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International Journal of Oral Science logoLink to International Journal of Oral Science
. 2022 Mar 31;14:17. doi: 10.1038/s41368-022-00167-3 IF: 24.897 Q1
.2022 年 3 月 31;14：17。doi： 10.1038/s41368-022-00167-3 IF: 24.897 Q1

Expert consensus on dental caries management
龋齿管理专家共识

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PMCID: PMC8971510 IF: 24.897 Q1   PMID:
PMCID：PMC8971510 IF：24.897 Q1 PMID：

Abstract  抽象

Dental Caries is a kind of chronic oral disease that greatly threaten human being’s health. Though dentists and researchers struggled for decades to combat this oral disease, the incidence and prevalence of dental caries remain quite high. Therefore, improving the disease management is a key issue for the whole population and life cycle management of dental caries. So clinical difficulty assessment system of caries prevention and management is established based on dental caries diagnosis and classification. Dentists should perform oral examination and establish dental records at each visit. When treatment plan is made on the base of caries risk assessment and carious lesion activity, we need to work out patient‑centered and personalized treatment planning to regain oral microecological balance, to control caries progression and to restore the structure and function of the carious teeth. And the follow-up visits are made based on personalized caries management. This expert consensus mainly discusses caries risk assessment, caries treatment difficulty assessment and dental caries treatment plan, which are the most important parts of caries management in the whole life cycle.
龋齿是一种慢性口腔疾病，极大地威胁着人类的健康。尽管牙医和研究人员几十年来一直在努力对抗这种口腔疾病，但龋齿的发病率和患病率仍然相当高。因此，改善疾病管理是龋齿全人群和生命周期管理的关键问题。因此，在龋齿诊断和分类的基础上，建立了龋齿预防和管理的临床难度评估体系。牙医应在每次就诊时进行口腔检查并建立牙科记录。在龋齿风险评估和龋齿病变活动的基础上制定治疗方案时，需要制定以患者为中心的个性化治疗方案，以恢复口腔微生态平衡，控制龋齿进展，恢复龋齿的结构和功能。后续访问是根据个性化的龋齿管理进行的。本专家共识主要讨论了龋齿风险评估、龋齿治疗难度评估和龋齿治疗方案，它们是龋齿全生命周期管理中最重要的部分。

Subject terms: Dental caries, Caries risk assessment
主题词：龋齿， 龋齿风险评估

Introduction  介绍

Dental caries is a common chronic infectious disease that occurs in the dental hard tissues. Dental caries and its complications can exacerbate or induce systemic diseases, which seriously reduce the quality of human life and cause a great economic burden. According to current investigations, there are still great challenges in dental caries prevention and treatment. Firstly, the prevalence of dental caries is very high. The results of the global burden of disease study released by Lancet in 2017 showed that among 328 diseases, the prevalence of permanent dental caries ranked first, and the incidence ranked second. There are around 2.44 billion population worldwide suffering from permanent tooth decay. Besides, The 4th National Oral Health Survey in the Mainland of China shows that the prevalence of deciduous tooth caries in 5-year-old children is 71.9%, which is 5.9% higher than that of 10 years ago, and the prevalence of permanent tooth caries in 12-year-old children is 38.5%, which is 9.6% higher than that of 10 years ago. Secondly, the ratio of treated caries is quite low. In 2017, 7.8% of the global population had untreated deciduous tooth caries, while those with untreated permanent tooth caries accounted for 29.4% of the global population. Thirdly, the failure rate of dental restorations is rather high. In the follow-up cases, the total failure rate of 1821 restorations was 24.1%, and 10-year survival rates for Class III and Class IV restorations were reported to be 95 and 90%, respectively. Therefore, we still need to make effective strategies to combat dental caries in clinical practice.
龋齿是一种常见的慢性传染病，发生在牙齿硬组织中。龋齿及其并发症可加剧或诱发全身性疾病，严重降低人类生活质量，造成巨大的经济负担。根据目前的调查，龋齿的预防和治疗仍然存在很大的挑战。首先，龋齿的患病率非常高。《柳叶刀》2017 年发布的全球疾病负担研究结果显示，在 328 种疾病中，永久性龋齿的患病率排名第一，发病率排名第二。 全球约有 24.4 亿人患有永久性蛀牙。此外，中国大陆第四次全国口腔健康调查显示，5 岁儿童乳牙龋患病率为 71.9%，较 10 年前高 5.9%，12 岁儿童恒牙患病率为 38.5%，较 10 年前高 9.6%。 其次，治疗龋齿的比例相当低。2017 年，全球 7.8% 的人口患有未经治疗的乳牙龋，而未经治疗的恒牙占全球人口的 29.4%。 第三，牙齿修复的失败率相当高。在随访病例中，1821 例修复体的总失败率为 24.1%，III 类和 IV 类修复体的 10 年生存率分别为 95% 和 90%。 因此，我们仍然需要在临床实践中制定有效的策略来对抗龋齿。

Dental caries management  龋齿管理

In the aspect of individualized management of patients with dental caries, traditional prosthetic treatment lacks comprehensive management of prevention and treatment based on risk assessment and difficulty assessment for it is mainly based on the “drill and fill” model. Carrying out caries risk assessment (CRA) for patients, analyzing and controlling risk factors for caries occurrence, and formulating personalized caries treatment and management plans on account of CRA have become the new trend of modern dental caries management. At present, there are several classification and management standards of dental caries being widely applied in the world. The International Caries Detection and Assessment System (ICDAS) was established in 2002, and in 2009, caries activity tests were added to develop the modified clinical caries classification standard—ICDAS‑II. Based on the ICDAS, the International Caries Detection and Evaluation System Collaboration Committee proposed the International Caries Classification and Management System, ICCMS. Recently, we proposed the dental caries management should be carried out in the whole life cycle for the first time. The physiological features of patients at different ages should be considered and personalized management plan of dental caries should be made according to different risk factors and risk levels (Fig. 1).
在龋病患者的个体化管理方面，传统的修复治疗主要基于“钻补”模式，缺乏基于风险评估和难度评估的防治综合管理。为患者进行龋齿风险评估（CRA），分析和控制龋齿发生的危险因素，并基于CRA制定个性化的龋齿治疗和管理计划，已成为现代龋齿管理的新趋势。 目前，世界上有几项龋齿分类和管理标准正在广泛应用。国际龋齿检测和评估系统 （ICDAS） 成立于 2002 年， 并于 2009 年增加了龋齿活动测试，以制定修改后的临床龋齿分类标准 — ICDAS-II。 国际龋齿检测和评估系统合作委员会在 ICDAS 的基础上提出了国际龋齿分类和管理系统 （ICCMS）。最近，我们首次提出龋齿管理应该在整个生命周期中进行。应考虑不同年龄患者的生理特征，根据不同的危险因素和风险程度制定个性化的龋齿管理方案 （图 D）。 1 ）。

Fig. 1.  图 1.

Fig. 1

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Process of difficulty assessment of dental caries prevention and treatment. *USPHS: United States Public Health Service Commissioned Corps
龋齿预防和治疗的难度评估过程。*USPHS：美国公共卫生服务委托团

Caries risk assessment  龋齿风险评估

The caries risk assessment is one of the most important elements of dental caries management. It has an impact on the difficulty assessment of caries prevention as well as making treatment plan before dental caries treatment; and the risk re-assessment after treatment is related to the curative effect and prognosis, which is also significantly important in caries management. And there are several dental caries risk assessment systems worldwide, including American Dental Association (ADA) caries risk assessment, Caries risk assessment tool (CAT), Caries management by risk assessment (CAMBRA) and Cariogram. And the caries risk assessment forms of ADA, CAT and CAMBRA are presented in Tables S6–S10.
龋齿风险评估是龋齿管理中最重要的要素之一。对龋齿预防的难度评估以及龋齿治疗前的治疗方案有影响;治疗后的风险再评估与疗效和预后有关，这在龋齿管理中也具有显著的重要性。全球有几种龋齿风险评估系统，包括美国牙科协会 （ADA） 龋齿风险评估、龋齿风险评估工具 （CAT）、风险评估龋齿管理 （CAMBRA） 和 Cariogram。ADA、CAT 和 CAMBRA 的龋齿风险评估表见表 S6 - S10 。

American Dental Association (ADA) caries risk assessment
美国牙科协会 （ADA） 龋齿风险评估

This risk assessment system was proposed by the ADA in 2004 and is divided into two forms. One form is for patients ages 0–6 years of age and the other is for patients over 6 years of age. It mainly includes three aspects: contributing conditions, general health conditions, and clinical conditions. Contributing factors refer to external factors that could influence the occurrence and development of dental caries; general health conditions refer to the physical conditions of patients; and clinical conditions refer to intraoral conditions that directly related to dental caries. The system divides caries risk into high, moderate, and low grades, and is mainly used to assist dentists in assessing patient’s caries risk in clinical practice.
该风险评估系统由 ADA 于 2004 年提出，分为两种形式。一种表格适用于 0-6 岁的患者，另一种适用于 6 岁以上的患者。它主要包括三个方面：促成病症、一般健康状况和临床状况。促成因素是指可能影响龋齿发生和发展的外部因素;一般健康状况是指患者的身体状况;临床病症是指与龋齿直接相关的口腔内病症。该系统将龋齿风险分为高、中、低等级，主要用于辅助牙医在临床实践中评估患者的龋齿风险。

Caries-risk assessment tool (CAT)
龋齿风险评估工具 （CAT）

CAT is developed by the American Academy of Pediatric Dentistry and is divided into 2 forms: (1) for children aged 0–5 (dental practitioners, physicians, and other non-dental health care providers); (2) for children ≥ 6 years old, adolescents and adults (used by dental providers). CAT’s evaluation indicators cover risk factors (social/biological), protective factors and clinical findings, and it is mostly used for CRA in infants, children and adolescents.
CAT 由美国儿科牙科学会开发，分为 2 种形式：（1） 适用于 0-5 岁的儿童（牙科医生、医生和其他非牙科医疗保健提供者）;（2） 适用于 6 ≥ 岁的儿童、青少年和成人（由牙科提供者使用）。CAT 的评价指标涵盖危险因素（社会/生物）、保护因素和临床表现，多用于婴儿、儿童和青少年的 CRA。

Caries management by risk assessment (CAMBRA)
通过风险评估管理龋齿 （CAMBRA）

CAMBRA was first proposed by the California Dental Association in 2002, and was modified afterwards to form the existing format. It consists of two tables: 0–6 years old and over 6 years old. And its assessment criteria include pathological indicators, risk factors, protective factors and bioprotective factors.
CAMBRA 于 2002 年由加利福尼亚牙科协会首次提出，随后进行了修改以形成现有格式。它由两张桌子组成：0-6 岁和 6 岁以上。其评估标准包括病理指标、危险因素、保护因素和生物保护因素。

Cariogram
字母图

Cariogram is a computer-programmed CRA system developed by Swedish scholars and is composed of 9 caries risk factors. The system can perform weighted analysis on the input data and apply a pie chart to predict the patient’s the overall caries risk; meanwhile, it can demonstrate the respective influences of different risk factors, predict the individual possibility of developing caries in the future, and propose targeted methods to prevent new caries.
Cariogram 是由瑞典学者开发的计算机编程 CRA 系统，由 9 个龋齿风险因素组成。系统可对输入数据进行加权分析，并应用饼图预测患者的整体龋齿风险;同时，它可以展示不同风险因素的各自影响，预测未来发生龋齿的个体可能性，并提出有针对性的预防新龋齿的方法。

The CRA systems mentioned above are applicable to population aged 0–6 years old and ≥6 years old (Table S1, S2). Among them, CAMBRA system covers the largest number (#25) of factors related to caries for adults, followed by ADA (#19) and Cariogram (#14).– CAMBRA system also suggests the largest number (#20) of factors associated with dental caries for children, then followed by ADA (#14) and CAT (#13), and Cariogram (#9). Studies had revealed that Cariogram had a limited extent in predicting dental caries in preschool children, but more useful in identifying caries risk for the elderly. Gao et al. reported a high sensitivity and low specificity of CAT and CAMBRA for 3-year-olds children, but could not effectively predict the occurrence of new caries. Such low specificity may overestimate the level of children’s caries risk, which might lead to overtreatment and raise the cost of prevention. The ADA assessment system is also most commonly used in children, but there is still a lack of relevant research to confirm its caries prediction ability in all age groups.
上述 CRA 系统适用于 0-6 岁和 ≥6 岁的人群（表 S1 ）。 S2 其中，CAMBRA 系统覆盖的成人龋齿相关因素数量最多 （#25），其次是 ADA （#19） 和 Cariogram （#14）。 岁CAMBRA 系统还表明与儿童龋齿相关的因素数量最多 （#20），其次是 ADA （#14） 和 CAT （#13） 以及 Cariogram （#9）。研究表明，Cariogram 在预测学龄前儿童龋齿方面的程度有限，但在识别老年人龋齿风险方面更有用。 Gao 等人 报道了 CAT 和 CAMBRA 对 3 岁儿童的高敏感性和低特异性，但不能有效预测新龋齿的发生。如此低的特异性可能会高估儿童龋齿的风险水平，这可能导致过度治疗并提高预防成本。ADA 评估系统也是儿童最常用的系统，但仍然缺乏相关研究来证实其在所有年龄段的龋齿预测能力。

Accurate and valid caries risk assessment can provide support for effective caries management, so as to implement targeted and progressive measures regarding caries prevention and treatment. However, the accuracy of caries risk assessment for children is still low, and there is still a lack of risk assessment guideline for low-income population. There are deficiencies among these assessment systems and certain limitations in the range of application., Therefore, appropriate assessment methods should be selected or adjusted according to patients’ age, region and other specific conditions. Currently, there is still a lack of multifactorial caries risk assessment system in China, and more research are needed to identify and evaluate whether the existing caries risk assessment system is suitable for Chinese populations.
准确有效的龋齿风险评估可以为有效的龋齿管理提供支持，从而实施针对性和渐进的龋齿预防和治疗措施。 然而，儿童龋齿风险评估的准确性仍然较低，并且仍然缺乏针对低收入人群的风险评估指南。这些评估系统存在缺陷，适用范围也存在一定的局限性。 元因此，应根据患者的年龄、地区和其他具体情况选择或调整适当的评估方法。目前，中国仍然缺乏多因素龋齿风险评估系统，需要更多的研究来识别和评估现有的龋齿风险评估系统是否适合中国人群。

Classification and activity of caries
龋齿的分类和活动

Caries is a dynamic development process. If the demineralization process of caries is in progress, which is accompanied by the rapid loss of calcium and phosphorus ions, it is called active caries. Otherwise, if the demineralization process stops, which means the chemical reaction has ended, it is called arrested caries. Besides, carious lesion activity could be classified according to surface characteristics. The enamel of active caries typically appears whitish or yellowish change with loss of luster, and the texture feels soft on probing. It often locates in the pit and fissure, the gingival margin and contact points of the proximal surface, which is generally covered with plaque. Dentine caries usually appears brownish. The surface of the cavity feels soft on probing, and it is cheese-like and fragile. For arrested caries, the enamel is whitish or brownish. The surface is smooth and feels hard on probing, and no obvious plaque on the surface. And the dentin appears typically dark brown. The surface of the cavity feels hard and leathery on probing.
龋齿是一个动态的开发过程。如果龋齿的脱矿过程正在进行中，并伴有钙和磷离子的快速流失，则称为活动性龋齿。否则，如果脱矿过程停止，即表示化学反应已经结束，则称为龋齿发作。此外，龋齿病变活动可根据表面特征进行分类。活动性龋齿的牙釉质通常呈白色或淡黄色变化，并随着光泽的丧失而发生变化，探查时质地感觉柔软。它通常位于凹坑和裂隙、牙龈边缘和近端表面的接触点，通常被牙菌斑覆盖。牙本质龋齿通常呈褐色。腔体表面在探测时感觉柔软，像奶酪一样脆弱。对于被抑制的龋齿，牙釉质呈白色或褐色。表面光滑，探查时感觉很硬，表面没有明显的斑块。牙本质通常呈深棕色。探查时，空腔表面感觉坚硬且呈皮革状。

Because carious management is related to the caries diagnostic criteria, we should recognize the importance of carious lesion activity. Nyvad previously proposed a detailed caries diagnostic criterion in 1999, distinguishing the active and inactive caries based on a combination of visual and tactile criteria (Table S3). This assessment was carried out at three levels of increasing severity which scored from 0 and 9.
因为龋齿管理与龋齿诊断标准有关，所以我们应该认识到龋齿病变活动的重要性。Nyvad 此前在 1999 年提出了一个详细的龋齿诊断标准，根据视觉和触觉标准的组合来区分活动性和非活动性龋齿（表 S3 ）。该评估在三个严重程度递增的级别进行，评分为 0 和 9。

In 2002, an international team of caries researchers harmonized global evidence around caries detection and assessment to create a standard system named the International Caries Detection and Assessment System (ICDAS)., This system encodes caries depending on the minor variations in visual signs of the lesion severity and the radiographic information for the depth of caries demineralization (Table S4)., which classifies caries effectively and is helpful for the early diagnosis of caries, but does not involve carious lesion activity.
2002 年，一个国际龋齿研究团队协调了有关龋齿检测和评估的全球证据，创建了一个名为国际龋齿检测和评估系统 （ICDAS） 的标准系统。该系统根据病变严重程度的视觉迹象的微小变化和龋齿脱矿深度的放射学信息对龋齿进行编码（表 S4 ）。 对龋齿进行有效分类，有助于龋齿的早期诊断，但不涉及龋齿病变活动。

ICDAS-Caries Lesion Activity Assessment (also called in the literature ICDAS-CAA for ICDAS-Clinical Characteristic Assessment) was proposed in 2009, which is based on combinations of visual (appearance and plaque stagnation) and tactile criteria (Table S5).,
ICDAS-龋齿病变活动评估（在文献中也称为 ICDAS-CAA 用于 ICDAS-临床特征评估）于 2009 年提出，它基于视觉（外观和斑块停滞）和触觉标准的组合（表 S5 ）。 元

ICDAS system has been widely used and constantly improved in European and American countries, which subsequently developed into International Caries Classification and Management System (ICCMS). ICCMS synthesizes the radiographic and clinical assessment to categorize the lesions with the ICDAS merged codes, which divides coronal caries into sound surfaces (ICDASTM code 0), initial stage caries (ICDASTM codes 1 and 2), moderate stage caries (ICDASTM codes 3 and 4) and extensive stage caries (ICDASTM codes 5 and 6). Combined with the lesion activity assessment, the ICCMS diagnostic classification of caries includes no lesion, initial inactive lesion, initial active lesion, moderate active lesion, moderate inactive lesion, extensive active lesion and extensive inactive lesion.
ICDAS 系统在欧美国家得到广泛应用和不断改进，随后发展成为国际龋齿分类和管理系统 （ICCMS）。ICCMS 综合放射学和临床评估，使用 ICDAS 合并代码对病变进行分类，该代码将冠状龋分为健全表面（ICDASTM 代码 0）、初始期龋齿（ICDASTM 代码 1 和 2）、中度期龋齿（ICDASTM 代码 3 和 4）和广泛期龋齿（ICDASTM 代码 5 和 6）。 结合病灶活动度评估，ICCMS龋齿诊断分类包括无病灶、初始非活动性病灶、初始活动性病灶、中度活动性病灶、中度非活动性病灶、广泛性活动病灶和广泛性非活动性病灶。

For the advantages of ICDAS-CAA: (1) easy to use; (2) no special equipment required; (3) the changes of lesions can be followed up; (4) low cost. However, this system also has some limitations: (1) there is a certain degree of subjectivity; (2) the tooth surface must be cleaned before use; (3) inspectors must be trained and calibrated.
ICDAS-CAA 的优点：（1） 易于使用;（2） 无需特殊设备;（3） 病灶的变化可以随访;（4） 成本低。但是，这个系统也有一些局限性：（1） 存在一定的主观性;（2） 使用前必须清洁齿面;（3） 检查员必须接受培训和校准。

Both the Nyvad criteria and ICDAS-CAA show relatively good intrinsic validity. For Nyvad criteria, which shows sensitivity at 0.71, the specificity is between 0.73 and 0.75, the intra-examiner reproducibility (Kappa value) is between 0.68 and 0.80, and the inter-examiner reproductivity is between 0.74 and 0.90. ICDAS-CAA, which is part of the ICCMTM, shows sensitivity at 0.87 in enamel and 0.60 in dentin, specificity at 0.50 in enamel and 0.95 in dentin, the intra- and inter-examiner reproducibilities (Kappa values) are between 0.11 and 0.96, and between 0.20 and 0.95, respectively. However, in the daily practice of general practitioners, Nyvad criteria and ICDAS-CAA are rarely used, further in vivo investigations with Nyvad criteria and ICDAS-CAA as gold standards are needed.
Nyvad 标准和 ICDAS-CAA 都显示出相对较好的内在效度。对于显示敏感性为 0.71 的 Nyvad 标准，特异性在 0.73 到 0.75 之间，检查者内可重复性（Kappa 值）在 0.68 到 0.80 之间，检查者间可重复性在 0.74 到 0.90 之间。ICDAS-CAA 是 ICCMTM 的一部分，在牙釉质中显示出 0.87 的敏感性，在牙本质中显示出 0.60 的敏感性，在牙釉质中显示出 0.50 的特异性，在牙本质中显示出 0.95 的特异性，检查员内和检查者之间的可重复性（Kappa 值）分别在 0.11 和 0.96 之间，在 0.20 和 0.95 之间。然而，在全科医生的日常实践中，很少使用 Nyvad 标准和 ICDAS-CAA，需要以 Nyvad 标准和 ICDAS-CAA 作为金标准进行进一步的体内研究。

The clinical significance of evaluating carious lesion activity is that identifying active lesions during clinical examination could directly help carious management and follow-up monitoring, especially for the caries with severe progression. For non-cavitated active caries, oral hygiene guidance could be carried out for patients, non-surgical interventions (oral hygiene instruction, topical application of fluoride) could be carried out according to individual conditions. Besides, no surgical intervention is required for arrested caries, except basic preventive measures (brushing with fluoride toothpaste). And many clinical studies have confirmed that non-surgical treatment can effectively control caries. Once active caries has affected dentin, it must be treated with restorations. For active caries, it is necessary to formulate a combined treatment plan. The carious management plan at the individual level could reduce the risk of caries and prevent future caries. Moreover, it is also necessary to develop a carious treatment plan for the tooth level, including non-surgical treatment and surgical restorative treatment to manage the existing carious lesion activity.
评估龋齿病变活动的临床意义在于，在临床检查中识别活动性病变可直接帮助龋齿管理和随访监测，尤其是对于严重进展的龋齿。对于非空洞性活动性龋齿，可根据患者情况进行口腔卫生指导，进行非手术干预（口腔卫生指导、局部应用氟化物）。此外，除了基本的预防措施（用含氟牙膏刷牙）外，对发作的龋齿不需要手术干预。并且许多临床研究证实，非手术治疗可以有效控制龋齿。 一旦活动性龋齿影响了牙本质，就必须用修复体治疗。对于活动性龋齿，有必要制定联合治疗计划。个人层面的龋齿管理计划可以降低龋齿的风险并防止未来的龋齿。此外，还需要为牙齿水平制定龋齿治疗计划，包括非手术治疗和手术修复治疗，以管理现有的龋齿病变活动。

Dental caries treatment plan
龋齿治疗计划

According to the modern etiology, dental caries results from complex interactions over time between host factors, oral microbe, fermentable carbohydrate. The prognosis of the disease is closely related to the general condition and oral factors. Although there is a relatively well-developed caries management system, the difficulty assessments of dental caries treatment are still needed before making treatment plan. Then caries management plan is conducted to control caries risk factors and manage individual lesions.
根据现代病因学，龋齿是宿主因素、口腔微生物、可发酵碳水化合物之间随着时间的推移而发生的复杂相互作用的结果。本病的预后与一般情况和口腔因素密切相关。虽然有相对完善的龋齿管理系统，但在制定治疗计划之前，仍然需要对龋齿的治疗难度进行评估。然后执行龋齿管理计划以控制龋齿风险因素并管理单个病变。

Difficulty assessment in caries treatment
龋齿治疗难度评估

Based on the difficulty factors of dental caries treatment, we proposed the difficulty assessment of caries prevention and treatment to guide the clinical diagnosis, treatment and referral, provide objective preoperative prediction of treatment outcomes, facilitate communication between dentists and patients and improve the quality of caries treatment and long-term therapeutic effect. The factors affecting the difficulty of caries treatment mainly include systemic and oral factors, individual susceptibility to caries, technical sensitivity, past dental filling experience and auxiliary factors. The caries factors include the involved carious tooth surface and the depth of lesion, which directly affect the difficulty of caries treatment and treatment decisions; secondly, with the development of materials and methods, the technical sensitivity of the treatment of caries has increased. As for technical factors, the main techniques commonly used in clinical practice such as non-surgical treatment, direct and indirect restorative treatment are scored; the treatment for secondary caries and old restorations is one of the difficult points affecting the treatment of caries, so the history of tooth restoration and failure of dental restoration are also the main contents of the difficulty evaluation; other factors, such as mouth opening, pharyngeal reflex, saliva secretion and dental phobia, can directly or indirectly affect the difficulty of caries treatment, so they were used as an additional factor to assess the difficulty of caries treatment.
基于龋齿治疗的难点因素，提出龋齿防治难度评估，以指导临床诊疗和转诊，提供客观的术前治疗结果预测，促进牙医与患者的沟通，提高龋齿治疗质量和长期治疗效果。影响龋齿治疗难度的因素主要包括系统因素和口腔因素、个体对龋齿的易感性、技术敏感性、既往补牙经验和辅助因素。 龋病因素包括受累的龋齿表面和病变的深度，直接影响龋齿治疗的难度和治疗决策;其次，随着材料和方法的发展，治疗龋齿的技术敏感性有所提高。在技术因素方面，对临床实践中常用的主要技术如非手术治疗、直接和间接修复治疗进行评分;继发性龋病和陈旧修复体的治疗是影响龋齿治疗的难点之一，因此牙齿修复的历史和牙齿修复失败也是难度评价的主要内容;其他因素，如张口、咽反射、唾液分泌和恐牙症等，可以直接或间接影响龋齿治疗的难度，因此它们被用作评估龋齿治疗难度的附加因素。

According to the difficulty of treatment, each factor is divided into Level 1-3 and the comprehensive assesment is divided into I, II and III grades. Dentists are also classified into A, B and C levels according to their technical proficiency. Combined the difficulty assessment grades and the referral advice, caries risk difficulty classification can be divided into low risk, medium risk, high risk and extremely high risk levels (Table1). The specific grades are as follows:
根据治疗的难易程度，将各因素分为 1-3 级，综合评估分为 I 、 II 和 III 级。牙医也根据他们的技术熟练程度分为 A、B 和 C 级别。结合难度评估等级和转介建议，龋齿风险难度分类可分为低风险、中风险、高风险和极高风险级别（表 1 ）。具体等级如下：

Table 1.  表 1.

Difficulty assessment of dental caries treatment
龋齿治疗的难度评估

Difficulty classification
难度分类		 Level 1  1 级 Level 2  2 级 Level 3  3 级
Involved tooth surface and site
受累牙齿表面和部位		 Class I and V  I 类和 V 类

Class II, III, IV and VI
II、III、IV 和 VI 类

Root caries (involving labial/buccal surface)
根部龋齿（涉及唇/颊面）

Cavity on the 1/3 gingival side of the distal surface of posterior teeth
后牙远端表面 1/3 牙龈侧的空腔

Attrition  磨损

Cusp defect  尖点缺陷

Severely defected crown  严重缺损的牙冠

Root caries (involving more than 2 surfaces)
根部龋齿（涉及 2 个以上的表面）

Rampant Caries  猖獗的龋齿
Depth of caries lession  龋齿缩小深度 Superficial caries and intermediate caries
浅表龋齿和中间龋齿		 Deep caries  深龋 Deep caries of immature permanent teeth
未成熟恒牙的深龋
Technique types  技术类型

Direct restoration of posterior teeth: composite resin restoration and amalgam restoration
后牙直接修复：复合树脂修复和汞合金修复

Minimally invasive techniques: ART, preventive resin restoration (PRR), glass ionomer transition repair, enamel molding, and micro-polishing
微创技术：ART、预防性树脂修复 （PRR）、玻璃离子过渡修复、牙釉质成型和微抛光

 Composite resin restoration of anterior teeth
前牙复合树脂修复

Cosmetic restoration of anterior teeth: non-invasive esthetic restoration, minimally invasive layered restoration, minimally invasive CAD/CAM ceramic veneer restoration
前牙美容修复：无创美学修复、微创分层修复、微创 CAD/CAM 陶瓷贴面修复

Inlay restoration of posterior teeth: composite resin inlay, CAD/CAM ceramic inlay restoration
后牙嵌体修复：复合树脂嵌体、CAD/CAM 陶瓷嵌体修复
History of restoration or filling failure
修复或填充失败的历史		 A history of restoration, but caries not affecting the old restoration
修复的历史，但龋齿不影响旧的修复		 Caries involving the old restoration or the first fracture of the old restoration
涉及旧修复体或旧修复体首次断裂的龋齿		 Old restoration falling off 2 or more times
旧修复体脱落 2 次或更多次
Mouth opening  张口 3 fingers wide  3 根手指宽 2 fingers wide  2 根手指宽 Less than 2 fingers wide
宽度小于 2 个
Pharyngeal reflexa
咽反射a 		No  不 Yes  是的 Strong  强
Salivary secretionb
唾液分泌物 b 		Normal  正常 Many  多 Excessive  过度
Dental phobia  牙科恐惧症 No  不 Yes  是的
Caries risk assessmentc
龋齿风险评估c 		Low and medium risk population
低风险和中风险人群		 High risk population  高危人群 Extremely high risk population
极高危人群
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aPharyngeal reflex: “no”, treatment of caries can be completed without special assistance; “yes”, patient’s pharyngeal reflex is obvious, but the caries treatment can be successfully completed with special assistance (such as rubber barrier); “strong”, it is also difficult to complete caries treatment with special assistance.
一个咽反射：“不”，龋齿的治疗可以在没有特殊帮助的情况下完成;“是”，患者的咽反射很明显，但龋齿治疗可以在特殊帮助（如橡胶屏障）下成功完成;“强”，在特殊帮助下也很难完成龋齿治疗。

bSalivary secretion: “normal”, the treatment can be successfully completed under the gauze ball isolation; “many”, it is difficult for the yarn ball to block moisture and requires four-handed operation; “excessive”, rubber barriers must be placed.
乙唾液分泌：“正常”，在纱布球隔离下可顺利完成治疗;“多”，纱球难以挡潮，需要四手作;“过度”，必须放置橡胶屏障。

cClassification of caries risk assessment: According to CAMBRA caries risk assessment model, patients will be divided into low risk, medium risk, high risk and extremely high risk population.
c龋齿风险评估分类：根据 CAMBRA 龋齿风险评估模型，将患者分为低风险、中风险、高风险和极高危人群。

Grade I: Preoperative evaluation of the cases is not difficult, and all the difficulty factors are in line with level 1 of difficulty assessment system of caries prevention and management. Doctors with low experience are competent for the diagnosis and treatment of these cases. This group of patients should be referred to grade A doctors (general practitioners).
I 级：病例术前评估不难，所有难点因素均符合龋病预防和管理难度评估体系 1 级。经验不足的医生有能力诊断和治疗这些病例。这组患者应转诊至 A 级医生（全科医生）。

Grade II: The preoperative evaluation showed that the cases are difficult, and one difficulty factor is in accordance with level 2 of difficulty assessment system of caries prevention and management. Even experienced dentists may face challenges in diagnosing and treating these cases. Such patients are supposed to refer to grade B doctors (cariology specialists).
II 级：术前评估显示病例疑难，1 个难点因素符合龋病预防和管理难度评估体系 2 级。即使是经验丰富的牙医也可能在诊断和治疗这些病例时面临挑战。这些患者应该转诊给 B 级医生（龋病学专家）。

Grade III: Preoperative evaluation of the cases is difficult, with at least 2 difficulty factors matching level 2 or 1 difficulty factor matching level 3 of difficulty assessment system of caries prevention and management. Experienced doctors also face challenges in achieving the desired outcome. Those patients should be referred to grade C doctors (clinical experts in cariology).
III 级：病例术前评价困难，至少有 2 个难度因素匹配龋病预防和管理难度评估系统 2 级或 1 个难度因素匹配 3 级。经验丰富的医生在实现预期结果方面也面临挑战。这些患者应转诊至 C 级医生（龋病学临床专家）。

Caries lesion management  龋齿病变管理

Caries treatment planning is a serialized process that aims to eliminate or control pathogenic factors, restore existing lesion, and produce a functional and sustainable environment. The essential steps include clinical examination, definite diagnosis, risk assessment, devising optimal treatment plan, delivering alternative plan and patient-participated decision making.
龋齿治疗计划是一个系列化的过程，旨在消除或控制致病因素，恢复现有病变，并产生功能性和可持续的环境。基本步骤包括临床检查、明确诊断、风险评估、制定最佳治疗计划、提供替代计划和患者参与决策。

Decision-making process and personalized caries care plan are based on accurate diagnosis. At the caries level, the diagnostic process should include caries detection, assessment of caries severity (e.g., penetration depth of the lesions, with or without cavities) and caries activity (i.e., active or inactive). Note that during the diagnosis phase caries risk assessment is also conducted.
决策过程和个性化的龋齿护理计划基于准确的诊断。在龋齿层面，诊断过程应包括龋齿检测、龋齿严重程度评估（例如，病变的穿透深度，有或没有龋齿）和龋齿活动度（即活动性或非活动性）。请注意，在诊断阶段，还会进行龋齿风险评估。

Caries management includes two aspects—controlling caries risk factors and managing individual lesions. Caries management is patient-centered and based on caries risk assessment, which takes comprehensive measures such as health promotion, prevention or treatment to affect various factors of caries occurrence and development, in order to regain oral microecological balance, control caries progression and restore the structure and function of the teeth. Overall, caries management refers to the use of interventions to stop the progression of existing lesions and non-self-cleaning active caries, aims at controlling the development of caries at the tooth level.
龋齿管理包括两个方面——控制龋齿风险因素和管理单个病变。龋齿管理以患者为中心，以龋齿风险评估为基础，采取健康促进、预防或治疗等综合措施，影响龋齿发生和发展的各种因素，以恢复口腔微生态平衡，控制龋齿进展，恢复牙齿的结构和功能。 总体而言，龋齿管理是指使用干预措施来阻止现有病变和非自我清洁活动性龋齿的发展，旨在控制牙齿水平龋齿的发展。

According to the different tissues (i.e., enamel or dentin) and surfaces (e.g., occlusal, proximal, and root) in which the caries is located, different interventions are required. Besides, lesions activity also influences the need for interventions. The transformation from active caries to inactive can happen through exposure to saliva, self-cleaning, and so on, or can be aided with products and/or interventions.
根据龋齿所在的不同组织（即牙釉质或牙本质）和表面（例如，咬合、近端和牙根），需要不同的干预措施。 此外，病变活动也会影响干预的需要。从活跃的龋齿转变为不活跃的可以通过接触唾液、自我清洁等来实现，也可以通过产品和/或干预措施来提供帮助。 元

Non-cavitated caries lesions
非空洞性龋齿病变

Guided by the caries risk assessment results, caries category (ICDAS 1~2) and caries activity, individual caries treatment plan can be formulated and corresponding caries management measures can be taken. Non-cavitated inactive caries lesions do not need operative care, while the treatment methods of active caries are different from caries locations.
根据龋齿风险评估结果、龋齿类别（ICDAS 1~2）和龋齿活动度，制定个体龋齿治疗方案，并采取相应的龋齿管理措施。 非空洞性非活动性龋病灶不需要手术护理，而活动性龋病的治疗方法与龋齿部位不同。 元

Dental sealant is considered to be the most cost-effective treatment for the prevention of pit and fissure caries., According to the 2018 American Dental Association’s (ADA) systematic review and subsequent evidence-based clinical practice guideline, Pit and fissure sealant has been recommended as the treatment method for non-cavitated pit and fissure caries., Sealant can be used alone or in combination with 5% NaF varnish (application every 3–6 months), and the combined approach has been confirmed as the effective intervention in arresting or reversing lesions. Additionally, 5% NaF varnish (application every 3–6 months), 1.23% acidulated phosphate fluoride (APF) gel (application every 3–6 months) or 0.2% NaF mouth rinse (once per week) can be considered as a suboptimal treatment strategy for non-cavitated pit and fissure caries.
牙科密封剂被认为是预防凹坑和裂隙龋齿的最具成本效益的治疗方法。 元根据 2018 年美国牙科协会 （ADA） 的系统评价和随后的循证临床实践指南，窝沟封闭剂已被推荐作为非空洞窝沟龋的治疗方法。 元密封剂可以单独使用或与 5% NaF 清漆联合使用（每 3-6 个月使用一次），并且联合方法已被证实是阻止或逆转病变的有效干预措施。 此外，5% NaF 清漆（每 3-6 个月使用一次）、1.23% 酸化磷酸盐氟化物 （APF） 凝胶（每 3-6 个月使用一次）或 0.2% NaF 漱口水（每周一次）可被视为非空洞和裂隙龋齿的次优治疗策略。

Resin infiltration is recommended as the non-invasive management of non-cavitated approximal caries lesions. Both applying resin infiltration alone and resin infiltration plus 5%NaF varnish every 3–6 months could effectively prevent non-cavitated caries lesions process on approximal surfaces. In addition, dental sealant can also be applied to non-cavitated approximal caries, but the clinical operation is difficult due to the need of special instruments and high technical sensitivity.
建议将树脂浸润作为非空洞性近龋齿病变的无创治疗。 单独应用树脂浸润和每 5-3 个月使用树脂浸润加 6%NaF 清漆都可以有效防止非空洞性龋齿病变在近似表面发生。 此外，牙科密封剂也可用于非空洞性近龋，但由于需要特殊器械和技术敏感性高，临床作困难。

For non-cavitated caries lesions on facial or lingual surfaces, 1.23% APF gel (application every 3–6 months) or 5% NaF varnish (application every 3–6 months) is recommended.
对于面部或舌侧表面的非空洞性龋齿病变，建议使用 1.23% APF 凝胶（每 3-6 个月使用一次）或 5% NaF 清漆（每 3-6 个月使用一次）。

In order to arrest the caries progress and promote remineralization, various forms of calcium-containing products came into being. However, due to the clinical efficacy limitations, calcium-containing agents can not be applied as a substitute for fluoride in the treatment for non-cavitated caries.
为了阻止龋齿的进展并促进再矿化，各种形式的含钙产品应运而生。然而，由于临床疗效的限制，含钙剂不能作为氟化物的替代品用于治疗非空洞性龋齿。

Cavitated caries lesions  空洞性龋齿病变

The caries risk factors management plan is tailored at the individual caries risk assessment result, and the caries lesions management strategy depends on the lesions severity and caries activity status. Compared with non-cavitated caries, the management of cavitated caries lesions increases the restorative treatment plan. Some cavitated caries lesions that do not invade dental pulp can take the nonrestorative treatment with silver diamine fluoride (SDF) temporarily or permanently, when the main purpose is to arrest the progression of caries regardless of functional and esthetic effects. Studies indicated that applying SDF every 6–12 months could effectively arrest the cavitated caries process., However, nonrestorative treatment measures have limitations, and cavitated caries lesions are generally noncleansable and active. Therefore, restorative treatment is the main intervention strategy for cavitated caries, which is aimed to control the biofilm in specific locations, seal the crown with adhesive materials, protect the dentin-pulp complex, terminate the activity of lesions as well as restore the function, shape and esthetic. For moderate stage caries (ICDAS 3~4), minimally invasive restorative treatments are carried out on the basis of controlling plaque as well as reducing caries risk and lesions activity. Selective removal to firm dentine is the treatment of choice for moderate stage caries in order to maintain the restoration longevity, while selective removal to soft dentine is recommended in deeper cavitated lesions to give priority to preserve pulpal health.
龋齿危险因素管理计划是根据个体龋齿风险评估结果量身定制的，龋齿病变管理策略取决于病变的严重程度和龋齿活动状态。与非空洞性龋齿相比，空洞性龋齿病变的管理增加了修复性治疗计划。一些不侵入牙髓的空洞龋齿病变可以暂时或永久地使用氟化二胺银 （SDF） 进行非修复治疗，其主要目的是阻止龋齿的进展，而不管功能和美学效果如何。研究表明，每 6-12 个月应用 SDF 可以有效阻止空洞龋齿过程。 元然而，非修复性治疗措施有局限性，空洞性龋齿病变通常是不可清洁的和活跃的。因此，修复治疗是空洞性龋齿的主要干预策略，旨在控制特定位置的生物膜，用粘合材料密封牙冠，保护牙本质-牙髓复合体，终止病变的活动以及恢复功能、形状和美学。对于中度龋齿 （ICDAS 3~4），在控制斑块、降低龋齿风险和病变活动度的基础上进行微创修复治疗。选择性去除坚硬的牙本质是中度龋齿的首选治疗方法，以保持修复寿命，而对于较深的空洞病变，建议选择性去除至柔软的牙本质，以优先保持牙髓健康。

Deep caries  深龋

Deep lesions are defined as those radiographically involving the inner pulpal third or quarter of dentine or with clinically assessed risk of pulpal exposure, which are similar to extensive stages caries (ICDAS 5~6). The treatment principles of deep caries include arresting the caries process, promoting pulp defensive response and giving priority to the preservation of pulp. Carious removal in deep caries should follow the principle of minimally invasive and gradual, which requests to use the hardness of the remaining dentine as the criterion in assessing the end point of carious tissue removal for cavity. Application of rubber dam were recommended to maintain an aseptic environment. Cavity disinfection is not a necessary means as there is insufficient evidence to support it. What’s more, magnification is advantageous to determine the end point of carious tissue removal and pulp exposure or not. Selective removal to soft dentine is recommended in deep caries lesions, in order to retain non-demineralized or remineralizable tissue, and maintain the vitality of dental pulp. Soft dentine is defined as that it will deform when a hard instrument is pressed on and can be easily scooped up.
深部病变定义为放射学上涉及牙髓内三分之一或四分之一牙本质或具有临床评估的牙髓暴露风险的病变， 类似于广泛期龋齿 （ICDAS 5~6）。深龋的治疗原则包括阻止龋齿过程、促进牙髓防御反应和优先保存牙髓。深部龋齿的龋齿切除应遵循微创渐进的原则，要求以剩余牙本质的硬度作为评价龋齿组织切除终点的标准。建议使用橡皮障以保持无菌环境。空腔消毒不是必要的手段，因为没有足够的证据支持它。更重要的是，放大有利于确定龋齿组织去除和牙髓暴露的终点。对于较深的龋齿病变，建议选择性去除软牙本质，以保留未脱矿或可再矿化的组织，并保持牙髓的活力。 软牙本质被定义为当按压硬器械时它会变形并且很容易被舀起。

Stepwise technique (SW) can be used on deep carious lesions. The first step in the SW is the procedure by which carious dentine is removed from the peripheral walls to hard dentine (a scratchy sound or ‘cri dentinaire’ can be heard in hard dentine when a straight probe is taken across), followed by excavation that soft carious tissue was left in the pulpal aspect of the cavity. Calcium hydroxide cement then is applied over the pulpal wall with high strength glass-ionomer cement (GIC) sealing the cavity temporarily. At the meantime, it is necessary to strengthen caries management measures and observe the symptoms. Dental visit after 6–12 months if the symptoms are improved or without obvious symptoms; In case of spontaneous pain, make an appointment for return at any time. The second treatment is performed after an interval of 6–12 months. If the symptoms disappear, remove all the GIC, excavate until only leathery/firm dentine (this kind of dentine is physically resistant to hand excavation, and some pressure needs to be exerted through an instrument to lift it) remains over the pulp. Then using selective etch adhesion technology and composite resin for restoration. It is necessary to implement caries management measures conventionally and maintain recalls at risk-based intervals.
逐步技术 （SW） 可用于深部龋齿病变。SW 的第一步是将龋齿牙本质从外围壁去除到坚硬的牙本质上（当直探头穿过时，可以在坚硬的牙本质中听到沙哑的声音或“cri dentinaire”），然后挖掘柔软的龋齿组织留在腔的牙髓方面。 然后将氢氧化钙水泥涂在纸浆壁上，用高强度玻璃离子水泥 （GIC） 暂时密封空腔。同时，要加强龋齿管理措施，观察症状。如果症状改善或没有明显症状，请在 6-12 个月后去看牙医;如果出现自发性疼痛，请随时预约返回。第二次治疗间隔 6-12 个月后进行。 如果症状消失，取出所有 GIC，挖掘直到牙髓上只剩下皮革/坚硬的牙本质（这种牙本质对手工挖掘具有物理抵抗力，需要通过仪器施加一些压力才能将其抬起）。 然后使用选择性蚀刻粘合技术和复合树脂进行修复。有必要按照常规实施龋齿管理措施，并在基于风险的时间间隔内保持召回。

SW as an early caries removal technique, calcium hydroxide is still the most commonly used indirect pulp capping materials in it. New materials such as hydraulic calcium silicates (hCSCs) have been developed, in particular various forms of the mineral trioxide aggregate (MTA), and another recent available type Biodentine and iRoot BP. Although recent reviews, provide the evidence for a more superior outcome for the biological properties and material advantages of hCSCs than calcium hydroxide, there remains insufficient evidence comparing and testing these indirect pulp capping materials in order to make definitive conclusions on the best material to use.
SW 作为一种早期的龋齿去除技术，氢氧化钙仍然是其中最常用的间接牙髓封盖材料。 已经开发了水硬硅酸钙 （hCSC） 等新材料，特别是各种形式的矿物三氧化物聚集体 （MTA），以及另一种最近可用的类型 Biodentine 和 iRoot BP。尽管最近的综述 提供了证据，证明 hCSCs 的生物学特性和材料优势比氢氧化钙更优越，但仍然没有足够的证据比较和测试这些间接髓压盖材料，以便对最佳使用材料得出明确的结论。

There are some evidences have suggested that the second removal step may be omitted, as it increases risk of pulpal exposure. In addition, it increases the cost, treatment time and uncomfortable feelings.– A randomized clinical trial has showed that the success rates for SW were 93% and 69% after 1 and 3 years follow-up, respectively, while partial caries removal group were 98% and 91%. The comparison between two groups showed statistically significant differences, which may be explained by the high number of uncompleted SW treatments.
有一些证据表明，可以省略第二个切除步骤，因为它会增加牙髓暴露的风险。此外，它还会增加成本、治疗时间和不舒服的感觉。–一项随机临床试验表明，随访 1 年和 3 年后，SW 的成功率分别为 93% 和 69%，而部分龋齿去除组为 98% 和 91%。两组之间的比较显示出统计学上的显着差异，这可能是由于未完成的 SW 处理数量多所解释的。

Restorative materials  修复材料

Direct restorative materials mainly contain GICs and composite resin. Due to the emission of mercury in the production and use of silver amalgam, the United Nations has formulated and issued a convention, requiring measures to phase down the use of silver amalgam. The materials selection varies according to the remaining coronal tooth tissue, the size of the restoration, occlusal forces, caries risk, and esthetics.
直接修复材料主要包含 GICs 和复合树脂。由于银汞合金的生产和使用会排放汞，联合国制定并发布了一项公约，要求采取措施逐步减少银汞合金的使用。 材料的选择根据剩余的冠状牙组织、修复体的大小、咬合力、龋齿风险和美学而有所不同。

GIC has good biocompatibility, binds chemically to dental hard tissues, releases fluoride, may protect against secondary caries., High viscosity glass-ionomer cements (HV-GICs) have been promoted in recent years, which have similar bond strength to both normal and caries-affected dentin. Unlike HV-GICs, resin adhesives have a significantly lower bond strength to caries-affected dentin than sound dentin. Therefore, HV-GIC is recommended as temporary restoration after selective removal of caries to soft or leathery dentin. Patients with xerostomia after radiation treatment will be classified as high caries risk with high likelihood of caries incidence. Multiple studies have shown that restorative treatment with HV-GIC in these patients has a good survival rate, and can protect against secondary caries even in the case of low fluoride compliance or the restoration falls off.– For the patients in high caries risk level, it is recommended to restore with GIC first, and then composite resin can be applied after caries risk factors are controlled. What’s more, recent system review suggested no difference in the failure rates between HV-GIC and hybrid resin composite restorations.
GIC 具有良好的生物相容性，与牙齿硬组织化学结合，释放氟化物，可以防止继发性龋齿。 元近年来，高粘度玻璃离子粘接剂 （HV-GIC） 得到了推广，其粘合强度与正常和龋齿受影响的牙本质相似。与 HV-GIC 不同，树脂胶粘剂对龋齿牙本质的粘合强度明显低于健全的牙本质。 因此，建议将 HV-GIC 作为选择性去除龋齿至柔软或皮革牙本质后的临时修复体。 放射治疗后口干症患者将被归类为高龋齿风险和龋齿发生率高的可能性。多项研究表明，这些患者使用 HV-GIC 进行修复治疗具有良好的生存率，即使在氟化物依从性低或修复体脱落的情况下也可以防止继发性龋齿。对于龋齿高危水平的患者，建议先用 GIC 修复，待龋齿危险因素得到控制后再使用复合树脂。更重要的是，最近的系统综述表明 HV-GIC 和混合树脂复合修复体之间的失败率没有差异。

The prevention of root caries is more important than treatment, in view of the high morbidity of root caries among older population. Due to the rapid progress of root caries, the carious tissue must be removed as soon as possible to protect the pulp once caries occurs. It suggests clinicians prioritize the use of fluoride-releasing GIC for root caries treatment. If the root caries located at the anterior region where the esthetic factors should be considered, it can be restored by composite resin after the cavity lining with the GIC.
鉴于老年人群中根部龋齿的发病率很高，预防根部龋齿比治疗更重要。由于根部龋齿进展迅速，一旦发生龋齿，必须尽快去除龋齿组织以保护牙髓。它建议临床医生优先使用释放氟化物的 GIC 治疗根部龋齿。如果牙根龋齿位于应考虑美学因素的前部区域，则可以在腔内衬后用 GIC 用复合树脂修复。

For the restoration of anterior region caries, attention should be paid to recover the beauty by using esthetic restoration measures. Composite resin is often used in the restoration of anterior region defects due to the minimally invasive, repairable and esthetic features. When the caries is involved in the incisal angle, the lingual wall can be restored with paste-like resin or flowable resin in conjunction with the guide plate. Dentin shade resin is used to restore the dentin above the lingual wall. The incisal edge is restored with transparent shade resin, and the enamel surface with enamel shade resin.
对于前部龋齿的修复，应注意使用美学修复措施恢复美丽。复合树脂由于其微创、可修复和美观的特点，常用于前部区域缺损的修复。当龋齿累及切开角时，可结合导板用糊状树脂或可流动树脂修复舌壁。牙本质色树脂用于修复舌壁上方的牙本质。切缘用透明阴影树脂修复，搪瓷表面用搪瓷阴影树脂修复。

Composite resin is commonly applied for posterior region restoration, and GIC can also be used under special circumstances. The selection of composite resin materials can be based on the location and depth of the cavity. Flowable composite resin can be applied to superficial pit and fissure caries, while for caries cavities whose depth of penetration is greater than 2 mm, high-viscosity or viscosity variable bulk-fill resin can be applied for one step filling. On the other hand, the low-viscosity bulk-fill resin has greater fluidity and lower mechanical properties than that of high-viscosity type, which needs to be covered with a layer of traditional composite resin after filling. The application of low-viscosity bulk-fill resin needs at least two steps filling to complete clinical operation, which increases the operation steps.
复合树脂常用于后部区域修复，特殊情况下也可以使用 GIC。复合树脂材料的选择可以根据型腔的位置和深度来决定。可流动复合树脂可应用于浅表凹坑和裂隙龋齿， 而对于穿透深度大于 2 mm 的龋齿，可采用高粘度或粘度可变填充树脂进行一步填充。另一方面，低粘度散装填充树脂比高粘度型具有更大的流动性和较低的机械性能，填充后需要覆盖一层传统的复合树脂。低粘度散装填充树脂的应用至少需要两步填充才能完成临床作，这增加了作步骤。

Overall, clinicians should synthesize the assessments of caries risk, caries severity and lesion activity to make personalized caries management plan (Fig. 2), so as to provide targeted personalized diagnosis and treatment for patients.
总体而言，临床医生应综合对龋齿风险、龋齿严重程度和病变活动的评估，以制定个性化的龋齿管理计划（图 D）。 2 ）， 以便为患者提供有针对性的个性化诊断和治疗。

Fig. 2.  图 2.

Fig. 2

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Clinical decision model for caries management
龋齿管理的临床决策模型

Assessment and management of caries after treatment
治疗后龋齿的评估和管理

After caries treatment, further management should be strengthened to improve the prognosis of caries treatment and reduce the risk of new caries. Caries risk assessment is throughout the whole management process before and after caries treatment. For example, CAMBRA requires dentists to put forward professional oral health care advice and implement corresponding management measures according to the assessment of patients’ caries risk (low, moderate, high and extreme) (Table 2). Regularly follow-ups (1, 6, 12 months) are required after the restorative treatment. Dentists could evaluate the treatment and the new caries risk by using the modified U.S. Public Health Service standard and update corresponding management measures combined with caries risk assessment system. Thus a cycle of management is formed.
龋齿治疗后，应加强进一步管理，以改善龋齿治疗的预后，降低新发龋齿的风险。龋齿风险评估贯穿龋齿治疗前后的整个管理过程。例如，CAMBRA 要求牙医根据对患者龋齿风险的评估（低、中、高和极）提出专业的口腔保健建议并实施相应的管理措施（表 2 ）。 修复治疗后需要定期随访（1、6、12 个月）。牙医可以使用修改后的美国公共卫生服务标准来评估治疗和新发龋齿风险，并结合龋齿风险评估系统更新相应的管理措施。 这样就形成了一个管理循环。

Table 2.  表 2.

Caries Management by Risk Assessment according to CAMBRA
根据 CAMBRA 通过风险评估管理龋齿

Risk Level  风险级别 Antibacterials  抗菌剂 Saliva Test (Saliva flow & bacterial Culture)
唾液测试（唾液流动和细菌培养）		 Fluoride  氟化物 Frequency of radiographs  X 线片频率 Frequency of caries recall Exams
龋齿召回频率检查		 Xylitol & soda water  木糖醇和苏打水 Sealants  密封 胶
Low risk  低风险 Not required  不需要 May be done as a base line reference for new patients
可作为新患者的基线参考		 OTC fluoride-containing toothpaste twice daily
每日两次非处方含氟牙膏		 Bitewing radiographs every 18–24 months
每 18-24 个月进行一次咬合 X 光片		 Every 6–12 months to reevaluate caries risk
每 6-12 个月重新评估龋齿风险		 Not required  不需要 Not required  不需要
Moderate risk  中度风险 Not required  不需要 May be done as a base line reference for new patients or if there is suspicion of high bacterial challenge
可作为新患者或怀疑高度细菌感染的基线参考		 OTC fluoride-containing toothpaste twice daily plus: 0.05% NaF rinse daily
每天两次非处方含氟牙膏，外加：每天 0.05% NaF 漱口水		 Bitewing radiographs every 12–18 months
每 12-18 个月进行一次咬合 X 光片检查		 Every 4–6 months to reevaluate caries risk
每 4-6 个月重新评估龋齿风险		 Two tabs of gum or two candies four times daily
每日四次，每次 2 片口香糖或 2 颗糖果		 Required  必填
High risk  高风险 Chlorhexidine gluconate 0.12% 10 ml rinse for one minute daily for one week each month
葡萄糖酸氯己定 0.12% 10 毫升，每天冲洗 1 分钟，每月 1 周		 Saliva flow test and bacterial culture initially and at every caries recall appointment
最初和每次龋齿回忆预约时进行唾液流测试和细菌培养		 1.1% NaF toothpaste twice daily instead of regular fluoride toothpaste. NaF varnish clinically
每天两次，每次 1.1% NaF 牙膏，而不是普通含氟牙膏。NaF 清漆临床		 Bitewing radiographs every 6–12 months or until no cavitated lesions are evident
每 6-12 个月进行一次咬合 X 线片检查，或直到没有明显的空洞病变		 Every 3–4 months to reevaluate caries risk and apply fluoride varnish
每 3-4 个月重新评估龋齿风险并涂上氟化物清漆		 Two tabs of gum or two candies four times daily
每日四次，每次 2 片口香糖或 2 颗糖果		 Required  必填
Extreme risk  极度风险 Chlorhexidine 0.12% (preferably CHX in water base rinse) 10 ml rinse for one minute daily for one week each month
洗必泰 0.12%（最好是 CHX 在水基冲洗液中）10 毫升，每天冲洗 1 分钟，每月一周		 Saliva flow test and bacterial culture initially and at every caries recall appointment
最初和每次龋齿回忆预约时进行唾液流测试和细菌培养		 1.1% NaF toothpaste twice daily instead of regular fluoride toothpaste. NaF varnish clinically; household fluoride gel tray 5 min daily
每天两次，每次 1.1% NaF 牙膏，而不是普通含氟牙膏。NaF 清漆临床上;家用氟化物凝胶托盘 每天 5 分钟		 Bitewing radiographs every 6 months or until no cavitated lesions are evident
每 6 个月进行一次咬合 X 线片检查，或直到没有明显的空洞病变		 Every 3 months to reevaluate caries risk and apply fluoride varnish
每 3 个月重新评估龋齿风险并涂上氟化物清漆		 Two tabs of gum or two candies four times daily. Soda rinses four to six times daily
每日四次，每次 2 片口香糖或 2 片糖果。苏打水每天冲洗四到六次		 Required  必填
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Conclusion and expectation
结论和期望

It is of great significance to carry out entire-population and full-life-cycle caries management to maintain oral and systemic health and protect natural teeth., With the development of new diagnostic and therapeutic techniques, such as ultrasonic and optical diagnosis, 3D printing and digital navigation, difficulty assessment system of caries prevention and management will be further improved. Based on the research progress of etiology and pathogenesis of caries, core microbiome is considered as the main factor of the occurrence and development of caries and the key to adjust the unbalanced micro ecological targets. It is expected to become the main microbiological index of caries risk assessment.– With the deep research of the microbial community and the application of machine learning, the caries prediction can be carried out by the big data of microbial community, which will further enrich the difficulty assessment system of caries prevention and management. Because of the high prevalence of caries in our country, it is essential to effectively integrate family doctors, community doctors, oral general practitioners and cariology specialists, and combine with community management and personalized treatment. Caries risk assessment and difficulty assessment system of caries prevention and management are important basis for hierarchical diagnosis and treatment. Through the promotion of full-life-cycle caries management, medical resources can be used more efficiently to achieve effective caries prevention and treatment.
开展全群、全生命周期的龋齿管理，维护口腔和全身健康，保护天然牙齿，具有重要意义。 元随着新的诊断和治疗技术的发展，如超声和光学诊断、3D 打印和数字导航，龋齿预防和管理的难度评估系统将得到进一步完善。根据龋病病因和发病机制的研究进展，核心微生物组被认为是龋病发生发展的主要因素，是调节不平衡微观生态靶点的关键。有望成为龋齿风险评估的主要微生物学指标。–随着微生物群落的深入研究和机器学习的应用，微生物群落大数据可以进行龋齿预测，这将进一步丰富龋齿预防和管理的难度评估体系。由于我国龋病患病率高，必须将家庭医生、社区医生、口腔全科医生和龋病学专家有效整合，并与社区管理和个体化治疗相结合。龋病风险评估和龋病预防与管理的难度评估体系是分级诊疗的重要依据。通过推动龋齿全生命周期管理，可以更高效地利用医疗资源，实现有效的龋齿预防和治疗。

Supplementary information
补充信息

41368_2022_167_MOESM1_ESM.docx (39.8KB, docx)
41368_2022_167_MOESM1_ESM.docx （39.8KB，文档x）

Supplementary Materials for Expert Consensus on Dental Caries Management
龋齿管理专家共识的补充材料

Acknowledgements  确认

This study was supported by National Natural Science Foundation of China [81870759].
这项研究得到了中国国家自然科学基金 [81870759] 的支持。

Author contributions  作者贡献

Conceptualization & Investigation, X.Z. and Z.C.; Supervision, X.Z. and Z.C.; Original draft, L.C. and L.Z.; Review & Editing, L.Y., J.L., M.F., D.Y., Z.H., Y.N., J.L., J.Z., Y.L., and B.G.
概念化与调查，X.Z. 和 Z.C.;监督，X.Z. 和 Z.C.;原稿，L.C. 和 L.Z.;审查与编辑，L.Y.，J.L.，M.F.，D.Y.，Z.H.，Y.N.，J.L.，J.Z.，Y.L.和B.G.

Competing interests  利益争夺

The authors declare no competing interests.
作者声明没有利益冲突。

Footnotes  脚注

These authors contributed equally: Lei Cheng, Lu Zhang
这些作者的贡献相同： Lei Cheng， Lu Zhang

Contributor Information  贡献者信息

Zhi Chen, Email: zhichen@whu.edu.cn.
Zhi Chen，电子邮件：zhichen@whu.edu.cn.

Xuedong Zhou, Email: zhouxd@scu.edu.cn.
Xuedong 周，电子邮件：zhouxd@scu.edu.cn.

Supplementary information
补充信息

The online version contains supplementary material available at 10.1038/s41368-022-00167-3 IF: 24.897 Q1 .
在线版本包含补充材料，可在 10.1038/s41368-022-00167-3 上获得。

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Supplementary Materials for Expert Consensus on Dental Caries Management

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