assessing patients’ caries risk margherita fontana

2006;137;1231-1239 J Am Dent Assoc

Margherita Fontana and Domenick T. Zero Assessing patients’ caries risk

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Background. Caries management historically hasfocused on the removal of cavitated carious tissue andrestoration of the tooth.Overview. Assessing a patient’s risk of developingcaries is a vital component of caries management. A com-prehensive caries assessment should consider factorssuch as past and current caries experience, diet, fluorideexposure, presence of cariogenic bacteria, salivary status,general medical history, behavioral and physical factors,and medical and demographic characteristics that mayaffect caries development. A caries risk assessment alsoshould consider factors that may challenge the patient’sability to maintain good oral hygiene (for example,crowded dentition, deep fissures, wide open restorativemargins or placement of oral appliances).Conclusions and Practical Implications. Theauthors review the importance of caries risk assessmentas a prerequisite for appropriate preventive and treat-ment intervention decisions and provide some practicalinformation on how general practitioners can incorporatecaries risk assessment into the management of caries.Key Words. Dental caries; risk assessment; diseasemanagement.JADA 2006;137(9):1231-9.

Caries treatment remains one of themost common and important aspectsof dental practice despite the dra-matic decline in caries prevalenceduring the past 30 years.1 Since 1960,

the rate of edentulous adults has dropped 60 per-cent among people aged 55 to 64 years.2 Withmore Americans keeping their teeth into theirlater years of life, treatment decisions gearedtoward preserving tooth structure with noninva-sive and preventive interventions will need to bebased on the patient’s risk of developing caries tobe most health- and cost-effective. While there issome research evidence of how to use single(especially previous caries experience) or mul-tiple risk factors to predict caries in either pri-mary or permanent teeth in children, there islittle evidence from adults or the elderly to helpguide practitioners on how to apply risk assess-ment models to adult populations.3

Historically, caries was thought to be a pro-gressive disease that eventually destroyed thetooth unless the dentist intervened surgically.But the understanding of caries has changedmarkedly, and this change needs to be reflectedin dental practice. In 2001, a National Institutesof Health (NIH) Consensus Statement recognizeda paradigm shift in the management of caries.That consensus statement, based on the NIH-sponsored consensus development conferencetitled Diagnosis and Management of DentalCaries Throughout Life, identified a shift towardimproved diagnosis of noncavitated, incipientlesions and treatment for prevention and arrestof such lesions.4 Restorations repair the toothstructure, do not stop caries, have a finite lifespan and are susceptible to disease.4

This paradigm shift should reflect changes inthe modern management of caries. These

A B S T R A C T

Dr. Fontana is an associate professor, Department of Preventive and CommunityDentistry, Indiana University School of Dentistry, and the director, MicrobialCaries Facility, Oral Health Research Institute, and the director, Predoctoral Edu-cation for the Department of Preventive and Community Dentistry, Indiana Uni-versity School of Dentistry, Indianapolis.Dr. Zero is an associate dean for research, Indiana University School of Dentistry,Indianapolis, a professor and the chair, Department of Preventive and CommunityDentistry, Indiana University School of Dentistry, Indianapolis, and the director,Oral Health Research Institute, Indiana University School of Dentistry, Indi-anapolis. Address reprint requests to Dr. Zero at Oral Health Research Institute,415 Lansing St., Indianapolis, Ind. 46202-2876, e-mail “[email protected]”.

Assessing patients’ caries risk

Margherita Fontana, DDS, PhD; Domenick T. Zero, DDS, MS

JADA, Vol. 137 http://jada.ada.org September 2006 1231

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Copyright ©2006 American Dental Association. All rights reserved.


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changes should include the following:ddetection of carious lesions at an early (incip-ient, noncavitated) stage;ddiagnosis of the disease process;didentification of all risk factors (including etio-logic factors such as diet and bacteria and noneti-ologic factors such as socioeconomic status);dtreatment planning that goes beyond cariesremoval and tooth restoration to include riskfactor modification or elimination, arresting orreversing active noncavitated carious lesions, andpreventing future caries.

This article discusses how general practitionersin private practice can incorporate caries riskassessment into the comprehensive managementof caries in their patients.

CARIES RISK ASSESSMENT

Caries risk assessment determines the proba-bility of caries incidence (that is, number of newcavities or incipient lesions) in a certain period.5

It also involves the probability that there will be achange in the size or activity of lesions in themouth. Most dentists likely incorporate into theirpractice some form of caries risk assessmentbased on their overall impression of the patient,which together with previous caries experiencehas been shown to have good predictive power.6 Itis unclear, however, how and if dentists system-atically incorporate this information into theirtreatment decisions.7 Bahleda and Fontana8 ran-domly surveyed 250 dentists in Indianapolisabout their use and formal recording of cariesrisk assessment and management strategies.The survey revealed that 72 percent of respon-dents performed some type of risk assessment,but only 27 percent of this group documentedthe outcome. Ninety percent of respondentsassessed caries activity (the most commonlycited risk variable in this study), but only 5 per-cent of respondents assessed salivary flow bymeasuring volume or weight (the least commonrisk variable cited in this study). However, ondiagnosing white-spot lesions in adults, only 51percent of respondents provided a treatment ormanagement plan based on the patient’s riskstatus. This finding suggests that caries riskassessment was not incorporated into almostone-half of all patient treatment plans. Theprocess of charting the results of caries detec-tion, diagnosis and risk assessment, as well asinforming patients about specific findings andtheir implications on treatment and prognosis,

are as important for appropriate patient careand effective management of the caries diseaseprocess as is recording the proposed treatmentplan and eventual treatment outcomes.

IMPORTANCE OF CARIES ACTIVITY IN CARIES DIAGNOSIS

The detection of frank cavitations in teethrequiring restorations has been a hallmark ofdentistry. In contrast, modern caries manage-ment also focuses on the detection of incipient,noncavitated lesions and the practitioner’sability to diagnose whether those lesions areactive. This diagnosis should be one of theguiding factors for caries risk assessment andmanagement decisions. An active carious lesionprogresses over time and requires management(remineralization or restoration). An inactivelesion may be visible either clinically or radiolog-ically (like “scar tissue” that reminds us of pastdamage to the tooth), but it will not progress orchange over time. In remineralized lesions, notonly has the caries process been arrested, butalso the affected area has experienced one ormore of the following changes that signal remin-eralization: increased radiodensity, decreasedlesion size, increase in mineral concentration,increased hardness and increased sheen as com-pared with a previously matte surface texture.9

Arrested or remineralized lesions do not requireintervention since they do not represent activedisease, unless the lesions are so advanced thatthey interfere with oral function or esthetics.

Available data suggest that previous cariesexperience is a strong predictor of caries risk inpeople.3,4,6 However, Zero and colleagues3 sug-gested that determining caries activity may be astronger predictor of caries risk than decayed,filled or missing teeth. The determination ofcaries activity can be made in a single visit andinvolves subjectively assessing the appearanceand physical properties of affected tooth surfaceswhile considering other risk factors that may bepresent (for example, plaque accumulation canbe an indicator of activity present) or followingthe lesion’s characteristics over time (forexample, roughness can be an indicator that the lesion is being demineralized).10,11 Researchon caries detection methodology should focus ondeveloping methodologies that provide real-timechairside caries diagnosis and more accuratemonitoring of lesion activity and severity over time.

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ROLE OF CARIES RISK ASSESSMENT IN PATIENT MANAGEMENT

Caries is a disease of multifactorial etiology, anda risk assessment should evaluate all factorsinvolved with the disease. Individual risk factorsstudied separately from the pool of risk factorstend to be poor predictors of caries onset.12 Theassessment of all risk factors not only allows for amore accurate assessment of risk of developing adisease, but it also identifies the etiologic factorsresponsible for the disease in a particularpatient. This approach encourages managementstrategies developed specifically for the patient.Therefore, caries risk assessment may be usefulin the clinical management of caries by helpingdental professionals do the following:devaluate the degree of the patient’s risk ofdeveloping caries to determine the intensity ofthe treatment (for example, a 226 parts per mil-lion sodium fluoride [NaF] rinse versus a 5,000 ppm NaF brush-on gel) and frequency ofrecall appointments or treatments (for example,every three months, every six months, everyyear);dhelp identify the main etiologic agents thatcontribute to the disease or that, because of theirrecent onset, may contribute to future disease, todetermine the type of treatment (for example,plaque control, diet control, increased fluorideexposure, antimicrobial agents);ddetermine if additional diagnostic proceduresare required (for example, salivary flow rateanalysis, diet analysis);daid in restorative treatment decisions (forexample, cavity designs, choice of dentalmaterials);dimprove the reliability of the prognosis of theplanned treatment;dassess the efficacy of the proposed manage-ment and preventive treatment plan at recallvisits.

DEFINITION OF CARIES RISK CATEGORIES

Although there are many ways to categorizecaries risk, we recommend an initial decision-making process based on three categories: highrisk, moderate risk and low risk. Our classifica-tion model (Figure 1) begins with caries experi-ence, since this is one of the strongest predictorsof future caries. It is, however, unfortunate thatdentists must wait until the disease manifestsitself before they can predict it accurately.13 Any


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patient with active disease faces an increased riskof developing the disease in the future. In mostpatients, the disease is a chronic disorder, sothere is a great chance that patients with activelesions may have developing lesions that are notyet visible during a standard clinical exami-nation. Patients who do not have active disease or clinical signs of caries are not necessarily atlow risk of developing the disease. For example,life stressors such as leaving home for college forthe first time, having orthodontic brackets placedon teeth or experiencing other significant lifeevents can affect caries risk. Therefore, an assess-ment of the patient’s behavior, lifestyle, oralhygiene habits (for example, plaque removal andfrequency of exposure to fluorides) and dietaryhabits should inform the decision-makingprocess.14

Providing an evidence-based definition for eachof these caries risk categories is not an easytask.15-17 Common sense dictates that a high-riskgroup of patients is a subset of a patient popula-tion considered at greater risk of developingcaries (that is, patient examination results clearlysuggest that if conditions remain unchanged,caries will progress over time) than is a subset ataverage risk.5 In most cases, data show thatshort-term predictions of risk (less than twoyears) are more reliable than long-term predic-tions of risk (more than five years) becauselifestyle changes that may occur can affect theaccuracy of long-term predictions. Consideringthe current understanding of the caries diseaseprocess, we have expanded the caries risk defini-tions developed by Reich and colleagues.5 We pro-pose that the following factors will yield a moderate-to-high assessment of caries riskwhether appearing singly or in combination: thedevelopment of new carious lesions, the presenceof active lesions and the placement of restorationsdue to active disease since the patient’s lastexamination (assuming a one- to two-year lapsebetween the previous and current appointment).We further propose that the differentiationbetween a moderate-to-high assessment of cariesrisk will depend on the following combined fac-tors: time (that is, the faster the lesions develop,the higher the risk of developing caries), andnumber and severity of the lesions. However, anyassessment developed from these factors shouldbe qualified, because a patient who develops onenew lesion within a three-month interval may beat a higher risk than a patient who develops five



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new lesions during a two-year period. Generally,the date and accuracy of the last examinationdrive the level of uncertainty associated with pre-dicting caries. The longer the interval, the moredifficult it is to assess the speed of progressionand changes in disease activity accurately and,therefore, the greater the level of uncertainty atpredicting disease.

We also propose that a moderate-to-low assess-ment of caries risk be based on the following fac-tors: no carious lesion development or progressionsince the previous examination, the amount ofplaque accumulation, the frequency of thepatient’s sugar intake, the presence of salivaryproblems, behavioral or physical disabilitychanges, history of fluoride exposure and patternof fluoride usage. Finally, a low assessment ofcaries risk (new lesions will not develop orexisting lesions will not progress over time)should be based on the following factors, singly orcombined: no current active caries; restorationsnecessitated by caries were placed five or moreyears ago; other caries risk factors are negligibleor, if they are present, there is evidence that overmany years they have not resulted in any lesions;

and the patient hasdemonstrated no evi-dence of active diseaseover many years. Gener-ally, the longer theinterval during which nonew activity or changeoccurs, the more reliablethe assessment of lowcaries risk.

CARIES RISK INDICATORS

We recommend a cariesrisk assessment thatrelies on informationfrom the patient’s medical and dental history and a clinical examination.

Bacteria and oralhygiene. Caries is amicrobial disease inwhich the etiologicagents are normal con-stituents of the oral florathat cause problemswhen their pathogenicity

and proportions change in response to environ-mental conditions. The microbial component ofcaries can be viewed from the perspective of spe-cific microorganisms that contribute to the dis-ease, or whole plaque.

Specific organisms. Mutans streptococci andlactobacilli historically have captured the greatestinterest among researchers and clinicians. How-ever, the accuracy of salivary tests for mutansstreptococci in predicting future caries in thewhole population is less than 50 percent.4,5,18 Inpopulations with low caries prevalence, thecaries-predictive ability of microbiological tests iseven lower.5,19 In addition, lactobacilli microbio-logical tests are less sensitive in predicting cariesthan are the tests for mutans streptococci.20 In theUnited States, dentists can purchase severaltypes of saliva tests to measure the amount ofcariogenic microorganisms in saliva.

Because these tests estimate bacterial levels insaliva, dentists readily can identify patients witha high salivary bacterial load. This type of testcan be useful to motivate patients and monitororal hygiene changes. In addition, it can be usefulwhen monitoring dietary changes because it has


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Yes

Yes

Yes

No

No

NoCaries detected?

Initialdiagnosis

Caries active?

At risk

High risk Moderate risk Low risk

Recent changes?

(Based on physicalappearance and location)

A

B

Check for recent changes that could have influenced caries riskfactors toward a more cariogenic challenge (for example, newmedical conditions or medications that decrease salivary flow, neworal appliances, such as braces, significant stress factors that couldmodify diet/oral hygiene habits, occupational and sociodemo-graphic changes)

Check for recent changes in oral conditions (for example,erupting teeth, recently placed restorations due to caries anddefective restorations)

Figure 1. Flowchart depicting clinician’s initial decision-making process in determining a patient’scaries risk.



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been suggested that the levels of lactobacilli insaliva can be related to the intake of carbohy-drates and sugars. These tests, however, havedisadvantages because they require incubators,enumerate bacteria in saliva only—not inplaque—and correlate poorly with future cariesrisk. Manufacturers are developing alternativesto effectively quantify bacteria and plaque pHfrom site-specific plaque areas. Another site-spe-cific plaque approach is an impression materialthat changes color from blue to pink in areas oflactic acid production, which presumably wouldbe at higher risk for caries. Supporting data onthis material still are scarce,21 and the material isnot approved for sale in the United States.

Available bacterial salivary tests could be usedto determine cariogenic bacteria in the mouth andperhaps motivate patient behavioral changes, aswell as help monitor the efficacy of antimicrobialtherapies such as chlorhexidine therapy, whichdecreases the levels of mutans streptococci in themouth but works less effectively on decreasinglactobacilli levels. However, based on the paucityof available data, using only the available bacte-rial salivary tests to predict future caries is notrecommended.

Whole plaque. Evidence shows that becausecaries is a microbial disease, without plaque therewould be no caries. Most patients, however, donot remove plaque effectively.22 To evaluate theeffectiveness of mechanical cleaning is difficultbecause toothbrushing usually involves using afluoridated dentifrice. Furthermore, most plaqueindexes are ineffective predictors of future cariesbecause caries typically develops in fissures andinterproximal areas, while most plaque indexeswere developed to evaluate periodontal disease orgingivitis on smooth surfaces.5 Because plaque isone of the main etiologic factors for caries, it isimportant to estimate the number of surfacesaffected, the amount of plaque accumulated, theage of the plaque and whether the presence ofplaque is associated with the presence of cariouslesions in those same sites. For a patient at lowrisk, a quick estimate should suffice. For apatient at high risk, however, a surface-by-surface investigation to determine risk sites andhelp guide plaque control measures tailored tothe patient’s needs is warranted.

Conditions that compromise the long-termmaintenance of good oral hygiene are associatedpositively with caries risk. These may includephysical and mental disabilities, the presence of

existing defective restorations (for example, wideopen margins, overhangs) or oral appliances (forexample, orthodontic brackets).4 Therefore, a riskassessment should consider not only the presenceof plaque, but also other factors such as crowdedteeth, deep fissures, restoration overhangs, gin-gival recession and appliances.

Saliva. It is well-established that saliva playsan important role in the health of soft and hardtissues in the oral cavity. Oral complications as aresult of salivary gland hypofunction includealtered oral sensations, taste dysfunction,mucosal dryness resulting in infection and toothwear due to abrasion.23,24 Pain and diminishedquality of life also are common complaints asso-ciated with salivary hypofunction. A chronicallylow salivary flow rate has been found to be one ofthe strongest salivary indicators for an increasedrisk of developing caries.25

Many dentists tend to rely on a patient’s com-plaint of xerostomia to diagnose hyposalivation.Unfortunately, a subjective complaint of xero-stomia often does not correlate with objectivefindings of reduced salivary flow rate.26 Therefore,dentists should assess the true presence andextent of salivary gland hypofunction beforedeveloping an appropriate preventive andrestorative treatment plan for a patient. How-ever, dentists rarely evaluate their patients’ sali-vary gland functions, probably because of thecumbersome nature of the available sialometricmethods.26,27 Fox and colleagues26 recommendedthat dentists ask their patients the followingquestions:dDoes your mouth feel dry when eating a meal?dDo you sip liquids to aid swallowing dry foods?dDo you have difficulty swallowing any foods?dDoes the amount of saliva in your mouth seemto be too little, too much or you do not notice it?

The dentist should consider the following fac-tors when evaluating the patient’s answers:dAre there any clinical signs that the patient’ssalivary flow rate is decreased (for example, dry lips)?dDoes the mouth mirror stick to the oralmucosa?dIs there a lack of pool of saliva in the floor ofthe patient’s mouth?dIs there difficulty expressing saliva from thepatient’s major salivary ducts?dDoes the mucosa appear dry?dIs there an increase in caries in an unusuallocation (for example, mandibular incisors)?


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dDoes the patient have any systemic condition(for example, autoimmune exocrinopathy, uncon-trolled diabetes) that may cause decreased sali-vary flow rate?dIs the patient taking any medications known to decrease salivary flow rate?dHas the patient received or will the patientreceive radiation of the head and neck that couldaffect salivary gland function?

A positive answer to any of these questionsshould prompt the dentist to consider how longthe patient has experienced the problem andwhether an increased caries experience hasresulted. The dentist also should determine if thehyposalivation is related to dehydration, as thiswould affect the management strategy. Studieshave shown that patients at risk of developingcaries due to hyposalivation can be treated suc-cessfully by exposing them to fluoride.28,29 Ascaries risk increases, patients should be exposedto fluoride more frequently, at higher doses thansolely from dentifrice or both. These additionalsources of fluoride may include one or more of thefollowing: 0.05 percent NaF over-the-counterrinses, high concentration (1.1 percent NaF) pre-scription fluoride dentifrices and in-office high-concentration fluoride applications. When con-ducting a risk assessment, a dentist shouldconsider as many factors as possible, includingfluoride exposure, to avoid arriving at an erro-neous conclusion.

If a patient is considered at risk and saliva isone of the influencing risk factors, an objectiveassessment of unstimulated flow rate should beperformed for diagnostic purposes and berecorded for future comparisons. Salivary flowrates can vary greatly not only between people,but also within the same person depending ontime of day, body position, amount of light andother factors.30,31 Navazesh and colleagues32 foundthat unstimulated flow rates have the strongestpredictive validity for estimating caries risk.When measuring unstimulated salivary flow rate,dentists should ask patients to not drink, eat,chew anything or smoke at least one to two hoursbefore the appointment. The normal unstimu-lated flow rate varies between 0.3 and 0.4 milli-liters per minute,33,34 and values of less than 0.1mL per minute should be considered abnormal.32,35

Dentists also should assess the stimulated flowrates to determine if management strategiesbased on salivary stimulation (for example, rec-ommending chewing sugarless gum, prescribing

pilocarpine) would benefit patients. Commerciallyavailable kits contain all the supplies that thedental office may need to assess salivary flow rate.

Diet. Sugar exposure is an important etiologicfactor in caries development.36,37 Owing to thewide use of fluoride and its effect in lowering theincidence and rate of caries, it is difficult to showa strong clear-cut positive association between aperson’s sugar consumption and his or her cariesdevelopment; if a patient consumes a lot of sugar,but at the same time uses a lot of fluoride, theteeth may not be as damaged as they would be ifthere were no fluoride use.

Starches are considered less cariogenic thanthe simple sugars sucrose, glucose and fructose,with sucrose possibly being the most cariogenicowing to its unique role in the production ofextracellular glucans.38 Other dietary considera-tions include the retentiveness of the food, thepresence of protective factors in foods (calcium,phosphate, fluoride) and the type of carbohydrate.Although sugar in liquid form (for example, softdrinks) is less cariogenic than sugar in solid form(for example, candy), excessive frequent consump-tion of soft drinks remains a major risk factorthat may be partly responsible for the rate ofcaries in teenagers and young adults.39,40

A dietary assessment should feature a probinginterview with follow-up questions. Patients maybe unaware of the cariogenicity of certain compo-nents of their diet, and they may not volunteerimportant information. The interview processshould focus on eating behaviors in betweenmeals, including late-night snacking. Follow-upquestions should determine the consumption pat-tern. For example, does the patient consume foodor drink rapidly, or does he or she nibble or sipover an extended period? Sipping a soft drinkover a five-hour period can be more detrimentalthan drinking three soft drinks during one meal.Dentists should ask patients who drink coffee ifthey add sugar or a nondairy creamer, whichmay contain sugar, to their coffee. Dentists alsoshould ask patients if they frequently consumehard candies or lozenges, especially if active car-ious lesions are evident. For at-risk patients,dietary assessments could feature several addi-tional approaches, including conducting 24-hourrecall interviews and asking patients to completethree-, five- or seven-day diet diaries, especiallyif the dentist cannot identify dietary etiologic fac-tors during the interview process.


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Lifestyle changes and occupation also canaffect caries risk status. For example, youngadults living away from home for the first timemay experience significant changes in their dietand resort to frequent snacking. Also, people who work evening or sedentary jobs might tend to snack on high-sugar foods and caffeinated beverages.

Generally, diet alone is an inadequate indicatorof caries risk. For example, a patient may snackseveral times a day but then brush immediatelyafterward, which would minimize the impact ofdiet alone on caries risk. Therefore, other risk fac-tors also need to be considered, such as assessing apatient’s pattern and frequency of carbohydrateintake and its relationship with oral hygienehabits. In addition, assessing the patient’s eatingand oral hygiene habits over time can help thedentist determine if the behavior has produced ahistory of caries experience. If the potentially nega-tive behaviors are recent, then the patient shouldbe considered at risk. If the negative behaviors areestablished and have not produced any problemsover many years, then the risk may be lower thanexpected.

Exposure to fluoride. The widespread use offluoride has reduced the prevalence of caries andthe rate of the progression of carious lesions dra-matically. Its use, which can be considered one ofthe most important protective factors whenassessing a patient’s caries risk, allows more con-servative management strategies for the preven-tion and treatment of caries.

What constitutes adequate fluoride exposurefor an adult or a child? We suggest that the den-tist first consider all fluoride sources to which thepatient is exposed—for example, fluoridateddrinking water (community water, well water orbottled water), food and drinks (such as sardinesand tea), home topical fluoride products (fre-quency and type of toothpaste or mouthrinse) andperiodical professional fluoride exposures. Thedentist then should determine if this pattern offluoride exposure has arrested the appearance orprogression of incipient or cavitated cariouslesions over time. A patient who uses a fluoridedentifrice once daily can be considered to haveadequate fluoride exposure if he or she is classi-fied as being at low risk and has shown no evi-dence of caries activity. If new lesions haveappeared or existing lesions have progressed,then the patient’s fluoride exposure is inade-quate. General guidelines for fluoride use based


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Low Risk/NoCaries Activity

High Risk/High Caries

Activity

1. Use an American Dental Association–approvedfluoridated dentifrice, at least two times a day.2. No major change in routine is needed.

1. Use an ADA-approved fluoridated dentifrice, three times a day. 2. Use a fluoride rinse before going to bed.

1. Use an ADA-approved fluoridated dentifrice, threetimes a day.2. Use a high concentration fluoride gel before goingto bed.3. Have routine professional fluoride topicalapplications (1.23 percent acidulated phosphofluoride,2 percent neutral sodium fluoride, 5 percent sodiumfluoride varnish).

Figure 2. Recommendations for fluoride use based on caries riskstatus.

on caries risk status are shown in Figure 2. Fluo-ride use should be determined for each patientbased on his or her age, physical abilities, healthawareness and attitude.

Past caries experience. As we mentioned,epdemiological studies have shown a positivestrong correlation between past caries experienceand future caries development. This single cariesrisk indicator provides the greatest predictiveability.3,4,6 The presence of caries in the motherincreases a young child’s risk.4 Caries prevalencein primary teeth can help predict future caries inpermanent teeth.41,42 In adults, there is an associa-tion between existing caries and the risk of devel-oping root caries.43

To analyze the information from this risk indi-cator adequately, at the examination dentistsshould record the number of teeth lost owing tocaries; when those teeth were lost; the numberand size of restorations; when the restorationswere placed; and the number, location and activitystatus of carious lesions present in the mouth. Ifactivity status of the carious lesions cannot bedetermined adequately, we recommend monitoringlesions by taking intraoral pictures of occlusal,buccal and lingual surfaces or radiographs of inter-proximal surfaces over time so that comparisonscan be made later. If lesions are active and noncavi-tated, we suggest that the dentist attempt to arrestand possibly remineralize these lesions. Whenassessing a patient’s caries history, more emphasisshould be placed on caries experience occurringover the past one to two years and current cariesactivity status, which are more indicative of currentrisk factors (Figure 1).

Medical and demographic factors. Epidemio-



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logical surveys show that caries prevalenceincreases with age. In addition, newly eruptedteeth are more susceptible to caries than are teeththat have erupted and have had a chance to maturein the oral cavity.5,44,45 Also, until the newly eruptedteeth have reached the occlusal plane, they are dif-ficult to clean, especially at pit and fissure sites.

Socioeconomic status is a stronger predictor ofcaries risk in children than it is in adults.4 Becausecaries generally is more prevalent in lower socioeco-nomic groups than in higher socioeconomic groups,the dentist should consider social variables such asthe patient’s education and occupation. Oneexample of how social variables can play a role inthe determination of caries risk was presented in astudy that showed that bakery workers have ahigher prevalence of caries than do workers inother industries.46

Another example of how social variables can playa role is shown in studies of identical twins raisedseparately. These studies suggest that etiologic orbehavioral factors could be more important thangenetic factors (for example, tooth morphology,position and occlusion, eruption time and sequence)in determining caries risk,5,47 even when there stillis a lot that is not known between the genetic-environmental relationships in caries etiology andrisk assessment.

Certain medications such as psychopharmaceu-tical drugs reduce the flow rate of saliva and mayaffect caries risk.48 Diseases such as Sjögren’s syn-drome and uncontrolled diabetes that are related todecreases in salivary flow rate can increase the riskof developing caries. Mental or physical disabilitiesthat affect regular oral hygiene or require a carbo-hydrate-enriched diet also may affect the person’srisk. Additionally, enamel defects, such ashypoplasia, have been related to increased cariesrisk in children.13 Lastly, long-term regular use ofmedications that contain glucose, fructose orsucrose, also may contribute to caries risk.4

CONCLUSIONS

Because caries is a multifactorial disease, the incor-poration of caries risk assessment into the conceptof caries management should include factors thatmay affect caries development. Factors such as pastand current caries, diet, fluoride exposure, presenceof cariogenic bacteria, salivary status, general med-ical history and sociodemographic influences shouldbe included when evaluating a patient’s caries riskstatus. The preventive and restorative caries man-agement plan and frequency of recall visits should

depend on a patient’s caries risk. Furthermore, therisk assessment, any proposed managementstrategy and outcomes should be recorded formallyover time to monitor and measure treatment effi-cacy. Patients should be given an opportunity toformally acknowledge the outcomes of a completerisk assessment evaluation. Thus, empoweredpatients can become true partners in and contribu-tors to their oral care. ■

This article was prepared as a Practical Science article in cooperationwith the American Dental Association Council on Scientific Affairs, theDivision of Science and The Journal of the American Dental Association.The mission of Practical Science is to spotlight scientific knowledge aboutthe issues and challenges facing today’s practicing dentists.

The opinions expressed in this article are those of the authors and donot necessarily reflect the views and positions of the American DentalAssociation, the ADA Council on Scientific Affairs or the Division of Science.

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2. U.S. National Institute of Dental and Craniofacial Research. Oralhealth in America: A report of the surgeon general, executive summary.Rockville, Md.: U.S. National Institute of Dental and CraniofacialResearch; 2000.

3. Zero D, Fontana M, Lennon AM. Clinical applications and outcomesof using indicators of risk in caries management. J Dent Educ 2001;65(10):1126-32.

4. National Institutes of Health. Diagnosis and management of dentalcaries throughout life. Bethesda, Md.: National Institutes of Health; 2001.

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