CARIES RISK ASSESSMENT

1. CARIES RISK
ASSESSMENT
PRESENTER – ZADENO KITHAN
PERCEPTOR- DR. ABHIK
MUKHERJEE
18.06.22

2. TABLE OF CONTENTS
◦ INTRODUCTION
◦ DEFINITIONS
◦ CARIES RISK FACTORS
◦ CARIES RISK GROUPS
◦ CARIES RISK CATEGORIES
◦ CARIES RISK ASSESSMENT TOOLS
◦ CARIES RISK ASSESSMENT SYSTEMS
- ICDAS
- ADA
- CARIOGRAM
- AAPD
- CAMBRA
- TRAFFIC LIGHT MATRIX
-CARE TEST
o MICROBIAL TEST FOR MUTANS
STREPTOCOCCI DETECTION
o CARIES ACTIVITY TESTS

4. In many countries the prevalence of dental caries has markedly regressed over the
past years. Epidemiological studies show an uneven distribution of dental caries.
Approximately 25 per cent of the population exhibits significantly more caries than
the rest of the population.
A systemic review and meta-analysis on the prevalence of dental caries In Indian
population revealed tha overall prevalence of 54.16% and there exists a remarkable
variation in dental caries prevalence rates as per age, diagnostic criteria, dentition,
and geographical region.
In reference to prevalence of dental caries across different types of dentition, highest
overall prevalence was noted in the mixed dentition (58%) category, followed by the
primary (54%).

5. Dental caries is an irreversible microbial disease of the calcified tissues of the teeth, characterized by
demineralization of the inorganic part and destruction of the organic substance of the tooth, which
often leads to cavitation.
DENTAL CARIES
Shafers textbook of oral
pathology 8th edition
Complex
and
dynamic
process
Effects all
geographic
areas of the
world
Latin word
meaning
'rot' or'
decay
Efforts at
prevention
have been
partially
successful

6. Dental caries/tooth decay occur when microbial biofilm (plaque) formed on
the tooth surface converts the free sugars contained in food and drinks into
acids that dissolve tooth enamel and dentine over time. With continued
high intake of free sugars, inadequate exposure to fluoride and without
regular microbial biofilm removal, tooth structures are destroyed, resulting
in development of cavities and pain, impacts on oral-health-related quality
of life, and, in the advanced stage, tooth loss and systemic infection.

7. Caries risk assessment
(CRA)

8. CRA refers to an approach to establish the probability of a future(new or incident)
enamel or dentine lesion, i.e. predicting caries after some period of follow-up
Identification of individuals with an increased risk of
the occurrence or progression of caries over a specified
period of follow-up
AIM
Naichuan Su, Maxim D. Lagerweij, Geert J.M.G. van der Heijden,
Assessment of predictive performance of caries risk assessment models based on a systematic review and meta-analysis,
Journal of Dentistry,
Volume 110,
2021

9. 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.
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

10. CRA CONTRIBUTES TO
DETERMINE THE NEED
AND EXTENT OF
PERSONALIZED
PREVENTIVE
MEASURES
MOTIVATION OF
PATIENT
IDENTIFY HIGH RISK
GROUPS
ESTABLISH CRITERIA
FOR SUCCESS OF
THERAPEUTIC
MEASURES
MONITOR
EFFECTIVENESS OF
PROGRAM DETERMINE THE NEED
FOR CARIES CONTROL
MEASURES
AIDS IN ESTABLISHING
RECALL PROTOCOL

11. FACTORS AFFECTING CARIES PREVALENCE
RACE AGE GENDER
FAMILIAL
Region wise data shows that South Indian five-year-old had a
higher mean deft compared to their North Indian counterparts.
However, among the 12-year-old, the highest mean DMFT was
observed among West Indian children followed by North India and
others.
studies done in Eastern region of India reported the least DMFT

12. CARIES RISK FACTORS
Is defined as factor that which plays an
essential role in the etiology and
occurrence of the disease, like the
lifestyle and the biochemical
determinants to which the tooth is
directly exposed and which contribute to
the development or progression of the
lesion.

13. PLAQUE
Enamel caries begin beneath the dental plaque
Important to estimate
• The number of surfaces affected
• The amount of plaque accumulated
• Age of the plaque
• Whether its presence is associated with carious lesions in those same sites.
Role of pH of Dental Plaque
According to Stephan (1940)-The pH
of plaques in different persons varied,
but averaged about 7.1 in caries-free
persons and about 5.5 in persons with
extreme caries activity.

14. Tooth factor
Composition Morphologic
Characteristics
Position

15. Saliva Factor
Calcium and
Phosphate
Concentrations
pH of Saliva
IAP = Ksp and SI= 0
Buffer Capacity of
Saliva
CRITICAL PH = 5.5
Bicarbonate carbonic acid
(HCO3/H2CO3) &
phosphate (HPO4 or
H2PO4)
Quantity of Saliva
salivary gland aplasia/
xerostomia = Rampant
caries

16. The retrieved studies show a highly significant correlation
between higher caries prevalence in preschool children with
higher levels of microbials, such as mutans streptococci, C.
albicans and Prevotella spp., and salivary proteins, including
IgA, IgG immunoglobulins, PRP and histatin peptides, in
saliva compared with caries-free individuals. Therefore,
based on the results of these studies, these saliva
components may be used as biomarkers for ECC

17. Objectives: The aim of this cross-sectional study was
to investigate how the level of metabolic control
affects salivary function, xerostomia prevalence and
incidence of caries, in children and adolescents with
type 1 diabetes.
Results: Higher caries levels, higher prevalence of xerostomia and a
decreased unstimulated salivary flow rate were recorded in poorly-
controlled diabetics. The average caries indexes were DMFT(poor c)
3.6, DMFT(well controlled)1.2, DMFT(healthy) 1.5, p < 0.05). Salivary
status and caries index were not found to be significantly different
between well-controlled patients and healthy controls.

18. The Diet Factor
Physical Form
soft, refined foods tend to cling tenaciously to the teeth
and are not removed because of the general lack of
roughage
The carbohydrate content of the diet has been almost
universally accepted as one of the most important factors
in the dental caries process

19. Infants and toddlers - regularly bottle fed with sweet
drinks at night or breast fed for > twelve months-
risk factors for caries.
Teenagers and young adults- excessive consumption
of soft drinks-risk factors for caries

20. CARIES RISK GROUPS

21. Key-risk age group 1: Ages 1 to 2 years
• Kohler et al (1978,1982) showed that mothers with high salivary MS levels
frequently transmit MS to their babies as soon as the first primary teeth
erupt, leading to greater development of caries
• It was also shown that the practice of giving infants sugar containing drinks
in nursing bottles at night increases the development of caries
(Wendt and Birkhed, 1995 )
Axelsson P. Prediction of caries risk and risk profiles. Textbook on Diagnosis and risk
prediction of Dental caries; 1st Ed 2000, vol 2:151-174

22. Key-risk age group 2: Ages 5 to 7 years
• In a study by Carvalho et al (1989), plaque
reaccumulation
was heavy on the occlusal surfaces of erupting maxillary
and mandibular molars, particularly in the distal and central
fossae
Axelsson P. The Effect of a Needs-Related Caries Preventive Program in Children and
Young Adults– Results after 20 Years. BMC Oral Health. 2006; 6( 1):S1-S7.

23. Key-risk age group 3: Ages 11 to 14 years
• Normally, the second molars start to erupt at the age of 11 to 11.5
years in girls and at around the age of 12 years in boys. Total
eruption time is 16- 18 mon.
• During this period, the approximal surfaces of the newly erupted
posterior teeth are most caries susceptible
Axelsson P. The Effect of a Needs-Related Caries Preventive Program in Children and
Young Adults– Results after 20 Years. BMC Oral Health. 2006; 6( 1):S1-S7.

24. Key-risk age groups in young adults
• Under certain circumstances, young adults (19 to 22 year olds) may
also be regarded as a risk age group.
• Most have erupting or newly erupted third molars without full
chewing function and with highly caries-susceptible fissures

25. CARIES RISK CATEGORIES
• Niessen L et al (1996) Based on the clinical
evaluation and information derived from a
patient’s medical and dental history, he or she
can be classified as
 Low,
 Moderate
 High Risk
Niessen LC, DeSpain B. Clinical strategies for prevention of oral diseases. J Esthet Dent 1996;8(1):3-11.

26. Low risk
Moderate
risk
High risk
• Caries inactive/ caries
controlled
• No active lesion, no
history of recent
restorations.
• The protective factors
outweigh the risk factors
•Can develop caries in the near
future if an imbalance occurs
between the protective factors and
risk factors
•Caries active but all relevant risk
factors can be potentially changed
(eg: plaque control, fluoride, diet)
•Caries control can be achieved
through changes in risk factors.
•Patients in whom the caries
balance is tilted towards
demineralization.
•Caries active but some risk
factors cannot be changed
(eg:dry mouth, medications)
or risk factors cannot be
identified

27. WHY THE NEED FOR CARIES RISK ASSESSMENT
Knowing which patients are at high risk for
developing caries provides an opportunity
to implement specific preventive strategies
that may prevent caries. These strategies
are specific to highrisk individuals and are
not intended for all patients
For patients at low risk for caries, preventive
measures may be limited to oral hygiene

28. CARIES RISK
ASSESSMENT TOOLS

29. 1.PATIENT HISTORY
AGE GENDER FLUORIDE
EXPOSURE
SMOKING
HABITS
ALCOHOL
INTAKE
DIETARY
HABITS
ECONOMIC
AND
EDUCATIONAL
STATUS
Medications

30. 2.CLINICAL EXAMINATION
Inadequate
salivary
functioning
Inflammation
of soft tissues
plaque
accumulation
cavitated
lesions
poor oral
hygiene Existing
restoration

32. 3. Nutritional Analyses
Frequent exposure to sucrose increases the likelihood of plaque
development by the more cariogenic MS organisms.
4. Salivary Analyses
Analyzing saliva may provide important information about
appropriateness of secretion rates and buffering capacity and
numbers of MS and lactobacilli

33. 5. Social, Economic, and Education
Status
Affect the
expression and
management of
the caries disease
predictive at the
population level but
are generally
inaccurate at the
individual level

34. 6. Radiographic Assessment
The minimal depth of a detectable lesion on a radiograph is about 500 μm
Approximately 60% of teeth with radiographic proximal lesions in the outer
half of dentin are likely to be noncavitated.
Early detection of incipient caries, limitation of caries activity before
significant tooth destruction has occurred, and identification of high-risk
patients are primary goals of an effective diagnosis and treatment program.

35. 7. Past caries experience
Most powerful single predictor for future caries incidence in
children and young adults
Represent the sum result of all the etiologic and modifying risk factors to which
individuals have been exposed

36. CARIES RISK ASSESSMENT
SYSTEMS

37. Developed in the year 2001. It is an Evidence-based,
preventively oriented strategy that classifies the visual
appearance of a lesion and culminates in diagnosis.
A two digit coding system ( X-Y)
Code X (lesion detection) - classify each tooth surface on whether it is sound, sealed, restored,
crowned or missing.
Code Y (lesion assessment )- classification of the carious status on an ordinal scale
The International Caries Detection and
Assessment System (ICDAS 1 & Ⅱ )

39. ICDAS 1(2001) ICDAS Ⅱ(2009)
◦ Includes D and A Component.
◦ Root caries were not included
due to lack of consensus.
◦ Describes both coronal caries
and caries associated with
restorations and sealants (CARS)
and root caries

40. Description and clinical examples of each score of ICDAS.
( Jablonski -Momeni et al . Caries Res 2008)
PIT AND FISSURES & SMOOTH SURFACE

41. CARIES ADJACENT TO RESTORATIONS AND
SEALANTS ( CARS )

42. ROOT CARIES 0 1
2 3-4
5-6

43. This systematic review discovered a number of root caries risk predictors in different
categories. People who are older, in lower socio-economic status or tobacco users,
and those with more root caries experience, gingival recession and poor oral hygiene
have higher risk of developing new root caries.

44. ADA SYSTEM
The American Dental Association offers caries assessment
forms for patients 0 to 6 years old, and those older than 6
years.

47. CARIOGRAM
• A computer program showing 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. It expresses as to what extent different
etiological factors of caries affect caries risk

48. PURPOSE OF CARIOGRAM
1. To determine the caries risk graphically, expressed as the “Chance to
avoid new caries” (i.e . to avoid getting new cavities or holes) in the near
future.
2. To exemplify to what extent different factors affect this “Chance”.
3. To encourage preventive measures to be introduced before new cavities
could develop.

51. ADVANTAGES OF CARIOGRAM
AFFORDABLE USER
FRIENDLY
EASY TO
UNDERSTAND
serve as a support for clinical decision making when selecting preventive
strategies for the patient

52. Methods: A prospective study recording root caries incidence was conducted on 334 dentate
older adults. Data were collected on participant's medical history, fluoride exposure, and diet.
Saliva samples were collected to measure salivary flow rate, buffer capacity and bacterial
counts. Clinical examination was completed to record decayed, missing and filled teeth (DMFT)
and also exposed, filled and decayed root surfaces (RDFS). This was repeated after 12 and 24
months. Scores were entered into the Cariogram and baseline risk category was recorded.
Results: 280 participants were examined at two year follow up. 55.6% of those in the highest
risk group developed new caries compared to 3.8% in the lowest risk group.
Conclusion: Within the limitations of this study, the
Cariogram was clinically useful in identifying individuals
with a high risk of developing root caries.

53. Caries Risk Assessment Tool (CAT): This tool was developed by the American
Academy of Paediatric Dentistry (AAPD) in 2006. Depending on the age of children
CAT incorporates three factors in assessing caries risk, namely, biological as well as
protective factors and clinical findings

54. Biological Factors
•Patient is of low socioeconomic status
•Patient has >3 between-meal sugar-containing snacks or
beverages per day
•Patient has special health care
needs
• Patient is a recent immigrant
Protective Factors
•Patient receives optimally-fluoridated
drinking water
•Patient brushes teeth daily with
fluoridated toothpaste
• Patient receives topical fluoride from
healthprofessional
• Patient has dental home/regular dental
care
•Clinical Findings
•Patient has >1 interproximal lesions
•Patient has active white spot lesions or enamel defects
• Patient has low salivary flow
•Patient has defective restorations
•Patient wearing an intraoral appliance

59. CAMBRA
•Caries management by risk assessment (CAMBRA) is an
evidence-based approach to preventing, reversing and, when
necessary, repairing early damage to teeth.
Evaluation of the etiologic and protective factors
Establishment of the risk of future disease (risk
assessment)
Development of a patient centered evidence based
caries management plan.
INVOLVES

60. The 4 caries disease indictors making up the reminder “WREC”
1. White spots visible on smooth surfaces
2. Restorations placed in the last 3 years as a result of caries
activity
3. Enamel radiographic proximal lesions
4. Cavitations/dentin indicating cavities or radiographic lesions
that show penetration into dentin.
Caries risk assessment

64. CAMBRA, Cariogram, American Dental Association (ADA), and
American Academy of Pediatric Dentistry (AAPD) CRAs
CRA methods for ages 0–6 years and 6 years-adult were compared using
26 hypothetical patients (13 per age group).

65. • Comparison results show that Cariogram and CAMBRA categorized
patients into identical risk categories. Each of the ADA and AAPD tools
gave different results than CAMBRA and Cariogram in several comparison
examples.
• Both the Cariogram and the CAMBRA CRA methods are equally useful for
identifying the future risk of dental caries

66. TRAFFIC LIGHT
MATRIX
commonly used CRA tool in Australia
uses color codes such as red, green, and orange to convey
specific threshold values for data obtained in the analysis.
Based on 19 criteria in 5 different categories
Saliva (6
criteria)
Plaque (3
criteria)
Fuoride
exposure
(3 criteria)
modifying
factors (5
criteria
Diet (2
criteria)

68. CARE TEST
Researchers at 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
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.

69. 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.
Lloyd KO. The chemistry and immunochemistry of blood group
A, B, H, and Lewis antigens: Past, present and future.
Glycoconj J 2000;17:531-41.
Leffler et al stated that just like blood group types, the salivary
oligosaccharide patterns remain quantitatively consistent over
time and across age groups.
Leffler H, Prakobphol A, Fisher SJ. The high-molecular-weight
human mucin is the primary salivary carrier of ABH, Lea, and
Leb blood group antigens. Crit Rev Oral Biol Med
1993;4:325-33.

70. Tooth genes
Tuftelin interacting protein11 associated with the enamel
surface's ability to uptake fluoride in very low concentrations,
thus decreasing individual susceptibility to demineralization at
subclinical levels
-Shimuzu et al
Taste genes
polymorphisms in the sweet taste receptor (TAS1R2) and
glucose transporter (GLUT2) genes individually and in
combination are associated with caries risk
-Kulkarni et al

71. Saliva
• salivary receptor gp-340, which mediates adhesion of S. mutans, showed more
caries experience in subjects positive for both gp-340 I variant and Db positive
allele.
-Jonasson et al
Immunity
• Being positive for the HLA DR 4 allele increases the risk for early childhood caries 10
times more compared to the caries-free group.
-Bagherian et al
• High levels of Streptococcus mutans were positively associated with the presence of
DR3 and DR4 alleles
-Acton et al

72. MICROBIAL TESTS FOR
MUTANS STREPTOCOCCI
DETECTION
Laboratory
Method
To measure the levels of mutans streptococci in
saliva and plaque and on individual tooth surfaces
Chair-side
Method
Survey
Method
Selective
Method
Adherence
Method

73. Laboratory
Method
Saliva (or dental plaque) is collected
Mixed with a proper transport medium and sent to a
microbiological laboratory
Incubation using a selective medium
mutans colonies on the plates are counted
and the results are expressed as number of
colony-forming units per ml saliva
For
screening
surveys

74. Chair-side
Method

75. Adherence
method
Categorizes salivary
samples based on
ability of S. mutans to
adhere to glass
surfaces when grown in
sucrose containing
broth.

76. The aim of the present study was to validate and
establish a cutoff point and the predictive value of
an adhesion test (AAMSMG), as a microbiological
method for evaluating cariogenic risk.
This method used in a population of 154
people showed that levels of MGS counts
higher than the cutoff point (1.68 x 105
CFU/ml), increase the microbiological risk of
developing caries up to 5 times
Polystyrene flask with mutants
streptococci adhered colonies

77. Selective
method
• Described by
Kristoffersson and
Bratthall.
• For the demonstration
of mutans streptococci
at specific sites

78. Survey
method
For field studies the plates can be placed into plastic bags
containing expired air, which are then sealed (Seal-aMeal) and
incubated at 37°C
Counts of more than 100 colony-forming units (CFU) by this
method are proportional to greater than 108 CFU of S. mutans per
mL of saliva by conventional methods.

79. MICROBIAL TESTS FOR
LACTOBACILLI DETECTION
Introduced by Hadley in 1933.

80. Estimates the number of acidogenic and aciduric bacteria in the
patient’s saliva by counting the number of colonies appearing on LBS
agar (Rogosa). The total number of colonies on this medium reflects
the proportion of the aciduric flora in the saliva

81. ORA TEST
Chair side simple caries activity test
Based on the rate of oxygen depletion by micro
organisms. Under aerobic conditions the bacterial
enzyme, aerobic dehydrogenase transfers electrons or
protons to oxygen. Once oxygen gets utilized by the
aerobic organisms and an anaerobic environment is
attained, methylene blue [redox indicator] acts as an
electron acceptor and gets reduced to leucomethylene
blue.
The metabolic activity of the aerobic microorganism is
reflected by the reduction of methylene blue to
leucomethylene blue.

83. RESULT
• when the time taken for the change in color increases, the ICDAS-LAA
scores decrease, which proves that a negative correlation exists between
the two groups and the difference is highly statistically significant,
• The mean time taken for the color change in OT was found to be higher in
Group A whereas Group B had a lower mean value

84. CARIES ACTIVITY TESTS
Snyder
test
Alban test
Reductase
test
Swab
test

85. Snyder Test
measures the ability of salivary microorganisms to
form organic acids from carbohydrate medium.

86. ALBAN TEST
Simplified substitute for the Snyder test.
Scoring is based on the depth in medium to which
color has changed

87. Aim
To evaluate CRAFT as a tool for caries risk prediction among 3-years to 6-years-old children
and to validate it against Alban test.
Materials and methods
A pilot study was conducted, including forty
3-years to 6-years-old children. Salivary
samples were collected and inoculated on
B.C.G.-Dextrose Agar. Caries activity was
assessed using Alban test. Their
parents/guardians completed the CRAFT
assessment in entirety.
Results
Conclusion
CRAFT scores were highly correlated with Alban scores in 3- to 6-year-old children. CRAFT could be
successfully employed as a reliable, economical, chairside, and clinically feasible risk assessment tool with
further research on a larger sample size.

88. REDUCTASE TEST
measures the ability of reductase enzyme present in
salivary bacteria.

89. SWAB TEST
Developed by Grainger et al. in 1965
can be used in young and uncooperative patients as there is no need for salivary collection
oral flora is sampled by swabbing the buccal surfaces of the teeth with a cotton applicator which is
subsequently incubated for 48 hours

90. CONCLUSION
l
p
r
a
c
t
i
t
i
o
n
e
r
s
c
a
• Caries risk assessment as a prerequisite for appropriate
preventive and treatment intervention provides some
practical information on how general practitioners can
incorporate caries risk assessment into the management of
caries
• A caries risk assessment tool can be used to identify dietary
habits that may contribute to caries risk

91. • Reich E, Lussi A, Newbrun E. Caries-risk assessment. Int Dent J. 1999 Feb;49(1):15-26. doi:
10.1111/j.1875-595x.1999.tb00503.x. PMID: 10887469.
• Naichuan Su, Maxim D. Lagerweij, Geert J.M.G. van der Heijden, Assessment of predictive
performance of caries risk assessment models based on a systematic review and meta-analysis,
Journal of Dentistry, Volume 110, 2021
• Hemadi AS, Huang R, Zhou Y, Zou J. Salivary proteins and microbiota as biomarkers for early
childhood caries risk assessment. Int J Oral Sci. 2017 Nov 10;9(11):e1. doi: 10.1038/ijos.2017.35.
PMID: 29125139; PMCID: PMC5775330.
• Pappa E, Vastardis H, Rahiotis C. Chair-side saliva diagnostic tests: An evaluation tool for
xerostomia and caries risk assessment in children with type 1 diabetes. J Dent. 2020 Feb;93:103224.
doi: 10.1016/j.jdent.2019.103224. Epub 2019 Nov 10. PMID: 31722239.
• Axelsson P. Diagnosis and risk prediction of dental caries. 2004. Bratthall D et al. Community Dent
Oral Epidemiol 2005; 33: 256–64
REFERENCES

92. • Guideline on Caries-risk Assessment and Management for Infants, Children, and Adolescents
• Axelsson P.Diagnosis and risk prediction of dental caries. Slovakia Quintessence International 2004;
p. 29.
•Bratthall D et al. Cariogram a multifunctional risk assessment model for a multifactorial disease.
Community Dent Oral Epidemiol 2005; 33: 256–64.
•Hayes M, Da Mata C, McKenna G, Burke FM, Allen PF. Evaluation of the Cariogram for root caries
prediction. J Dent. 2017 Jul;62:25-30. doi: 10.1016/j.jdent.2017.04.010. Epub 2017 Apr 26. PMID:
28456556.
•Textbook of pediatric dentistry, 3rd edition: Nikhil Marwa
•Sturdevants art and science of operative dentistry, 7th edition