CARIES RISK ASSESSMENT

1. CARIES RISK
ASSESSMENT
Dr Shruti Sudarsanan
Department of Pediatric
and Preventive Dentistry

2. CONTENTS
Introduction
Terms
Historical background
Evidence for caries risk
assessment
Tools of caries risk assessment
CRAFT
Conclusion

3. TERMS

4. TERMS
Caries
Early childhood caries
Caries Diagnosis
Caries Detection
Caries Activity
Caries susceptibility
Caries risk
Caries risk assessment

5. CARIES:
An irreversible microbial disease
characterised by demineralisation
of inorganic and dissolution of
organic hard substance of a
tooth which may result in
cavitation.
-Shafer, 2006
This
definition
does not
state:
Whether caries is always progressive or at
times ‘regressive’
About the demineralisation-
remineralisation cycle
Regarding the arrival of the
microorganisms at the site of the disease
How much loss of tooth
substance would mean dental
caries
Whether microorganisms are commensals
or pathogens
The role of natural host defense such as
the role of saliva

6. TO DIAGNOSE OR TO DETECT?
Caries diagnosis has been defined as
“the art or act of identifying a disease
from its signs and symptoms”
Caries diagnosis implies more than just
detecting lesions..
Consequently, it is an intellectual
process-it is the determination of the
presence and extent of a carious lesion.
Caries detection is the signs and
symptoms identified ie it implies an
objective method of determining
whether or not disease is present.
Traditional and Novel Caries Detection Methods-

7. The assessment of lesion activity as well as lesion detection, both are
essential to arrive at the disese diagnosis and the appropriate clinical
decision.
Ekstrand KR, Ricketts DN, Kidd EA. Occlusal caries: Pathology,
diagnosis and logical management. Dent Update. 2001;28;380-7

8. Caries Activity
Increment of active lesions,
including new and recurrent
lesions that occur over a stated
period of time.
Caries Susceptibility
Inherent propensity of the host
and the target tissue, the tooth,
to be afflicted by the caries
process.
Nikiforuk 1985 Understanding dental caries Vol 2: Prevention Basic
and Clinical Aspects, vol 2, pp 225-242

9. CARIES RISK
“Risk is a probability
that an event will
occur” (Burt 2005)

10. CARIES RISK
ASSESSMENT
Caries risk assessment (CRA) is ‘prediction of future caries
based on the diagnosis of current disease by evaluation of risk
and protective factors for making evidence based clinical
decisions.
Determination of the likelihood of the increased
incidence of caries (ie 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.
-AAPD. The reference manual of pediatric
dentistry.2020
PROCEDURE TO
PREDICT FUTURE
CARIES
DEVELOPMENT
BEFORE THE
CLINICAL ONSET
OF DISEASE---
Nikhil Marwah

11. HISTORICAL
BACKGROUND

12. IS DENTAL CARIES:
A treatable
condition
A preventable
disease?
OR

13. PARADIGM SHIFT IN THE
UNDERSTANDING OF DENTAL
CARIES
Era of fluorides in prevention
Skewed distribution of disease : 80
% of disease was seen in 20% of
population
Dental caries is expensive to treat
Risk based prevention is most
appropriate strategy
Fiction (Filling children’s teeth
indicated or not?) Three year, multi
centre, pragmatic trial in high caries
risk children of 3-7 year olds.
Interventions:
 Preventative advice alone
 Prevention + conventional restorations
 prevention + biological management with
Hall technique crowns
Innes et al. Child caries management: A Randomised Controlled trial in
Dental Practice; Dental Res 2019

14. CARIES RISK
The causes of caries in individuals and the causes of the caries in
populations may not always be the same (Fejereskov and Kidd 2008)
Preventive strategies could be based on targeting individuals at risk:
the high risk strategy, or the entire population: the whole population
strategy (Rose 1985)
Risk factors and markers need to be identified at population as well as
individual level

15. IS DENTAL CARIES:
An infectious and
transmissible
disease or A non communicable
disease
At
individua
l level
At public
health level

16. RISK BASED CARIES PREVENTION
STRATEGY
--ROSE 1985
High
risk
strategy
Directed
population
strategy
Whole population
strategy
Eg: Dentists carrying out risk
assessment and preventive
procedures
Eg: School based varnish
programmes
Eg water fluoridation
PROPORTIONATE
UNIVERSALISM
Those who are at Higher
risk should be helped with
resources and manpower
and who are not at a
higher risk and who are
taking good care of their
health should also be
incentivised

17. RISK FACTORS: CAUSES OF
CAUSES
Biological
Behaviours and lifestyles
Environment
Culture
Society
Economy
Other macro factors

18. CAUSES OF ECC: SELWITZ ET AL
2007

19. DENTAL CARIES IN CHILDREN: 2
PERSPECTIVES
Pediatric dentist’s
perspective
Lesions in oral cavity- infectious disease
Biological factors, lifestyles and
behaviours are responsible for causing
the disease
Treatable condition; treatment helps an
individual, can eradicate the problem
Customise prevention and treatment
Dental Public health
perspective
Problem in a society- a non communicable
disease
“Macro” factors responsible such as social,
cultural, environmental, economical, legal etc
Preventable disease, treatment is a huge
economic burden, cannot eradicate the
problem
Broad prevention and management strategies:
Upstream and common risk factor approach

20. CARIES RISK ASSESSMENT
There is no precise indicator
Clinician’s judgement is the best predictor of risk

21. ADVANTAGES
fosters the treatment of the disease process (Determine need for caries control measures) inst
the outcome of the disease
allows an understanding of the disease factors for a specific patient and aids in individualizi
discussions
individualizes, selects, and determines frequency of preventive and restorative treatment for a
recall appointments)
anticipates caries progression or stabilization.
Monitor the effectiveness of programs
Criteria for the success of therapeutic measures
Motivation of patient
To identify high-risk groups
Aid in selection of patient for caries study

22. EVIDENCE FOR CARIES RISK
ASSESSMENT

23. SRMA
RCTs/NRCTs
Cohort/ Case
Control
Observational/ Ecological/
Qualitative
In- vitro, animal
Books, editorials, articles, expert
opinions, comments

25. EVIDENCE ON CARIES
PREVENTION
DIET: Sugar
Fluorides
Sealants
Non-fluoride remineralising agents
other

26. SUGAR

27. TOOLS FOR CARIES RISK
ASSESSMENT

28. TOOLS Risk groups
CAT
•CARIES RISK ASSESSMENT TOOL
CAMBRA
•CARIES MANAGEMENT BY RISK ASSESSMENT
Cariogram model
CRAFT
•CARIES RISK ASSESSMENT FOR TREATMENT
Earlier tool:
based on
imprecise factor

29. RISK GROUPS
In children, the key risk periods for initiation of caries seem to be during
eruption of permanent molars and the period during which the enamel is
undergoing secondary maturation.
 Baseline caries prevalence is the most accurate single prediction of all
groups.
Mejare. CRA-A systematic review. Acta Odontol Scand
Key risk age group 1:
Ages 1 to 2 years
(Feeding Practices)
(eruption of primary
teeth)
Key risk age group 2:
Ages 5 to 7 years
(eruption of first
molars)
Key risk age group 3:
Ages 11 to 14 years
(eruption of 2nd
molars)

30. CARIES RISK ASSESSMENT FORMS AND
CARE PATHWAYS (CARIES-RISK ASSESSMENT
AND MANAGEMENT PROTOCOLS, ALSO CALLED
CARE PATHWAYS)
Documents designed to assist in clinical decision making
Provide criteria regarding diagnosis and treatment and lead to
recommended course of action
Based on evidence from current peer reviewed literature and the
considered judgement of expert panels, as well as clinical experience
of practitioners.
2 forms: 0-5 year and >6year olds
The Reference Manual of Pediatric Dentistry
AAPD 2020

31. CARIES RISK ASSESSMENT TOOL
(CAT)
Introduced by AAPD in 2006
Incorporates 3
factors in
assessing risk
biological Protective Clinical findings

36. CAMBRA
Featherstone 1999, 2000, 2003
Formed by western CAMBRA coalition
Evidence based approach to prevent or treat the cause of dental craies
at the earliest stages rather than waiting for irreversible damage to
the teeth
Essentially based on the same factors as CAT to assess caries risk
Progression or reversal of dental caries is driven by the “caries
balance”
Pathological factors, primarily
Pathogenic bacteria
Fermentable carbohydrates
Salivary dysfunction
Protective factors
Sufficient saliva
Remineralisation requiring calcium,
phosphate and fluoride
Antibacterial agents
Caries
Manageme
nt by Risk
Assessmen
t

37. CARIOGRAM: 1ST VALIDATED
RISK ASSESSMENT TOOL
2
goals
Individual risk
and resistant
factors
provides
targeted
strategies for
individuals
 Computer based caries risk
assessment model
 The pioneer of Cariogram is
Bo Krasse and its
development and
functionality as a
comprehensive model of
the caries risk profile was
done by Douglas Bratthall

38. Presents a graphical picture that illustrates a possible overall caries risk scenario
Program contains an algorithm that presents a ‘weighted’ analysis of the input data, mainly biological factors. It expresses
as to what extent different etiological factors of caries affect caries risk
A circle divided into 3 sectors : diet, bacteria and susceptibility
Open circle: favourable situation
Closed circle: unfavourable situation
Small gap: large sector(high risk situation) and a large gap indicates a small sector (low caries risk) ie safety sector
OPEN CIRCLE CLOSED CIRCLE

39. EVALUATION OF CARIOGRAM
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’.

40. ADVANTAGES
• The model is affordable
User-friendly
Easy to understand
Tool for motivating the patient
Model can also serve as a support for clinical decision making
when selecting preventive strategies for the patient.

41. OTHER DOCUMENTED TOOLS
1. NUSCRA (Singapore)
2. TLM (Australia): Traffic Light Matrix tool
3. UIT- University of Tromso method of caries risk assessment
4. CRAFT (India)

42. CRAFT: CARIES RISK ASSESSMENT
FOR TREATMENT
CRAFT is an indigenous, chairside 4-point
scale proposed for the risk based
management of caries risk in chiidren.
“sugar- metre”, a ready reckoner for
counting free sugars consumed from
commonly marketed foods, is integrated with
CRAFT in an android app APT4CARIES

43. DEVELOPMENT AND TESTING OF A
CRAFT FOR INDIAN CHILDREN
Various tools for western countries------none for Indian
scenario
CRAFT: indigenous chair side 4 point scale (questionnaire
based, economical, no microbial component)
Proposed for risk based management of caries in children

46. CRAFT STUDY 1

47. CRAFT STUDY 2

48. CRAFT STUDY 3

49. CRAFT STUDY 4

50. CRAFT has a potential as a caries risk assessment tool.
It is quick, economical and non invasive.
It allows a dentist to customise a risk based caries management plan,
and presents a framework for enhanced patient participation.

51. CONCLUSION
Caries management must be risk based for effective control of caries
in an individual as well as in a population.
No one tool can be regarded as universal
Clinicians can use tools specific to the needs of the patients and for
a better judgement.

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