2012 John Wiley & Sons A/S.

Published by Blackwell Publishing Ltd

Community Dent Oral Epidemiol 2012; 41; e53e63

All rights reserved

Caries management by risk

assessment

Douglas A. Young1 and

John D. B. Featherstone2
1
Department of Dental Practice, University
of the Pacific, San Francisco, CA, USA,
2
School of Dentistry, University of
California, San Francisco, CA, USA

Young DA, Featherstone JDB. Caries management by risk assessment.

Community Dent Oral Epidemiol 2013; 41: 112.
2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd
Abstract Caries disease is multifactorial. Whether caries disease will be
expressed and damage dental hard tissue is dependent on the patients own
unique make-up of pathogenic risk factors and protective factors.
Objectives: This manuscript will review the science of managing caries disease
based on assessing caries risk. Methods: The caries balance/imbalance model
and a practical caries risk assessment procedure for patients aged 6 years
through adult will illustrate how treatment options can be based on caries risk.
Results: Neither the forms nor the clinical protocols are meant to imply there is
currently only one correct way this can be achieved, rather are used in this
manuscript as examples only. Conclusions: It is important to have the forms and
protocols simple and easy to understand when implementing caries
management by risk assessment into clinical practice. The science of CAMBRA
based on the caries balance/imbalance model was reviewed and an example
protocol was presented.

The caries management by risk assessment (CAMBRA) philosophy is built on the understanding that
dental caries is a disease initiated by a complex
biofilm (rather than any one pathogen), which
changes dynamically with its environment and the
local chemistry of the tooth site, pellicle, and saliva.
This is in stark contrast to the classic medical
model of one pathogen-one disease, thus, rather
than focusing on the elimination of any one pathogen, caries management must determine which of
many factors is causing the expression of disease
and takes corrective action. For purposes of this
paper, the phrase caries management by risk
assessment or CAMBRA will be used to describe
this risk-based approach to prevent, reverse and,
when necessary, repair damage to teeth using minimally invasive methodologies (1). CAMBRA is not
a trade name for products or a company, nor is it a
caries risk assessment (CRA) form, it is a concept
for managing dental caries and its manifestations.
In its simplest form, it means (i) assessing the risk
for future caries lesions, (ii) reducing the pathological factors, (iii) enhancing the protective factors,
doi: 10.1111/cdoe.12031

Key words: caries; caries management;

caries protocols; caries risk assessment;
CAMBRA; remineralization
Douglas A. Young, Department of Dental
Practice, University of the Pacific, San
Francisco, 2155 Webster St. Rm. 400, San
Francisco, CA 94115, USA
Tel.: +1 415 749 3308
Fax: +1 415 749 3339
e-mail: dyoung@pacific.edu

and (iv) minimally invasive restorative care resulting in control of the disease.

The caries balance/imbalance model

The caries balance/imbalance model is a visual
representation of the multifactorial nature of the
dental caries disease. It illustrates the determining
factors of caries disease, and it is the dynamic interaction of the biofilm with the oral environment. It
is the local environment that determines how the
biofilm will behave at any given tooth site and if
the disease is severe enough to result in demineralization and visible changes to the tooth site. By collecting actual patient information about the
patients unique caries balance an astute clinician
can assess the risk of future demineralization
based on weighing all the disease indicators and
risk factors against existing protective factors. This
is process is called a CRA.
The caries balance/imbalance (Fig. 1) is the balance among disease indicators, risk factors and

e53

Young & Featherstone

Fig. 1. The caries balance/imbalance. Adapted from Featherstone JD et al. (2)

protective factors and determines whether dental

caries progresses, halts, or reverses. Refer to
Appendix and the text below for more detail on
disease indicators. Cavities/dentin refers to frank
cavities or lesions well into the dentin by radiograph. Restorations <3 years means restorations
placed in the previous 3 years or within the last 1
year for recall/POE exam. This figure has been
updated from previous versions of the caries balance (24). If these indicators are present, they
weigh heavily on the side of predicting caries progression unless therapeutic intervention is carried
out. The leading letters that help to remember the
imbalance (WREC; BAD; SAFER). Destructive
Lifestyle Habits indicate poor diet (e.g., frequent
ingestion of fermentable carbohydrates), recreational drug use, poor oral hygiene, etc.

Caries disease indicators

The literature varies regarding definitions for risk
indicators and factors (also refer to Appendix). In
this manuscript, we are using the term caries disease indicator to refer to clinical observations that
tell about the past caries history and activity. Disease indicators are clinical signs that there is either
caries disease currently present or that there has
been caries disease in past. Caries disease indicators do not tell us anything about what caused the
caries disease or how to treat it. They are physical
proof (cavitations, white spots, radiolucencies) of
the existence (past or present) of caries disease.
These are not pathological factors nor are they
causative in any way. The disease indicators presented in Appendix are also strong predictors of
future disease (5, 6), and strong indicators that the

e54

disease will continue unless therapeutic intervention is implemented.

The four caries disease indictors making up the
reminder WREC (think of this as meaning
wreck) outlined in both Fig. 1 and Appendix are
the following:
White spots visual on smooth surfaces,
Restorations placed in the last 3 years as a result
of caries activity, or restorations within the
last 1 year for recall/POE exams.
Enamel approximal lesions visualized
radiographically, and
Cavitations/dentin indicates cavities or lesions
that show penetration well into dentin
visualized radiographically.
A positive response to any one of these four indicators automatically places the patient at high caries
risk, unless therapeutic intervention is already in
place and progress has been arrested. A patient with
frank cavities has high levels of cariogenic bacteria,
and placing restorations does not significantly lower
the overall acidogenic bacterial challenge in the
mouth (7, 8).

Caries risk factors

Caries risk factors are biological factors that contribute to the level of risk for the patient of having
new carious lesions in the future or having the
existing lesions progress (also refer to Appendix).
The risk factors are the biological factors (including
pathological factors) that have contributed to the
disease or will contribute to the future manifestation of the disease on the tooth. These pathologic
factors not only tell us what is out of balance but
also suggest how the imbalance can be corrected.
Figure 1 lists only the three risk factors that

Caries management by risk assessment

research has proven to be causative of caries

lesions (given a pathogenic environment) and can
be easily remembered because their first letters
spell the word BAD. They are as follows:
Bad bacteria (meaning cariogenic bacteria),
Absence of saliva (hyposalivation),
Destructive lifestyle habits (e.g., poor dietary
habits, frequent ingestion of fermentable
carbohydrates, recreational drugs, etc.).
The CRA form shown in Appendix lists several
other risk factors (totaling nine) identified in outcomes measures of CRA (5, 6). They are as follows:
(i) medium or high MS (mutant streptococci) and
LB (lactobacillus species) counts, (ii) visible heavy
plaque on teeth, (iii) frequent (>3 times daily)
snacking between meals, (iv) deep pits and fissures, (v) recreational drug use, (vi) inadequate saliva flow by observation or measurement, (vii)
saliva reducing factors (medications/radiation/
systemic), (viii) exposed roots, and (ix) orthodontic
appliances.

Caries protective factors

Caries protective factors are biological or therapeutic factors that can collectively offset the pathologic
challenge presented by the above caries risk factors
(also refer to Appendix). The more severe the caries risk factors are, the higher the intensity of protective factors must be to keep the patient in
balance or to reverse the caries process. Figure 1
only lists a few that are known to be highly protective and can be remembered by SAFER. They are
as follows:
Saliva and sealants
Antibacterials
Fluoride and calcium/phosphate (as supportive
to fluoride not a replacement) (9)
Effective lifestyle habits
Risk-based reassessment
Industry is responding to the need for more and
better products to treat dental caries disease and
the current list in Appendix is sure to expand in
the near future. Currently, the protective factors
listed in Appendix are as follows: (i) lives/work/
school located in a fluoridated community, (ii)
fluoride toothpaste at least once daily, (iii) fluoride
toothpaste at least two times daily, (iv) fluoride
mouthrinse (0.05% NaF) daily, (v) 5000 ppm F
fluoride toothpaste daily, (vi) fluoride varnish in
last 6 months, (vii) office fluoride topical in last
6 months, (viii) chlorhexidine prescribed/used

daily for 1 week each of last 6 months or other

antibacterial agent of choice based on current evidence. (ix) xylitol gum/lozenges four times daily
in the last 6 months, (x) calcium and phosphate
supplement paste during last 6 months, and (xi)
adequate saliva flow (>1 ml/min stimulated).
Fluoride toothpaste frequency is included as studies have shown that brushing twice daily or more
is significantly more effective than once a day or
less (10). Any or all of these protective factors can
contribute to keep the patient in balance and to
enhance remineralization, which is the natural
repair process of the early carious lesion.

Hard tissue exam and charting (by

location, severity, and activity)
The existence of previous or current disease is the
highest predictor of future disease. Therefore a
careful hard tissue exam must precede the CRA to
detect signs of previous or existing caries disease
(disease indicators). There are many ways to
record hard tissue findings. The following example
is a simple approach that mimics clinical practice
and considers both precavitated and cavitated caries lesions.
Occlusal: chart ICDAS Codes (11) noting deep
pits or fissures. See Table 2 (For description
of ICDAS for clinical practice see http://
www.icdas.org/clinical-practice)
Approximal: chart depth of lesions noted on
bitewing radiographs as E1, E2, D1, D2, or D3
and note activity if possible (see approximal
lesion management later this article)
Facial/Lingual; visual and tactile exam (round
end of explorer or ball ended probe) noting:
(i) active white spots (dull, rough surface)
(ii) inactive white spots (smooth, shiny and
hard)
(iii) active brown spots (tan to tooth colored,
dull, rough surface)
(iv) inactive brown spots (smooth, shiny, and
hard)
(v) cavitations still in enamel
(vi) cavitations extending into dentin

Caries risk assessment

A CRA is simply a way to formalize and expand
upon the patients caries balance/imbalance in the
most predicable fashion to diagnose current caries

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Young & Featherstone

disease, to help predict future disease, and to

determine what factors are out of balance so evidence-based clinical decisions can be made (8, 12).
The CRA may draw upon relevant historical data
of the patient such as medical history (medications
and systematic disease), dental history (previous
caries experience), social history (recreational
drugs, alcohol, smoking), dietary history, and any
other personal or cultural habits that could contribute to caries disease. Lastly, a CRA may also
include additional tests such as saliva/pH/buffer
assessment and bacterial load assessment. These
test all have lower levels of evidence, yet the real
benefit may be as a teaching and motivating tool to
help modify patient behaviors.
Implementation of a CRA in clinical practice is
best carried out by the use of a CRA form, insuring
each patient will be systematically assessed in the
same manner, which is based on the best available
research. The CRA form presented here is based
upon published science and outcomes measures of
the use of the form (5, 6). The items in the form
have been trimmed to include only those that had
significant relationships to the onset of future cavitation in thousands of patients. The aim is to keep
the form and procedure as simple and rapid as
possible for use in practice, to keep to one page,
and to have only proven components included.
The CRA form presented here is based on the caries balance/imbalance theory, and the factors evaluated were discussed previously. Although there
are several published CRA forms, the one shown
in Appendix was chosen to use as an example in
this manuscript because the content of the form
and the procedures have been validated by published outcomes research using a large cohort of
patients (5, 6). The included items all had statistically significant odds ratios relating to the future
onset of cavitation.
To use the form (Appendix): Simply circle the
Yes answers, count them up and visualize how
these will affect the balance at the bottom of the
form. Some clinicians have reported improved
results by engaging the patient early by handing
out the form in the reception room and letting
them self-select answers for questions they are
familiar with. This allows the practitioner to readily determine low, moderate, high, or extreme risk
while saving valuable time as well. Extreme risk is
high risk plus major salivary dysfunction (hyposalivation). Low risk should indicate that there is a
very low risk of future dental caries disease, provided no deleterious changes are made. On the

e56

other hand, high risk indicates the high likelihood

of new caries lesions in the near future (a year or
2). If there is doubt about low or high risk, then the
classification is moderate.
There are several other versions of CRA forms
available, and clinical outcomes of using many risk
indicators and factors are summarized in a systematic review by Zero et al. (13). In addition, there are
differences in the relative predictive value given to
different factors in the literature (e.g., according the
2001 NIH Consensus Conference on Dental Caries,
presence of mutant streptococci alone is no more
than weakly predictive of clinical caries activity) (14).
However, none of these other forms have published
outcomes results. The ADA offers caries assessment
forms for patients 06 years old, and those over
6 years of age. The forms can be found here:
http://www.ada.org/sections/professionalResources/pdfs/topic_caries_over6.pdf. In addition,
the AAPD also offers their form for children under
6 at: http://www.ada.org/sections/professionalResources/pdfs/topics_caries_under6.pdf.
All these forms vary from each other in some
way or another; however, all of them agree that
caries experience is the strongest predictor of
future caries disease, even though they may use
different variables to describe caries experience. In
addition, they all measure the other etiological factors involved in the disease in some manner; the
weight that these other factors receive varies from
form to form, in part because the literature on risk
assessment (except for past caries experience) is
very limited.
Any CRA form should systematically weigh
the factors research has proven to be pathogenic
against the protective factors that are known to
protect from caries disease. The astute clinician
can then manipulate these environmental factors
via treatment interventions that will tip the caries balance to favor health. As not all factors
have equal predictive value, the questions used
in any CRA form must be weighted is some
fashion. The weighting system shown in Appendix is a visual weighting system created by the
three-column format based on outcomes research
and statistical odds ratios mentioned previously.
Other forms may use a mathematical weighting
system.
The end result of any CRA is to combine historical and current clinical data, information from the
CRA form, including any additional test such as
saliva or pH assessment and bacterial load assessment, to ultimately allow a determination of an

Caries management by risk assessment

overall caries risk for your patient. This will help

establish a caries disease diagnosis and disease
activity level (caries active or caries inactive). Caries risk changes with time and needs to be reassessed as time goes on.

Chemical intervention protocols

Once caries risk diagnosis is made (low, moderate,
high, or extreme risk), there must be therapeutic
intervention protocols attached to the risk level for
that patient, so that treatment options along with
prognosis can be presented to the patient and a
treatment plan formulated. The level and type of
risk is used to determine the level and type of
corrective therapeutic intervention. Note that currently there is no consensus on correct treatment
protocol, just as there is no one correct way to
assess the caries risk of the patient. The process of
management based on caries risk was recently validated by a randomized clinical trial where the test
group using CRA, based on salivary fluoride levels
and bacterial load (MS and LB), to drive chemical
treatment decisions (chlorhexidine and/or fluoride) had lower mean caries increment compared
to the control group, which did not employ risk
assessment or chemical based treatments (restorative only) (8). The fact that multiple treatment
interventions may be necessary to treat a complex
multifactorial disease, by nature does not lend
itself well to future randomized clinical trials and
systematic reviews. With that said, Table 1 lists an
example protocol of interventions that could be
used based on the caries risk level of the patient.
Table 1 is a modified version of an example protocol previously published for age 6 to adult based
on caries risk category (10). The eight interventions
summarized in Table 1 are the following: (i) sealants (resin-based or glass ionomer), (ii) saliva
assessment (flow and bacterial load measurement),
(iii) antibacterials, (iv) fluoride, (v) factors favorable for remineralization (pH control calciumphosphate topical supplements), (vi) effective lifestyle habits, (vii) frequency of radiographs, and
(viii) frequency of caries recare exams (Table 1).

Minimally invasive restorative

options
Caries risk assessment should be a mandatory part
of every initial examination and every caries

re-care appointment, because caries risk is likely to

change with time. If an interventive therapy is
applied successfully, the aim is to lower the caries
risk. Once a caries risk diagnosis is made, appropriate prevention or therapeutic protocols are
started based on caries risk (low, moderate, high or
extreme risk). If caries lesions (precavitated or cavitated) are present, the decision to treat chemically
versus surgically based on the site, extent, and
activity of the caries lesion must be made (see summary Table 3). This requires early detection and
precise terminology (refer to previous mentioned
Hard Tissue Exam and Charting). Bacteria are physically too large to fit into diffusion channels of intact
enamel; thus, intact enamel prevents bacterial
ingress into the dentin. In contrast, cavitation
through the enamel should trigger surgical procedures.
Caries risk status may or may not have any bearing on the restorative phase of treatment; it is not
an absolute requirement. At the occlusal site, the
ICDAS system may help determine the extent of
preventive and/or restorative treatment (see
Table 2). Caries risk status may help drive the decision to place a sealant or not (e.g., sealants are a
recommended option for high caries risk patients)
(15).
On the approximal surface, most dentists rely
heavily on the bitewing radiograph (conventional
or digital). Based on a review of the scientific literature American Dental Association Council on
Scientific Affairs determined that the diagnostic
quality of digital images is comparable to that of
conventional films (1618). One way to record
radiographic radiolucency depth is to divide the
enamel in half (E1 = outer of enamel.
E2 = inner of enamel) and dentin into thirds
(D1 = outer 1/3 of dentin, D2 = middle 1/3 of
dentin, and D3 = inner 1/3 of dentin). Radiographic radiolucency in the enamel (E1, E2) have
low chance of being cavitated (14) and should be
treated chemically. If left untreated therapeutically, the likelihood of progressing to cavitation
is high (6). Radiographic radiolucency well into
dentin (D2, D3) is more likely cavitated (14) and
should be restored. It is the radiographic radiolucencies that just penetrate the dentinal enamel
junction (D1), which trouble many dentists. Many
were taught in dental school that early D1 lesions
are the ideal board patient, yet most of these
lesions may not be cavitated. In the US, activity
of these lesions is rarely considered and the use
of elastomeric separation to confirm cavitation is

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e58

Not indicated
(optional for
primary prevention
of at risk deep pits
and fissures)
Sealants are
recommended per
ICDAS code (see
Table 3) for
secondary
prevention

Low risk

Low resting pH, low

stimulated flow or pH
may indicate need for
supplementation

OTC fluoride
toothpaste used
bid
OTC fluoride
toothpaste used
bid. 0.05% NaF
rinse bid.
Varnish applied
every 46
months
5000 ppm
toothpaste used
od or bid. 0.05%
NaF rinse bid.
Varnish applied
every 34
months

Not indicated

Xylitol therapy 23
times/day for a total
daily dose of 610 g
If patient has high
levels of acidogenic
bacteria then treating
with the following
agents it must be
understood that the
evidence is very limited
for antibacterials and
pH neutralization, such
as chlorhexidine,
sodium hypochlorite,
povidine iodine,
essential oils, per
manufacturer s
instructions. Retest
bacterial load test in
1 month, discuss and
motivate patient, and
repeat as needed

Saliva testing is
optional or may be
done for purposes
of baseline records
Measure resting and
stimulated flow and
pH especially if
hyposalivation is
suspected
Objective
measurement of
acidogenic bacterial
load via culturing
or direct
measurement of
plaque ATP
Consider supplementing
if topical fluoride alone
is not effective
Required if xerostomia is
three present

Recession or sensitive
roots may indicate
need for
supplementation

Fluoride (topical)

Factors favorable for

remineralization (pH,
Ca2+ and PO34 )

Antibacterials

Saliva

Encourage healthy
dietary habits, low
frequency of
fermentable
carbohydrates,
adequate protein
intake and effective
oral hygiene
practices using
motivational
interviewing
techniques.
Substitute xylitol
for sucrose

Effective lifestyle
habits

Every 46
months

Every 34
months

Every 1824
months

Every 618
months

Every 3 months

Every 6 months

Every 2436
months

Every
6 months
until no new
caries
lesions

Recare

Radiographs

Patients with one (or more) cavitated lesion(s) are high risk patients. Patients with one (or more) cavitated lesion(s) and hyposalivation are extreme risk patients. All restorative work to be done with the minimally invasive philosophy in mind. Existing smooth surface lesions that do not significantly penetrate the DEJ and are not cavitated
should be treated chemically not surgically. For extreme risk patients with multiple cavitations, some choose to use caries control procedures with glass ionomer materials
until caries progression is halted and/or reversed followed my more permanent restorative care. Patients with appliances (RPDs, Orthodontics) require excellent oral
hygiene together with intensive fluoride therapy (e.g. high fluoride toothpaste and fluoride varnish every 3 months). If antibacterial therapy is tried, it should be done in
conjunction with fluoride therapy (and every attempt be made not to interfere with the fluoride intervention). A 1 month initial treatment evaluation may be helpful for
positive reinforcement. Patients must maintain good oral hygiene (a powered toothbrush may be helpful to high and extreme risk patients). A diet low in frequency of fermentable carbohydrates is recommended. It is important to know the amount of xylitol in the product being recommended. Xylitol products should contain 100% xylitol
(daily dosages of 610 g/day for antimicrobial effects) and pose extreme health risks to family pets, especially dogs.

Extreme risk

High risk

Moderate risk

Sealants

Caries risk level

Table 1. SAFER CAMBRA example protocolfor patients 6-adult

Young & Featherstone

Caries management by risk assessment

Table 2. Example occlusal protocola based on ICDAS code and caries risk level

All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined
to enemel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part of
the preparation in dentin and the preparation extends to a second surface (note: the second surface does not have to be
in dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamel
is immature, or where fissure preparation is not desired, or where rubber damn isolation is not practical. Patients should
be given a choice in sealant placement and material selection.
b
Patients with one (or more) cavitated lesion(s) are high risk patients.
c
Patients with one (or more) cavitated lesion(s) and xerostomia are extreme risk patients.
Adapted from Jenson et al. (11).

even more rare. At this site, caries risk status

may not help in treatment decision. In other
words, you should not justify surgical treatment
based on high-risk status. All risk categories
should receive the benefit of remineralization
therapy on noncavitated lesions.
On the facial and lingual surfaces, direct visual
and tactile examination is possible, making the
decision easy. It is also much easier to assess
lesion activity and to monitor the progress of
remineralization therapy. If restoration is necessary on the root area, a high-risk status may
preclude one to use a fluoride releasing material

such as conventional glass ionomer cement

(Tables 2 and 3) (19).

Treatment planning and behavioral

change
Individualized, evidence-based treatment options
along with prognosis is presented to the patient
and decisions are made based on the patients
wants and needs. Implementation of the treatment
phase requires the clinician to assist the patient in
modification of behaviors that favor health. This

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Young & Featherstone

Table 3. Site specific risk-based management

SITE SPECIFIC RISK-BASED MANAGEMENT

SITE

EXTENT
Initial caries management stage
(non-surgical approach)

OCCLUSAL SITE

ICDAS code 0

ICDAS code 1

Moderate caries management stage

(*** minimal removal of caries and tissue)

ICDAS code 2

ICDAS code 3

ICDAS code 4

ICDAS code 5

Severe caries
management
stage
(conventional
restorative
approach)
ICDAS code 6

Management Low Risk: Sealants not indicated for inactive lesions;

All Risk Levels:
continue nonsurgical preventive maintenance; however Minimal removal of tooth structure to ensure adequate
sealants may be considered optional for primary
seal for dental material used.
prevention of at risk (deep) pits and fissures.
Moderate Risk: sealants recommended
*High or ** Extreme Risk: sealants recommended
APPROXIMAL SITE

Radiographic E0
****

Management

Chemical treatment or preventive

maintenance.

Chemical or preventive therapy.

Demonstration of lesion
progression or regression and/or
elastomeric tooth separation
preferred before surgical
intervenon is considered.

Minimally invasive
restoration probable
(but not absolute) based
on lesion progression,
regression, or tooth
separaon.

Minimally invasive restoration

needed. Conservative caries
removal when near the pulp;
ensure adequate seal for dental
material used.

Non-cavitated lesions
Inacve
Acve

Parally cavitated lesions

Fully cavitated lesions

Fully cavitated lesions

Parally cavitated lesions

May receive nonsurgical chemical
therapy or minimally invasive
restoraon depending on clinician
and paent discussion of
treatment opons.

Fully cavitated lesions

Fully cavitated lesions

FACIAL/LINGUAL
SITE

(shiny, smooth)

Radiographic E1

Radiographic D1
(outer 1/3 dentin)

Radiographic D2
(middle 1/3 dentin)

All Risk Levels:

Conservative
caries removal
when near the
pulp; ensure
adequate seal for
dental material
used.
Radiographic D3
(inner 1/3 dentin)

(matt, rough)

Non-cavitated lesions
Management
Acve white or brown spot lesions
receive chemical therapies based on
caries risk assessment (CRA).

Minimally invasive
restoraon

Conservave caries removal

when near the pulp; ensure
adequate seal for dental
material used.

Lesion activity assessment (adapted from Kim Ekstrand) (Parameters in red indicate activity; in black, no activity) Initial caries risk status: high, moderate, or low; Visual appearance: cavitation/shadow, whitish, or brownish; Location of
the lesion: plaque stagnation area, natural, or not; Tactile feeling: rough enamel/soft dentin, or smooth enamel/hard
dentin; Gingival status (if the lesion is located near the gingiva): inflammation, bleeding on probing, or no inflammation,
no bleeding on probing; surface luster: matt, shiny; Plaque: sticky, not sticky; Age of the lesion: <3 years, >3 years.
a
All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confined
to enamel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part of
the preparation in dentin and the preparation extends to a second surface (Note: the second surface does not have to be
in dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamel
is immature, or where fissure preparation is not desired, or where rubber dam isolation is not practical. Patients should
be given a choice in sealant placement and material selection.
b
Patients with one (or more) cavitated lesion(s) are high risk patients.
c
Patients with one (or more) cavitated lesion(s) and xerostomia and/or hyposalivation are extreme risk patients.
d
Notations system used here: on bitewing radiographs as E1 (outer of enamel), E2 (inner of enamel), D1 (outer 1/3
of dentin), D2 (middle 1/3 of dentin), or D3 (inner 1/3 of dentin) and note the progression/regression from previous
radiographs if possible #33.

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Caries management by risk assessment

will require skill in obtaining patient cooperation

in use of the recommended therapeutic interventions. In doing so, it is important to give patients
encouragement and clear instructions on what they
need to do (20).

7.

8.

Summary
Dental caries is a complex multifactorial disease
that cannot be controlled by restoration alone
(8). A CRA is a way to predict risk of future
disease, but it is also a systematic way to identify factors that are out of balance that could
lead to demineralization on a susceptible patient.
To assist the clinician in assessing caries risk,
several forms and procedures are in existence, of
which one form and one example protocol was
used in this paper to illustrate the science of caries management by risk assessment, CAMBRA.
CAMBRA is not a trade name for products or a
company, nor is it a CRA form, it is a concept
for managing dental caries and its manifestations. In its simplest form it means (i) assessing
the risk for future cries lesions, (ii) reducing the
pathological factors, (iii) enhancing the protective
factors, and (iv) minimally invasive restorative
care resulting in control of the disease.

9.

10.

11.

12.
13.
14.

15.

References
1. Young DA, Featherstone JD, Roth JR, Anderson M,
Autio-Gold J, Christensen GJ et al. Caries management by risk assessment: implementation guidelines.
J Calif Dent Assoc 2007;35:799805.
2. 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;35:7037, 103.
3. Featherstone JD. The caries balance: contributing factors and early detection. J Calif Dent Assoc
2003;31:12933.
4. Featherstone JD. Prevention and reversal of dental
caries: role of low level fluoride. Community Dent
Oral Epidemiol 1999;27:3140.
5. Domejean-Orliaguet S, Gansky SA, Featherstone JD.
Caries risk assessment in an educational environment. J Dent Educ 2006;70:134654.
6. Domejean S, White JM, Featherstone JD. Validation
of the cda cambra caries risk assessment a six-year

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retrospective study. J Calif Dent Assoc 2011;39:

70915.
Featherstone JDB, Gansky SA, Hoover CI, RapozoHilo M, Weintraub JA, Wilson RS et al. A randomized clinical trial of caries management by risk
assessment. Caries Res 2005;39:295 (abstract #25).
Featherstone JD, White JM, Hoover CI, Rapozo-Hilo
M, Weintraub JA, Wilson RS et al. A randomized
clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk
assessment). Caries Res 2012;46:11829.
Rethman MP, Beltran-Aguilar ED, Billings RJ, Hujoel
PP, Katz BP, Milgrom P et al. Nonfluoride caries-preventive agents: executive summary of evidencebased clinical recommendations. J Am Dent Assoc
2011;142:106571.
Curnow MM, Pine CM, Burnside G, Nicholson JA,
Chesters RK, Huntington E. A randomised controlled trial of the efficacy of supervised toothbrushing in high-caries-risk children. Caries Res
2002;36:294300.
Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez FJ, Spolsky VW, Young DA. Clinical protocols
for caries management by risk assessment. J Calif
Dent Assoc 2007;35:71423.
Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health
Prev Dent 2004;2(Suppl 1):25964.
Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ 2001;65:112632.
Diagnosis and management of dental caries throughout life. National Institutes of Health Consensus
Development Conference Statement, March 2628,
2001. J Dent Educ 2001;65:11628.
Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal
R, Gooch B et al. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a
report of the american dental association council on
scientific affairs. J Am Dent Assoc 2008;139:25768.
American Dental Association Council on Scientific
Affairs. The use of dental radiographs: update and
recommendations. J Am Dent Assoc 2006;137:
130412.
White SC, Yoon DC. Comparative performance
of digital and conventional images for detecting
proximal surface caries. Dentomaxillofac Radiol
1997;26:328.
Syriopoulos K, Sanderink GC, Velders XL, van der
Stelt PF. Radiographic detection of approximal caries: a comparison of dental films and digital imaging
systems. Dentomaxillofac Radiol 2000;29:3128.
Young DA. The use of glass ionomers as a chemical
treatment for caries. Pract Proced Aesthet Dent
2006;18:24850.
Peltier B, Weinstein P, Fredekind R. Risky business:
influencing people to change. J Calif Dent Assoc
2007;35:7948.

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Young & Featherstone

Appendix
Appendix 1. Caries risk assessment form for ages 6 years through adult. Adapted from Featherstone JD et al. (2)
Patient Name:
Assessment Date:

CHART #:
DATE:
Is this (please circle) Baseline or Recall

Disease Indicators (Any one YES signifies likely High

Risk and to do a bacteria load test**)
New/Progressing visible cavitations or radiolucencies into
dentin
New/Progressing approximal enamel Lesions by radiograph
New/Active White spots on smooth surfaces
Restoration for caries lesion in the last 3 years (for initial
exam or within the last 1 year for recall/POE exam)

YES =
CIRCLE
YES

YES =
CIRCLE

YES=
CIRCLE

YES
YES
YES

Risk Factors (Biological predisposing factors)

MS and LB both medium or high (by culture or ATP
bioluminescence **)
Visible heavy plaque on teeth
Frequent snack (> 3x daily between meals)
Deep pits and fissures
Recreational drug use
Inadequate saliva flow by observation or measurement (**If
measured note the flow rate below)
Saliva reducing factors (medications/radiation/systemic)
Exposed roots
Orthodontic appliances

YES
YES
YES
YES
YES
YES
YES
YES
YES

Protective Factors
Lives/work/school fluoridated community
YES
Fluoride toothpaste at least once daily
YES
Fluoride toothpaste at least 2x daily
YES
Fluoride mouthrinse (0.05% NaF) daily
YES
5000 ppm F fluoride toothpaste daily
YES
Fluoride varnish in last 6 months
YES
Office F topical in last 6 months
YES
Chlorhexidine prescribed/used one week each of last 6
YES
months
Xylitol gum/lozenges 4x daily last 6 months
YES
Calcium and phosphate paste during last 6 months
YES
Adequate saliva flow (> 1 ml/min stimulated)
YES
** Biofilm Assessment: ATP bioluminescence: _______ or culture MS:_______LB:_______
Stimulated Salivary Flow Rate:_______ ml/min. Stimulated pH______ Date: _________
Resting Salivary Flow Rate: _______ ml/min. Resting pH ________ Date: _________
Buffering Capacity test:______________Consistency of resting saliva: thick-stringy-ropey vs watery
VISUALIZE CARIES BALANCE
(Use circled indicators/factors above)
(EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION)
CARIES RISK ASSESSMENT (CIRCLE):
EXTREME HIGH
MODERATE

Doctor signature/#:

How tooth decay happens (to be given to each

patient)
Tooth decay is caused by acid-producing bacteria
that live in your mouth. The bacteria feed on what
you eat, especially sugars (including fruit sugars)
and cooked starch (bread, potatoes, rice, pasta,

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LOW

Date:

etc.). Within just a few minutes after you eat, or

drink, the bacteria begin producing acids as a byproduct of their digesting your food. Those acids
can penetrate and dissolve the minerals (calcium
and phosphate) in your teeth. If the acid attacks are
infrequent and of short duration, your saliva can

Caries management by risk assessment

help to repair the damage by neutralizing the acids

and supplying minerals and fluoride that can
replace those lost from the tooth. However if:
(i) your mouth is dry, (ii) you have too much acid
exposure, or (iii) you snack frequently, then the
tooth mineral lost by attacks of acids is too great
and cannot be repaired. This is the start of tooth
decay and leads to cavities.

bad bacteria that cause tooth decay and can be useful in patients at high risk for tooth decay.
Fluorides. Fluorides help to make the tooth more
resistant to being dissolved by the bacterial acids.
Fluorides are available from a variety of sources
such as drinking water, toothpaste, over-the-counter rinses, and products prescribed by your dentist
such as brush-on gels or high-fluoride toothpastes
used at home or gels, foams, and varnishes applied
in the dental office. Daily use is very important to
help protect against the acid attacks.
Factors favorable for remineralization. Calcium and
phosphate at the proper pH is necessary for tooth
repair. Normally, this is carried out by your saliva
but when you have a lack of saliva (dry mouth) or
when fluoride alone is not effective, you may consider supplementing with calcium/phosphate and
acid-neutralizing products.

Methods of controlling tooth decay

Saliva. Saliva is critical for controlling tooth decay.
It neutralizes acids and provides minerals and proteins that protect the teeth. If you cannot brush after
a meal or snack, you can rinse or chew some sugarfree gum. This will stimulate the flow of saliva to
help neutralize acids and bring lost minerals back to
the teeth. Sugar-free candy or mints could also be
used, but some of these contain acids themselves.
These acids will not cause tooth decay, but they can
slowly dissolve the enamel surface directly over
time (a process called erosion). Some sugar-free
gums are designed to help fight tooth decay and are
particularly useful if you have a dry mouth (many
medications can cause a dry mouth). Some gums
contain baking soda that neutralizes the acids produced by the bacteria in plaque.
Sealants. Sealants are plastic or glass ionomer
coatings bonded to the biting surfaces of back teeth
to protect the deep grooves from decay. In some
people, the grooves on the surfaces of the teeth are
too narrow and deep to clean with a toothbrush, so
they may decay in spite of your best efforts. Sealants are an excellent preventive measure used for
children and young adults at risk for this type of
decay. They do not last forever and should be
inspected once a year and replaced if needed.

Effective lifestyle habits. Improving diet by reducing

the number of sugary and starchy foods, snacks,
drinks, or candies can help reduce the development of tooth decay. That does not mean you can
never eat these types of foods, but you should limit
their consumption particularly when eaten
between main meals. Gum that contains xylitol as
its first listed ingredient will stimulate saliva and is
the gum of choice. If you have a dry mouth, you
could also fill a drinking bottle with water and add
a couple teaspoons of baking soda for each 8 ounces
of water and swish and spit with it frequently
throughout the day. Toothpastes containing baking
soda are also available by several companies.
Effective oral hygiene practices plaque removal:
Removing the plaque from your teeth on a daily
basis is helpful in controlling tooth decay. Plaque
can be difficult to remove from some parts of your
mouth especially between the teeth and in grooves
on the biting surfaces of back teeth. If you have an
appliance such as an orthodontic retainer or partial
denture, remove it before brushing your teeth.
Brush all surfaces of the appliance also.

Antibacterial mouth rinses. Rinses that your dentist

can prescribe are able to reduce the numbers of

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