BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

Caries-risk Assessment and Management for

Infants, Children, and Adolescents
Latest Revision
2019

Purpose Caries-risk assessment models currently involve a combina-

The American Academy of Pediatric Dentistry recognizes that tion of factors including diet, fluoride exposure, a susceptible
caries-risk assessment and management protocols, also called host, and microflora that interplay with a variety of social,
care pathways, can assist clinicians with decisions regarding cultural, and behavioral factors. Caries-risk assessment is the
treatment based upon child’s age, caries risk, and patient determination of the likelihood of the increased incidence of
compliance and are essential elements of contemporary clinical caries (i.e., the number of new cavitated or incipient lesions)
care for infants, children, and adolescents. These recommen- during a certain time period9 or the likelihood that there will
dations are intended to educate healthcare providers and other be a change in the size or activity of lesions already present.
interested parties on the assessment of caries risk in contem- With the ability to detect caries in its earliest stages (i.e.,
porary pediatric dentistry and aid in clinical decision-making non-cavitated or white spot lesions), health care providers can
regarding evidence- and risk-based diagnostic, fluoride, dietary, help prevent cavitation.3
and restorative protocols. Caries risk indicators are variables that are thought to
cause the disease directly (e.g., microflora) or have been shown
Methods useful in predicting it (e.g., life-time poverty, low health
This document was developed by the Council on Clinical literacy) and include those variables that may be considered
Affairs and adopted in 20021 and last revised in 20142. To protective factors. The most commonly used caries risk indi-
update this best practices document, an electronic search of cators include presence of caries lesions, low salivary flow,
systematic reviews/meta-analyses or expert panels was conduc- visible plaque on teeth, high frequency sugar consumption,
ted from 2012 to 2018 using the terms: caries risk assessment, presence of appliance in the mouth, health challenges, socio-
diet, sealants, fluoride, radiology, non-restorative treatment, demographic factors, access to care, and cariogenic microflora.3
active surveillance, caries prevention. There were four systematic Protective factors in caries risk include a child’s receiving
reviews that informed this update on caries risk assessment.3-6 optimally-fluoridated water, having teeth brushed daily with
There were 10 systematic reviews and clinical practice guide- fluoridated toothpaste, receiving topical fluoride from a health
lines that inform this update on care pathways for caries.7-16 professional, and having regular dental care.3
When data did not appear sufficient or were inconclusive, Some issues with the current risk indicators include past
recommendations were based upon expert and/or consensus caries experience is not particularly useful in young children
opinion by experienced researchers and clinicians. and activity of lesions may be more important than number
of lesions. Low salivary flow is difficult to measure and may
Background not be relevant in young children.17 Frequent sugar consump-
Caries-risk assessment tion is hard to quantitate. Socio-demographic factors are just a
Risk assessment procedures used in medical practice generally proxy for various exposures/behaviors which may affect caries
have sufficient data to accurately quantitate a person’s disease risk. Predictive ability of various risk factors across the life span
susceptibility and allow for preventive measures. However, in and how risk changes with age have not been determined.3
dentistry there still is a lack of sufficiently validated multivari- Furthermore, genome-level risk factors may account for sub-
ate screening tools to determine which children are at a higher stantial variations in caries risk.3
risk for dental caries.5,6 Nevertheless, caries-risk assessment: Risk assessment tools can aid in the identification of reliable
1. fosters the treatment of the disease process instead predictors and allow dental practitioners, physicians, and other
of treating the outcome of the disease. non-dental health care providers to become more actively
2. allows an understanding of the disease factors for a involved in identifying and referring high-risk children. Tables
specific patient and aids in individualizing preventive 1 and 2 incorporate available evidence into practical tools to
discussions. assist dental practitioners, physicians, and other non-dental
3. individualizes, selects, and determines frequency of health care providers in assessing levels of risk for caries devel-
preventive and restorative treatment for a patient. opment in infants, children, and adolescents. As new evidence
4. anticipates caries progression or stabilization. emergences, these tools can be refined to provide greater

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 BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

predictably of caries in children prior to disease initiation. unstandardized dental school instruction and then refined
Furthermore, the evolution of caries-risk assessment tools and by clinicians over years of practice.
care pathways can assist in providing evidence for and justi- It is now known that surgical intervention of dental caries
fying periodicity of services, modification of third-party alone does not stop the disease process. Additionally, many
involvement in the delivery of dental services, and quality of lesions do not progress, and tooth restorations have a finite
care with outcomes assessment to address limited resources longevity. Therefore, modern management of dental caries
and work-force issues. should be more conservative and includes early detection of
non-cavitated lesions, identification of an individual’s risk
Care pathways for caries management for caries progression, understanding of the disease process
Care pathways are documents designed to assist in clinical for that individual, and active surveillance to apply preven-
decision-making; they provide criteria regarding diagnosis and tive measures and monitor carefully for signs of arrest or
treatment and lead to recommended courses of action.8 The progression.
pathways are based on evidence from current peer-reviewed Care pathways for children further refine the decisions
literature and the considered judgment of expert panels, as concerning individualized treatment and treatment thresholds
well as clinical experience of practitioners. Care pathways for based on a specific patient’s risk levels, age, and compliance
caries management in children aged 0-2 and 3-5 years old with preventive strategies (Tables 3 and 4). Such clinical
were first introduced in 2011.18 Care pathways are updated pathways yield greater probability of success, fewer complica-
frequently as new technologies and evidence develop. tions, and more efficient use of resources than less standard-
Historically, the management of dental caries was based ized treatment.8
on the notion that it was a progressive disease that eventually Content of the present caries management protocol is
destroyed the tooth unless there was surgical/restorative inter- based on results of systematic reviews and expert panel
vention. Decisions for intervention often were learned from recommendations that provide better understanding of and

Table 1. Caries-risk Assessment Form for 0-5 Years Old

Factors High risk Moderate risk Low risk

Risk factors, social/biological

Mother/primary caregiver has active dental caries Yes
Parent/caregiver has life-time of poverty, low health literacy Yes
Child has frequent exposure (>3 times/day) between-meal sugar-containing
Yes
snacks or beverages per day
Child uses bottle or non-spill cup containing natural or added sugar
Yes
frequently, between meals and/or at bedtime
Child is a recent immigrant Yes
Child has special health care needs Yes

Protective factors
Child receives optimally-fluoridated drinking water or fluoride supplements Yes
Child has teeth brushed daily with fluoridated toothpaste Yes
Child receives topical fluoride from health professional Yes
Child has dental home/regular dental care Yes

Clinical findings
Child has non-cavitated (incipient/white spot) caries or enamel defects Yes
Child has visible cavities or fillings or missing teeth due to caries Yes
Child has visible plaque on teeth Yes

Circling those conditions that apply to a specific patient helps the practitioner and parent understand the factors that contribute to
or protect from caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual.
However, clinical judgment may justify the use of one factor (e.g., frequent exposure to sugar-containing snacks or beverages, more than
one decayed missing filled surfaces [dmfs]) in determining overall risk.

Overall assessment of the child’s dental caries risk: High  Moderate  Low 

Adapted with permission from the California Dental Association, Copyright © October 2007.

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BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

Table 2. Caries-risk Assessment Form for ≥6 Years Old

(For Dental Providers)

Factors High risk Moderate risk Low risk

Risk factors, social/biological

Patient has life-time of poverty, low health literacy Yes
Patient has frequent exposure (>3 times/day) between-meal sugar-containing
Yes
snacks or beverages per day
Child is a recent immigrant Yes
Patient has special health care needs Yes

Protective factors
Patient receives optimally-fluoridated drinking water Yes
Patient brushes teeth daily with fluoridated toothpaste Yes
Patient receives topical fluoride from health professional Yes
Patient has dental home/regular dental care Yes

Clinical findings
Patient has ≥1 interproximal caries lesions Yes
Patient has active non-cavitated (white spot) caries lesions or enamel defects Yes
Patient has low salivary flow Yes
Patient has defective restorations Yes
Patient wears an intraoral appliance Yes

Circling those conditions that apply to a specific patient helps the practitioner and patient/parent understand the factors that contribute to
or protect from caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual.
However, clinical judgment may justify the use of one factor (e.g., interproximal lesions, low salivary flow) in determining overall risk.

Overall assessment of the dental caries risk: High  Moderate  Low 

Adapted with permission from the California Dental Association, Copyright © October 2007.

Table 3. Example of a Caries Management Pathways for 0-5 Years Old

Interventions
Risk Category Diagnostics Fluoride Dietary Sealants Restorative
Counseling

Low risk – Recall every six to 12 – Drink optimally fluoridated Yes Yes – Surveillance
months water
– Radiographs every 12 – Twice daily brushing with
to 24 months fluoridated toothpaste

Moderate risk – Recall every six months – Drink optimally fluoridated Yes Yes – Active surveillance of non-
– Radiographs every six water cavitated (white spot)
to 12 months – Twice daily brushing with caries lesions
fluoridated toothpaste – Restore of cavitated or
– Fluoride supplements enlarging caries lesions
– Professional topical treatment
every six months

High risk – Recall every three months – Drink optimally fluoridated Yes Yes – Active surveillance of non-
– Radiographs every six water cavitated (white spot)
months – Twice daily brushing with caries lesions
fluoridated toothpaste – Restore of cavitated or
– Professional topical treatment enlarging caries lesions
every three months
– Silver diamine fluoride on
cavitated lesions

Refer to notes below Table 4.

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 BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

recommendations for diagnostic, preventive, and restorative (prevention therapies and close monitoring) of enamel lesions
treatments. Recommendations for the use of fluoridated is based on the concept that treatment of disease may only be
toothpaste are based on the three systematic reviews,9,11,12 necessary if there is disease progression,22 and that caries can
and dietary fluoride supplements are based on the Centers arrest without treatment.23
for Disease Control and Prevention’s fluoride guidelines;19 Other approaches to the assessment and treatment of
professionally-applied and prescription strength home-use dental caries will emerge with time and, with evidence of
topical fluoride are based on two systematic reviews;10,12 the effectiveness, may be included in future guidelines on caries-
use of silver diamine fluoride to arrest caries lesions also is risk assessment and care pathways.
based on two systematic reviews.13,14 Radiographic diagnos-
tic recommendations are based on the uniform guidelines Recommendations
from the three national organizations.7 Recommendations 1. Dental caries-risk assessment, based on a child’s age, social/
for pit and fissure sealants, especially regarding primary teeth, biological factors, protective factors, and clinical findings,
are based on the American Dental Association Council on should be a routine component of new and periodic
Scientific Affairs’ systematic review of the use of pit-and-fissure examinations by oral health and medical providers.
sealants.15 Dietary interventions are based on a systematic 2. While there is not enough information at present to have
review of strategies to reduce sugar-sweetened beverages.16 quantitative caries-risk assessment analyses, estimating
Caries risk is assessed at both the individual level and tooth children at low, moderate, and high caries risk by a pre-
level. Treatment of caries with interim therapeutic restorations ponderance of risk and protective factors will enable a
is based on the American Academy of Pediatric Dentistry more evidence-based approach to medical provider referrals,
policy and recommended best practices.20,21 Active surveillance as well as establish periodicity and intensity of diagnostic,
preventive, and restorative services.

Table 4. Example of a Caries Management Pathways for ≥6 Years Old

Interventions
Risk Category Diagnostics Fluoride Dietary Sealants Restorative
Counseling

Low risk – Recall every six to 12 – Drink optimally fluoridated Yes Yes – Surveillance
months water
– Radiographs every 12 – Twice daily brushing with
to 24 months fluoridated toothpaste

Moderate risk – Recall every six months – Drink optimally fluoridated Yes Yes – Active surveillance of non-
– Radiographs every six water cavitated (white spot)
to 12 months – Twice daily brushing with caries lesions
fluoridated toothpaste – Restore of cavitated or
– Fluoride supplements enlarging caries lesions
– Professional topical treatment
every six months

High risk – Recall every three months – Drink optimally fluoridated Yes Yes – Active surveillance of non-
– Radiographs every six water cavitated (white spot)
months – Brushing with 0.5 percent caries lesions
fluoride gel/paste – Restore of cavitated or
– Professional topical treatment enlarging caries lesions
every three months
– Silver diamine fluoride on
cavitated lesions

Notes for caries management pathways tables:

Twice daily brushing: Parental supervision of a “smear” amount of fluoridated toothpaste twice daily for children under age 3, “pea size”
amount for children ages 3-6.
Optimize dietary fluoride levels: Ideally by consuming optimally-fluoridated water; alternatively by dietary fluoride supplements, in a
non-fluoridated area, for children at high caries risk.
Surveillance and active surveillance: Periodic monitoring for signs of caries progression and active measures by parents and oral health
professionals to reduce cariogenic environment and monitor possible caries progression.
Silver diamine fluoride: Use of 38 percent silver diamine fluoride to assist in arresting caries lesions. Informed consent, particularly
highlighting expected staining of treated lesions.
Interim therapeutic restorations: also may be called protective restorations.20
Sealants: Although studies report unfavorable cost/benefit ratio for sealant placement in low caries risk children, expert opinion favors
sealants in permanent teeth of low risk children based on possible changes in risk over time and differences in tooth anatomy. The
decision to seal primary and permanent molars should account for both the individual level and tooth level risk.

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BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT

3. Care pathways, based on a child’s age and caries risk, 12. Scottish Intercollegiate Guidelines Network: SIGN 138:
provide health providers with criteria and protocols for Dental interventions to prevent caries in children, March
determining the types and frequency of diagnostic, 2014. Available at: “https://www.sign.ac.uk/assets/sign
preventive, and restorative care for patient specific man- 138.pdf ”. Accessed February 12, 2019. (Archived by
agement of dental caries. ®
WebCite at: “http://www.webcitation.org/768Bl4pgr”)
13. Crystal YO, Marghalani AA, Ureles SD, et al. Use of
References silver diamine fluoride for dental caries management in
1. American Academy of Pediatric Dentistry. The use of a children and adolescents, including those with special
caries-risk assessment tool (CAT) for infants, children, health care needs. Pediatr Dent 2017;39(5):135-45.
and adolescents. Pediatr Dent 2002;24(7):15-7. 14. Slayton R, Araujo M, Guzman-Armstrong S, et al.
2. A merican Academy of Pediatric Dentistry. Caries-risk Evidence-based clinical practice guideline for non-
assessment and management for infants, children, and restorative management of dental caries. J Am Dent Assoc
adolescents. Pediatr Dent 2014;36(special issue):127-34. 2018;149(10):837-49.
3. American Dental Association. Guidance on caries risk 15. Wright JT, Crall JJ, Fontana M, et al. Evidence-based clinical
assessment in children, June 2018. Available at: “https:// practice guideline for the use of pit-and-fissure sealants.
www.ada.org/~/media/ADA/DQA/CRA_Report.pdf?la=en”. American Academy of Pediatric Dentistry, American
Accessed February 12, 2019. (Archived by WebCite
at: “http://www.webcitation.org/768BDwVDc”)
® Dental Association. Pediatr Dent 2016;38(5):E120-E36.
16. Vercammen KA, Frelier JM, Lawery CM, McGlone ME,
4. Fontana M. The clinical, environmental, and behavioral Ebbeling CB, Bleich SN. A systematic review of strategies
factors that foster early childhood caries: Evidence for to reduce sugar-sweetened beverage consumption among
caries risk assessment. Pediatr Dent 2015;37(3):217-25. 0-year to 5-year olds. Obesity Review 2018;19(11):
5. Cagetti MG, Bonta G, Cocco F, Lingstrom P, Strohmenger 1504-24.
L, Campus G. Are standardized caries risk assessment 17. Alaluusua S, Malmivirta R. Early plaque accumulation: A
models effective in assessing actual caries status and sign for caries risk in young children. Community Dent
future caries increment? A systematic review. BMC Oral Oral Epidemiol 1994;22(10):273-6.
Health 2018;18(1):123. 18. Ramos-Gomez F, Ng MW. Into the future: Keeping
6. Moyer V. Prevention of dental caries in children from healthy teeth caries free. Pediatric CAMBRA protocols.
birth through age 5 years: U.S. Preventive Services Task J Cal Dent Assoc 2011;39(10):723-32.
Force recommendation statement. Pediatrics 2014;133 19. Centers for Disease Control and Prevention. Recommen-
(6):1102-10. dations for using fluoride to prevent and control dental
7. Food and Drug Administration, American Dental Asso- caries in the United States. MMWR Recomm Rep 2001;
ciation, Department of Health and Human Services. 50(RR14):1-42.
Dental radiographic examinations for patient selection 20. American Academy of Pediatric Dentistry. Policy on
and limiting radiation exposure, 2012. Available at: interim therapeutic restorations. Pediatr Dent 2018;40
“https://www.ada.org/~/media/ADA/Member%20Center/ (special issue):58-9.
FIles/Dental_Radiographic_Examinations_2012.pdf ”. 21. American Academy of Pediatric Dentistry. Pediatric
Accessed February 12, 2019. (Archived by WebCite at:
“http://www.webcitation.org/768BXNww3”)
® restorative dentistry. The Reference Manual of Pediatric
Dentistry. Chicago, Ill.: American Academy of Pediatric
8. Rotter T, Kinsman L, James E, et al. The effects of clini- Dentistry; 2019:341-53.
cal pathways on professional practice, patient outcomes, 22. Parker C. Active surveillance: Toward a new paradigm in
length of stay, and hospital costs: Cochrane systematic the management of early prostate cancer. Lancet Oncol
review and meta-analysis. Eval Health Prof 2012;35(1): 2004;5(2):101-6.
3-27. 23. Ekstrand KR, Bakhshandeh A. Martignon S. Treatment
9. Santos APP, Nadanovsky P, Oliveira BH. A systematic of proximal superficial caries lesions on primary molar
review and meta-analysis of the effects of fluoride tooth- teeth with resin infiltration and fluoride varnish versus
paste on the prevention of dental caries in the primary fluoride varnish only: Efficacy after 1 year. Caries
dentition of preschool children. Community Dent Oral Research 2010;44(1):41-6.
Epidemiol 2013;41(1):1-12. 24. Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL,
10. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride Featherstone JDB. Caries risk assessment appropriate for
for caries prevention: Executive summary of the updated the age 1 visit (infants and toddlers). J Calif Dent Assoc
clinical recommendations and supporting systematic 2007;35(10):687-702.
review. J Am Dent Assoc 2013;144(11):1279-91. 25. Featherstone JBD, Domejean-Orliaguet S, Jenson L, et
11. Wright JT, Hanson N, Ristic H, et al. Fluoride toothpaste al. Caries risk assessment in practice for age 6 through
efficacy and safety in children younger than 6 years. J adult. J Calif Dent Assoc 2007;35(10):703-13.
Am Dent Assoc 2014;145(2):182-9.

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