Caries risk assessment and management in infant, children and adolescent Introduction Definition Changing Paradigms for Dealing with Dental Caries Advantages Caries Balance/Imbalance Risk Indicators Caries Risk Assessment Methods Caries Questionnaire in combination with Clinical Observations AAPD's Caries-risk Assessment Form The Cariogram Model Caries Assessment and Risk Evaluation (CARE) test  Caries management by risk assessment (CAMBRA) Traffic Light Matrix (TLM). Caries management protocol for infants and children Conclusion References

1. Caries Risk Assessment and
Management
Dr Sudeep Madhusudan Chaudhari
Dept of Pediatric and Preventive Dentistry

2. Content
 Introduction
 Definition
 Changing Paradigms for Dealing with Dental Caries
 Advantages
 Caries Balance/Imbalance
 Risk Indicators

3.  Caries Risk Assessment Methods
A. Caries Questionnaire in combination with Clinical Observations
B. AAPD's Caries-risk Assessment Form
C. The Cariogram Model
D. Caries Assessment and Risk Evaluation (CARE) test
E. Caries management by risk assessment (CAMBRA)
F. Traffic Light Matrix (TLM).
 Caries management protocol for infants and children
 Conclusion
 References

4. Introduction
Caries is an infectious disease that is manifested to varying degrees in different
individuals. While caries can be prevented, to be effective and lasting,
prevention should be initiated before the cariogenic process begins. Thus, if
the preventive treatments are to acknowledge the variation in extent of the
disease between individuals while minimizing irreversible, invasive treatment,
a prediction of the anticipated degree of the disease is needed. This is often
designated as a risk level.

5. One of the earliest acknowledgements that different risk levels exist was the
assignment of individuals into “caries-prone” and “caries-resistant” groups.
This system is based on the significant positive correlation between past caries
history and the number of future lesions, but is inadequate in at least two areas.
First, because the number of caries in the population is a continuum and the
other shortcoming is that the prediction is based on existing caries for which
prevention is not possible.

6. Currently, the use of a questionnaire, in combination with clinical observation,
is a popular approach for caries risk assessment. The questionnaires play an
important role by revealing medical conditions and/or health and eating habits
that are known to increase the risk of developing caries. The remainder of the
questionnaire often addresses many of the other factors that contribute to the
multifactorial genesis of caries.

7. Caries-risk assessment models currently involve a combination of factors including
diet, fluoride exposure, a susceptible host and microflora that interplay with a
variety of social, cultural and behavioral factors. Caries-risk assessment is the
determination of the likelihood of the increased incidence of caries (i.e., the
number of new cavitated or incipient lesions) during a certain time period or the
likelihood that there will be a change in the size or activity of lesions already
present. With the ability to detect caries in its earliest stages (i.e., non-cavitated or
white spot lesions), health care providers can help prevent cavitation.

8. Definition
 Hausen H (1997) has defined caries risk as the probability that an
individual will develop a certain number of carious lesions (cavitated or
noncavitated) or reach a given level of disease progression, over a specific
period of time, provided his or her exposure status remains the same during
this period.
 Caries risk assessment is a procedure to predict future caries development
before the clinical onset of the disease.
Hausen H. Caries prediction – State of the art. Community Dent Oral Epidemiol 1997;25:87-96.

9. Changing Paradigms for Dealing with Dental
Caries

10. Advantages
1. Fosters the treatment of the disease process instead of treating the
outcome of the disease.
2. Allows an understanding of the disease factors for a specific patient and
aids in individualizing preventive discussions.
3. Individualizes, selects and determines frequency of preventive and
restorative treatment for a patient.
4. Anticipates caries progression or stabilization.

11. Caries Balance/Imbalance

12. Risk Indicators
 Past caries experience:
 This has been the most consistent predictive factor observed in caries risk
assessment studies.
 However, it is not particularly useful in young children as determining
caries risk before the disease manifests is much important in them.
 White spot lesions are considered good indicators to predict future caries
development in young children

13.  Socioeconomic status :
 Most dental studies use, low, middle or high socioeconomic advantage as
a measure of socioeconomic status.
 An inverse association present between caries and socioeconomic status
levels indicating a higher caries experience in both primary and
permanent teeth among children who are socioeconomically
disadvantaged.

14.  Sugar consumption :
 The quantity of sugar consumption as well as the frequency of sugar
intake contributes to dental caries.
 The relationship between sugar consumption and caries in developed
countries has long been viewed as a positively linear one – the more the
consumption and the higher the frequency the greater the caries severity.
 Since the last decade, this linear relationship has been affected by
fluoride exposure with most studies reporting a moderate or weak
relationship between sugar consumption and caries.
Burt BA, Eklund SA, Morgan KJ, Larkin FE, Guire KE, Brown LO and Weintraub JA. The effects of sugars intake and
frequency of ingestion on dental caries increment in a threeyear longitudinal study. J Dent Res 1988;67:1422-1429.

15.  However, consumption of beverages with high sugar content such as soda
pop or powdered beverage concentrates made with sugar was associated
with progression of dental caries.
 Recently, WHO guideline on sugar intake for adults and children concluded
that even a small reduction in risk of dental caries due to less consumption
of sugar in childhood is of significance in later life.
Guideline: Sugars intake for adults and children. Geneva: World Health Organisation, 2015.

16.  Oral hygiene habits:
 The available evidence does not demonstrate a clear and consistent
relationship between oral hygiene and dental caries prevalence.
 The reported association with tooth brushing frequency is more likely
due to use of fluoridated toothpaste.

17.  Bacteria:
 Streptococcus Mutans and Lactobacilli, the main bacteria that are
involved in the caries process, are constituents of the normal flora.
 Therefore caries is considered as a bacterial ecologic imbalance rather
than as an exogenous infection.
 At a population (group) level, total bacterial count has been weakly
associated with caries experience.
 At the individual level, bacterial count is a poor predictor of future caries.
 Mutans Streptococci levels and the age of colonization with cariogenic
flora are valuable in assessing caries risk, particularly in very young
children.

18.  Saliva:
 No variation in a single salivary component in a healthy population has
been shown to be a significant predictive factor.
 Nevertheless decreased salivary function, as manifested by extreme
xerostomia, is a consistent predictor of high caries risk.
 Despite the fact that normal salivary flow is an extremely important
intrinsic host factor providing protection against caries, there is little
information about the prevalence of low salivary flow in children.

19. Caries Risk Assessment Methods
A. Caries Questionnaire in combination with Clinical Observations
B. AAPD's Caries-risk Assessment Form
C. The Cariogram Model
D. Caries Assessment and Risk Evaluation (CARE) test
E. Caries management by risk assessment (CAMBRA)
F. Traffic Light Matrix (TLM).

20. A. Caries Questionnaire in combination with Clinical Observations
 Based on the concept that dental caries is an infectious disease where there
is a dynamic balance or imbalance between pathological factors (that cause
demineralization) and protective factors (that favor remineralization),
Featherstone et al (2002) evolved a consensus statement to assess individual
caries risk from a questionnaire that addresses issues such as maternal
dental history, family dynamics, socioeconomic factors, oral hygiene
measures, fluoride exposure and frequency of sugar exposures.
Featherstone JD, Adair SM, Anderson MH, Berkowitz RJ, Bird WF, Crall JJ, et al. Caries management by risk assessment:
Consensus statement, April 2002. J Calif Dent Assoc 2003;31:257-69

21.  Along with the questionnaire, clinical observations were made by visual,
tactile and radiographic examination of teeth.
 Once individual risk status was determined, they suggested using a
minimally invasive caries management protocol that included appropriate
preventive and therapeutic recommendations.

25. B. AAPD's Caries-risk Assessment Form
 Incorporating the most recent evidence and expert/consensus opinion, the
AAPD modified its original Caries-risk Assessment Tool (CAT), into a more
sensitive and practical tool to assist dental practitioners, physicians and
nondental health-care providers in assessing the levels of risk for caries
development in infants, children and adolescents.
 Caries-risk Assessment forms were formulated that can be used by dentists
to assess caries risk status for 0–5-year-old and ≥6-year-old children. Risk
assessment categorization of low, moderate, or high is based on the
preponderance of factors for the individual.
 However, clinical judgment may justify the use of one factor (e.g., frequent
exposure to cariogenic snacks, ≥1 interproximal lesions and low salivary
flow) in determining the overall risk.
American Academy of Pediatric Dentistry. Caries-risk assessment and management for infants, children, and adolescents.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:243-7

29.  AAPD Recommendations
 Caries-risk assessment, based on a child’s age, biological, protective factors
and clinical findings, should be a routine component of new and periodic
examinations.
 Estimating children at low, moderate, and high caries risk by reflecting on
risk and protective factors will enable a more evidence-based approach to
establish periodicity and intensity of diagnostic, preventive and restorative
services.
 Clinical management protocols, based on a child’s age, caries risk, and level
of patient/parent cooperation, provide health providers with criteria and
protocols for determining the types and frequency of diagnostic, preventive
and restorative care for patient specific management of dental caries.

30. C. The Cariogram model
 A challenge for the biological factor approach is to correctly summarize the
complex picture of the various inter-related caries risk factors, so that it can
easily be used by the dental professional routinely in the clinic.
 A new model for understanding the interactions of various factors was
therefore proposed by Bratthall D (2005) and a graphical model, the
Cariogram, was drawn up to illustrate the fact that caries can be controlled
by several different means.
Bratthall D, Hänsel Petersson G. Cariogram – A multifactorial risk assessment model for a multifactorial disease.
Community Dent Oral Epidemiol 2005;33:256-64.

31.  The computer version of the Cariogram presents a graphical picture that
illustrates a possible overall caries risk scenario.
 The program contains an algorithm that presents a ‘weighted’ analysis of the
input data, mainly biological factors.
 Furthermore, it expresses the extent to which different etiological factors of
caries affect the caries risk for a particular individual and provides targeted
strategies for those individuals.
 The Cariogram does not specify the particular number of cavities that will
or will not occur in the future.

32. Example of a Cariogram indicating high caries risk with the ‘chance of avoiding caries (new cavities)’
estimated to only 13%.
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 programme,
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’.

33.  Peteraaon HG et al. (2002) did the study to assess caries risk in
schoolchildren using the Cariogram concluded that it predicted caries
increment more accurately than any other single-factor model.
Hänsel Petersson G, Twetman S, Bratthall D. Evaluation of a computer program for caries risk assessment in
schoolchildren. Caries Res 2002;36:327-40.

34. D. Caries Assessment and Risk Evaluation test
 Evaluating a child’s genetic susceptibility to dental caries may thus play a
vital role in assessing the child’s overall caries risk status.
 Several studies have also shown a strong, statistically significant, genetic
component determining caries experience.
 This may be especially important in developed societies that have a good
dental coverage, adequate fluoride exposure and where gross malnutrition
and negligent oral hygiene are rare; increasing the role a child’s genes may
play in determining his or her caries susceptibility.

35.  The Division of Diagnostic Sciences of the University of Southern
California School of Dentistry developed a novel salivary test for genetic
CRA called the CARE test based on the high correlations they found
between caries history and quantities of specific oligosaccharides in whole
saliva.
Denny PC, Denny PA, Takashima J, Si Y, Navazesh M, Galligan JM. A novel saliva test for caries risk assessment. J Calif
Dent Assoc 2006;34:287-90, 292-4.

36.  Certain salivary oligosaccharides are known to facilitate bacterial
attachment and colonization of the salivary pellicle, while other salivary
sugar chains promote agglutination and removal of free bacteria. In the case
of the former, there is a positive correlation with caries experience, while
for the latter, a negative correlation is seen.
 Since the pattern of these salivary oligosaccharides is 100% genetically
determined, identifying individual salivary oligosaccharide concentrations
can help determine the genetic risk of the child to develop caries.
 It was also established that, just like blood group types, the salivary
oligosaccharide patterns remain quantitatively consistent over time and
across age groups.

37.  The CARE test is probably the only CRA method that can potentially
promote caries prevention at the primary level itself (before any carious
lesions have appeared), by identifying high caries risk children early and
instituting a preemptive aggressive preventive regimen in them. The
widespread incorporation of the CARE test in clinical practice and its use in
conjunction with other more traditional risk assessment methods is probably
the future of dental CRA.
Suneja ES, Suneja B, Tandon B, Philip NI. An overview of caries risk assessment: Rationale, risk indicators, risk
assessment methods, and risk-based caries management protocols. Indian J Dent Sci 2017;9:210-4.

38. E. Caries Management by Risk Assessment (CAMBRA)
 CAMBRA philosophy was first introduced nearly a decade ago when an
unofficial group called the Western CAMBRA Coalition was formed that
included stakeholders from education, research, industry, governmental
agencies and private practitioners based in the western region of the United
States.
Young DA, Featherstone JD, Roth JR. Curing the silent epidemic: Caries management in the 21st century and beyond. J
Calif Dent Assoc 2007;35:681-5.

39.  CAMBRA philosophy of care -

40. a. Unique individual disease indicators –

41. b. Risk Factors
 Described as biological reasons that cause or promote current or future
caries disease. Risk factors traditionally have been associated with the
etiology of disease.
 CAMBRA philosophy identifies nine risk factors that are outcome
measures of the risk for current or future caries disease, and each of these
is supported with research .

42.  Bad bacteria, meaning acidogenic, aciduric or cariogenic bacteria
 Absence of saliva, meaning hyposalivation or salivary hypofunction
 Destructive lifestyle habits that contribute to caries disease, such as
frequent ingestion of fermentable carbohydrates and poor oral hygiene.

43. Mucans
streptococcus
&
Lactobacillus
high by
culture
Visible heavy
plaque on
teeth
Frequent
snacking >3
times
Deep pits and
fissures
Inadequate
saliva
Orthodontic
appliance
• Biological predisposing factors –

44. Fluoridated
community
5000 ppm fluoride
toothpaste daily
Fluoride varnish
last 6 months
Fluoride
mouthrinses
(0.05%) NaF daily
Chlorhexidine
mouthwash in last
6 months
Xylitol
gum/lozenges 4x
daily last 6 months
Adequate saliva
flow
c. Protective factors –

45.  CAMBRA clinical guidelines-
 Saliva testing
 Bacterial testing a baseline for all new patients
 Recommend that the placement of sealants be based on the risk of the
patient, and resin-based sealants and glass ionomers are optional for
patients at lower risk for caries.
 For moderate-, high- and extreme-risk caries patients, pit and fissure
sealants are recommended.

46.  Recommend the use of antimicrobials for patients over six years of age
who are classified as being at high or extreme risk for caries
 CAMBRA clinical guidelines recommend the use of xylitol to control the
cariogenic bacteria S. mutans for patients over six years of age who are
classified as being at moderate to extreme risk for caries. The 2007
clinical guidelines for patients over 6 years of age recommend no more
than 6-10 grams/day of xylitol.

47.  ADA’s clinical guidelines suggest that applications of fluoride varnish two
to four times per year are effective in reducing carious lesions in children
and adolescents who are at high risk for caries, and the CAMBRA clinical
guidelines recommend a frequency of application of fluoride varnish as
indicated by the patient’s caries risk.

48.  Effective Lifestyle Habits -
 Reducing the amount and frequency of sugar consumption, including the
“hidden sugars”.
 CAMBRA clinical guidelines (>6 years old) suggest the use of calcium
phosphate for patients with excessive root exposure or sensitivity and is
recommended for use several times daily for patients classified as being
at extreme risk.
 For pediatric patients (0-6 years old), CAMBRA clinical guidelines
suggest alternating brushing between toothpaste and calcium phosphate,
leaving the latter on at bedtime for patients classified as noncompliant
and at moderate to extreme risk

49.  Assessment of the caries risk of the individual patient is a critical
component in determining an appropriate and successful management
strategy.
 CAMBRA supports clinicians in making decisions based on research,
clinical expertise, and the patient’s preferences and needs.

50.  Reassessment –
 Reassessment of the patient’s risk for dental caries is considered best
practices and should occur 3 to 12 months after the initial caries risk
assessment, with the interval of time depending on the risk level of the
patient.

51. F. Traffic light matrix
 This is a commonly used CRA tool in Australia.
 TLM is based on 19 criteria in 5 different categories including saliva (6
criteria), plaque (3 criteria), diet (2 criteria), fluoride exposure (3 criteria)
and modifying factors (5 criteria) where traffic light colours convey varying
risk levels (red=high, yellow=moderate and green=low).

52.  Saliva:
 (a) Resting: Hydration, viscosity, and pH
 (b) stimulated: Quantity/rate, pH and buffering capacity
 Plaque:
 PH, maturity, and bacteria – mutans count
 Diet:
 Number of sugar and acid exposures in-between meals/day
 Fluoride:
 Exposure to fluoride through water/toothpaste/ professional treatment
 Modifying factors:
 Drugs that reduce salivary flow, diseases resulting in dry mouth, fixed/removable
appliances, recent active caries, and poor compliance.

53. The specific threshold values for the data obtained
in the analysis of the aforementioned factors are
conveyed in traffic light color codes conveying
varying risk levels (red = high, yellow = moderate,
and green = low). This color code model keeps the
visual interpretation simple and communicable to
the patient as well.

54. Caries management protocol for infants and children
 In the modern day clinical practice, the focus of any caries management
protocol should rely more on a “medical” rather than solely on a “surgical”
approach to the treatment of dental caries.
 This change has occurred due to a paradigm shift in our understanding of
two important aspects:
 The principal mechanisms by which fluorides bring about their cariostatic
action, where its topical role is emphasized over any presumed systemic
benefit.
 The chronic, infectious, transmissible and multifactorial nature of dental
caries where the interplay between demineralization/remineralization
factors will determine whether caries progresses or not.

55.  The AAPD has developed one of the best clinical protocols for the
management of caries in different age groups of infants and children.
 These protocols were evolved from evidence-based peer-reviewed literature,
considered judgment of expert panels and clinical experience.
 Following these protocols will enable dentists treating children to make
standardized diagnostic, preventive and restorative recommendations
depending on child’s risk status and the compliance expected from parents.

56.  Caries management protocols need to be constantly evolving based on the
latest evidence-based research and should also reflect newer therapeutic
modalities.
 The application of casein phosphopeptide-amorphous calcium phosphate
products for its positive effect on the demineralization/remineralization
caries cycle, using more effective fluoride compounds such as silver
diamine fluoride, or the potential of antimicrobials to reverse caries are
some of the innovative technologies that may be included in the future
caries management protocols.
 On the other hand, some of the current recommendations such as use of
systemic fluoride supplements may be avoided in the future protocols.

60. Conclusion
The paradigm change in our understanding of dental caries and its prevention
and treatment makes it mandatory for all dentists treating infants, children,
adolescents and adults to incorporate caries risk assessment into their clinical
practice and utilize risk-based caries management protocols to make
diagnostic, preventive and restorative recommendations for their patients.

61. References
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Infancy through Adolescence. Elsevier Health Sciences; 2018 May 10.
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2018 Oct 31.
 Tandon S. Textbook of pedodontics. Paras Medical Publisher; 2009.
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Reference manual, American Academy of Pediatric dentists 37(6) ,132-137
 Featherstone, J.D.B., Domejean-Orliaguet, S., Jenson, L., Wolff, M., & Young, D.A. (2007). Caries
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 Bratthall D, Petersson G H, Stjernswärd JR (2004).Manual on cariogram.internet version 2.1