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Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 49-53

Caries risk assessment – An initiation to prevention: A literature review

Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Date of Submission12-Jun-2021
Date of Decision09-Sep-2021
Date of Acceptance18-Sep-2021
Date of Web Publication15-Mar-2022

Correspondence Address:
Dr. Seema Bargale
Department of Pediatric and Preventive Dentistry, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara - 591 760, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jihs.jihs_18_21

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The high incidence of dental caries in young children has highlighted the need for a more comprehensive approach to caries prevention in children. Caries risk assessment (CRA) is widely recognised as a foundation for clinical decision-making and disease management for individual patients, as well as allocating time and resources to those in the group who are most in need. It also notes that the course of action taken to prevent caries will alter a patient's caries risk status at an early stage. The approach takes into account past caries experience, sociodemographic, socioeconomic, oral hygiene, eating habits, oral bacteria, and saliva characteristics in patients. Various types of Caries Risk Assessment Tools that can be implemented in practice are Caries Questionnaire, Cariogram, Caries Assessment tool, Caries Management by Risk Assessment, Traffic Light Matrix, Caries Assessment and Risk Evaluation test.

Keywords: Risk assessment, early childhood caries, caries susceptibility, sensitivity, disease indicators

How to cite this article:
Dharmatti S, Bargale S, Khandelwal JR, Jain S. Caries risk assessment – An initiation to prevention: A literature review. J Integr Health Sci 2021;9:49-53

How to cite this URL:
Dharmatti S, Bargale S, Khandelwal JR, Jain S. Caries risk assessment – An initiation to prevention: A literature review. J Integr Health Sci [serial online] 2021 [cited 2023 Jun 10];9:49-53. Available from: https://www.jihs.in/text.asp?2021/9/2/49/339645

  Introduction Top

The detection of demineralization or cavitation on the tooth surface has been the emphasis of dental caries diagnosis since a long period of time. It is now well established that a procedure for the management of caries which is limited to surgical treatment of chronic infectious disease, without resolving the risk factors responsible for the disease, will ultimately only result in the emergence of new carious lesions and failure of any care offered.[1]

The determination of the risk status of a patient's caries is an important component of modern-day dental caries treatment, where the focus is on an archaic preventive approach instead of only restorative procedure.[2]

The amalgamation of caries risk assessment (CRA) into routine clinical practice will allow the dental professional to make standardized recommendations for prevention according to the risk status of caries of each patient. Thus, risk management may also lead to a more successful distribution of time and money for oral health services by removing certain needless measures.[3]

Risk indicators

Past caries experience

This was the most constant prognostic factor discovered in CRA researches.[4] It does not however serve the purpose in youngsters, because it is critical for them to assess the risk of caries before the disease manifests. White spot lesions are considered excellent markers for predicting the development of caries in young children.

Socioeconomic status

Research indicates an inverse correlation between the levels of caries and socioeconomic status, suggesting a greater experience of caries in both dentitions among socioeconomically deprived children.[5]

Sugar consumption

Decay of the tooth is caused by the sugar quantity consumption by the children. Sugar consumption and caries severity have long been thought to be linked in poorer nations, with the higher the consumption and frequency, the greater the severity of caries.[6] Fluoride has affected this linear relationship ever since the last decade, with most research showing a moderate relationship between sugar intake and carious substances.[7],[8]

The WHO sugar intake guideline for adults and children recently concluded that even a modest reduction in the risk of dental caries due to less childhood sugar consumption is important. The risk of caries can be determined in three factors: protective, biological and clinical findings depending upon the age of the child for Caries Assessment Tool.[9]

Oral hygiene habits

There is no strong and consistent relationship between oral hygiene and the caries occurrence in the available data.[10] The correlation with the frequency of toothbrushing mentioned is due to fluoridated toothpaste use in children.


The pioneer bacteria engaged in the process of caries, mutans streptococci, and lactobacilli are constituents of natural flora. Caries is thus viewed not as an exogenous infection but as a bacterial ecological imbalance. The total bacterial count has been weakly correlated with the experience of caries at population (group) stage. Bacterial count is a weak indicator of potential cavities at the person level.[11] Levels of Streptococcus mutans and the age of colonization with cariogenic flora are important for evaluating the risk of caries, particularly in very young children.[12]


A major predictive factor has been proven to be no variance in a single salivary variable in a healthy population. However, as manifested by severe xerostomia, reduced salivary function is a consistent predictor of elevated risk of caries.[13] More research is needed to determine the existence of less flow of saliva in spite of the fact that normal salivary flow is an inherent host factor in preventing caries.

Protective factors: Fluoride

Water fluoridation's protecting effect has been recognized in many systematic reviews. Fluoridated toothpaste has been accepted as a standard procedure for preventing dental caries. In-office application of topical fluorides in the form of fluoride varnishes is beneficial in decreasing caries.[14]

Pit-and-fissure sealants

Fissure sealants protect against caries in comprehensive studies[15] as an evidence-based tool for improving the resistance against carious pits and fissures.

Why caries risk assessment should be used?

The identification and determination of various risk factors is an important component to decide the diagnosis and treatment because of the following reasons:

CRA helps to define the key etiological agents that lead to the disease and/or to assess the treatment form and to make decisions on restorative treatment, including whether or not to intervene, the planning of cavity designs, and the selection of dental products.

To decide the intensity of care and the frequency of recall appointments or procedures, CRA is helpful in determining the grade of patient's risk of developing caries.

At recall visits, CRA will help to improve the outcome of the preventive care and assess the effectiveness of the said management.

  Discussion Top

Various types of CRA methods that could be implemented in clinical practice are as follows:

Caries Questionnaire

Dental caries is a multifactorial disease, in which pathological factors (that cause demineralization) and protective factors are in either dynamic equilibrium or imbalance (that favor remineralization).[16] Featherstone et al.[17] evolved a consensus statement in questionnaire form that enlightens topics such as socioeconomic factors, maternal dental history, family dynamic measures for oral hygiene, exposure of fluoride, and sugar exposure frequency to evaluate discrete caries risk. An appropriate therapeutic and preventive recommendation can be achieved through minimally invasive dental practice [Figure 1].[17]
Figure 1: Caries Risk Assessment Questionnaire for children

Click here to view

American Academy of Pediatric Dentistry's Caries-Risk Assessment Form

The American Academy of Pediatric Dentistry (AAPD) had introduced the tool Caries Assessment Tool. The WHO sugar intake guideline for adults and children recently concluded that even a modest reduction in the risk of dental caries due to less childhood sugar consumption is important. The risk of caries can be determined in three factors: protective, biological and clinical findings depending upon the age of the child for Caries Assessment Tool. The tool provides patient-based guidelines for treatment planning.

In order to help nondental health-care providers, dental practitioners, and doctors in evaluating caries risk in pediatric patients,[18] this document incorporates the latest expert opinion and evidences.[19],[20],[21] The AAPD altered the Caries-Risk Assessment Tool (CAT)[22] into a more applicable tool for the pediatric dentists.

Dentists may use Caries Risk Assessment (CRA) forms to determine the caries risk status of children aged 0–5 and ≥6-year-old children [Figure 2]a and [Figure 2]b.[18] The risk assessment categories are low, moderate, and high risk which are based on the individual's majority of factors. Clinical assessment, on the other hand, may justify the use of a single factor in assessing caries risk.[18]

Click here to view

Christian et al.[23] had assessed the validity and reliability of various tools for caries in children. The lack of information to determine the level of evidence for the measurement of construct validity and reliability was common across all CRATs.

Jørgensen and Twetman[24] had found that CRA could improve the oral care and reduce chances of caries in preschool children. The CRA tools in preschool children and the question whether or not the CRA process results in better oral care remained unanswered.[3]

The Cariogram model

The definition and formula for Cariogram in Malmö were established by Prof. D. Bratthall. In collaboration with K-O Lybegård and Dr. L. Allander, the PC version was developed and the manual was written by D. G. Hänsel Petersson, Bratthall, and J. R. Stjernswärd. Cariogram is a software application that graphically depicts the risk of a patient developing new caries as a pie diagram while articulating the contribution of various factors to the caries risk for that patient.

It also represents simultaneously the degree to which various etiological variables of dental caries affect the risk of caries for that person.[25] The initial Cariogram pie diagram had three separate-colored sectors representative of the primary causative factors in caries – bacteria (red), sugars (blue), and host susceptibility (light blue). It was later updated to include two more sectors – a yellow sector reflecting circumstances (general health status and past caries experience) and a green sector representing “Percent Chance to Develop Caries.” The other four sectors' size determines the size of the green “Chance” sector, so any modifications in the size of these sectors will increase the Percent Chance to Avoid Cavities. In schoolers, a study was conducted with Cariogram had projected caries increment more precisely compared to any other single-factor model.[26] The use of Cariogram® is restricted to areas where a computer system is accessible and where it is possible to carry out these tests. Alternative methods of performing CRA have also been proposed.

Mejàre et al.[27] in 2014 had found future caries development using Caries Management by Risk Assessment (CAMBRA) and Cariogram risk assessment tools. There is a need to regulate study design, outcome measures, and reporting of data in the studies on CRA.

Caries Assessment and Risk Evaluation test

The Caries Assessment and Risk Evaluation (CARE) test,[28] which is a new salivary test for genetic CRA, was developed by scientists at the Diagnostic Sciences Division of the Southern California School of Dentistry. They found the history of caries and the amounts of specific oligosaccharides in saliva depending on the high correlations.

Although the above risk indicators are of prime importance in assessment of the risk status of individual caries, many studies have also revealed a solid, statistically relevant experience in determining the genetic components of caries.[29] This may be important in developed societies with dental exposure and adequate fluoride exposure, as well as where poor oral hygiene and malnourishment are infrequent, thereby the importance of a child's genes in assessing one's caries risk increases. Assessment of the entire caries risk status could be evaluated by a child's genetic susceptibility to dental caries. Bacterial attachment and colonization of the salivary pellicle are known to be facilitated by certain salivary oligosaccharides, while agglutination and clearance of free bacteria are known to be facilitated by other salivary sugar chains. Caries experience has a positive correlation, whereas the latter has a negative correlation.[30]

Because the pattern of these salivary oligosaccharides is entirely regulated by genetics, determining individual salivary oligosaccharide concentrations can aid in determining a child's hereditary risk of developing caries. The salivary oligosaccharide patterns, like blood group types, were found to be quantitatively consistent over time and across age groups.[31] The CARE test is likely the only CRA method that has the potential to achieve caries prevention at the primary level (before any carious lesions have emerged), by identifying high-caries-risk children early and putting them on an aggressive preventive regimen. The CARE test's extensive usage in clinical practice, as well as its usage in conjunction with other more traditional risk assessment tools, is likely to be the future of dentistry.

Caries Management by Risk Assessment

CAMBRA's ideology was first implemented 10 years ago when the Western CAMBRA Alliance, an unofficial party, was found based in the western area of the USA.

A consensus conference on the management of caries through risk assessment was held in Sacramento, California, in April 2002.

One type was intended for 6-year-old patients to adulthood, and the second was 0–5 for patients. In 2003, a bunch of experts from the United States released the CAMBRA model. Risk evaluation of dental caries (CAMBRA) is an evidence-based approach for avoiding or treating the cause at the earliest stages for tooth decay.

The first CAMBRA analysis was conducted between 1999 and 2004 at the University of California, San Francisco.

CAMBRA's research deals with the management of caries using diagnostic, care, and prevention risk evaluation protocols for restoring or remineralizing the tooth structure. Therefore, with CAMBRA philosophy, CRA based on evidence is accompanied by detailed guidelines for treatment.

In order to improve well-being, this will help create the balance of pathological and protective factors. The implementation of CAMBRA required the development of CRA types to be used by clinicians. One type was intended for use in children aged 5 years and older,[19] and the second was intended for patients aged 6 years and older into adulthood[21] [Figure 3]a and [Figure 3]b.[18]

Click here to view

Similar predictive validity was demonstrated by the CAMBRA-CRA tool for 0–5-year-olds. The addition of fluoride to the restorative treatment plan based on caries-risk status decreases caries by 20%–38% in high-caries-risk patients. A mixture of twice-daily high-concentration fluoride toothpaste and daily antibacterial treatment both for in-house application, was used in high-risk patients.

Cagetti et al.[32] in 2018 conducted a study wherein they had used CAMBRA, NUS-CRAT, and Cariogram where they found the actual caries status and caries increment.

Rechmann et al.[33] in 2018 compared two caries risk assessment tools CAMBRA with CARE; wherein caries risk levels and recorded caries risk indicators at recall intervals.They had found caries risk levels at recall and recorded caries risk indicators.

Traffic Light Matrix

This is a CRA instrument widely used in Australia. To express unique threshold values for data obtained in the study, it uses color codes such as orange, green, and red.

It comprises 19 criteria in five categories, including saliva (6 criteria), plaque (3 criteria), nutrition (2 criteria), exposure to fluoride (3 criteria), diet (2 criteria), fluoride exposure (3 criteria), and modifying factors (5 criteria).[34] The aim is to make the dentist aware of the caries risk status of the patient.

Saliva: (a) resting: hydration, viscosity, and pH and (b) stimulated: quantity/rate, pH, and buffering ability; plaque: pH, maturity, and bacteria – S. mutans count; diet: amount of acid and sugar exposures between meals/day; fluoride: fluoride exposure through water/toothpaste/professional treatment; modifying factors: salivary flow reduction medications, dry mouth diseases, and traffic light color codes depicting varying risk levels (and green is low, yellow is moderate, and red means high).

  Conclusion Top

All dentists treating pediatric and adult patients must incorporate CRA into their clinical practice and make necessary recommendations for their patients using risk-based caries management protocols. CRA tools such as CAT, CAMBRA, and Cariogram are some of the tools that can be practically implicated in daily practice considering its feasibility and simplicity.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]


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