Caries Risk Assessment and Management

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CONTENTS
1. Introduction
2. Terms used in caries risk assessment
and risk prediction
3. Defining risk assessment and risk prediction
4. The course of a typical prediction study
5. Principles of caries risk prediction

6. CARIES RISK PREDICTION
 Key risk age groups
 Risk individuals
 Key risk teeth
 Key risk surfaces
7. COMMUNITY AND GROUP APPROACHES TO CARIES
RISK PREDICTION BASED ON
 Past caries experience
 Microbial colonization
 Salivary factors
 Dietary habits and oral hygiene practices
 Social and behavioral factors

8.THE CARIOGRAM MODEL
9. CONCLUSIONS
10. REFERENCES

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RISK
The probability that an event will occur.
It is the probabiltiy that a particular outcome
Will occur following a particular exposure,
And it usually implies a bad outcome,
A disease or mortality, rather than a good One. (Burt B A,2005)

RISK FACTOR
It is defined as “An aspect of personal behavior, an environmental
exposure or an inborn or inherited characteristic, which on the
basis of epidemiological evidence is known to be associated with
health related condition considered to be important to prevent”
(Last 1988)

RISK PREDICTOR (RISK MARKER)
A characteristic associated with elevated risk of
disease (i.e. it predicts well), but is not thought to be
part of the causal chain.
e.g. Number of missing teeth or baseline caries
is a good predictor of future caries.
They are useful to identify who is at risk.
.

RISK INDICATOR
(Potential, probable, putative risk factor)
Factors that have proved, in cross-sectional studies, to be
significantly associated with Increased prevalence of a specific
disease.
(PER AXELSSON)
IT MAY BE A PROBABLE RISK FACTOR

PREDICTION MODEL
A multivariate model developed when we think that we
understand the disease’s etiology and we are mainly interested
in identifying who is at high risk.
RISK MODEL
A multivariate model developed when it is important to
identify one or more risk factors for the disease so that
likely points for intervention can be planned
(BECK JD,1998)

Risk assessment studies differ from Risk
prediction studies.
RISK ASSESSMENT
Clinicians assess risk.
They try to know what happens to the individuals with
different levels of risk factors if no individual protection is
offered to them.
The interest of the clinician is to influence the patient’s
exposure status so as to bring the risk down to an acceptable
level.

RISK PREDICTION
Researchers predict risk.
Researcher’ s who predict future caries are not interested in
preventing it.
THE ESSENCE OF PREDICTION STUDIES
PROVIDE TOOLS For assessing caries risk in clinical practice
at the individual or Community level.

N
BHR
BLR
HIGH TCI (a)
LOW TCI (b)
HIGH TCI (c)
LOW TCI (d)
Follow- up interval

1. The higher the risk of developing caries for most of the
population, the more significant the effects of one single
preventive measure and the stronger the correlations
between one single etiologic or modifying Risk factor
and the risk for caries Development.
2. In populations in which only a minority of the people
will develop new carious lesions, it is necessary to use
accurate risk predictive measures to select at-risk
individuals and introduce needs related combinations of
caries preventive measures.
A high risk strategy.

GOALS OF CARIES RISK PREDICTION
Screen out low risk patients (to allow safe recommendation of
long recall intervals).
Identify high risk patients before they become caries active.
Monitor changes in disease status in caries active patients.
(IVERSON MN et.al., 2000)

CARIES RISK PREDICTION (PER AXELSSON)
Key risk age groups
Risk individuals
Key risk teeth
Key risk surfaces

I RISK GROUPS FOR DENTAL CARIES
Carious lesions are initiated more frequently
At specific ages –risk age groups.
Key Risk Age Group 1 : Ages 1 To 2 Years
Key risk age groups
in young adults
and adults
Ages 19 to 22 years
Dentate elderly

KEY RISK AGE GROUP 1: AGES 1 TO 2 YEARS
All newly erupted teeth are deficient in mineral
content and thus more susceptible for caries.
(Kotsanos and Darling,1991)
The eruption of teeth per se, constitutes a caries
risk since new surfaces become available for
the disease.

Mothers with high salivary mutans streptococcus
levels transmit them to their babies as soon as the first
primary teeth erupt, leading to greater development of caries.
(Kohler et. Al. 1982)
In infants, the specific immune system, immunoglobins in
saliva, is immature.
First priority risk age groups are:
Expectant mothers
1-2 year olds, starting with girls.

KEY RISK AGE GROUP 2: AGES 5 TO 7 YEARS
(ERUPTION OF 1st
MOLARS)
Eruption Of First Permanent Molars Constitute
a well known occlusal risk.
Plaque reaccumulation after mechanical tooth
cleaning is heavy on the occlusal surfaces
of erupting molars. (Carvalho et. Al. 1989)
Enamel of erupting and newly erupted teeth
is more susceptible to caries until secondary
maturation is completed.

Key risk age group 3: ages 11 to 14 years
(Eruption of second molars)
This period offers a high number of newly
erupted surfaces susceptible for decay.
The enamel of the approximal surfaces of
newly erupted posterior teeth are undergoing
secondary maturation. Hence they are highly
caries susceptible.

Key risk age groups in young adults and adults
Erupting or newly erupted third molars
Without full chewing function are highly
susceptible to caries as secondary maturation
is not complete.
Ensuing changes in lifestyle, dietary and oral
Hygiene habits.

OTHER RISK GROUPS
Persons in frequent food sampling occupations.
Obese people who eat frequently.
Drug abusers.
Persons with systemic diseases on medications.
Pregnant women.
Persons with impaired salivary function and
immune response.
Persons with poor dental care habits.

II RISK INDIVIDUALS FOR DENTAL CARIES
Risk individual: subject whose individual risk
of developing dental caries is high.
CARIES RISK ASSESSMENT OF THE INDIVIDUAL
 BACKGROUND DATA
( General diseases, medications, Social/family situation
Dietary/ oral hygiene habits)
 Clinical examination
 Caries activity tests

III KEY RISK TEETH
 Molars are the key risk teeth for caries.
 The pattern of dental caries in the dentition is
reflected in terms of missing teeth and DMFS.
Risk For Tooth Loss Can Be Predicted By
 Measuring the bucco-lingual width of tooth
crown.

IV KEY RISK SURFACES
1. The fissures of the molars.
2. The approximal surfaces of the posterior
teeth, from the mesial surfaces of second
molars to the distal surfaces of the
first premolars.
3. The approximal surfaces of the maxillary
incisors, the buccal surfaces of molars,
lingual surfaces of mandibular molars.
4. In elderly people, exposed root surfaces,
particularly buccal and approximal surfaces.

METHODS AND MODELS FOR ASSESSING CARIES RISK
There are two perspectives to caries risk
Assessment methods:
Assessment methods used by clinicians in
examining patients and in making decisions in
treatment planning and case management.
The Assessment Methods Studied In Prospective
Research Studies.

THE METHODS USED FOR IDENTIFICATION OF
INDIVIDUALS OR GROUPS AT RISK FOR CARIES
IS BASED ON:
Past caries experience
Microbial colonization
Salivary factors
Dietary habits and oral hygiene practices
Social and behavioral factors

I. RISK PREDICTION BASED ON PAST CARIES EXPERIENCE
The most commonly used factor in the assessment
of caries risk.
Across age and circumstances, indicators of Past caries experience
are the strongest Predictors and the most reliable single predictor.
( HAUSEN H, 1997, ERIKSSON HM et.al., 1991,
DEMERS M et.al., 1990)

The status of the most recently erupted or exposed surface is the
best predictor of caries for the newly emerging surfaces.
(POWELL et.al., 1998).
Unrestored lesions on primary and permanent teeth are the
strongest predictors of caries.
Proximal caries scores are stronger predictors than past occlusal
caries.
(SAEMUNDSSON SR, 1997).

Early restoration of a first permanent molar is powerful
indicator of the later need for restorations in all other molar
teeth.
( VIRTANEN JI, 1997).
Once the first molars have erupted, their occlusal anatomy
becomes a good predictor.Once the fissured surfaces are filled
or sealed,Smooth surfaces become better predictors.
Gingival recession secondary to periodontal disease along with
previous tooth damage is a good predictor of root caries.
(ABERNATHY JR et.al., 1987).

LIMITATIONS:
In children where first molars are sealed shortly
after eruption, caries experience in first molars
Will be of limited value.
In adults where considerable tooth surfaces
are filled, the DMF score is a less reliable
Predictor of coronal caries.
A person with high DMF score may have no risk of
further caries at all if the level of relevant
risk factors has turned favorable and vice-versa.

II RISK PREDICTION BASED ON MICROBIAL
COLONIZATION
Basis: microbial model of caries control
Dental caries is an infection caused by putative
Cariogenic organisms.
THE KEY TO CONTROL CARIES:
Diagnosis of infection prior to the appearance
of clinically apparent lesions.

TESTS FOR MUTANS STREPTOCOCCI
1. Lab test
Culturing mutans streptococci in saliva or plaque on agar plates
With mitis-salivarius bacitracin agar.
A count of >1 million cfus/ml of saliva indicates
that most teeth are colonised by streptococcus mutans.
Many tooth surfaces are at high caries risk.

2. CHAIR SIDE TEST
Strip-mutans test
Developed by JENSON and BRATTHALL.
Values of 103
cfu/ml in saliva Low risk
Values of >106
cfu/ml in saliva High risk

SALIVARY LACTOBACILLI COUNT
Considered as Secondary invaders and responsible for
the Progression of already established Lesions.
LACTOBACILLI Count Estimates Caries activity due
to poor eating habits.

TESTS FOR SALIVARY LACTOBACILLI
1. LAB TEST
Culturing of lactobacilli in saliva or plaque using
Selective medium, Rogosa sl-agar.
2. CHAIR-SIDE TEST
Dentocult-lb Test (LARMAS M,1975)
104
cfu/ml of saliva ------ low value
≥ 106
cfu/ml of saliva ------ high value

STUDIES:
There is an association between the number of carious lesions
and the level of mutans streptococci in saliva and plaque,
in children and adults.
(BEIGHTON, 1991, BRATTHAL, 1991)
There is a positive correlation between mutans streptococci
levels in saliva and caries levels in italian Children.
(CAMPUS G et.al.,1997)

The caries predictive power of lactobacilli and yeasts
in 6-11 year olds, over 3 year period was higher than that
using lactobacilli alone.
(PIENIHAKKINEN et.al., 1987)
Plaque candida and lactobacilli were significant predictors of
root caries among 47-79 year old People.
(Specificity :0.88 and sensitivity:0.79)
(SCHIENIN et.al., 1992)
Along with past caries experience lactobacillus count was found to
be significant predictor
(Specificity :0.82 and sensitivity:0.77)

LIMITATIONS:
Bacterial counts in the oral cavity have only
A moderate predictive ability because:
Past caries experience usually enters most prediction
models first, thus diminishing the prediction added by
bacterial variables.
Bacterilogical tests are highly specific but they have low
positive predictive value.

Because of the multifactorial nature of Dental caries,
microbial counts are not fully effective in diagnosing caries
risk.
The Predictive Power of mutans streptococi in saliva has not
proven better than that of past caries experience
The reported sensitivities are < 50%.
Salivary lactobacilli count as a screening test is of
limited value because of low caries incidence.

III PREDICTION BASED ON SALIVARY FACTORS
MEASUREMENT OF SALIVARY FLOW RATE:
Saliva sample
STIMULATED
UNSTIMULATED
Salivary flow rate can provide a diagnostic basis for
treatment planning.

STIMULATED SALIVA:
Normal stimulated secretion rate is 1-3 ml/min
Values below 0.7 ml/min ----- xerostomia
Risk for caries
(BEVENIUS J, 1996)

UNSTIMULATED SALIVA
Normal flow rate : 0.25 to 0.35ml/min
Xerostomia : < 0.1 ml/min Risk for caries

STUDIES:
Salivary flow rate is a “key parameter” in caries risk assessment.
(Tenovuo j, 1997)
Severe reduction of salivary flow rate can predispose to caries
attack. (Powell lv, 1991)

LIMITATIONS:
Apart from true xerostomia, the caries predictive
Power of salivary flow rate is modest.
Salivary flow rates vary widely between individuals.

BUFFER CAPACITY OF SALIVA:
The buffer capacity of saliva is important for
The maintenance of normal pH levels in saliva
and plaque.
The buffer capacity of saliva is one of the best
indicators of caries susceptibility.

MEASUREMENT OF BUFFER CAPACITY
Dentobuff method
ERICSSON AND BRATTHALL,1989.
PH < 3 ----- low buffer capacity---- risk for caries
PH > 6 ----- high buffer capacity

STUDIES:
Along with streptoccus mutans and lactobailli, salivary phoshpates
were found to be a very good predictor
(Leverett et al 1993)
Patients with a high buffer capacity are caries
resistant, as high host response can compensate
for cariogenic habits.
(LARMAS M, 1992)

LIMITATIONS:
Sensitivity of salivary buffer capacity is low.
Commercial salivary kits are expensive.
Salivary tests measure the causes of caries or the actual
caries risk factors, but the subsequent development of
caries is so complex that the presence of one risk factor
does not mean caries will develop.

IV RISK PREDICTION BASED ON DIETARY HABITS AND
ORAL HYGIENE PRACTICES
High consumption of sugars has known to be an etiologic
factor in caries for decades.
In the modern age of frequent fluoride exposure, the
relationship between sugar consumption and caries
experience is not consistent.(Burt B A and Pai S, 2001)

The relationship between the presence of plaque and dental
caries is clearly established.
Professional plaque removal can result in a
Significant reduction in caries.(Lindhe J, 1975).
The relationship between plaque and dental caries is vague.
(Bellini H T, 1981).

High sucrose consumption and poor oral hygiene are
found in the same individual and the effect of one of
these two factors may vary with the degree of exposure
to the other.
STUDIES:
The risk of caries increased significantly with increasing sugar
consumption only when oral hygiene was poor in 5-13 year old
children.
(KLEEMOLA KE et.al., 1982).

Children with clean teeth had a low caries experience
irrespective of their diet.
(SCHRODER U,1983).
When oral hygiene indices were combined with dietary factors,
there was a significant association between plaque levels and
caries at all levels of sugar consumption.
But there was a low association between total sugar consumption
and caries.
(DEMERS M et.al., 1990)

LIMITATIONS:
As a screening criteria for high caries risk, self-reported
sucrose intake is of little value because obtaining accurate
information about dietary habits is difficult.
The positive predictive value of oral hygiene and dental
caries is low.

V RISK PREDICTION BASED ON SOCIAL AND
BEHAVIORAL FACTORS
Dietary and health habits are affected by income,
education and social environment.
Social background is important in assessing caries risk of
an individual.

STUDIES:
In western industrialized countries, people of low socioeconomic
status have higher caries score than people from higher
socioeconomic Status
(HUNT RJ,1990)
A negative association was found between socioeconomic status
and caries prevalence in primary and mixed dentitions,
regardless of Socioeconomic status index used.
(DEMERS M et.al., 1990)

In very young children without a long dental history ,
sociodemographic factors were successful in predicting the
caries (Grindgeford et al 1995)
Immigrant background was the strongest predictor of caries for
one year old children at the end of two and half years.
(Grindefjord et.Al., 1995).
Asian ethnicity was the strongest predictor of root caries for
people aged 59 years and above. (Powell et. Al., 1998).
Low maternal education was a predictor of dental caries among
11 year old children after 3 years. (Verrips et.Al., 1993).

Simple caries predictive models for infants Solely based on
behavioral factors have been developed.
Age, nocturnal bottle usage, additives on pacifier during sleep
and breast feeding were able to predict correctly 84% of affected
subjects. (Hogct, 1993)

Past caries experience and microbial counts along with
race,brushing, dental visits, parent education were significant
predictors of dental caries in 6 year old children after 3 years.
(Beck et.Al., 1992)

Social and behavioral factors are important to models of young
children and the elderly. This is because, the immune system is
more challenged at these ages, and thus, bacterial insults and
poor health behaviors have a more significant effect. (Powell
Pa, 1998)

LIMITATIONS:
In assessment of caries risk the reported sensitivities and
specifities are low.
Social status may affect caries risk differently in different
countries.
Screening based on social status may not be considered ethically
accepatable in most countries.

COMBINATION OF DIFFERENT PREDICTORS
The power of any single predictor in risk assessment is not
satisfactory.
Using screening criteria based on multiple factors like past caries
experience, microbial tests, socio-demographic details can
improve the accuracy of risk prediction.

A new model, the cariogram, was presented in 1996 by Bratthall
for illustration of the interactions of caries-related factors.
The model makes it possible to single out individual risk or
resistance factors.
The original cariogram was a circle divided into three
sectors, each representing factors strongly influencing
carious activity:
Diet, bacteria, and susceptibility.

NEED:
Graphically, the program maps the interactions of relevant
factors – cariography.
The findings, with their varying impact on caries, are
entered into a computer and the factors are weighed against
each other forming a risk Profile of the patient.

They can represent a situation at a single tooth surface, in a
particular individual, or for a whole population.
The chance, expressed as percentage , for a Person to
avoid new decay is thereafter presented graphically on
the screen.

THE CARIOGRAM: A graphic map of the
interactions of factors that determine
carious activity and caries risk.
D-Diet, B-bacteria, and
S- susceptibility
.
In this example, all sectors are equal in size.
If one factor is extremely unfavorable,
It can occupy more than one third of the circle.
A closed circle illustrates a situation in which carious lesions will
develop over a given time. Sufficient bacteria, a caries inducing
diet, and a susceptible host is present.
D
B
S

Open circles indicate a situation in which
carious lesions will not develop over a given
time. in this case, all sectors have been
reduced, indicating, for example, sugar
discipline, plaque control, and increased
resistance to disease. The result is that the
risk for caries is reduced.
No carious lesions will develop over time.

This represents an extremely unfavorable situation.
• No factor is favorable, and one factor is so prominent that it
would have needed more space.
• The dietary habits are poor, and the plaque is abundant and
contains high proportions of mutans streptococci and
lactobacilli. the host is also susceptible.
• The result is that carious activity is high several new carious
lesions each year can develop.
• A slight improvement in any sector is not enough to stop
Carious Activity; more radical improvements are needed.

Prediction of caries risk using
cariogram

The purpose of the program is educational and it illustrates a
possible risk evaluation.
It does not replace the responsibility of the Dentist, but it may
help in making proper Decisions.

The cariogram model is a simple way to illustrate
how various caries-related factors can interact. It is
useful in various situations when there is a need to
discuss the importance of etiologic factors.
In its interactive version, it is possible to demonstrate
how the risk may change as a result of various actions.

The predictive power of even the best screening measures that
are currently available is modest.
None of the reported measures of assessing caries risk is
accurate enough to be relied on mechanically, when targeting
caries-preventive measures.
Any mass screening program relying on methods that are
available today fails to identify a considerable proportion of
persons with a true high risk / or suggest a high risk for persons
with actual low risk.

The complex nature of dental caries makes prediction difficult.
Even a perfect test is only capable of predicting a person’s
future caries experience if the condition on which the prediction
is based remain stable.
Most caries risk prediction studies have been conducted in
industrialized countries, the populations here are exposed to a
variety of professional prevention and treatment regimens as well
as self-care. This probably reduces the observed power of such
studies.
The living conditions and oral health behaviors may change
over time, thus modifying a person’s caries risk in either
direction.

Few caries prediction models have achieved the target of 80%
sensitivity and 80% specificity set by experts in the field.
Certain percentage of “errors” is inevitable in the diagnostic
and prognostic elements of treatment planning.
Incorrect risk assessment can lead to inappropriate treatment
that may include elements of both over and under treatment.
Prediction of root surface lesions is problematic because of
Absence Of Global Consensus On Detection of clinical signs.
Availability of few data for elderly teeth.

Caution is needed,
On the generalisability of research results From different
populations and socio-economic perspectives.
The soundness of the experimental methodology used in any
reported research.

Dental practice in the future can change in response to the
unfolding scientific evidence by the use of evidence based
clinical guidelines.
Evidence based clinical decision making will help dentists cope
with the increasingly disparate caries risk levels among their
patients.
Dentists should have a clear understanding of how to evaluate
and judge the new technologies and new therapies on the
horizon.
Independent health technology assessments should ensure that
new technologies improve health as well as demonstrate
economic viability in general practice settings.

Clinical variables, especially past caries experience, have been
confirmed as the most significant predictors of future caries
development.
Bacterial levels are included in the most accurate prediction
models.
Socio-demographic variables are most important to prediction
models for young children and older adults
There is no universal caries predicition model.
Caries risk assessment is the goal of academics and practitioners
alike as they strive to establish more efficient dental care delivery
systems.

ReferencesReferences
1. Anders Thylstrup And Ole Fejerskov. Textbook Of
Clinical Cariology. 2nd
Edition,1994; Munskgaard
Publications.
2. Per Axelsson. Diagnosis and risk prediction of dental caries
volume 2, 2000;quintessence.
3. Norman O Harris And Franklin Garcia Godoy. Primary
Preventive Dentistry. 6th
Edition,2004:appleton And Lange.
4. Hausen h. Caries prediction-state of the art.Community dent
oral epidemiol 1997;25:87-96.

5. POWELL LV.CARIES PREDICTION:A REVIEW OF THE
LITERATURE. COMMUNITY DENT ORAL EPIDEMIOL
1998;26:361-71.
6. NIGEL B PITTS.RISK ASSESSMENT AND CARIES
PREDICTION. JOURNAL OF DENTAL EDUCATION
1998;62(10):762-69.
7. MESSER LB. ASSESSING CARIES RISK IN CHILDREN.
AUSTRALIAN DENTAL JOURNAL;2000:45(1);10-16.
8. BURT BA.CONCEPTS OF RISK IN DENTAL PUBLIC
HEALTH. COMMUNITY DENT ORAL EPIDEMIOL 2005;33:240-47
.
9. BECK JD. RISK REVISITED COMMUNITY DENT ORAL
EPIDEMIOL 1998;26:220-25.

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Brattal D Hansell peterson G cariogram - A multifactorial risk
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assessment. Jol of dental education 1995:59:10:981-5
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 Marie d, et al Caries prediction suitable for mass screening in
children a a literature review community dental health 1990 &, 11-
21
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17
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utility . jol of dental education 1995:59:10:933-940

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2008:36 357-362

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