Assessment of Dental caries for better oral health

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3. • The 'Cariogram' is a concept, conceived initially as an
educational model, aiming at illustrating the multifactorial
background of dental caries in a simple way.
• It is a graphical picture illustrating in an interactive way the
individual's/patient's risk for developing new caries in the
future, simultaneously expressing to what extent different
etiological factors of caries affect the caries risk for that
particular patient.
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4. • Cariogram as an interactive PC-program has been developed
for educational, preventive and clinical purposes.
• However, the Cariogram does never specify a particular
number of cavities that will or will not occur in the future.
• It rather illustrates a possible over-all risk scenario, based on
what can be expected depending on our interpretation of
available information.
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5. • Professor D. Bratthall in 1996 developed the concept and
the formula for the Cariogram.
• The PC version was created in collaboration with Dr L.
Allander and K-O. Lybegård.
• The Swedish version of the Cariogram(modified
Cariogram) was first launched officially in November
1997 after extensive trials.
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6. Cariogram – aims
• Expresses caries risk graphically.
• Illustrates the interaction of caries related factors.
• Illustrates the chance to avoid caries.
• Recommends targeted preventive actions.
• Can be used as an educational programme.
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7. Original Cariogram
CLOSED
Where demineralization
occurs resulting in cavities
over a given time
OPEN
Where no caries lesions will
occur because 'something is
missing', in order to create
demineralization. 7

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9. NEW CARIOGRAM -So what do the five
sectors represent?
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10. • The dark blue sector ‘Diet’ is based on a combination of diet
contents and diet frequency.
• The red sector ‘Bacteria’ is based on a combination of amount of
plaque and mutans streptococci.
• The light blue sector ‘susceptibility’ is based on a combination of
fluoride program, saliva secretion and saliva buffer capacity.
• The yellow sector ‘Circumstances’ is based on a combination of
caries experience and related diseases.
• The green sector shows an estimation of the ‘Chance of avoiding
caries’.
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11. Original Version Modified Version
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12. 1. The risk for future carious activity varies on a scale from 0% to
100% but it cannot be more than 100% i.e sectors do not over lap.
2. The chance of avoidance is seen as green zone in new one where
as in old one it was seen as Blank space/Gap.
3. New sector, circumstances, was included. This sector includes
factors such as caries experience and systemic diseases-factors to
consider when the risk is calculated, in spite of the fact that these
factors themselves do not participate directly in the development
of the lesion.
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13. What makes Sectors
Small or Large?
• The Red sector increases if there is a lot of plaque, high
proportion of extra cariogenic bacteria in the plaque (such
as mutans streptococci and lactobacilli).
• The Red sector decreases if there is a good oral hygiene
and if a low proportion of cariogenic bacteria in the
plaque.
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14. • The Blue sector increases if there is a high and frequent
intake of sugar and other easily fermentable
carbohydrates.
• The Blue sector decreases if there is a low and
infrequent intake of sugar and other easily fermentable
carbohydrates.
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15. • The Light blue sector increases if susceptibility is high,
for example due to low exposure to fluorides, low saliva
secretion, low buffering capacity of saliva.
• The Light blue sector decreases if susceptibility is low, for
example due to proper exposure to fluorides, normal
saliva secretion, good buffering capacity of saliva.
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Flouride

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19. Age in years Better than
Normal
(mean DMFT)
Normal
(mean DMFT)
Worse than normal
(mean DMFT)
20 8 10 12
30 10 12 15
40 14 18 21
50 18 21 23
60 21 22 24
70 22 24 25
80 23 25 26
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24. • The factors included in the Cariogram have been given
different ‘weights’. This means that the key factors, which
support the development of caries, or resist caries, have
a stronger impact than the less important factors(socio-
economic factors and past caries experience) when the
program calculates the ‘Chance to avoid new cavities’.
• The factors are also weighted in relation to each other.
Thus, different factors have different ‘weights’ in
different situations and the number of combinations of
factors is enormous.
‘Weights’ - the relative impact of
factors

25. Is the Cariogram a risk model or a prediction model?
• Actually, it is both because it acts as a prediction model
that predicts who is at high risk, and it is a risk model
identifying the risk factors to facilitate planning of
interventions.
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26. Why are social factors not included in the Cariogram?
• A number of papers have clearly indicated the importance of social
factors for caries risk. Still, the Cariogram does not address these
factors directly.
• The reason is that social factors do not directly act on the tooth
surface (if they had, there would be carious lesions everywhere, not
just where there are bacteria).
• Social background can often explain reasons for factors such as
neglected oral hygiene and increased sucrose consumption, factors
that are already included in the Cariogram.
• Hence, social factors need not be taken into account separately
when constructing the Cariogram.
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27. What is the sensitivity and specificity of the
Cariogram?
• Calculating such values demands ‘cut-off’ points and the Cariogram
does not have such a point.
According to Rodricks:
• Risk is the probability that some harmful event will occur. Because it
is a probability, risk is expressed as a fraction, without units. It takes
values from 0 (absolute certainty that there is no risk, which can
never be shown) to 1.0, where there is absolute certainty that a risk
will occur.
• In other words, the Cariogram expresses a probability. For example,
‘90% chance of avoiding caries’ means that most people with that
particular combination of risk factors would stay without new
cavities. If a person anyway developed caries with that probability,
the program was not ‘wrong’ as it had not said ‘100%’.
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29. 1. Caries Risk Profiles of 12-13 year-old Children in Laos
and Sweden
• Purpose: To analyse caries risk factors of 12-13-year-old children
living in Laos, using the computer program Cariogram to illustrate
the caries risk profile. In addition, to compare the results with a
study performed in Sweden.
• 100 Laotian and 392 Swedish children were included. Interviews
were performed to obtain information on diet intake and fluoride
use.
Various risk factors in cariogram were evaluated
• Caries prevalence was recorded according to WHO. The data were
entered into the Cariogram to determine each child’s caries risk,
expressed as ‘the chance of avoiding caries’. The children were
divided into five risk groups.
Oral Health Prev Dent 2005; 3: 15–23.
G. L. Tayanina/G. Hänsel Peterssona/D. Bratthalla
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32. Caries Risk Profiles of 12-13Year-old Children in Laos and
Sweden
• Results: Mean DMFT level of the Laotian children was
4.61+2.95 and 1.38+1.97
• Only 6% of Laotian children belonged to the Cariogram low risk
group versus 40% of the Swedish children.
• The mean chance of avoiding caries was 37.3% for the Laotians
and 69.2% for the Swedish children (p < 0.001).
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36. 2.Caries risk profiles in schoolchildren over 2 years assessed by
Cariogram
• Aim. To evaluate longitudinal changes in caries risk profiles in
a group of schoolchildren in relation to caries development.
• Design. The Cariogram model was used to create caries risk
profiles and to identify risk factors in 438 children being 10–
11 years at baseline.
The assessment was repeated after 2 years and the
caries increment was recorded.
• The frequency of unfavourable risk factors were compared
between those considered at the lowest and the highest risk.
International Journal of Paediatric Dentistry 2010; 20: 341– 346 36
Gunnel haansel petersson, Pererik isberg & Svante twetman

37. • Results. 50% of the children remained in the same risk
category after 2 years. One third of the children were
assessed in a higher-risk category while 18.4% showed a
lower risk.
• Those with increased risk compared with baseline developed
significantly more caries than those with an unchanged risk
category.
• The most frequent unfavourable risk factors among those
with high risk at baseline were high-salivary mutans
streptococci and lactobacilli counts as well as frequent meals.
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40. • Conclusion. Half of the children showed a change risk
category after 2 years, for better or for worse, which suggests
that regular risk assessments are needed in order to make
appropriate decisions on targeted preventive care and recall
intervals.
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41. 3.Caries risk profile using the Cariogram in governmental and
private orthodontic patients at de-bonding
• Objectives -To analyze various caries-related factors in
orthodontic patients at de-bonding between governmental
and private orthodontic patients immediately after
orthodontic treatment.
• Materials and Methods: A cross-sectional examination was
carried out on 89 orthodontic patients aged 13–29 years,
mean age 21.5 years.
They were divided into two groups based on the center of
treatment, governmental group (G -45) and private group (P-
44).
Angle Orthod 2012;82:267–274.
Naif Abdullah Almosaa; Anas H. Al-Mullab; Dowen Birkhedc
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43. • The investigation comprised a questionnaire, plaque scoring,
caries examination, bitewing radiographs, salivary secretion
rate, buffering capacity, and cariogenic microorganisms. Data
were entered into the Cariogram PC program to illustrate
caries risk profiles.
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46. • Results: Findings revealed that ‘‘the chance of avoiding new
cavities,’’ according to the Cariogram, was high in the P-group
and low in the G-group (61% and 28%, respectively) (P 0.001).
• (DMFS), plaque index, mutans streptococcus and lactobacillus
counts, and salivary buffer capacity were significantly higher
in the G-group compared with the P-group.
• The total number of caries lesions at de-bonding in the G-
group was more than two times higher than that in the P-
group
(Angle Orthod. 2012;82:267–274.)
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47. • CONCLUSIONS The null hypothesis was rejected. The chance
to avoid new cavities in orthodontic patients at de-bonding
appears to be more negative at governmental clinics than at
private clinics.
• This study shows the importance of improving preventive
measures used during orthodontic treatment, especially at
governmental clinics.
• The Cariogram may be a useful tool for illustrating caries risk
profiles for orthodontic patients..
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48. 4.Evaluation of the caries profile and caries risk in adults with
endodontically treated teeth
• Objectives. The present study was set up to explore
(1) a potential association between a person’s caries risk profile
and the presence or absence of root-filled teeth,
(2) the caries risk in endodontically treated teeth.
• Study design. 200 Saudi adults were divided into an Endodontic
Group (EG) n-100 , with a minimum of 2 root-filled teeth, and a Non-
Endodontic Group (NEG) n-100, without any root filling.
Various caries risk factors were evaluated using a computer-based
program (Cariogram). Clinical and radiographic examinations were
also carried out.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:264-269)
Merdad K, Sonbul H, Gholman M, Reit C, Birkhed D
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49. • Results. Cariogram findings showed that “the chance of avoiding
caries” was low in both groups (35% in EG and 37% in NEG), and
there was no statistically significant difference between the 2
groups.
However, DMFS, recurrent caries, and mutans streptococcus
count in saliva were significantly higher in the EG compared to the
NEG (P > 0.05).
When teeth in the EG were evaluated independently, the
proportion of recurrent caries to the total fillings associated with
endodontically treated teeth was 31.6% versus 19.2% in the non-
endodontically treated teeth.
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50. • Conclusions. Data were not in favor of an association between
caries risk profile and presence of root-filled teeth, but
supported the notion that root-filling procedures might make
the tooth more susceptible to caries.
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51. 5. Caries assessment in school children using a reduced Cariogram model
without saliva tests
Gunnel Hansel Petersson, Per-Erik Isberg and Svante Twetman
• Methods: The study group consisted of 392 school children, 10-11 years of
age, who volunteered after informed consent.
A caries risk assessment was made at baseline with aid of the computer-
based Cariogram model and expressed as "the chance of avoiding caries" and
the children were divided into five risk groups.
• The caries increment (ΔDMFS) was extracted from the dental records and
bitewing radiographs after 2 years. The reduced Cariogram was processed by
omitting the variables "salivary mutans streptococci", "secretion rate" and
"buffer capacity" one by one and finally all three.
• Differences between the total and reduced models were expressed as area
under the ROC-curve.
BMC Oral Health 2010, 10:5 51

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54. • Results: Both Cariogram models displayed a statistically relationship
with caries development (p < 0.05) more caries was found among
those assessed with high risk compared to those with low risk.
• Almost all children (99%) remained in the same risk group when the
buffer and secretion rate values were aborted.
• The corresponding value for mutans streptococci elimination was
68% indicating that almost one third of the children changed their
risk group, for better or for worse, without use of the salivary
mutans streptococci enumeration. The vast majority (74%) were
placed in a lower risk category.
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55. • Conclusion- the accuracy of caries prediction in school
children was significantly impaired when the Cariogram model
was applied without enumeration of salivary tests.
• The mutans streptococci enumeration seemed to be most
important of the salivary variables.
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57. 1. Caries risk profile of 12 year old school children in an Indian city
using Cariogram
Mamata Hebbal , Anil Ankola , Sharada Metgud
• The present study was conducted with an aim to assess the caries
profile of 12 year old Indian children using Cariogram.
• Study design: 100 children were interviewed to record any illness,
oral hygiene practices and fluoride exposure after obtaining a three
day diet diary.
Examination was done to record plaque and dental caries
status. Stimulated saliva was collected and salivary flow rate,
salivary buffering capacity, Streptococcus mutans and Lactobacillus
were assessed. The information obtained was scored and
Cariogram was created.
Med Oral Patol Oral Cir Bucal. 2012 Nov 1;17 (6):e1054-61. 57

58. • Differences between mean ( DMFT) and Cariogram risk groups
were assessed using ANOVA. Spearman Correlation
coefficients were used to explore correlation among
Cariogram scores and individual variables.
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60. • Results: Significant correlation was observed between
Cariogram score and DMFT, diet content, diet frequency,
plaque scores, Streptococcus mutans counts and fluoride
programme.
• Conclusions: Cariogram model can identify the caries-related
factors that could be the reasons for the estimated future
caries risk, and therefore help the dentist to plan appropriate
preventive measures.
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61. 2. Evaluation of a preventive program based on caries risk among mentally
challenged children using the cariogram model.
Y.B. Patil, S. Hegde-Shetiya, P.V. Kakodkar, R. Shirahatti
Objectives: To assess the caries risk and to evaluate the risk based
preventive program at the end of 10 months amongst the mentally
challenged children using the Cariogram model.
Basic research design: Longitudinal field trial with before and after
comparison. 54 children (7-17years old) with mild to severe mental
disability from Brahmadutta School, for the mentally challenged
children situated in Pimpri (Maharashtra) India.
Community Dent Health. 2011 Dec;28(4):286-91 61

62. Interventions
Phase I: Information of the Cariogram parameters (caries experience, diet
content, diet frequency, plaque amount, mutans streptococci, fluoride
program, saliva secretion and saliva buffer capacity) were collected, which
were used to generate the individual caries profile, based on which the
children were divided into 5 risk groups.
Phase II: Risk based preventive program was implemented.
0-20% chance avoidance-APF gel 1.23% at beginning,3 months and at
end of 6 months
21-100% chance of avoidance- avoidance-APF gel 1.23% at beginning,
and end of 6 months
Phase III: At the end of 10 months, caries profile was generated again.
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63. The effectiveness of the preventive program was assessed by
comparing the baseline and follow-up caries profile. Wilcoxon
Signed Ranks test was used for statistical analysis.
Results: As compared to the baseline, there was a 57%
increase in the number of children in low caries risk group
and for the caries risk factors diet content, diet frequency,
plaque amount and Mutans streptococci count had
significantly lower values. At follow-up, only 4 new carious
lesions developed.
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64. • Conclusion: The preventive program was effective in
improving the caries risk factors and increasing the chance to
avoid caries from a mean of 44% to 87%.
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66. • Caries Risk Assessment is one of the cornerstones in patient
centered caries management in order to assist the clinician in
the decision making process concerning treatment, recall
appointments and need for additional diagnostic procedures.
• Ideal Risk assessment tool
-high precision and accuracy
- should be easy to use in the daily practice
-utilize inexpensive risk factors that can be scored in reliable
way.
-the process should be rapid and the outcome understandable so
it can used as didactic tool in patient motivation.
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67. • Ultimately,predictive tool should be sensitive enough to catch
as many as possible of those with a true caries risk but also
correctly identify those with low risk.
• The cariogram model is truly comprehensive and illustrates
the relative importance of various background factors in an
individual risk profile but the increased costs and timely
handling of salivary tests may have limited its use.
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68. REFERENCES
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69. References
• Caries Risk Profiles of 12-13-Year-old Children in Laos and
SwedenG. L. Tayanina/G. Hänsel Peterssona/D. Bratthalla Oral
Health Prev Dent 2005; 3: 15–23.
• Caries risk profiles in schoolchildren over 2 years assessed by
cariogram Gunnel Ha¨ Nsel Petersson1, Per-erik Isberg2 &
Svante twetmaninternational journal of paediatric dentistry
2010; 20: 341– 346.
• Caries risk assessment-a comparison between the computer
program ’Cariogram’, dental students and dental instructors G.
H-el Petersson, I? Carlsson and D. Bratthall Eur Dent Educ
1998; 2: 184-190
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70. • Dental Caries: intervened - interrupted - interpreted.
Concluding remarks and Cariography. Bratthall D. Eur J Oral
Sci 1996; 104: 486-491. 1996.
• Caries risk profiles in schoolchildren over 2 years assessed by-
Cariogram .Gunnel hansel petersson ,Per-erik isberg ,Svante
twetman.International Journal of Paediatric Dentistry 2010;
20: 341– 346
• Hansel Petersson G. Cariogram – a multifactorial risk
assessment model for a multifactorial disease. Community
Dent Oral Epidemiol 2005; 33: 256–64.
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71. • Caries risk profile of 12 year old school children in an Indian
city using Cariogram Hebbal M, Ankola A, Metgud S.. Med
Oral Patol Oral Cir Bucal. 2012 Nov 1;17 (6):
• Caries risk profile using the Cariogram in governmental and
private orthodontic patients at de-bondingAlmosa NA, Al-
Mulla AH, Birkhed D. Angle Orthod. 2012 Mar;82(2):267-74.
• Caries assessment in school children using a reduced
Cariogram model without saliva tests
Gunnel Hansel Petersson, Per-Erik Isberg and Svante
TwetmanBMC Oral Health 2010, 10:5
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72. Thank you.!!
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