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REFERENCE MANUAL V 38 / NO 6 16 / 17

Guideline on Caries-risk Assessment and
Management for Infants, Children, and Adolescents
Review Council
Council on Clinical Affairs

Latest Revision*
2014

Purpose 2. Gives an understanding of the disease factors for a
The American Academy of Pediatric Dentistry (AAPD) recog- specific patient and aids in individualizing preventive
nizes that caries-risk assessment and management protocols discussions.
can assist clinicians with decisions regarding treatment based 3. Individualizes, selects, and determines frequency of
upon caries risk and patient compliance and are essential preventive and restorative treatment for a patient.
elements of contemporary clinical care for infants, children, 4. Anticipates caries progression or stabilization.
and adolescents. This guideline is intended to educate health
care providers and other interested parties on the assessment Caries-risk assessment models currently involve a combina-
of caries risk in contemporary pediatric dentistry and aid in tion of factors including diet, fluoride exposure, a susceptible
clinical decision making regarding diagnostic, fluoride, dietary, host, and microflora that interplay with a variety of social,
and restorative protocols. cultural, and behavioral factors.3-6 Caries risk assessment is
the determination of the likelihood of the incidence of caries
Methods (i.e., the number of new cavitated or incipient lesions) during
This guideline was originally developed by the Council on a certain time period7 or the likelihood that there will be a
Clinical Affairs and adopted in 2002. This document is an change in the size or activity of lesions already present. With
update of AAPD’s Policy on Use of a Caries-risk Assessment the ability to detect caries in its earliest stages (i.e., white spot
Tool (CAT) for Infants, Children, and Adolescents, revised in lesions), health care providers can help prevent cavitation.8-10
2006 that includes the additional concepts of dental caries Caries risk indicators are variables that are thought to
management protocols. The update used electronic and hand cause the disease directly (e.g., microflora) or have been shown
searches of English written articles in the medical and dental useful in predicting it (e.g., socioeconomic status) and include
literature within the last 10 years using the search terms caries those variables that may be considered protective factors. Cur-
risk assessment, caries management, and caries clinical proto- rently, there are no caries-risk factors or combinations of factors
cols. From this search, 1,909 articles were evaluated by title or that have achieved high levels of both positive and negative
by abstract. Information from 75 articles was used to update predictive values.2 Although the best tool to predict future
this document. When data did not appear sufficient or were caries is past caries experience, it is not particularly useful in
inconclusive, recommendations were based upon expert and/ young children due to the importance of determining caries
or consensus opinion by experienced researchers and clinicians. risk before the disease is manifest. Children with white spot
lesions should be considered at high risk for caries since these
Background are precavitated lesions that are indicative of caries activity.11
Caries-risk assessment Plaque accumulation also is strongly associated with caries de-
Risk assessment procedures used in medical practice normally velopment in young children.12,13 As a corollary to the presence
have sufficient data to accurately quantitate a person’s disease of plaque,14 a child’s Mutans Streptococci (MS) levels3 and the
susceptibility and allow for preventive measures.1 Even though age at which a child becomes colonized with cariogenic flora15,16
caries-risk data in dentistry still are not sufficient to quanti- are valuable in assessing risk, especially in preschool children.
tate the models, the process of determining risk should be While there is no question that fermentable carbohydrates
a component in the clinical decision-making process.2 Risk are a necessary link in the causal chain for dental caries, a sys-
assessment: tematic study of sugar consumption and caries risk has con-
1. Fosters the treatment of the disease process instead cluded that the relationship between sugar consumption and
of treating the outcome of the disease. caries is much weaker in the modern age of fluoride exposure
than previously thought.17 However, there is evidence that
night-time use of the bottle, especially when it is prolonged,
* The 2014 revision was limited to use of toothpaste in young children. may be associated with early childhood caries.18 Despite the fact

142 CLINICAL PRACTICE GUIDELINES

However.30 and fluoride varnishes generally are equal to that of for and justifying periodicity of services..26. frequent exposure to sugar containing snacks or beverages. because of its known benefit for dental health. Tables 1. Risk assessment categorization of low or high is based on preponderance of factors for the individual.23. the evolution of caries-risk fluoride applications performed semiannually also reduce assessment tools and protocols can assist in providing evidence caries. there is little evaluated in several populations with high caries prevalence.g. clinical judgment may justify the use of one factor (e. an inverse relationship be. studies have shown fined to provide greater predictably of caries in children prior consistent reduction in caries experience. reliable predictors and allow dental practitioners. Overall assessment of the child’s dental caries risk: High  Low  CLINICAL PRACTICE GUIDELINES 143 . Children with immigrant and adults. physicians.28 cents.and post-eruption fluoride exposure maximize the practical tools to assist dental practitioners. these tools can be re- With regard to fluoridated toothpaste. including children via their mothers. As new evidence emergences. modification of other professional topical fluoride vehicles. dren.33 With backgrounds have three times higher caries rates than non. and adoles significant caries reduction in primary and permanent teeth. 2.22 Perhaps another whether the effect is actually a measure of fluoride application type of sociodemographic variable is the parents’ history of or whether it is a result of mechanical removal of plaque.32 data about the prevalence of low salivary flow in children. Risk assessment tools can aid in the identification of and tooth brushing with fluoridated toothpaste. there only is a weak relationship immigrants. tween socioeconomic status and caries prevalence is found in which is confounded because it is difficult to distinguish studies of children less than six years of age.24 titioner is included in many caries-risk assessment models The most studied factors that are protective of dental ca. Furthermore. Caries-risk Assessment Form for 0-3 Year Olds 59. this has been found to be a The dental home or regular periodic care by the same prac- predictor of treatment for early childhood caries. physicians. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY that normal salivary flow is an extremely important intrinsic The effect of sugar substitutes on caries rates have been host factor providing protection against caries.34 cavities and abscessed teeth. other non-dental health care providers in assessing levels of fluoridated communities. regard to toothbrushing.31 Table 1. visible cavities) in determining overall risk. and caries-preventive effects.35 ries include systemic and topical fluoride.29 Professional topical to disease initiation. children. fluoride supplements have shown a risk for caries development in infants.20 Studies indicate that xylitol can decrease MS levels in plaque Sociodemographic factors have been studied extensively to and saliva and can reduce dental caries in young children determine their effect on caries risk.25 Additionally.60 (For Physicians and Other Non-Dental Health Care Providers) Factors High Risk Low Risk Biological Mother/primary caregiver has active cavities Yes Parent/caregiver has low socioeconomic status Yes Child has >3 between meal sugar-containing snacks or beverages per day Yes Child is put to bed with a bottle containing natural or added sugar Yes Child has special health care needs Yes Child is a recent immigrant Yes Protective Child receives optimally-fluoridated drinking water or fluoride supplements Yes Child has teeth brushed daily with fluoridated toothpaste Yes Child receives topical fluoride from health professional Yes Child has dental home/regular dental care Yes Clinical Findings Child has white spot lesions or enamel defects Yes Child has visible cavities or fillings Yes Child has plaque on teeth Yes Circling those conditions that apply to a specific patient helps the health care worker and parent understand the factors that contribute to or protect from caries. and 3 incorporate available evidence into both pre. Teeth of chil.19. dren who reside in a fluoridated community have been shown and other nondental health care providers to become more to have higher fluoride content than those of children who actively involved in identifying and referring high-risk chil- reside in suboptimal fluoridated communities. between frequency of brushing and decreased dental caries.27 For individuals residing in non. sugar substitutes.21 Most consistently.

Caries-risk Assessment Form for ≥6 Years Olds 60-62 (For Dental Providers) Factors High Risk Moderate Risk Low Risk Biological Patient is of low socioeconomic status Yes Patient has >3 between meal sugar-containing snacks or beverages per day Yes Patient has special health care needs Yes Patient is a recent immigrant Yes Protective Patient receives optimally-fluoridated drinking water Yes Patient brushes teeth daily with fluoridated toothpaste Yes Patient receives topical fluoride from health professional Yes Additional home measures (e. However.. MI paste. clinical judgment may justify the use of one factor (e. or high is based on preponderance of factors for the individual.60 (For Dental Providers) Factors High Risk Moderate Risk Low Risk Biological Mother/primary caregiver has active caries Yes Parent/caregiver has low socioeconomic status Yes Child has >3 between meal sugar-containing snacks or beverages per day Yes Child is put to bed with a bottle containing natural or added sugar Yes Child has special health care needs Yes Child is a recent immigrant Yes Protective Child receives optimally-fluoridated drinking water or fluoride supplements Yes Child has teeth brushed daily with fluoridated toothpaste Yes Child receives topical fluoride from health professional Yes Child has dental home/regular dental care Yes Clinical Findings Child has >1 decayed/missing/filled surfaces Yes Child has active white spot lesions or enamel defects Yes Child has elevated mutans streptococci levels Yes Child has plaque on teeth Yes Circling those conditions that apply to a specific patient helps the practitioner and parent understand the factors that contribute to or protect from caries. or high is based on preponderance of factors for the individual. clinical judgment may justify the use of one factor (e. frequent exposure to sugar-containing snacks or beverages. moderate. Risk assessment categorization of low. ≥1 interproximal lesions. more than one dmfs) in determining overall risk. antimicrobial) Yes Patient has dental home/regular dental care Yes Clinical Findings Patient has >1 interproximal lesions Yes Patient has active white spot lesions or enamel defects Yes Patient has low salivary flow Yes Patient has defective restorations Yes Patient wearing an intraoral appliance Yes Circling those conditions that apply to a specific patient helps the practitioner and patient/parent understand the factors that contribute to or protect from caries. low salivary flow) in determining overall risk. moderate. Overall assessment of the dental caries risk: High  Moderate  Low  144 CLINICAL PRACTICE GUIDELINES ..g. xylitol.REFERENCE MANUAL V 38 / NO 6 16 / 17 Table 2.g. Risk assessment categorization of low. However. Caries-risk Assessment Form for 0-5 Year Olds 59.g. Overall assessment of the child’s dental caries risk: High  Moderate  Low  Table 3..

and Caries management protocols quality of care with outcomes assessment to address limited Clinical management protocols are documents designed to resources and work-force issues. – Active surveillance e of a parent not engaged – Baseline MS fluoridated toothpaste b with limited incipient lesions – Professional topical treatment expectations every six months High risk – Recall every three months – Twice daily brushing with Counseling – Active surveillance e of parent engaged – Baseline and follow fluoridated toothpaste b incipient lesions a up MS – Fluoride supplements d – Restore cavitated lesions – Professional topical treatment with ITR f or definitive every three months restorations High risk – Recall every three months – Twice daily brushing with Counseling. – Active surveillance e of parent not engaged – Baseline and follow fluoridated toothpaste b with limited incipient lesions up MS a – Professional topical treatment expectations – Restore cavitated lesions every three months with ITR f or definitive restorations Table 5. Yes – Restore incipient. Yes – Active surveillance e of parent not – Radiographs every fluoridated toothpaste g with limited incipient lesions engaged six to 12 months – Professional topical expectations – Restoration of cavitated – Baseline MS a treatment every six months or enlarging lesions High risk – Recall every three months – Brushing with 0. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY third-party involvement in the delivery of dental services. assist in clinical decision-making.5 percent Counseling. Example of a Caries Management Protocol for 3-5 Year Olds Interventions Risk Category Diagnostics Restorative Fluoride Diet Sealants l Low risk – Recall every six to 12 months – Twice daily brushing with No Yes – Surveillance χ – Radiographs every fluoridated toothpaste g 12 to 24 months – Baseline MS a Moderate risk – Recall every six months – Twice daily brushing with Counseling Yes – Active surveillance e of parent engaged – Radiographs every fluoridated toothpaste g incipient lesions six to 12 months – Fluoride supplements d – Restoration of cavitated – Baseline MS a – Professional topical treatment or enlarging lesions every six months Moderate risk – Recall every six months – Twice daily brushing with Counseling.5 percent Counseling Yes – Active surveillance e of parent engaged – Radiographs every fluoride (with caution) incipient lesions six months – Fluoride supplements d – Restoration of cavitated – Baseline and follow – Professional topical or enlarging lesions up MS a treatment every three months High risk – Recall every three months – Brushing with 0. parent not – Radiographs every fluoride (with caution) with limited cavitated. Example of a Caries Management Protocol for 1-2 Year Olds Interventions Risk Category Diagnostics Restorative Fluoride Diet Low risk – Recall every six to12 months – Twice daily brushing with Counseling – Surveillance χ a – Baseline MS fluoridated toothpaste b Moderate risk – Recall every six months – Twice daily brushing with Counseling – Active surveillance e of a parent engaged – Baseline MS fluoridated toothpaste b incipient lesions – Fluoride supplements d – Professional topical treatment every six months Moderate risk – Recall every six months – Twice daily brushing with Counseling. they provide criteria regard- ing diagnosis and treatment and lead to recommended courses Table 4. or enlarging engaged six months – Professional topical expectations lesions – Baseline and follow treatment every three months up MS a CLINICAL PRACTICE GUIDELINES 145 .

Additionally. b Parental supervision of a “smear” amount of toothpaste. or not engaged six months – Professional topical treatment expectations enlarging lesions every three months – Xylitol Legends for Tables 4-6 a Salivary mutans streptococci bacterial levels. e Careful monitoring of caries progression and prevention program. Decisions for intervention often were learned from Additionally. The protocols are based on evidence from current measures and monitor carefully for signs of arrestment or peer-reviewed literature and the considered judgment of progression.29 Guidelines for the use of topical fluoride 146 CLINICAL PRACTICE GUIDELINES . defects. and active surveillance to apply preventive for using fluoride. thresholds based on a specific patient’s risk levels.5 percent – Counseling. many panel recommendations that give better understanding of and lesions do not progress. the management of dental caries was based compliance with preventive strategies (Tables 4. understanding of the disease process for for Disease Control and Prevention’s (CDC) recommendations that individual. γ Parental supervision of a “pea sized” amount of toothpaste. systematic reviews. Yes – Active surveillance e of m patient/parent – Radiographs every toothpaste with limited incipient lesions not engaged six to 12 months – Professional topical treatment expectations – Restoration of cavitated every six months or enlarging lesions High risk – Recall every three months – Brushing with 0.REFERENCE MANUAL V 38 / NO 6 16 / 17 Table 6. The radiographic diagnostic guidelines are based should be more conservative and includes early detection of on the latest guidelines from the American Dental Association noncavitated lesions. Such on the notion that it was a progressive disease that eventually protocols should yield greater probability of success and better destroyed the tooth unless there was surgical/restorative inter. as well as clinical experience of practitioners. vention. Yes – Restore incipient. and Historically.63 χ Periodic monitoring for signs of caries progression. expert panels. preventive. Example of a Caries Management Protocol for ≥6 Year-Olds Interventions Risk Category Diagnostics Fluoride Diet Sealants l Restorative Low risk – Recall every six to12 months – Twice daily brushing with No Yes – Surveillance χ – Radiographs every fluoridated toothpaste m 12 to 24 months Moderate risk – Recall every six months – Twice daily brushing with – Counseling Yes – Active surveillance e of patient/parent – Radiographs every fluoridated toothpaste m incipient lesions engaged six to 12 months – Fluoride supplements d – Restoration of cavitated – Professional topical treatment or enlarging lesions every six months Moderate risk – Recall every six months – Twice daily brushing with – Counseling. identification of an individual’s risk for (ADA).36 Content of the present caries management protocol is It is now known that surgical intervention of dental caries based on results of clinical trials. μ Less concern about the quantity of toothpaste. patient/parent – Radiographs every fluoride with limited cavitated.40 Systemic fluoride protocols are based on the Centers caries progression.39 tion of carious lesions. modern management of dental caries treatments. treatment uncertainties. The Caries management protocols for children further refine the protocols should be updated frequently as new technologies decisions concerning individualized treatment and treatment and evidence develop.5 percent – Counseling Yes – Active surveillance e of patient/parent – Radiographs every fluoride – Xylitol incipient lesions engaged six months – Fluoride supplements d – Restoration of cavitated – Professional topical treatment or enlarging lesions every three months High risk – Recall every three months – Brushing with 0. age. and expert alone does not stop the disease process. Therefore. f Interim therapeutic restoration. 5. and guarantee more correct strategies. λ Indicated for teeth with deep fissure anatomy or developmental d Need to consider fluoride levels in drinking water. and tooth restorations have a finite recommendations for diagnostic. caries management protocols free practitioners of unstandardized dental school instruction.36-38 eliminate criteria dentists use when making decisions involving restora. cost effectiveness of treatment than less standardized treatment. stand- by clinicians over years of practice. Little is known about the ardize decision making and treatment strategies. and then refined the necessity for repetitive high level treatment decisions. 6). and restorative longevity. of action.

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