|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 2018 Jan 18];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.
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