International Journal of Applied Dental Sciences 2022; 8(2): 476-479

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2022; 8(2): 476-479 Caries risk assessment methods: An overview
© 2022 IJADS
www.oraljournal.com
Received: 01-01-2022 Dr. Suchetha GM, Dr. Archana Krishna Murthy, Dr. Shilpashree KB, Dr.
Accepted: 04-03-2022
Divya BM and Dr. Antara Shome
Dr. Suchetha GM
Post Graduate Student,
DOI: https://doi.org/10.22271/oral.2022.v8.i2g.1546
Department of Public Health
Dentistry, The Oxford Dental Abstract
College, Bommanahalli, Dental caries preventive approaches must be integrated based on knowledge and understanding of the
Bengaluru, Karnataka, India predicted risk. Caries risk assessment is a concept that is firmly grounded on the well-known fact that
dental caries is a preventable disease. It denotes the process of establishing the probability for an
Dr. Archana Krishna Murthy individual patient to develop new caries lesions over the near future. In caries risk assessment methods,
Professor and Head of the patients who are at risk are identified, factors that are directly or indirectly responsible for the disease are
Department, Department of eliminated/reduced, and measures are taken to prevent future disease. This review article discusses the
Public Health Dentistry, The various methods used in caries risk assessment. The articles were searched in Pubmed and Google
Oxford Dental College,
scholar database, a total of 18 articles were reviewed from 2006 to 2020. Caries risk assessment is the
Bommanahalli, Bengaluru,
Karnataka, India
critical component of dental caries management and should be considered a standard of care and included
as part of the dental examination. Although Caries Risk Assessment utilization rates are low among
Dr. Shilpashree KB general dentists, with continued development of supporting evidence and guidelines Caries Risk
Professor, Department of Public Assessment will increasingly become the accepted standard of care.
Health Dentistry, The Oxford
Dental College, Bommanahalli, Keywords: Dental caries, caries risk assessment, cariogram, CAMBRA
Bengaluru, Karnataka, India
Introduction
Dr. Divya BM
Dental caries, the most typical oral disease, affecting both children and adults worldwide. High
Reader, Department of Public
Health Dentistry, The Oxford prevalence of primary and secondary caries in at risk populations result in significant lifetime
Dental College, Bommanahalli, costs. Validated assessment strategies, such as the caries risk assessment methods, allow dental
Bengaluru, Karnataka, India providers to implement a systematic and evidence-based approach to astutely assess and record
changes in the caries risk status of patients in an attempt to stop disease [1].
Dr. Antara Shome Caries preventive approaches must be integrated based on knowledge and understanding of the
Senior lecturer, Department of predicted risk. The risk model and the prediction model, are the two different approaches
Public Health Dentistry, The
Oxford Dental College,
described for caries risk assessment. The risk model is employed to work out the causative
Bommanahalli, Bengaluru, caries factors called risk factors but it cannot predict the caries outcome. The prediction model
Karnataka, India estimates the danger of caries progression within the future. Risk models counting multiple
variables end in better predictions because the disease process is multifactorial [2].
Incorporation of caries risk assessment as a motivating tool for patients encouraging them to
undertake measures that will move them from a high or moderate risk category to a low risk
category. Risk assessment can thus also contribute to a more efficient allocation of your time
and resources for oral health programs by eliminating many unnecessary interventions, e.g.
Professional topical fluoride applications in a low caries risk child. Besides this, Caries Risk
Assessment can potentially promote caries prevention at the primary level itself i.e. before the
initiation of the disease process. This could enable even high caries risk children to reach
adulthood caries free- a goal every dentist strives to achieve for their patients [3]. This article is
an attempt to highlight the various methods used in caries risk assessment.

Corresponding Author: Materials and Methods

Dr. Suchetha GM The articles were searched in Pubmed and Google scholar database, a total of 18 articles were
Post Graduate Student, reviewed from 2006 to 2020. A number of Caries Risk Assessment methods have been
Department of Public Health proposed for use in clinical practice as follows [3].
Dentistry, The Oxford Dental AAPD’s caries risk assessment Form, Cariogram Model, Caries assessment and risk
College, Bommanahalli, evaluation (CARE) test, Caries management by risk assessment (CAMRA), Traffic light
Bengaluru, Karnataka, India
matrix (TLM), Cariometer App, Lactic acid impression.
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1. AAPD’s Caries Risk Assessment Form latter, a negative correlation is seen. Since the pattern of these
American Academy of Pediatric Dentistry (AAPD) salivary oligosaccharides is 100% genetically determined,
recognizes that caries risk assessment and management identifying individual salivary oligosaccharide concentrations
protocols, also known as care pathways, can aid clinicians can help determine the genetic risk of the child to develop
with decisions regarding treatment based upon child’s age, caries. The CARE test is probably the only Caries Risk
caries risk and patient compliance and are essential elements Assessment method that can potentially promote caries
of contemporary clinical care for infants, children and prevention at the primary level itself (before any carious
adolescents. The document was developed by the Council on lesions have appeared), by identifying high caries risk
Clinical Affairs and adopted in 2002 and last revised in 2019 children early and instituting a preventive regimen in them.
[4]
. The widespread incorporation of the CARE test in clinical
Caries Risk Assessment forms were formulated that can be practice and its use in conjunction with other more traditional
used by dentists to evaluate caries risk status for 0–5 year old risk assessment methods is probably the future of dental
and ≥6 year old children. Risk assessment categorization of Caries Risk Assessment.
low, moderate, or high is based on the preponderance of
factors for the individual. Care pathways are documents for 4. C Aries management by risk assessment (CAMBRA)
caries management designed to aid in clinical decision- CAMBRA philosophy of care is the assessment of each
making; provide criteria regarding diagnosis and treatment patient for his or her unique disease indicators, risk factors
and lead to recommended courses of action. Care pathways and protective factors to determine current and future dental
for caries management in children aged 0-2 and 3-5 years old caries disease [8]. The caries imbalance model was created to
were first introduced in 2011. Caries risk assessment for represent the multifactorial nature of dental caries disease and
children further refine the decisions concerning individualized to emphasize the balance between pathological and protective
treatment and treatment thresholds based on a specific factors in the caries process. Progression or reversal of caries
patient’s age, risk levels, and compliance with preventive disease is determined by the imbalance between disease
strategies. Such clinical pathways yield greater probability of indicators and risk factors on one side and the competing
success, fewer complications, and more efficient use of protective factors on the other side.
resources than less standardized treatment [5]. In response to the lack of a universally accepted carious lesion
detection system, a group of cariologists and epidemiologists
2. Cariogram Model generated the International Caries Detection Assessment
Cariogram is a graphical picture illustrating in an interactive System (ICDAS) in 2002 in Scotland [9]. This visual system
way the individual's or patient's risk for developing new caries was developed as a detection system for occlusal carious
in the future, simultaneously expressing to what extent lesions, with a two-digit coding system: The first digit (0-9)
different etiological factors of caries affecting the caries risk identifies the tooth status, and the second digit (0-6) describes
for that particular patient. The cariogram, by explaining the the severity of the caries disease. Once the clinician has
caries risk graphically, depicts the ‘chance’ for promotion of a identified the patient’s caries risk, a therapeutic and/or
new carious lesion in the near future and might illustrate to preventive plan should be implemented. For example, if an
what extent various factors might affect this chance. The adult is classified as moderate risk to caries, the guideline
Cariogram states a particular number of cavities that will or proposes recall visits every 4–6 months. If the same patient
will not occur in the future. It rather elucidates a possible were classified as low-risk, the recall intervals suggested
over-all risk picture, based on the interpretation of gathered would then be for every 6–12 months.
information [6].
The Swedish version of the Cariogram was first launched 5. Traffic Light Matrix (TLM)
officially in November 1997 by Proffessor Douglas Bratthall Traffic Light Matrix is a commonly used CRA tool in
at the Faculty of Odontology at Malmo University College in Australia. It is based on 19 criteria in 5 different categories
Sweden after extensive trials. It has been translated into including saliva (6 criteria), plaque (3 criteria), diet (2
several languages to be used in different countries. Cariogram criteria), fluoride exposure (3 criteria), and modifying factors
as an interactive PC-program developed for educational, (5 criteria) [10].
preventive and clinical purposes. The main aim of the  Saliva:
Cariogram is to demonstrate the caries risk graphically, a. Resting: hydration, viscosity, pH
expressed as the “Chance to avoid new caries” (i.e. to avoid b. Stimulated: quantity/rate, pH, buffering capacity
getting new cavities’) in the near future. It also demonstrates  Plaque: PH, maturity, bacteria – mutans count
to what extent various factors affect this ‘Chance’. A further  Diet: Number of sugar and acid exposure in between
propose of this program is to encourage preventive measures meals/day
to be introduced before new cavities could develop [6].  Fluoride: Exposure to fluoride through water or
toothpaste or professional treatment
3. Caries Assessment and Risk Evaluation (CARE) test  Modifying factors: Drugs that reduce salivary flow,
Researchers at the Division of Diagnostic Sciences of the diseases resulting in dry mouth, fixed or removable
University of Southern California School of Dentistry appliances, recent active caries, and poor compliance.
developed a novel salivary test for genetic Caries risk
assessment called the CARE test [7] based on the high The specific threshold values for the data obtained in the
correlations between caries history and quantities of specific analysis of the aforementioned factors are transferred in
oligosaccharides in whole saliva. Certain salivary traffic light color codes conveying varying risk levels (red-
oligosaccharides are known to facilitate bacterial attachment, high, yellow-moderate, and green-low).3 The color code
while other salivary sugar chains promote agglutination and model keeps the visual interpretation simple. The objective is
removal of free bacteria. In the case of the former, there is a to alert the clinician regarding the current risk status and
positive correlation with caries experience, while for the communicable to the patients as well.
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6. Recent Advances questionnaire model for children, and assessed the caries
Cariometer App prediction with and without the biological tests, concluded
Cariometer app gives an estimate of cariogenic risk of with a logical suggestion that the initial “screening model”
dentition based on daily diet and other oral hygiene practices. without the microbiological test be used for identifying the
Patient should register their details in the app. This app aims potential high-risk patients, and later the risk can be assessed
in the prevention of dental caries at an early age. It also accurately for specific clinical decisions, with a “full-blown
provides daily cariogenic risk status which can be shared with model” that included those tests.
healthcare professionals [11]. Exhaustive reviews have concluded that consistent evidence
is lacking in terms of good longitudinal prospective studies
Lactic Acid Impression supporting any of the recent Caries Risk Assessment tools to
Lactic acid impression method is done by using clinpro 3M possess such a dependable accuracy [19]. This makes it
ESPE which can detect lactic acid which has a main role in difficult to choose the correct one for clinical use. More
fermentation of caries. This impression material consists of a importantly, it was observed that a tool constructed for a
powder, an activator to induce setting and a sugar solution specific population taking into cognizance the baseline caries
which is metabolised during the 3 minutes of setting. Thus risk/prevalence of the population has better outcome and
fermentation of sugar and production of lactic acid takes place accuracy, compared with the same tool being used for a
immediately and there is colour change of the impression different population. In addition, the subjectivity around the
material to indicate reaction with lactic acid. Another type of interpretation of data and the way high risk or low risk has
clinpro is Clinpro Cario L-Pop (CCLP) which is used to been defined by each tool have also been pointed out as
monitor the individual caries risk [11]. In this technique tongue reasons for weakness of evidence. In the current scenario, the
swab is taken introduced in lactic acid solution and the colour algorithm-based Caries Risk Assessment systems that
change indicates the level of risk. evaluate the factors in a “weighted way” are claimed to be
more objective and possess better accuracy [20]. However, the
Discussion interpretation of the data still seems to have profound
Caries risk assessment is a concept that is firmly grounded on influence on the diagnostic accuracy and this aspect is
the well-known fact that dental caries is a preventable disease. intricately woven in all the Caries Risk Assessment tools [19].
CRA tools can be broadly categorized as reasoning-based and
algorithm-based tools. In reasoning-based models, important Conclusion
risk factors and indicators are collected in a checklist and the Caries risk assessment is the critical component of dental
risk is qualitatively assessed. In algorithm-based tools, the caries management and should be considered a standard of
risk is quantitatively calculated to improve the objectivity and care and included as part of the dental examination. It is not
diagnostic accuracy [12]. Currently, the widely researched indeed difficult to understand that the CRA as an important
reasoning-based risk assessment tools available are step toward caries management, but it is not yet into the
CAMBRA [13], tools devised by ADA and AAPD. Cariogram mainstream of education or practice, not because the current
is a popular computerized, algorithm-based program, which CRA tools are ineffective, it is just that the mounting
analyzes the combination of risk factors in a weighted manner evidences are still “not sufficient” enough given the
and project the likelihood of avoiding development of new complexity of the disease itself. To make it effective, with
lesions in percentage [14]. available evidence, it is essential that a given CRA tool be
The ideal prerequisite of a CRA, as described by Stamm et al. adapted to suit the local population needs and preferences.
[15]
is that “To be useful, a working caries prediction model Especially for a country as diverse as India, with wide
should produce a sensitivity level of 0.75 or higher and spectrum in culture, socioeconomic status, food habits, oral
specificity level of at least 0.85 or higher.” They further hygiene habits, and caries prevalence, this local adaptation
elaborated that “any model, regardless of its ultimate assumes a paramount significance. The lack of sufficient
accuracy, would have to be based on a data collection system robust evidence can easily be overcome by further good-
that is relatively quick, inexpensive, requires a limited quality, longitudinal prospective studies in the specific
armamentarium, and be acceptable to those to whom it is population for which the tool is devised. Using a risk
applied [16].” General perception among the clinicians or assessment provides cost-effectiveness and greater success in
learners about CRA process is that obtaining data is a lengthy treatment compared with the more traditional approach of
process. Collection of wholesome data on all the causative applying identical treatments to all patients, independent of
and noncausative variables as discussed above would indeed their risk [13]. Although Caries Risk Assessment utilization
make an accurate tool, but tends to make the process anything rates are low among general dentists, with continued
but quick. Thus, recent studies have been conducted on the development of supporting evidence and guidelines Caries
diagnostic accuracy of few/single predictor factors against Risk Assessment will increasingly become the accepted
analysis of multiple factors. It has been stated that the standard of care.
presence of clinical indicators, namely, carious lesions,
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