levels (ICDAS, 2010a). Key joint work of rele-
vance carried out for this initiative in partnership by Group
members is detailed further in the Appendix.
FINDINGS OF THE TASK GROUP
Global Inequalities in Oral Health and
Dental Caries, Taking into Account Inequalities
within as Well as between Countries
There are marked differences in caries-related health inequali-
ties in developing as well as developed countries, and both must
be addressed. It is also evident that there is a gradient in caries
levels between the least- and most-well-developed countries.
The situation is further complicated by the fact that some coun-
tries are in rapid transition. While there are very significant
differences in all aspects of dental care between such countries,
the fundamental clinical options and the science supporting car-
ies prevention and control are universal. For these reasons, we
have taken an international approach and stated that all solutions
should be appropriate for the particular characteristics, cultures,
and behaviors of the end user location.
The scale and enduring nature of the caries inequalities in
both developing and developed countries are well-established.
WHO Reports and the global policy for improvement of oral
health adopted by the World Health Assembly in 2007 (Petersen,
2008) state that:
Oral disease is still a major public health problem in high-
income countries, and the burden of oral disease is growing
in many low- and middle- income countries.
Oral disease, such as dental caries. . . ., is a serious public-
health problem. Its impact on individuals and communities in
terms of pain and suffering, impairment of function, and
reduced quality of life is considerable. Globally, the greatest
burden of oral diseases lies on disadvantaged and poor popu-
lations. The current pattern of oral disease reflects distinct
risk profiles across countries related to living conditions,
behavioral and environmental factors, oral health systems,
and implementation of schemes to prevent oral disease.
In several high-income countries with preventive oral care
programs, the prevalence of both dental caries in children
and tooth loss among adults has fallen. Globally, the burden
of oral disease is particularly high among older people and
has a negative effect on their quality of life. In most low- and
middle-income countries, the general population does not
benefit from systematic oral health care, and preventive pro-
grams have not been established. In some countries, the
incidence of dental caries has increased over recent years and
may further increase as a result of the growing consumption
of sugars and inadequate exposure to fluorides.
Social inequality in oral health status and the use of services
is somewhat universal. Even in the Nordic countries, with
public responsibility in financing and delivery of oral health
care, remarkable differences are observed by social class.
Surprisingly, despite recent efforts to make the most of avail-
able data from WHO and elsewheresuch as in the FDI World
Dental Federation Oral Health Atlas (FDI, 2009)the quality,
coverage, and utility of much of the information available for
caries status and inequalities are poor. Reasons for this include
variable methodological and quality standards, and dependence
on the assessment of dentin cavitation to estimate the need for
restorative care. Research findings are out of date, and there is
an absence of reliable, recent data from many countries and
regions that cover the disease severity continuum. The need for
timely information relates to both the severe end of the spec-
trum, with regard to pain, sepsis, and urgent needs, and the
opposite end of this spectrum, where reliable information is
lacking on the prevalence and pattern of initial caries amenable
to preventive and nonsurgical interventions. It may safely be
concluded, however, that there are profound inequalities in car-
ies status, both between and within countries, and that the distri-
bution of disease in a population is a changing dynamic.
Adv Dent Res 23(2) 2011 GOHIR Dental Caries Task Group Report 213
Likely Reasons to Account for
These Oral Health Inequalities
A wide range of factors has been implicated in caries initiation
and progression (see Fig. 1), but these are dominated by the
social determinants of health. The personal and social factors
in the outer circle, particularly income, education, and behav-
iors, have been shown to have profound effects. Other macro-
level factors include access to and use of fluorides, diet, and
access to preventive and restorative care services. However, it is
also important to understand the research evidence in all parts of
the diagram, since the oral environmental factors have a major
impact on the core factors that are required for the initiation or
progression of caries. There are also suggestions that one of the
major barriers to achieving equitable improvements in caries
prevention and control has been the lack of effective communi-
cation among dental stakeholders about the cariology evidence
which has developed over the last decades.
Despite good evidence about methods for delivering effec-
tive clinical prevention and caries control, the existence of
implementation gaps has meant that health systems have been
slow to move away from the traditional restorative approach to
caries management, which is linked directly to access to dentists
providing surgically based interventions beyond the economic
reach of many. WHO recommends the building of capacity in
oral-health systems oriented to disease prevention and primary
health care, with special emphasis on meeting the needs of dis-
advantaged and poor populations (Petersen, 2008).
Fundamental Gaps in Knowledge and Understanding
Basic Cariology Sciences
The key basic science knowledge gaps that need to be addressed
in terms of understanding the caries process include the delivery
of more effective remineralization, and the dynamics of the
biofilm, with the potential this has to develop novel antibacterial
approaches.
Remineralization is the natural repair process for caries
lesions. While the existence of this process has been known for
at least a hundred years, it is only in recent decades that the
therapeutic importance of remineralization has been appreci-
ated. Fluoride delivered topically in various vehicles has pro-
duced major reductions in the prevalence and incidence of
dental caries, in part through its role in remineralization. How-
ever, when the bacterial challenge is high or the salivary compo-
nents are lacking, the ensuing remineralization is insufficient to
arrest or reverse the caries process. Consequently, there is a need
Fig. 1. Illustration of the factors involved in caries development and progression; reproduced with permission from Selwitz et al., 2007.
214 Pitts et al. Adv Dent Res 23(2) 2011
to discover how to enhance remineralization and to transfer such
knowledge into clinical therapy (Featherstone, 2009).
Although the use of fluoride schemes has been successful,
the discovery of effective antimicrobial therapies would increase
the range of caries-preventive products and make prevention
less dependent on fluoride. Because caries is caused by bacterial
metabolites, reducing the quantity and pathogenicity of dental
plaque could work synergistically with fluoride. New paradigms
of caries etiology focus on ecological factors and complex
microflora, rather than on the traditional caries pathogens. This
is because of appreciation of the fact that dental plaque has the
properties of a biofilm, with bacteria growing on a surface and
embedded in a polysaccharide matrix. This has opened promis-
ing new approaches for study of the etiology of dental caries.
Furthermore, findings on other environmental biofilms and
approaches to their reduction might be applicable to the devel-
opment of oral biofilm remedies. There is optimism that the
study of antimicrobials from this perspective could lead to the
development of more effective caries-preventive agents (ten
Cate, 2009).
Gaps in Clinical Knowledge and Understanding
The issues in this domain center on the failure in many countries
to move away from the restorative-oriented approach to treat-
ment planning and caries management. These have generally
been based on the flawed assumption that the disease could be
treated away with dental amalgam (Elderton, 1990; Pitts,
2004) or other imperfect substitutes for tooth tissue, without
modifying either etiological factors or patient behaviors. The
difficulty in achieving a paradigm shift has been frustrated by
organizational and economic system influences, with the result
that little real progress has been made in many developed countries
since the 1970s. Furthermore, this approach is not only ineffec-
tive, but is also completely unaffordable and inappropriate in
many developing countries.
Dental Public Health: Implementation Gaps in
Knowledge and Understanding
Despite advocacy over a long period for the common risk factor
approach to the management of caries, the integration of oral
health promotion into health promotion strategies, and emphasis
on the importance of oral health to systemic well-being
(Petersen, 2008), there remains a disappointing focus on sepa-
rate, dedicated, dental health education. It is not surprising that
this approach has had limited impact. It appears, in some coun-
tries, that traditional dental public health advocates have had
limited opportunity to update their knowledge or to gain an
understanding of the potential synergies between aligned public
health and clinical preventive strategies.
A further knowledge gap relates to understanding the impact
of the different caries detection levels legitimately used when
caries assessments are made for different purposes. Tradition-
ally, there has been an assumption that there must be a single
index or method for collecting caries information, but it is now
appreciated that a one size fits all approach is inappropriate.
Debates during the development of the European Oral Health
Indicators Project (Bourgeois et al., 2008), around the use of
ICDAS assessments in epidemiology and public health (Pitts,
2009) and in setting up the current FDI Global Caries initiative,
have all underscored the importance of having available a caries
measurement method appropriate to the task at hand. Fig. 2
shows the ICDAS adaptation of the WHO Stepwise approach
to Surveillance of Non-Communicable Diseases for use with
oral health indicators and caries surveillance employed in these
Fig. 2. ICDAS adaptation of the WHO Stepwise approach to the Surveillance of Non-Communicable Diseases for use with dental caries and
oral health indicators. Reproduced with permission of S. Karger AG, Basel (Pitts, 2009).
Adv Dent Res 23(2) 2011 GOHIR Dental Caries Task Group Report 215
initiatives. This approach gives a choice of measures with differ-
ent levels of detail and complexity, appropriate to the task at
hand and the resources available.
Reasons for Failure to Implement at
Scale Measures That Have Been Shown
to Be Effective in Clinical or Laboratory Studies
The failure to implement promising research findings is not
unique to the management of dental caries, but is common
across the health sciences. There is increasing concern about
research findings not making a difference, not improving health,
and failing to have a positive impact on reducing caries and
inequalities in oral health. This is not a new concern, but it is a
persisting one, thrown into sharper focus in an era of more strin-
gent financial constraints.
Over the past decade, medical scientists and public health
policymakers in the US have been increasingly concerned that
the scientific discoveries of the past generation are not translated
efficiently into tangible clinical benefit. This concern was
addressed in June 2000 by the Clinical Research Roundtable at
the Institute of Medicine, one outcome of which was the identi-
fication of two translational blocks. The first of these was the
translation of basic science discoveries into human clinical stud-
ies; the second was the translation of new findings into clinical
practice and health decision-making in systems of care (Sung
et al., 2003). Similar concerns have also been raised in the
United Kingdom by the Cooksey Report (Cooksey, 2006),
which recognized the same two translation gaps. The previously
rarely acknowledged second gap, between the end stage of
clinical trials and appropriate adoption in routine care, has now
been prioritized as the focus for implementation research to
understand the best way to achieve knowledge transfer.
Translation of Basic Science Research
the First Implementation Gap
Past failures to translate the findings from basic science research
into practice are in large measure the result of poor communication
between basic and clinical sciences and the lack of a systematic
route for the translation of research findings into clinical or
public health practice. The failure to develop a systematic
approach to the integration of basic science and clinical research
to achieve improvements in oral health outcomes, and particu-
larly to reduce health inequalities, has been a major obstacle to
progress. A further issue has been that research into caries has
also been accorded a low priority by funders of research, in
some developed countries, because of the erroneous belief that
caries is no longer a public health problem. In addition, the
complex role that the ecology of the biofilm plays in caries ini-
tiation and prevention has not been understood.
Clinical Sciences and Public Health Practice
the Second Implementation Gap
Advances in dental materials have dominated restorative den-
tistry to a greater extent than any advance in the field of cariol-
ogy. The failure to change how caries is managed can be
attributed in large measure to factors such as clinical and profes-
sional conservatism, economic incentives that reward surgical
treatment more highly than preventive caries control, and the
consistent failure of communication between the dental sub-
groups, with poor communication by the research community
and limited attempts at systematic implementation of research
findings by clinicians working in health systems that promote
the status quo.
The existence of the deep silos which dental public health
practitioners, clinicians, and researchers inhabit has militated
against the translation of research into policy and practice.
There has also been a view that the public health and clinical
perspectives on caries management have been mutually exclu-
sive, instead of potentially synergistic.
Strategies to Close the Implementation
Gaps in Caries Prevention and Treatment
Promoting consistency in terminology and knowledge across
the silos of research, practice, epidemiology, public health,
Fig. 3. The two implementation gaps which thwart the translation of health research into practice.
216 Pitts et al. Adv Dent Res 23(2) 2011
and education. This process has begun with the promulgation
of a standardized Glossary of key caries terms (Longbottom
et al., 2009) produced by ICDAS, the European Organisation
of Caries Research (ORCA), and the American Dental
Education Association (ADEA). This has now also been
adopted by the FDI and is being developed further.
Getting research findings, distilled systematically as best
evidence, into both practice and policy. These processes are
being documented with knowledge bases from outside of
dentistryfor example, from medicine and psychology
and are being addressed in several ways, outlined below.
Addressing inequalities at the regional, country, and local
levels and improving the methodology by which we can
recognize and monitor inequalities at these levels. A series of
options to record and monitor caries impact using appropri-
ate oral health indicators should be developed further.
Using the Collaboration for Improving Dentistry model to
build partnerships in the caries world. This model (Pitts and
Wefel, 2009) is proving helpful in discussions with numerous
stakeholders in determining how multiple partners, including
industry as well as other global organizations, can engage
most effectively to improve oral health and reduce inequali-
ties in caries. The Collaboration for Improving Dentistry
model is shown in Fig. 4.
Using implementation research to improve the knowledge
transfer process. Implementation research is itself a develop-
ing and complex field, but with the increasing importance of
all types of translational research, there is much confusion in
the research and health communities. The key priority is to
meet the need to move knowledge into action (Graham et al.,
2006); in clinical settings, we need not only evidence-based
guidelines, but also a process by which knowledge is devel-
oped into specific tools and products. These need to be
appropriate to the local context and applied in tailored inter-
ventions, the outcomes of which are evaluated so knowledge
use can be optimized and sustained.
Current Priorities for Both Basic and Applied Research
There are four overriding priorities for caries research in the
context of this initiative:
1. It must play its part in integrating health and oral health wher-
ever possible, using the common risk factors approach link-
ing caries to diet and hygiene.
2. It must be able to respond to and influence international
developments in health, healthcare, and health payment sys-
tems, as well as dental prevention and materials. This is par-
ticularly important in view of global discussions around the
future use of dental amalgam.
3. It must explore the potential for novel funding partnerships
with organizations, industry, and foundations which will
allow research to be taken forward at a time of economic
challenge.
Fig. 4. Collaboration for Improving Dentistry (CID) model of implementing research findings into practice. Reproduced with permission from Pitts
and Wefel (2009).
Adv Dent Res 23(2) 2011 GOHIR Dental Caries Task Group Report 217
4. It must establish effective two-way communication between
and among the basic science, clinical science, and health pro-
motion/public health research communities. Implementation
research should be a priority for all three groupings.
Basic Cariology Sciences Priorities
ICNARA-derived priorities for caries research include caries
remineralization and biofilm/antibacterial/probiotic approaches
to caries management (ICNARA, 2009).
Remineralization. The aim of remineralization therapy is to
facilitate caries control over a lifetime, using evidence-based,
clinically effective, multifactorial prevention to keep the caries
process in balance. The following priorities have been broadly
agreed (Pitts and Wefel, 2009):
A validated menu of caries control strategies/methods/
products, which are effective for individuals, subgroups, and
populations, is needed.
A corresponding menu of standardized, agreed, comparable
protocols is also needed to allow for meaningful comparisons
across studies.
Over the coming years, the dental research community in this
field should also continue to apply new knowledge and meth-
ods from outside dentistry.
Biofilm and Caries Control. The successful approaches to caries
control will be those that are clinically effective and profitable.
The following have been highlighted as future priorities (Adair
and Xie, 2009):
Development of targeted, rather than broad-spectrum, che-
motherapeutic approaches, which are presently in their
infancy. There is a need for a better understanding of biofilm
physiology and pathogenicity, and the role of the biofilm in
promoting oral health.
The genome revolution opens up new ways to view the bio-
film and develop novel anticaries approaches, and these need
to be explored.
Research should be conducted in synergistic approaches to
promote simultaneous remineralization and biofilm-targeted
anti-caries approaches.
Clinical Sciences Priorities
Over the past 8 years, the ICDAS framework for grading caries
has resulted in the publication of many research papers from
around the globe, using consolidated, compatible, and compa-
rable measures of dental caries (ICDAS Foundation, 2010b).
Since the IADR General Session in Miami in 2009, when the
Grand Challenge was issued (Williams, 2009), the wider
clinical caries management research and implementation priori-
ties have been synthesized and taken forward by a broad group
of stakeholders (see Appendix). This work has produced a new
ICDAS-International Caries Classification and Management
System (ICDAS-ICCMS), a brief outline of which is reported
here, since it reflects recent work undertaken to support this
IADR initiative. The System addresses both clinical and public
health issues: It is about applied cariology research translated
into clinical practice, and it shares the overall health improve-
ment goal agreed by the FDI World Dental Federation of seek-
ing to bring optimal oral and thus general health and well-being
to all people. It supports both general and personalized caries
prevention, and, when implemented in concert with appropriate
parallel upstream public health and integrated health promotion
approaches, should facilitate a reduction in health inequalities.
Implemented effectively the ICDAS-ICCMS approach
should support the objectives and approach set out in Fair Soci-
ety, Healthy Lives (Marmot, 2010). This report stresses that, to
reduce the steepness of the social gradient in health, actions must
be universal, but with a scale and intensity that are proportionate
to the level of disadvantage. Marmot also points out the chal-
lenge that Greater intensity of action is likely to be needed for
those with greater social and economic disadvantage, but focus-
ing solely on the most disadvantaged will not reduce the health
gradient, and will only tackle a small part of the problem.
To translate best evidence from clinical sciences research
into practice, the ICCMS groups the clinical procedures for
caries prevention, management, monitoring, and review into
four linked key elements (see Fig. 5).
The System aims to expand the management decisions that
are intuitively made by dentists to include secondary preventive
measures applied on early or noncavitated caries lesions, as well
as modern evidence-informed strategies for risk assessment,
decision making, and minimally invasive restorative care. Using
these management decisions, the ICDAS-ICCMS Group has
developed analytical algorithms that will enable dentists to
make clinical decisions that incorporate information on lesion
extent and activity, as well as individual caries risk status.
The guiding principles for the ICDAS-ICCMS are as follows:
1. Prevention is a priority, with surgical intervention used only
as a last resort.
2. Where surgery is indicated, use minimal removal of tooth
tissue.
3. Cavity size and selection of material are governed by preserva-
tion of tooth tissue destruction and healthy patient outcomes.
Detailed practice-friendly protocols are being developed and
tested by 11 universities from Colombia, Denmark, Germany,
Iceland, Kuwait, the UK, and the US, and these should be
evaluated in a range of settings. Discrete elements of the system
may be evaluated in isolation, but, in addition, comparative
effectiveness designs should be used to assess the overall impact
and costs of the new System.
Implementation Research/Dental Public
Health/Oral Health Promotion Priorities
The priority in implementation research is to embed a system-
atic process (see Fig. 4) in which the particular areas that need
to be addressed are identified, with an improvement cycle incor-
porated. It requires an informed research agenda, mounting
effective dissemination of research findings to key groups, and
also taking proactive systematic steps to achieve effective
implementation of the results by properly prepared clinicians to
218 Pitts et al. Adv Dent Res 23(2) 2011
help informed patients. The clinical or public health systems so
produced will, in turn, be re-evaluated.
Other priorities include theory-based studies to gain insights
into the individual and organizational barriers to, and enablers
of, the translation of research findings into primary care, and the
evaluation of different payment systems for prevention.
Further topics identified by WHO include the development
of appropriate information systems as an integral part of national
surveillance of oral health and risk factors, provision of evi-
dence for oral health policy and practice, formulation of goals
and targets, and measurement of progress in public health. Pri-
orities include: the promotion of research in oral health aimed at
bridging gaps in research between low-/middle-income and
high-income countries; conduct of operational research; and
translation of knowledge about oral-health promotion and dis-
ease prevention into public health action programs.
In attempts to meet the need for more comprehensive epide-
miological surveillance, research is under way supported by the
IADR Regional Development Program in eight countries in
Latin America using ICDAS epidemiology codes in field studies
with standardized training and calibration. At this early stage,
the project shows promise, and an extension to the study is
planned. This work follows a range of enhanced caries surveil-
lance activities ranging from National Surveys in Iceland,
including initial lesions and radiographs (Agustsdottir et al.,
2010), to the European Global Oral Health Indicators Projects
EGOHID I and II (Bourgeois et al., 2008), and assessing the
determinants of early childhood caries in low-income African
American young children (Ismail et al., 2008). It is envisaged
that this pattern of working jointly, with sharing of experiences
and methodology as practiced by the European Association for
Dental Public Health, will be further built with groups in IADR
and the FDI World Dental Federation.
The surveillance and planning data generated will make a
beneficial change to caries levels and other health inequalities
only if they are used actively to promote prevention, health, and
well-being. Furthermore, planned actions should be universal,
but with a scale and intensity that are proportionate to the level
of disadvantage (Marmot, 2010). While there is quite properly a
focus on children and early years, it is also a priority to consider
what action is needed across the life course. Disadvantage starts
before birth and accumulates throughout life (Fig. 6). Action to
reduce health inequalities must start before birth and be fol-
lowed through the life of the child. Only then can the close links
between early disadvantage and poor outcomes throughout life
be broken. Meanwhile, there is much that can be done to
improve the lives and health of people who have already
reached school, working age, and beyond. Services that promote
the health, well-being, and the dental and social independence
of older people and, in so doing, prevent or delay the need for
more intensive or institutional care, make a significant contribu-
tion to ameliorating oral health and health inequalities.
Fig. 5. Graphical overview of the goal and components of the ICDAS-International Caries Classification and Management System (ICDAS-ICCMS).
Adv Dent Res 23(2) 2011 GOHIR Dental Caries Task Group Report 219
The 7th WHO Global Conference on Health Promotion,
toward integration of oral health, held in Nairobi, Kenya, in
2009 (Petersen and Kwan, 2010), highlighted the need to close
the implementation gap and outlined strategies for tackling
social determinants of oral health to improve oral health, includ-
ing caries, and reduce inequalities. The meeting outlined a range
of priorities to be carried out in support of the World Health
Assembly Resolution (WHA60.17) on oral health.
A Five-year Research Agenda, Which Will Lead to Key
Improvements in Global Oral Health, with Particular
Reference to Inequalities between and within Countries
The research agenda should address all of the priorities for
research listed in the preceding section. The research focus must
be capable of being taken forward on a global basis, but must
remain sensitive to countries, cultures, economies, and aspira-
tions, nationally and locally.
Priority research recommendation: to translate existing evi-
dence into routine clinical and public health practice; to tailor
interventions to a more equal and person-centered preventive
focus; and to reduce any social gradient in health. The sequence
of priorities is to start with clinical and public health implemen-
tation of existing research findings, and, in parallel, to seek new
basic science insights in key areas.
Clinical Sciences in Cariology Agenda
The evaluation, as a holistic systems and social model, of
the implementation of the ICDAS-ICCMS in educational and
primary care network settings. This research should include the
use of novel eHealth record linkages to assess the impact of caries
prevention on a longitudinal basis, using patients in dental schools,
in primary care, and in clinics. The use of comparative effective-
ness designs will allow for clinical and economic real-world
assessment of the overall disease management approach, as com-
pared with the traditional restorative model of caries treatment.
Optimization of the individual ICDAS-ICCMS elements of
risk assessment, lesion detection, caries activity assessment,
synthesis, decision making, nonsurgical treatment of lesions,
and the monitoring and review of both patients and lesions are
included under this umbrella.
Other research priorities for clinical caries management are
set out as a more detailed list in the Appendix and include:
development of an agreed matrix of designs for in situ and
in vivo research to develop and evaluate a menu of clinically
effective caries control products for enamel, dentin, root-
surface, and orthodontics-related caries across anatomic pre-
dilection sites, ages, and risk groups; and
determination of how best to educate health-care providers to
deliver effective caries management incorporating remineral-
ization, nonsurgical clinical management, and maintenance
of early caries lesions.
Health Promotion/Public Health Caries Agenda
The key priority in this agenda is the evaluation of the impact
of caries prevention programs designed to achieve a greater
intensity of action and effectiveness for those with greater
Fig. 6. Areas of preventive action across the life course. Reproduced with permission from Marmot (2010).
220 Pitts et al. Adv Dent Res 23(2) 2011
social and economic disadvantage, so reducing the health gra-
dient while improving oral health for the whole population
under study.
Within that overall scope, priorities include the evaluation
and assessment of:
public health interventions delivering oral health promotion
activity linked to general health promotion;
the feasibility and acceptability of epidemiological map-
ping by recording of the total clinical caries experience
(including initial lesions as well as sepsis) to better recog-
nize and monitor inequalities at regional, country, and local
levels;
models of care in which there are integrated roles for dental,
medical, and other health-care providers;
the barriers and facilitators to using the preventive caries
management system approach, using theory-based methods
from implementation science to better define options appro-
priate to different settings and economies;
the effectiveness and economic benefit of different skill-mix
combinations used to deliver the ICDAS-ICCMS approach
to improving health and reducing caries inequalities; and
the impact of remuneration systems on the types of clinical
caries care delivered and the outcomes achieved.
Basic Sciences in Cariology Agenda
It is recommended that, to translate both existing and new
research into clinical and public health practice to best effect,
grouped topics should be considered at International Consensus
Development Workshops on:
1. defining valid and efficient research methods for demon-
strating caries arrest and assessing the remineralization
potential of candidate agents; and
2. defining ways to ensure that findings about remineralization
and new biofilm-based methods of effective caries control
can be transferred more efficiently and rapidly into routine
clinical therapy and practice.
ACKNOWLEDGMENTS
We acknowledge the numerous wider collaborators who have
participated willingly and helpfully in this process, particularly
Dr. Michael Glick, Baltimore, MD, USA, in his capacity as
Chair of the FDI Science Committee, and Dr. Mark Wolff,
NYU, New York, US, both a caries researcher and a lead in the
development of a new Cariology Section within the American
Dental Education Association. The authors of this paper have all
published specific studies relating to cariology. These studies
were supported by a wide range of sources, ranging from gov-
ernment research funding agencies (e.g., National Institutes of
Health), to research charities, to foundations and commercial
companies working in the oral health industry.
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