|Year : 2017 | Volume
| Issue : 3 | Page : 210-214
An overview of caries risk assessment: Rationale, risk indicators, risk assessment methods, and risk-based caries management protocols
Ekta Singh Suneja1, Bharat Suneja2, Bhuvanesh Tandon1, Nebu Ivan Philip3
1 Department of Conservative Dentistry and Endodontics, BJS Dental College and Hospital, Ludhiana, Punjab, India
2 Department of Pediatric and Preventive Dentistry, BJS Dental College and Hospital, Ludhiana, Punjab, India
3 Department of Pediatric and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Kothamangalam, Kerala, India
|Date of Web Publication||7-Aug-2017|
Ekta Singh Suneja
Department of Conservative Dentistry and Endodontics, BJS Dental College and Hospital, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
The paradigm shift in our understanding of the dynamic, multifactorial nature of dental caries and the resultant change in caries preventive and treatment strategies necessitates that caries risk assessment (CRA) should be an integral part of any caries management protocol. This review discusses the rationale for CRA and the role various risk indicators play in the fluctuating demineralization-remineralization cycle of dental caries. It also provides an overview of different CRA methods and a risk-based clinical protocol for dental caries management in infants and children.
Keywords: Caries risk, management protocol, risk assessment
|How to cite this article:|
Suneja ES, Suneja B, Tandon B, Philip NI. An overview of caries risk assessment: Rationale, risk indicators, risk assessment methods, and risk-based caries management protocols. Indian J Dent Sci 2017;9:210-4
|How to cite this URL:|
Suneja ES, Suneja B, Tandon B, Philip NI. An overview of caries risk assessment: Rationale, risk indicators, risk assessment methods, and risk-based caries management protocols. Indian J Dent Sci [serial online] 2017 [cited 2020 Jul 14];9:210-4. Available from: http://www.ijds.in/text.asp?2017/9/3/210/212397
| Caries Risk Assessment – Rationale|| |
For a long time, the diagnosis and treatment of dental caries was based on identifying demineralization or cavitation on the tooth surface, and its treatment by “surgical” removal of the carious tooth structure and placement of a suitable restoration. However, it is now well-recognized that a caries management protocol that is limited to surgical treatment of the chronic infectious disease of dental caries, without addressing the risk factors responsible for the disease, will eventually only result in new carious lesions appearing and failure of any treatment rendered.
Hausen has defined caries risk as the probability that an individual will develop a certain number of carious lesions (cavitated or noncavitated) or reach a given level of disease progression, over a specific period of time, provided his or her exposure status remains the same during this period. Assessing a patient's caries risk status is an essential component in the modern day management of dental caries, where the emphasis is on a nonoperative/preventive approach, rather than just the surgical/restorative intervention to the disease process.,
Incorporation of caries risk assessment (CRA) into regular clinical practice can assist the dental professional in making standardized preventive and treatment recommendations (e.g., frequency of recall visits, number of diagnostic radiographs needed, fluoride treatment modalities, anticipatory guidance protocols, etc.) according to each patient's caries risk status. Risk assessment can thus also contribute to a more efficient allocation of time and resources for oral health programs by eliminating many unnecessary interventions (e.g., professional topical fluoride application in a low caries risk child).
CRA can be used as a valuable motivating tool for patients, encouraging them to undertake measures that will move them from a high/moderate-risk category to a low-risk category. Besides this, CRA can potentially promote caries prevention at the primary level itself, i.e., even before the initiation of the disease process. This could enable even high caries risk children to reach adulthood caries free – a goal every pediatric dentist strives to achieve for their patients.
| Caries Risk Assessment - Risk Indicators|| |
Keyes triad of the primary factors responsible for dental caries (fermentable substrate, cariogenic bacteria, and a susceptible host) still holds true, however it is now well established that dental caries is a multifactorial, chronic infectious disease, with fluctuating cycles of demineralization and remineralization. The dynamic interplay between pathologic factors that favor demineralization (e.g., high MS levels) and protective factors that promote remineralization (e.g., presence of free F − ion in the oral environment) will ultimately determine whether caries lesions develop/progress or not.
Caries risk indicators are thus multivariate between pathological factors that cause the disease directly (e.g., frequent sugar exposures, high MS counts), variables that may be considered protective (e.g., topical fluoride exposure, adequate plaque control), and those factors that may play a contributing role (e.g., deep pits and fissures, salivary factors, and socioeconomic status). A summary of the various caries risk indicators broadly divided into pathological and protective factors is shown in [Table 1].,,,,,,,,,,,,,,,,,,,,,,,,,,,,
After an extensive review of literature on caries risk indicators, Zero, Fontana, and Lennon concluded that no single indicator or combination of risk indicators could consistently be a good predictor of caries risk status when applied across different populations and age groups. In general, however, the best indicator of future caries risk is the past caries experience, although this may not be particularly useful in children where it is vital to determine caries risk status before any caries lesions develop.
| Caries Risk Assessment Methods|| |
A number of CRA methods have been proposed for use in clinical practice as follows:
- Caries Questionnaire in combination with Clinical Observations 
- AAPD's Caries-risk Assessment Form.
- The Cariogram Model 
- Caries Assessment and Risk Evaluation (CARE) test 
- Caries management by risk assessment (CAMBRA)
- Traffic Light Matrix (TLM).
Caries questionnaire in combination with clinical observations
Based on the concept that dental caries is an infectious disease where there is a dynamic balance or imbalance between pathological factors (that cause demineralization) and protective factors (that favor remineralization), Featherstone et al. evolved a consensus statement to assess individual caries risk from a questionnaire that addresses issues such as maternal dental history, family dynamics, socioeconomic factors, oral hygiene measures, fluoride exposure, and frequency of sugar exposures. Along with the questionnaire, clinical observations were made by visual, tactile, and radiographic examination of teeth. Once individual risk status was determined, they suggested using a minimally invasive caries management protocol that included appropriate preventive and therapeutic recommendations.
American Academy of Pediatric Dentistry's caries risk assessment form
Incorporating the most recent evidence and expert/consensus opinion,,,, the AAPD modified its original Caries-risk Assessment Tool (CAT), into a more sensitive and practical tool to assist dental practitioners, physicians, and nondental health-care providers in assessing the levels of risk for caries development in infants, children, and adolescents. Caries-risk Assessment forms were formulated that can be used by dentists to assess caries risk status for 0–5-year-old and ≥6-year-old children. Risk assessment categorization of low, moderate, or high is based on the preponderance of factors for the individual. However, clinical judgment may justify the use of one factor (e.g., frequent exposure to cariogenic snacks, ≥1 interproximal lesions, and low salivary flow) in determining the overall risk.
The Cariogram model
The Cariogram model was first presented by Brathall as a graphical illustration of an individual's risk of developing new caries lesions in the future. It also simultaneously expresses the extent to which the different etiological factors of dental caries affect caries risk for that particular individual.
The original Cariogram pie chart had three differently colored sectors representing the primary factors in caries etiology – bacteria (red), sugars (blue), and host susceptibility (light blue). This was later modified to include two more sectors – a yellow sector representing circumstances (past caries experience and general health status), while a green sector representing “Percent Chance to Avoid Cavities.” The size of the green “Chance” sector is determined by the size of the other four sectors, and by reducing or modifying the size of these sectors, one can increase the “Percent Chance to Avoid Cavities.”
The Cariogram is an interactive computer-based program that calculates the “Percent Chance to Avoid Cavities” after entering a number of scores for different risk factors. The results come out based on “weighted” values. These “weights” are a result of literature reviews using an evidence-based approach, in combination with clinical experience of evaluating dental caries including the use of saliva tests.
The Cariogram model is a valuable educational tool to demonstrate to patients the different etiological factors of dental caries and how the patient's caries risk status can change as a result of various preventive actions he/she may undertake. A study to assess caries risk in schoolchildren using the Cariogram concluded that it predicted caries increment more accurately than any other single-factor model.
Caries Assessment and Risk Evaluation test
While the above-mentioned risk indicators are still of primary importance in assessing individual caries risk status, several studies have also shown a strong, statistically significant, genetic component determining caries experience., This may be especially important in developed societies that have a good dental coverage, adequate fluoride exposure, and where gross malnutrition and negligent oral hygiene are rare; increasing the role a child's genes may play in determining his or her caries susceptibility. Evaluating a child's genetic susceptibility to dental caries may thus play a vital role in assessing the child's overall caries risk status.
Researchers at the Division of Diagnostic Sciences of the University of Southern California School of Dentistry developed a novel salivary test for genetic CRA called the CARE test  based on the high correlations they found between caries history and quantities of specific oligosaccharides in whole saliva. Certain salivary oligosaccharides are known to facilitate bacterial attachment and colonization of the salivary pellicle, while other salivary sugar chains promote agglutination and removal of free bacteria. In the case of the former, there is a positive correlation with caries experience, while for the latter, a negative correlation is seen., Since the pattern of these salivary oligosaccharides is 100% genetically determined, identifying individual salivary oligosaccharide concentrations can help determine the genetic risk of the child to develop caries. It was also established that, just like blood group types, the salivary oligosaccharide patterns remain quantitatively consistent over time and across age groups.
The CARE test is probably the only CRA method that can potentially promote caries prevention at the primary level itself (before any carious lesions have appeared), by identifying high caries risk children early and instituting a preemptive aggressive preventive regimen in them. The widespread incorporation of the CARE test in clinical practice and its use in conjunction with other more traditional risk assessment methods is probably the future of dental CRA.
Caries management protocol for infants and children
In the modern day clinical practice, the focus of any caries management protocol should rely more on a “medical” rather than solely on a “surgical” approach to the treatment of dental caries. This change has occurred due to a paradigm shift in our understanding of two important aspects:
- The principal mechanisms by which fluorides bring about their cariostatic action, where its topical role is emphasized over any presumed systemic benefit ,
- The chronic, infectious, transmissible, and multifactorial nature of dental caries where the interplay between demineralization/remineralization factors will determine whether caries progresses or not.
The AAPD has developed one of the best clinical protocols for the management of caries in different age groups of infants and children. These protocols were evolved from evidence-based peer-reviewed literature, considered judgment of expert panels, and clinical experience. Following these protocols will enable dentists treating children to make standardized diagnostic, preventive, and restorative recommendations depending on child's risk status and the compliance expected from parents. Caries management protocols need to be constantly evolving based on the latest evidence-based research and should also reflect newer therapeutic modalities. The application of casein phosphopeptide-amorphous calcium phosphate products for its positive effect on the demineralization/remineralization caries cycle, using more effective fluoride compounds such as silver diamine fluoride, or the potential of antimicrobials to reverse caries  are some of the innovative technologies that may be included in the future caries management protocols. On the other hand, some of the current recommendations such as use of systemic fluoride supplements may be avoided in the future protocols.
Caries Management by Risk Assessment
The science of CAMBRA deals with caries management using risk assessment protocols for diagnosis, treatment, and prevention, including nonsurgical means for repairing or remineralizing tooth structure. So, with CAMBRA methodology, evidence-based CRA is followed by specific treatment recommendations, for example, behavioral, chemical, and minimally invasive procedures. This will further establish the balance of pathologic and protective factors back to favor health. The introduction of CAMBRA involved the production of CRA forms for clinicians to use in practice. One form was designed to use with newborns to children aged 5 years  and the second for patients aged 6 years through adulthood.
Traffic light matrix
This is a commonly used CRA tool in Australia. It uses color codes such as red, green, and orange to convey specific threshold values for data obtained in the analysis. The objective is to alert the clinician regarding the current risk status. The model is designed to keep the visual interpretation simple and easily communicable to the patient. It is based on 19 criteria in 5 different categories including saliva (6 criteria), plaque (3 criteria), diet (2 criteria), fluoride exposure (3 criteria), and modifying factors (5 criteria).
- Saliva: (a) Resting: Hydration, viscosity, and pH (b) stimulated: Quantity/rate, pH, and buffering capacity
- Plaque: PH, maturity, and bacteria – mutans count
- Diet: Number of sugar and acid exposures in-between meals/day
- Fluoride: Exposure to fluoride through water/toothpaste/professional treatment
- Modifying factors: Drugs that reduce salivary flow, diseases resulting in dry mouth, fixed/removable appliances, recent active caries, and poor compliance.
The specific threshold values for the data obtained in the analysis of the aforementioned factors are conveyed in traffic light color codes conveying varying risk levels (red = high, yellow = moderate, and green = low). This color code model keeps the visual interpretation simple and communicable to the patient as well.
| Conclusion|| |
The paradigm change in our understanding of dental caries and its prevention and treatment makes it mandatory for all dentists treating infants, children, adolescents, and adults to incorporate CRA into their clinical practice and utilize risk-based caries management protocols to make diagnostic, preventive, and restorative recommendations for their patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tsang P, Qi F, Shi W. Medical approach to dental caries: Fight the disease, not the lesion. Pediatr Dent 2006;28:188-91.
Hausen H. Caries prediction – State of the art. Community Dent Oral Epidemiol 1997;25:87-96.
Anderson MH, Bales DJ, Omnell KA. Modern management of dental caries: The cutting edge is not the dental bur. J Am Dent Assoc 1993;124:36-44.
Pitts NB. Are we ready to move from operative to non-operative/preventive treatment of dental caries in clinical practice? Caries Res 2004;38:294-304.
Keyes PH. The infectious and transmissible nature of experimental dental caries. Findings and implications. Arch Oral Biol 1960;1:304-20.
Featherstone JD, editor. Clinical aspects of de/remineralization of teeth. In: Advances in Dental Research, e-supplement to the Journal of Dental Research 1995;9:1-340.
Featherstone JD. The caries balance: Contributing factors and early detection. J Calif Dent Assoc 2003;31:129-33.
Weiss RL, Trithart AH. Between-meal eating habits and dental caries experience in preschool children. Am J Public Health Nations Health 1960;50:1097-104.
Hallonsten AL, Wendt LK, Mejà re I, Birkhed D, Håkansson C, Lindvall AM, et al.
Dental caries and prolonged breast-feeding in 18-month-old Swedish children. Int J Paediatr Dent 1995;5:149-55.
Gardner DE, Norwood JR, Eisenson JE. At-will breast feeding and dental caries: Four case reports. ASDC J Dent Child 1977;44:186-91.
Burt BA, Pai S. Sugar consumption and caries risk: A systematic review. J Dent Educ 2001;65:1017-23.
Tinanoff N. Association of diet with dental caries in preschool children. Dent Clin North Am 2005;49:725-37, v.
Thitasomakul S, Piwat S, Thearmontree A, Chankanka O, Pithpornchaiyakul W, Madyusoh S. Risks for early childhood caries analyzed by negative binomial models. J Dent Res 2009;88:137-41.
Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J Am Dent Assoc 1998;129:1229-38.
Litt MD, Reisine S, Tinanoff N. Multidimensional causal model of dental caries development in low-income preschool children. Public Health Rep 1995;110:607-17.
Berkowitz RJ, Turner J, Green P. Maternal salivary levels of Streptococcus mutans
and primary oral infection of infants. Arch Oral Biol 1981;26:147-9.
Berkowitz RJ, Jones P. Mouth-to-mouth transmission of the bacterium Streptococcus mutans
between mother and child. Arch Oral Biol 1985;30:377-9.
Nowak AJ, Casamassimo PS. The dental home: A primary care oral health concept. J Am Dent Assoc 2002;133:93-8.
Way RM. The effect on dental caries of a change from a naturally fluoridated to a fluoride-free communal water. J Dent Child 1964;31:151-7.
Hayes RL, Littleton NW, White Cl. Posteruptive effects of fluoridation on first permanent molars of children in Grand Rapids, Michigan. Dent Abstr 1987;2:615.
Featherstone JD. Prevention and reversal of dental caries: Role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31-40.
Jenkins GN. Recent changes in dental caries. Br Med J (Clin Res Ed) 1985;291:1297-8.
Rock WP, Gordon PH, Bradnock G. Dental caries experience in Birmingham and Wolverhampton school children following the fluoridation in Birmingham Water in 1964. Method and overall caries experience in the two populations. Br Dent J 1981;150:61-6.
Englander HR, Reuss RC, Kesel RG. Roentgenographic and clinical evaluation of: Dental caries in adults who consume fluoridated versus fluoride-deficient water. J Am Dent Assoc 1964;68:14-9.
Glassman P, Miller C. Dental disease prevention and people with special needs. J Calif Dent Assoc 2003;31:149-60.
McDonald RE, Avery DR, Stookey GK. Dental caries in the child and adolescent. In: McDonald RE, Avery DR, Dean JA, editors. Dentistry for the Child and Adolescent. 8th
ed. St. Louis: CV Mosby Co.; 2004. p. 212-3.
Bigeard L. The role of medication and sugars in pediatric dental patients. Dent Clin North Am 2000;44:443-56.
Leone CW, Oppenheim FG. Physical and chemical aspects of saliva as indicators of risk for dental caries in humans. J Dent Educ 2001;65:1054-62.
Köhler B, Andréen I, Jonsson B. The earlier the colonization by mutans streptococci, the higher the caries prevalence at 4 years of age. Oral Microbiol Immunol 1988;3:14-7.
Grindefjord M, Dahllöf G, Nilsson B, Modéer T. Prediction of dental caries development in 1-year-old children. Caries Res 1995;29:343-8.
Rosenbloom RG, Tinanoff N. Salivary Streptococcus mutans
levels in patients before, during, and after orthodontic treatment. Am J Orthod Dentofacial Orthop 1991;100:35-7.
Gregory RL, el-Rahman AM, Avery DR. Effect of restorative treatment on mutans streptococci and IgA antibodies. Pediatr Dent 1998;20:273-7.
Adair SM. The role of sealants in caries prevention programs. J Calif Dent Assoc 2003;31:221-7.
Maguire A, Rugg-Gunn AJ. Xylitol and caries prevention – Is it a magic bullet? Br Dent J 2003;194:429-36.
Caufield PW, Dasanayake AP, Li Y. The antimicrobial approach to caries management. J Dent Educ 2001;65:1091-5.
Köhler B, Andréen I, Jonsson B. The effect of caries-preventive measures in mothers on dental caries and the oral presence of the bacteria Streptococcus mutans
and lactobacilli in their children. Arch Oral Biol 1984;29:879-83.
Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ 2001;65:1126-32.
Featherstone JD, Adair SM, Anderson MH, Berkowitz RJ, Bird WF, Crall JJ, et al.
Caries management by risk assessment: Consensus statement, April 2002. J Calif Dent Assoc 2003;31:257-69.
American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2013;35:E157-64.
Bratthall D, Hänsel Petersson G. Cariogram – A multifactorial risk assessment model for a multifactorial disease. Community Dent Oral Epidemiol 2005;33:256-64.
Denny PC, Denny PA, Takashima J, Si Y, Navazesh M, Galligan JM. A novel saliva test for caries risk assessment. J Calif Dent Assoc 2006;34:287-90, 292-4.
Young DA, Featherstone JD, Roth JR. Curing the silent epidemic: Caries management in the 21st
century and beyond. J Calif Dent Assoc 2007;35:681-5.
Caries Risk Assessment for Children: Information for Oral Health Practitioners. Colgate Dental Education Programs, Special Topic No. 10; 2015.
Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL, Featherstone JD. Caries risk assessment appropriate for the age 1 visit (infants and toddlers). J Calif Dent Assoc 2007;35:687-702.
Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc 2007;35:703-7, 710-3.
American Academy of Pediatric Dentistry. The use of a caries-risk assessment tool (CAT) for infants, children and adolescents. Pediatr Dent 2002;24 7 Suppl:15-7.
Hänsel Petersson G, Twetman S, Bratthall D. Evaluation of a computer program for caries risk assessment in schoolchildren. Caries Res 2002;36:327-40.
Bretz WA, Corby PM, Schork NJ, Robinson MT, Coelho M, Costa S, et al.
Longitudinal analysis of heritability for dental caries traits. J Dent Res 2005;84:1047-51.
Hassell TM, Harris EL. Genetic influences in caries and periodontal diseases. Crit Rev Oral Biol Med 1994;5:203-48.
Denny PC, Denny PA, Navazesh M. Correlation of saliva mucin concentrations with caries history in Caucasian young adults. J Dent Res 2003;82:250-7.
Stenudd C, Nordlund A, Ryberg M, Johansson I, Källestål C, Strömberg N. The association of bacterial adhesion with dental caries. J Dent Res 2001;80:2005-10.
Lenander-Lumikari M, Loimaranta V. Saliva and dental caries. Adv Dent Res 2000;14:40-7.
Lloyd KO. The chemistry and immunochemistry of blood group A, B, H, and Lewis antigens: Past, present and future. Glycoconj J 2000;17:531-41.
Prakobphol A, Leffler H, Fisher SJ. The high-molecular-weight human mucin is the primary salivary carrier of ABH, Le a
, and Le b
blood group antigens. Crit Rev Oral Biol Med 1993;4:325-33.
Fejerskov O, Thylstrup A, Larsen MJ. Rational use of fluorides in caries prevention. A concept based on possible cariostatic mechanisms. Acta Odontol Scand 1981;39:241-9.
Hicks J, Garcia-Godoy F, Flaitz C. Biological factors in dental caries: Role of remineralization and fluoride in the dynamic process of demineralization and remineralization (part 3). J Clin Pediatr Dent 2004;28:203-14.
Yengopal V, Mickenautsch S. Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): A meta-analysis. Acta Odontol Scand 2009;67:321-32.
Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: A caries “silver-fluoride bullet.” J Dent Res 2009;88:116-25.
Ismail AI, Hasson H. Fluoride supplements, dental caries and fluorosis: A systematic review. J Am Dent Assoc 2008;139:1457-68.