This document provides information on caries risk assessment tools and models. It discusses the CAMBRA (Caries Management By Risk Assessment) model, which takes an individualized approach to caries risk assessment and management based on a patient's risk factors, protective factors, and disease indicators. The Cariogram is introduced as another caries risk assessment tool that provides a graphical representation of a patient's caries risk based on entered data on factors like diet, bacteria levels, fluoride exposure, and past caries experience. It calculates the patient's "chance to avoid new cavities" to help determine their risk level and guide preventive recommendations.

1. CARIES RISK
ASSESSMENT
Dr. Sucheta Prabhu
Second year MDS student

2. Questions asked previously
• 1oo mark : Caries risk assessment in children
• 20 mark :Discuss the recent advances in caries diagnosis , caries risk
assessment and management in pediatric dentistry.
• Short essay : Cariogram

3. Introduction
• Caries Risk Assessment is used by most general dentists daily, usually on an
intuitive level.
• Caries risk is a term to indicate what will happen in the future- will there be
demineralizations, will new cavities occur?
• It is understood that the evaluation is made for a certain period of time.

4. Definition
A procedure to
predict future
caries development
before the clinical
onset of the disease.

5. Applications of Caries Risk Assessment
Caries Risk
Assessment assists
in predicting and
diagnosing this
type of case-
Should you observe
this?

6. Applications of Caries Risk Assessment
Or does it conceal this?

7. Responding to Changing Paradigms
for Dealing with Dental Caries
• Surgical “drill
and fill”
• Deal with
consequences
Earlier model
• One size fits all
Prevention!!!
• Individualised approach
• Early intervention
• Anticipatory guidance
• Tailor make program
Current model

8. Caries Balance
• Balance between Risk Factors & Protective Factors
Risk factors: Promote
demineralization
• Fermentable sugars
• Cariogenic microbes
• Reduced salivary
flow
Protective factors
Promote
remineralisation
• Fluorides
• Plaque control

9. Situations where using tests is important
Individual
treatment of a
patient
Information
provided about
etiological factors
present.
Information can
be used to assess
if treatment
needs.
Prediction of
caries in a group
of population
More caries
succeptible
groups can be
identified earlier.
Measures to
tackle the disease
before irreversible
damage occurs.

10. Caries Risk Assessment contributes to:
Determine need and
extent of
personalized
preventive measures
Motivation of patient
Monitor
effectiveness of
programs
Establish criteria for
success of
therapeutic
measures
Identify high risk
groups
Determine the need
for caries control
measures
Aid is establishing
recall protocol
Aid in patient or
group selection

11. Guideline on Caries-risk Assessment and
Management for Infants, Children, and
Adolescents
• AAPD 2002, revised in the year 2014

12. Risk assessment:
Treatment of the
disease process
instead of treating
the outcome of the
disease.
Anticipates caries
progression or
stabilization
Individualizes,
selects, and
determines frequency
of preventive and
restorative treatment
for a patient.
Gives an
understanding of the
disease factors for a
specific patient.

13. Current Caries-risk assessment models
Factors
including diet,
fluoride
exposure,
susceptible
host,
microflora
Interplay with a
variety of social,
cultural, and
behavioral
factors

14. Caries risk indicator variables
.
shown useful
in predicting it
(eg,
socioeconomic
status)
protective
factors
cause the disease
directly (eg
microflora)

15. Tools to predict caries in children
white spot lesions
Plaque accumulation
Child’s Mutans Streptococci (MS) levels
Best tool is past caries experience
not particularly useful in young children since it is
important in determining caries risk before the
disease is manifested.

16. Factors contributing to the disease
Fermentable carbohydrates
Night-time use of the bottle
Altered salivary flow (low evidence)
Sociodemographic factors

17. Protective factors
systemic and
topical fluoride
sugar
substitutes
tooth brushing
with fluoridated
toothpaste

18. Caries Risk AssessmentTool(CAT)
• CAT provides assessment of caries at a point in time and must be reassessed
periodically.
• Intended to be used when clinical guidelines call for caries assessment.
• User friendly can be utilized by non dental professionals

19. Caries Risk AssessmentTool(CAT)

20. Caries Risk AssessmentTool(CAT)
• LOW RISK
Clinical
conditions
No decay in past
24 months
No white spot
lesions
No visible
plaque,gingivitis
Environmental
conditions
Optimal systemic
& topical F
exposure
Established dental
home
Simple sugars
ingested primarily
at mealtimes

21. •MODERATE RISK
Clinical conditions
Decay in past 24
months
1 area white spot
lesion
Gingivitis
Environmental
conditions
Suboptimal systemic
& topical F exposure
optimum
1-2 in between meal
snacking
Midlevel
socioeconomic group
Irregular utilization of
services

22. • HIGH RISK
• Decay in past 12 months
• More than 1 area white spot
lesion
• Radiographic evidence
• Visible plaque anteriorly
• High titres of MS
• Wearing of appliances
Clinical
conditions
• Enamel Hypoplasia
• Suboptimal topical F
exposure
• Frequent in between meal
snacking
• Low socioeconomic group
• Active decay in mother of a
preschooler
Environmental
conditions
• Children with special
healthcare needs
• Impairement of flow
of saliva
General health
conditions

29. AAPD Recommendations
• 1. 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.
• 2. 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.
• 3. 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. CAMBRA
Caries management by risk assessment

31. CAMBRA
evidence-
based
approach
preventing
or treating
dental
caries
earliest
stages

32. Basis for caries management by risk
assessment
Decrease caries risk
factors
Increase caries
protective factors

33. Introduction
• 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.

34. CAMBRA philosophy of care
assessment of each patient
unique
individual
disease
indicators
risk factors
protective
factors
determine current and future dental caries disease

35. Advantages in using risk assessment
.
Better cost-
effectiveness
Greater
success in
treatment
CAMBRA philosophy advocates the detection of the carious lesion at the earliest
possible stage so the process can be reversed or arrested before cavitation and
subsequent restoration is needed.

36. 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.

37. Disease Indicators
• The Caries Imbalance model uses the acronym “WREC” (pronounced “wreck”) to
describe the following four disease indicators:
• White spots visible on smooth surfaces
• Restorations placed in the last three years as a result of caries activity
• Enamel approximal lesions (confined to enamel only) visible on dental radiographs
• Cavitation of carious lesions showing radiographic penetration into the dentin

38. Patient Examination
Visual tactile method
appropriate use of the dental explorer is to use it to
remove plaque from the examination area
determine surface roughness of non cavitated lesions
by gently moving the explorer across the tooth surface

39. • Bitewing radiographs are the current standard for examination of the
proximal surfaces, used because these surfaces cannot be accessed for
assessment using direct visual or tactile methods.

40. 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 .

41. • The Caries Imbalance model uses the acronym “BAD” to describe three risk
factors that are supported in the literature as causative for dental caries:
• 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 (self
care)

42. Biological predisposing factors
MS & LB
high by
culture
Visible
heavy
plaque on
teeth
Frequent
snacking >3
times
Deep pits
and fissures
Inadequate
saliva
Saliva
reducing
factors
Orthodontic
appliance

43. Protective factors
Fluoridated community
Fluoride toothpaste x1 daily/x2
daily
Fluoride mouthrinses (0.05%)
NaF daily
5000 ppm fluoride toothpaste
daily
Fluoride varnish last 6 months

44. Protective factors
Chlorhexidine mouthwash
in last 6 months
Xylitol gum/lozenges 4x
daily last 6 months
Calcium and phosphate
paste in last 6 months
Adequate saliva flow

45. • The Caries Imbalance model uses the acronym “SAFE” to describe the
following four protective factors:
• Saliva and sealants
• Antimicrobials or antibacterials (including xylitol)
• Fluoride and other products that enhance remineralization
• Effective lifestyle habits

46. 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.

47. CAMBRA clinical guidelines
• 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.

48. • 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.

49. 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

50. • 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.

51. CARIOGRAM
• Pioneered by Bo krasse and team
• D. Bratthall, G Hänsel Petersson, JR Stjernswärd
• 'Cariogram' is a new concept, conceived initially as an educational
model, aiming at illustrating the multifactorial background of
dental caries in a simple way.

52. What is a Cariogram?
• 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.
• It illustrates a possible over-all risk scenario, based on what can be expected
depending on our interpretation of available information.

53. Cariogram – Aims
• Illustrates the interaction of caries related factors.
• Illustrates the chance to avoid caries.
• Expresses caries risk graphically.
• Recommends targeted preventive actions.
• Can be used in the clinic.
• Can be used as an educational programme.

54. Which factors are to be considered in the
estimation of caries risk?
Attack
• Dental plaque
• Microbes(specific)
• Diet
Defense
• Salivary
protective system
• Fluoride exposure
Factors immediately involved in the caries
process

55. Factors related to the occurrence of caries, without actually participating in
the development of the lesion.
• Socioeconomic factors
• Past caries experience

56. ‘Weights’ - the relative impact of factors
• This means that the key factors, which support the development of caries,
or resist caries, have a stronger impact than the less important factors when
the program calculates the ‘Chance to avoid new cavities’.

57. Cariogram - the five sectors
Actual chance to avoid
new cavities
Diet contents &
frequency
Bacteria in plaque
Succeptibility
Fluoride, saliva
buffer
capacity,saliva
secretion
Circumstances
Past caries experiences

58. What does ‘Chance to avoid caries’ imply?
• .
• The bigger the green sector, the better from a dental health point of
view
• A green sector of 75% or more would indicate a very good chance to
avoid new cavities in the coming year, if conditions are unchanged. A
green sector of 25% or less indicates a very high caries risk.
CARIES RISK CHANCETO AVOID
CARIES
CARIOGRAM
High risk = Low chance Small green sector
Low risk = High chance Large green sector

59. Caries related factors according to the
program
Factor Info/data needed
Caries experience DMFT, DMFS, new caries experience in the
past one year
Related general diseases Medical history, medications
Diet frequency Questionnaire results (24- h recall or 3 days
dietary recall).
Plaque amount Plaque index
Mutans streptococci Strip mutans test or other similar test
Fluoride programme Fluoride exposure
Saliva secretion Stimulated saliva test - secretion rate
Saliva buffer capacity Dentobuff test
Clinical judgement Clinical judgement of operator

60. Cariogram: Explanation for the scores to be
entered
• Caries experience (caries prevalence)
Score Explanation
0 = Caries free and no fillings Completely caries-free, no previous
fillings, no cavities or M-missing teeth
due to caries
1 = Better than normal better status than normal, for that age
group in that area
2 = Normal for age group Normal status for that age group
3 =Worse than normal several new caries-lesions the last year

61. Related general diseases
Score Explanation
0 = No disease The patient is healthy
1 = Disease/conditions, mild degree general disease, which can indirectly influence the
caries process, or other conditions which can
contribute to higher caries risk
2 = Severe degree Patient could be bed-ridden or may need
continuous medication

62. Diet, contents
Score Explanation
0 =Very low fermentable carbohydrate extremely ‘good’ diet from the caries point of view.
1 = Low fermentable carbohydrate Sugars or other caries inducing carbohydrates on a
low level
2 = Moderate fermentable carbohydrate Diet with relatively high content of sugars or other
caries inducing carbohydrates.
3 = High fermentable carbohydrate intake High intake of sugar or other caries inducing
carbohydrates.

63. Diet, frequency
Score Explanation
0 = Maximum three meals per day (including
snacks)
Very low diet intake frequency
1 = Maximum five meals per day Low diet intake frequency
2 = Maximum seven meals per day High diet intake frequency
3 = More than seven meals per day Very high diet intake frequency

64. How to use the Cariogram
• Start program
• Hints - informative text
• Functions
• 1. Exit
• 2. New
• 3. About
• 4. Help
• 5. Notes
• 6. Preliminary interpretation and proposed measures - targeted preventive
and clinical actions you could take, based on the scores you entered
• 7. Print

65. Estimation of the caries risk. How to build the
Cariogram?
For all factors, ‘0’ is the best value and ‘3’ (or ‘2’ where
2 is maximum) is the most unfavourable score.

67. Preliminary interpretation and proposed
measures

68. Conclusion
• Current science has determined that the key to dental caries treatment and
disease prevention lies with modifying and correcting the complex dental
biofilm and transforming oral factors to favor health.
• Caries risk assessment (CRA) is a critical component of dental caries
management and should be considered a standard of care and included as
part of the dental examination.
• Thus the treatment of caries can be based on biological principles and not
on chance or beliefs. Recommended to treat the actual disease , as a whole
not just the traditional drill and fill approach.

69. References
• Marwah N.Textbook of pediatric dentistry.3rd edn.
• Guideline on Caries-riskAssessment and Management for Infants,
Children, and Adolescents Reference manual, AmericanAcademy of
Pediatric dentists 37(6) ,132-137
• Featherstone, J.D.B., Domejean-Orliaguet, S., Jenson, L.,Wolff, M., &
Young, D.A. (2007). Caries risk assessment in practice for age 6
through adult. Journal of the California Dental Association, 35(10), 703-
713.
• Ramos-Gomez, F.J., Crystal,Y.O., Ng, M.W., Crall, J.J. & Featherstone,
J.D.B. (2010). Pediatric Dental Care:Prevention and Management
Protocols Based on Caries Risk Assessment. Journal of the California
Dental Association, 38 (10), 748-761
• Bratthall D, Petersson G H, Stjernswärd JR (2004).Manual on
cariogram.internet version 2.1