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28 Caries Risk Assessment

CM Marya

case of caries progression, obviously, intervention is needed

either antibacterially, with fluoride or with other techniques.

Beck offered a definition for risk factors that was adopted for
Caries is not the consequence of a single event (as is a classical the World Workshop on Periodontics
infectious disease for example) but it is rather a sequel of a
series of processes happening over a longer period of time. The
etiological factors which can be diagnosed today, that is, the risk
of caries, do not necessarily have to be identical with the
causative factors which led to the development of a carious

In scientific studies various so-called ‘predictors’ for the risk of

caries have been investigated. These could be clinical signs of
caries or risk indicators, such as factors associated with the
development of caries. Their effects on the development of
caries can be either causative or modifying. Causative
relationships are often identified as risk factors. An individual
with an increased risk of caries may, therefore, be a person with
a higher than average exposure to the causative risk factors
mentioned below.

Several studies have attempted to determine risk factors that can

be reliably used to assess the level of risk of caries progression
in individual patients. Studies still are underway, and there is no
definitive formula yet available. It has been established that
high-risk patients include those who have a high bacterial
challenge, which may consist of a combination of high numbers
of mutans streptococci, lactobacilli or both. Although fluoride
has excellent properties in terms of balancing caries challenge,
if the challenge is too high, then fluoride— even at increased
concentrations, with increased use or both— cannot balance that
challenge. Therefore, in case of high bacterial challenge, the
bacterial infection must be dealt with, typically with a
chlorhexidine rinse, as well as the enhancement of salivary
action by topical delivery of fluoride. These principles apply
equally well to adults and children. Accurate detection of early
caries can increase the reliability of caries risk assessment,
particularly if those measurements are made at three- or
six-month intervals and caries progression can be measured. In
Risk factor: an environmental, behavioral, or biologic factor
confirmed by temporal sequence, usually in longitudinal studies,
which if present directly increases the probability of a disease
occurring, and if absent or removed reduces the probability.
Risk factors are part of the causal chain, or expose the host to
the causal chain. Once disease occurs, removal of a risk factor
may not result in a cure.

This definition is longer than the one offered by Last, but it is

much clearer.
The key contributions of this definition are (a) the emphasis on a
temporal sequence of events preceding the outcome; (b) the
unequivocal acceptance that a risk factor is part of a causal
chain; and (c) the acceptance that risk factors are involved in the
onset of disease but not necessarily in its progression or


The goals of caries risk assessment can be summarized as

a. 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.

The aim is to identify caries-active individuals and to

convert them to caries -inactive status, so that they become low

risk for the disease (Bevenius J, 1997)


Caries disease indicators are clinical observations that tell about

the past caries history and activity. They are indicators or
clinical signs that either disease is present or that there has been
recent disease. These indicators say nothing about what caused
the disease or how to treat it. They simply describe a clinical
observation that indicates the presence of disease. These are
neither pathological factors nor are they causative in any way.
They are simply physical observations (cavitations, white spots,
 Section 3 
​ ​ Preventive Dentistry plaque and an increase in the percent of cariogenic bacteria.
These appliances will generally place the patient at high risk
The four caries disease indictors are: (1) frank cavita-tions or of new carious lesion in the future.
lesions that radiographically show penetration into dentine; (2)
approximal radiographic lesions confined to the enamel Any physical or mental illness and any oral application or
only; (3) visual white spots on smooth surfaces; and (4) restoration that compromises the maintenance of optimal
any restorations placed in the last three years. oral health.


Caries risk factors are biological factors that contribute to the These are biological or therapeutic factors or measures that can
level of risk for the patient of having new carious lesions in the collectively offset the challenge presented by the previously
future or having the existing lesions progress. The risk factors
are the biological reasons or factors that have caused or
contributed to the disease, or will contribute to its future
manifestation on the tooth. These we can do something about.

The best indicators for increased risk of dental caries are:

Medium or high MS and LB counts

Visible heavy plaque on teeth: ​This indicates poor oral

hygiene and/or prolific plaque growth by the individual and
is an indirect indicator that there are likely to be high levels
of cariogenic bacteria.

Inadequate exposure to fluoride

Frequent (>three times daily) snacking between meals: I​ f ​a

person is snacking greater than 3 times daily between meals
on foods or beverages that contain sucrose, glucose,
fructose, or cooked starch (cookies or bread), this increases
the acid challenge to the teeth to a high level.
Xylitol-containing gum or mints should be recommended as
a substitute for these snacks.

Deep pits and fissures

Lower socioeconomic status

Recreational drug use

Inadequate saliva flow by observation or measure-ment:

Saliva reducing factors (medications/radiation/systemic)
Saliva flow rate can be measured by having the patient chew
and spit into a measuring cup and calculate the number of
milliliters (mL) per minute. A value less than 0.7 mL/minute
is low, whereas 1 to 4 mL/minute is normal

Exposed roots

​ he presence of fixed or removable

Orthodontic appliances: T
appliances in the mouth such as orthodontic brackets or
removable partial dentures leads to undue accumulation of
caries-risk, therefore, is the risk of an individual developing a
mentioned caries risk factors. The more severe the risk factors, carious lesion. Increased risk may be the result of several
the higher must be the protective factors to keep the patient in caries-producing factors coinciding or of insufficient defense
balance or to reverse the caries process. As industry responds to mechanisms leading to different caries prevalence. By
the need for more and better products to treat dental caries, the definition, risk is aimed at assessing developments in the future.
current list is sure to expand in the future. It can, however, be assessed only on the basis of symptoms
present at, or having manifested themselves by, the time of
The protective factors are: assessment.

Lives/work/school located in a fluoridated community. The following factors should be considered when assessing
caries risk primarily for an adult as shown in Table 28.1 (Caries
Fluoride toothpaste at least two times daily. risk assessment tool):

Fluoride mouthrinse (0.05 percent NaF) daily.

15,00 ppm fluoride toothpaste daily.

Fluoride varnish in last six months.

Office fluoride topical in last six months.

Chlorhexidine prescribed/used daily for one week each for

last six months.

Xylitol gum/lozenges four times daily in the last six

Calcium and phosphate supplement paste during last six
Adequate saliva flow (ml/min stimulated).

Fluoride toothpaste frequency is included since studies have

shown that brushing twice daily or more is significantly more
effective than once a day or less. Any or all of these protective
factors can contribute to keep the patient “in balance” or even
better to enhance remineralization, which is the natural repair
process of the early carious lesion.

Caries Susceptibility

This is the susceptibility (or resistance) of a tooth to a

caries-producing environment. The risk of developing a lesion,
however, is individual and varies, depending on the tooth, its
localization, surfaces, previous fluoride exposure etc.

Caries Activity

Caries activity is a measure of the speed of progression of a

carious lesion. Retrospectively it can be determined as caries
incidence, that is, new carious lesions over time of an individual
or population.


Generally speaking, risk is defined as the probability of

incidence of an event within a certain period of time. The
  Chapter 28 ​Caries Risk Assessment 319
Table 28.1: ​Caries risk assessment tool for an adult

Risk factors High risk Low risk

Clinical/oral evidence • Previous caries • Very few restoration

• New lesions • No new carious lesion
• Unsealed deep pits and fissures • Sealants in pits and fissures
• Fixed orthodontic appliances • No orthodontic appliances
• Prosthesis • No prosthesis to care for
• Exposed root surfaces • Exposed root surfaces with special fluoride
• Premature extraction of teeth application regularly
• Multiple restorations • Nil extraction for caries
• Caries in anterior teeth • Sound anterior teeth

Dietary habit • Frequent sugar intake • Infrequent sugar intake

• Frequent snack in between meal • Rare in between meals snacks
• Use of xylitol gum

Medical history • Medically compromised • No medical problems

• Physical disability/handicapped • No physical problems or handicaps
• Xerostomia • Normal salivary flow
• Radiation therapy • No long-term medication for chronic diseases

Social history • Low knowledge of dental disease • Dentally aware

• Irregular dental visits • Regular appointments with dentist
• Low dental aspiration • High dental aspiration
• High caries in sibling • Low caries in siblings
• General poor oral care in family • Good oral care by family

Plaque/biofilm control • Irregular brushing • Frequent effective cleaning using toothbrush

• Ineffective cleaning • Use of dental floss
• Poor manual dexterity or handicap • Good dexterity; no handicap
• High biofilm scores • Low biofilm scores
• Orthodontic appliance and prosthesis care • No orthodontic or prosthesis care requirement

Saliva • Low flow rate • Flow rate normal

• Low buffering capacity • High buffering capacity

Use of fluoride • No fluoride supplement • Use of fluoride supplement

• Non-fluoridated drinking water • Drinking water fluoridated
• Use of non-fluoridated toothpaste or irregular • Fluoride toothpaste used
brushing with a fluoridated toothpaste • Use of fluoride mouthwash
• Does not use a fluoridated mouthwash

Moderate risk • Individuals who do not clearly fit into high or low risk categories are considered to be at moderate risk.

Adapted from the table cpompiled by Professor Edwina Kidd for the Faculty of General Dental Practitioners Guidelines.

Clinical evidence of previous disease

Dietary habits, especially frequency of sugary food and
drink consumption caries could be detrimental to their general health.
Social history, especially socio-economic status These patients should receive intensive preventive
dental care.
Use of fluoride

Plaque control

Clinicians should be aware of individuals with a medical or
physical disability for whom the consequences of dental
Clinical Evidence

The patients with following oral characteristics

are at high risk.
 320 Section 3 ​Preventive Dentistry Saliva

Multiple new lesions in past 12 months Many features of saliva affect the risk of dental caries like:

Unsealed pits and fissures Low buffering capacity (as acids are not neutralized)

History of premature extraction for caries Low quantity

Multiple restorations High S. mutans and Lactobacillus count

Exposed root surfaces Xerostomia is a known predisposing factor.

Anterior caries or restorations Use of Fluorides

Dietary Habits Fluoride has been a known factor which delays the progression
of dental caries; thus patients who do not have fluoridated water
It is seen that all patients who have high sugar intake develop or use fluoridated toothpaste may be at risk.
dental decay. Frequent smokes in-between meal are also
considered as risk factors.

Medical History

Medically compromized and handicapped people may be at high

risk of caries. Many medicaments, such as Antidepressants,
Antipsychotic, Tranquilizers, Antihyper-tensive and Diuretics
cause dry mouth. Patients who have radiotherapy in salivary
gland region for head and neck malignancy or removal of
salivary gland suffer from xerostomia. Patients with rheumatoid
arthritis may also have Sjogren’s syndrome, which affect
salivary and lacrimal gland, leading to dry mouth and dry eyes.

Social History

The following features of social history may also be present in

high risk patient
Caries in sibling is high

The patient possesses little knowledge

Irregular dental visits to dentist and dental awareness are


The patient’s access to snacks is high

Poor oral care in family.

Plaque Control

Dental plaque is the most important risk factor for dental caries.
The patients who do not clean their teeth frequently and
effectively or have poor manual dexterity may be at high risk.
Orthodontic appliances and dental prosthesis are a major source
of plaque accumulation which needs to be cleaned effectively to
prevent plaque accumulation.
XEROSTOMIA Rheumatoid arthritis

Systemic lupus erythematosus

Xerostomia is defined as a subjective complaint of dry mouth Systemic sclerosis

that may result from a decrease in the production of saliva.
Mixed connective tissue disease

To assess the risk for caries involvement due to xerostomia, the

clinical evidence of hyposalivation must be identified. Dry lips,
dryness of buccal mucosa, absence of saliva in response to gland
palpation, and a high number of decayed, missing, or filled teeth
have been cited as an easily assessed set of clinical parameters
for identifying most patients with salivary gland dysfunction


A major complication of xerostomia is the promotion of dental OTHER CONDITIONS

caries (Fig. 28.1). This process is accelerated owing to a
reduction in oral irrigation and an inability to clear foods from
the oral cavity rapidly, particularly if proteins and electrolytes
Radiation therapy
that inhibit cariogenic microorganisms and buffer oral acids,
respectively, are diminished. The development of rampant Primary biliary cirrhosis
caries, particularly at the cervical area, has been observed within
a few weeks after radiation therapy to the head and neck. Vasculitis

Chronic active hepatitis



Bone marrow transplantation

CAUSES OF XEROSTOMIA Graft-vs-Host disease

Renal dialysis

Primary Sjögren’s syndrome Anxiety or depression.

Secondary Sjögren’s syndrome

Surgical removal of glands due to neoplasm








  dentist’s subjective judgment of the size of the ‘Decayed’,
‘Missing’ and ‘Filled’ increment (newly developing caries) over
subsequent years is also a relatively strong predictor.

In diagnosing caries risk, no single test can simultaneously

measure host resistance, microbial pathogens, and cariogenicity
of the diet. Multiple predictor models (including mutans scores,
baseline caries prevalence, fissure retentiveness score, dietary

Fig. 28.1: ​Theoretical model of the relationship between medication,

salivary gland hypofunction, xerostomia and dental caries

Much progress has been achieved in the prevention of dental

decay over the past decades. Epidemiological studies have
demonstrated high caries active individuals in the same
population as moderate or low caries active individuals. Caries
prevalence indicators can be used for assessing either caries
activity or the risk of future caries. However, caries-risk does
not remain constant throughout life and may be modified by
preventive intervention both by the patient and by the dentist.


‘high caries-risk’ group is defined as a sub-group of the

population which is at greater risk of acquiring caries than the
average population. The borderline between low, moderate or
high risk is not precise, but depends on the prevalence within the
population and on additional factors. When there are only a few
caries-risk factors present, then the evaluation is of a ‘low caries
risk’, when there are many risk-factors present the classification
is of a ‘high caries-risk,’ and the moderate caries-risk group falls
in between (Box 28.1).


For individual patients, the objective clinical judgment of the

dentist, their ability to combine and use these risk factors and their
knowledge of the patient has been shown to be one of the most
powerful predictors of that individual’s caries risk. In particular, the
​ ​ Caries Risk Assessment
Chapter 28  321 preventive program in order to minimize the
development of carious lesions.
habit index, salivary buffering and flow rate) are The prevalence and incidence of caries influences the
necessary to classify a person according to caries
risk. predictability of the caries-risk assessment. The
identification of subjects with high caries-risk is
Several studies have attempted to determine risk relatively accurate where children and adolescents
factors that can be reliably used to assess the level are concerned and when sufficient base-line data
of risk of caries progression in individual patients. is available. The situation is different where adults
Studies still are under way, and there is no are concerned because they receive more dental
definitive formula yet available. It has been treatment but lack preventive programs. Since
established that high-risk patients include those secondary caries is the most frequent cause of
who have a high bacterial challenge, which may replacement of restorations and root caries
consist of a combination of high numbers of becomes a problem for adults, caries-risk
mutans streptococci, lactobacilli or both. Although assessment and, when needed, preventive
fluoride has excellent properties in terms of intervention is also necessary for adults.
balancing caries challenge, if the challenge is too
high, then fluoride—even at increased In the clinical situation the accurate prediction of
concentrations, with increased use or caries is not as important as the assessment of the
both—cannot balance that challenge. Therefore, in individual caries risk and risk factors. Even with
the case of high bacterial challenge, the bacterial routinely available clinical and sociodemographic
infection must be dealt with, typically with a information at clinical examination a dentist can
chlorhexidine rinse, as well as the enhancement of identify high caries risk subjects with good
salivary action by topical delivery of fluoride. accuracy.
These principles apply equally well to adults and
children. Accurate detection of early caries can In order to arrest the development of caries as
increase the reliability of caries risk assessment, early as possible it is important that caries-risk
particularly if those measurements are made at status be assessed. For children in kindergarten a
three- or six-month intervals and caries simple assessment of previously acquired lesions
progression can be measured. In the case of caries will suffice.
progression, obviously, intervention is needed
either antibacterially, with fluoride or with other



Determination of caries-risk is important for:

Assessment of the individual etiological

factors of existing carious lesions and of the
caries risk situation
Repeated determination of the caries-risk
allows an evaluation of the success of, or the
need for, modification of preventive measures

Indications of an increased caries-risk in

specific children in community preventive
programs will allow selection of an individual
3 ​ ​ Preventive Dentistry
Section 3 


Children Adults
Low risk Low risk
• No new or incipient carious lesions in the past year No new or incipient lesion
Moderate risk (any of the following) Moderate risk (any of the following)
• One new, incipient or recurrent carious lesion in the • One to two new, incipient or recurrent carious lesions
past year during the past three years
• Deep or noncoalesced pits and fissures. • History of numerous or severe caries
• High caries experience in siblings • Deep or noncoalesced pits and fissures
• History of pit and fissure caries • Frequent sugar exposures
• Early childhood caries • Decreased salivary flow
• Frequent sugar exposures • Irregular dental visits
• Decreased salivary flow • Inadequate fluoride exposure
• Compromised oral hygiene
• Irregular dental visits
• Inadequate fluoride exposure
• Proximal radiolucency
High risk High risk
Two or more new, incipient or recurrent carious lesions in Three or more carious lesions in the past three, or two
the past year, or two or more of the following: or more of the following:
• Deep or noncoalesced pits and fissures • History of numerous or severe caries
• Siblings or parents with high caries rate • Deep or noncoalesced pits and fissures
• History of pit and fissure caries • Frequent sugar exposures
• Frequent sugar exposures • Decreased salivary flow
• Decreased salivary flow • Irregular dental visits
• Compromised oral hygiene • Inadequate fluoride exposure
• Irregular dental visits • Compromised oral hygiene
• Inadequate fluoride exposure
• Proximal radiolucency

The Cariogram serves the purpose of demonstrating the caries

Caries management by risk assessment now is receiving risk graphically in terms of:
considerable attention, and software programs are being
developed that will aid practitioners in assessing risk and lead Risk for ​developing new caries​ in the future
them to the use of current and new technologies by specifying
treatments recommended for the various risk categories (Box Chance to ​avoid new caries​ in the near future
Cariogram helps to understand the multi-factorial aspects of
dental caries and can be used as a guide in attempts
to estimate caries risk

Cariogram is an interactive version for estimation of caries risk

and for understanding the interactions of various factors causing
caries. In simple terms, Cariogram is a way to illustrate
interactions between caries related factors, by a computer
version which presents a graphical picture that illustrates the
overall risk scenario. It was developed by D. Bratthall, L.
Allander and K. Lybegard in 1997.
Fig. 28.2: ​Cariogram

The idea is to:

a. Identify those persons who will most likely develop caries

Provide these individuals proper preventive and treatment
measures to stop the disease.
  Chapter 28 ​Caries Risk Assessment 323


Factors Caries Risk

S No. Risk factor to consider High Moderate Low Finding

1. Child has visible decay Yes No

2. Caries restored (time lapsed in last restoration) <12 months 12-24 months >24 months
3. Visible heavy plaque/debris on teeth of child Yes No
4. Frequency of between meal snacks/sugars by the child >3 1-2 Meal time only

Presence of conditions that impairs/reduce saliva

(dry mouth) in child Yes No

6. Family socio-economic status Low Mid-level High
7. Child has orthodontic/oral appliance in the mouth Yes No
8. Deep pits & fissures/enamel defects Yes No
9. White spot lesion/areas of enamel demineralization >1 1 None
10. Gingivitis Present Absent
11. Levels of mutans streptococci or lactobacilli High Moderate Low

Child’s exposure to fluoride

A. Daily use of fluoride toothpaste No Yes Yes

B. Drinking water fluoridated No No Yes
C. Daily use of fluoride No No Yes
mouthwash or gel
D. Intake of fluoride supplements No No Yes
13. Child needs special health care Yes No
14. Childs’s frequency of tooth brushing per day Irregular or <1 1 2 Times
But the idea of caries risk assessment is highly varied, as dental
caries is a multi-factorial disease. On account of several studies Expresses caries risk graphically.
performed, one could define three main approaches for risk
assessment, which are based on: Recommends targeted preventive actions.

past caries experience Can be used in the clinic and as an educational program.

socioeconomic factors and The Cariogram, a pie-circle diagram, is divided

into five sectors, in the following colors:
biological factors
The Dark blue sector ‘Diet’ - Based on a
So, in view of the fact, a new model for understanding the combination of diet contents and diet
interactions of various factors was proposed and a graphical frequency.
model, the Cariogram, was drawn up to illustrate the fact that
caries can be controlled by several different means. Cariogram The Red sector ‘Bacteria’ - Based on a
was originally developed as an educational model but later on combination of amount of plaque and mutans
served as a routine caries assessment tool.
The Cariogram presents caries risk profile of an individual
The Light blue sector ‘Susceptibility’- Based
graphically, simultaneously taking into account the interaction
on a combination of fluoride program, saliva
off different causative factors/parameters of caries. It also
secretion and saliva buffer capacity.
provides recommendations for target preventive measures one
could implement, in order to overcome new caries formation.
The Yellow sector ‘Circumstances’ - Based
on a combination of past caries experience
and related diseases.

The Green sector shows an estimation of the

Illustrates the interaction of caries related factors. ‘Actual chance to avoid new cavities’.

Illustrates the chance to avoid caries.

The bigger the green sector, the better from a
dental health point of view. Smaller the green
sector means low chance to avoid caries = high
caries risk. For the other sectors, the smaller the
sector, the better from dental health point of view.