Caries risk assessment ppt

CONTENTS
• Introduction
• Caries imbalance
• Objectives
• Caries risk assessment tool
• Cambra
• Cariogram
• Traffic light matrix
• Caries risk factors

• Microbial tests for mutans streptococci detection
• Microbial tests for lactobacilli detection
• Caries activity tests
• Caries risk indicators
• Key risk groups
• Uses
• Conclusion
• References

INTRODUCTION
• DENTAL CARIES:- Acc to Shafers in 1993
Dental caries is an irreversible microbial disease of the
calcified tissue of the teeth, characterized by demineralization
of inorganic portion and destruction of organic substance of
tooth which often leads to cavitation.

• CARIES RISK ASSESSMENT:- can be defined as a
procedure to predict future caries development before the
clinical onset of the diseases.
• Caries risk assessment is the determination of the likelihood of
the incidence of caries (ie, the number of new cavitated or
incipient lesions) during a certain time period. It also involves
the probability that there will be a change in the size or activity
of the lesion in the mouth.
Guideline on Caries-risk Assessment and Management for Infants, Children,
and Adolescents Reference manual 2011; 37( 6): 15 -16.

• CARIES ACTIVITY TEST:- Estimate the actual state of
disease activity (progression/regression).
• RISK FACTOR:- is defined as factor that which plays an
essential role in the etiology and occurrence of the disease, like
the lifestyle and the biochemical determinants to which the
tooth is directly exposed and which contribute to the
development or progression of the lesion.

• RISK INDICATOR:- is a factor or circumstance that is
indirectly associated with the disease like socioeconomic
factors and epidemiologic factors.

Disease indicators:
•White spots
•Restorations >3
years
•Enamel lesions
•Cavities/ dentin
Risk Factors
•Bad bacteria
•Absence of saliva
•Dietary
habits(poor)
Protective factors:
•Saliva & sealants
•Antibacterial
•Fluorides
•Effective diet
Caries progression No caries
CARIES IMBALANCE

OBJECTIVES
 To improve the oral health in children, adolescents and adults
 Introduce causal measures before irreversible lesions have
become established
 Utilize resources in a cost effective way

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

Factors
Biological
Patient is of low socioeconomic status
Patient has >3 between meal sugar-containing snacks or
beverages per day
Patient has special health care needs
Patient is a recent immigrant

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

Clinical Findings
Patient has >1 interproximal lesions
Patient has active white spot lesions or enamel defects
Patient has low salivary flow
Patient has defective restorations
Patient wearing an intraoral appliance

FACTORS low moderate high
Caries activity none With in 24 months With in 12 months
Demineralized
areas
No white spots 1 white spot >1 white spot
Family history-
mother, father,
siblings
No caries activity Low caries rate High caries rate
Presence of plaque none moderate Visible plaque on
anterior teeth
Fluoride exposure optimal Low to optimal low
Sugar consumption With meals only 1-2 b/w meals >3 b/w meals
Dental home Established Irregular use none
Special conditions Enamel hypoplasia
impaired salivary
flow
Caries risk assessment tool- age 6 months through 35 months

Caries activity none With in 24 months With in 12 months
Demineralized
areas
No white spots Inactive white spot Active white spots
Parent/primery
caregiver
No decay Low caries rate High caries rate
Family history No caries activity Low caries rate High caries rate
Presence of plaque none moderate Visible plaque on
anterior teeth
Special conditions Special needs
patient
Enamel hypoplasia
impaired salivary
flow
Caries risk assessment tool- age 3 through 5 years

Caries activity none Incipient lesion >1 cavitated lesion
Demineralized
areas
No white spots Inactive white spot Active white spots
Parent/primery
caregiver
None Low caries rate High caries rate
Restoration or
missing teeth
None 1 or 2 restorations
with in last 36
mnths
3 or more
restorations or
extracted tooth in
last 36 months
Presence of plaque none moderate heavy
Special conditions Dental/ ortho
applianceSpecial
needs patient
Enamel hypoplasia
impaired salivary
flow
Caries risk assessment tool- age 6 through 20 years

• The CAMBRA philosophy was first introduced nearly a
decade ago when an unofficial group called the Western
CAMBRA Coalition was formed that included stakeholders
from education, research, industry, governmental agencies and
private practitioners based in the western region of the United
States
Caries Management by Risk Assessment
(CAMBRA):

• Evidence-based approach to preventing or treating the
cause of dental caries at the earliest stages rather than
waiting for irreversible damage to the teeth.
• Essentially based on the same factors as CAT to assess
caries risk

Cariogram
• Cariogram is a new way in which to illustrate the interaction
between caries related factors.
• This educational interactive program has been developed for
better understanding of the multifactorial aspects of dental caries
and to act as a guide in the attempts to estimate the caries risk.

• Peterson G et al in 2003 gave the opinion that the Cariogram
predicted caries increment more accurately than any included
single-factor model.
• Petersson GH. Assessing caries risk-using the Cariogram model. Swed Dent J Suppl.
2003;(158):1-65

• Mieravet AR et al in 2007 said that the past caries experience,
Streptococcus mutans count, fluoridation programme and
buffer capacity of the saliva are the factors included in the
Cariogram that showed significant correlation with the caries
risk determined by the program. Other factors that the
Cariogram does not include directly, such as, DMFT, DMFS
and the plaque index, also showed high correlation with risk.
• Mieravet AR, Letra A, Rose EK, Brandon CA, Resick JM, Marazita ML, Vieira AR. Inherited risks
for susceptibility to dental caries. Caries Res. 2007;42:8–13.

Factors and relevant information required to create a cariogram

• Traffic Light Matrix (TLM):
• This is a commonly used CRA tool.
• TLM is based on 19 criteria in 5 different categories including
saliva (6 criteria), plaque (3 criteria), diet (2 criteria), fluoride
exposure (3 criteria) and modifying factors (5 criteria).

• traffic light colours convey varying risk levels (red=high,
yellow=moderate and green=low).
• The objective is to alert the clinician regarding the current risk
status.
• This color code model keeps the visual interpretation simple and
communicable to the patient as well.

• Saliva: a) Resting: hydration, viscosity and pH
b) Stimulated: quantity/rate, pH and buffering capacity
• Plaque: pH,
maturity and
bacteria – Mutans count
• Diet: number of sugar and
acid exposures in between meals/ day

• Fluoride: water
Toothpaste
professional treatment
• Modifying factors: drugs that reduce salivary flow, diseases
resulting in dry mouth, fixed/removable appliances, recent
active caries and poor compliance

• The system scores Red, yellow & green light for each risk
factors depending on predetermined criteria.
• Tests are carried for each risk factors independently and scores
are generated.
• The scores are compared with predetermined criteria.
based on theis criteria Red for- high risk
yellow for- moderate risk
green for- low risk

CARIES RISK FACTORS
1)- PLAQUE
Important to estimate
• the number of surfaces affected
• the amount of plaque accumulated
• age of the plaque
• whether its presence is associated with carious lesions in those
same sites.

RISK AREAS FOR PLAQUE ACCUMULATION
• Mesiolingual and distolingual mandibular surfaces of molars
• Mesiobuccal and distobuccal surfaces of maxillary and
mandibular molars.
• Plaque accumulation on the palatal surfaces of maxillary teeth
is low

2)- SPECIFIC MICROBES AND CARIES RISK
• Can readily estimate bacterial levels in saliva, and dentists can
identify patients with a high bacterial load
• A high count in saliva more than 1 million colony forming
units per ml of saliva indicates that most teeth are colonized by
bacteria i.e. many tooth surfaces are subject to increased risk.

3)-DIET
• Diet rich in fermentable carbohydrates (frequent sugar
intake) is a very powerful external risk factor and
prognostic risk factor for dental caries in populations with
poor oral hygiene habits and associated lack of regular
topical fluoride exposure from tooth pastes
• In populations with good oral hygiene and daily use of
fluoride toothpaste, sugar is a very weak RF and PRF

4)- EATING PATTERN
• Fall in plaque pH after consumption of sugary foods may be
modified by the consumption of less fermentable foods before,
concurrently or afterward egs: cheese.

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

5) SALIVA
•Saliva plays an important role in the health of soft and hard
tissues in the oral cavity.
SALIVARY FLOW RATE
• Chronically low salivary flow rate one of the strongest
salivary factors increased risk of developing caries.
• caries is extreme absence of saliva.

Navazesh (1992) et al found that unstimulated salivary flow rates
have the strongest predictive validity of estimating caries risk.
The normal unstimulated values vary from 0.3-0.4 ml/min and
values less than 0.1ml/ min are considered as abnormal.
Navazesh, M., Christensen, C. & Brightman, V. 1992a, "Clinical criteria for the diagnosis of
salivary gland hypofunction", Journal of dental research, vol. 71, no. 7, pp. 1363-1369.

• Grindefjord et al (1995) studied the relative risk (odds ratio)
that 1year-old infants would develop caries by the age of 3.5
years: Those with poor oral hygiene, bad dietary habits,
salivary MS, little or no exposure to fluoride, and parents with
a low educational level or an immigrant background were at
32 times greater risk than were children without the
corresponding etiologic and external risk factors.
Grindefjord M, Dahllöf M, Modéer T. Caries development in children from 2.5 to 3.5 years of
age: a longitudinal study. Caries Res. 1995;29:449–454.

Leone CW et al (2001), performed a literature review on the
physical and chemical aspects of saliva as indicators of risk for
dental caries.
‘the review showed that normal salivary output as quantified
by flow rate is an intrinsic host factor providing protection
against caries and the evidence shows that pathologically
diminished flow rate is a significant risk factor for caries
development.’
Leone CW et al. Physical and Chemical Aspects of Saliva as Indicators of Risk for Dental
Caries in Humans J Dent Edu 2001;10:1054-1062.

DEMINERALIZATION AND REMINERALIZATION
•Main factors governing stability of enamel are the pH and
concentration of Ca, PO3 4-, and F in solution which are all derived
from saliva.
•The role of saliva in this process is highly dependent on
accessibility, which is closely related to thickness of plaque.

•The ability of saliva to remineralize demineralized enamel
crystals stems from its ability to supply bioavailable calcium and
phosphate ions to the tooth. At physiological pH, unstimulated
and stimulated parotid, submandibular, and whole saliva are
supersaturated with respect to most solid calcium phases (Larsen
and Pearce, 2003)
Larsen, M.J., and Pearce, E.I.F. (2003). Saturation of human saliva with respect to calcium salts, Arch.
Oral Biol., 48: 317-322.

•Precipitation of calcium phosphate phases in saliva normally
does not occur, due to the presence of salivary proteins,
particularly statherin (Schlesinger and Hay, 1977)
Schlesinger, D. H. and D. I. Hay: Complete Covalent Structure of Statherin, a Tyrosine-Rich Acidic
Peptide Which Inhibits Calcium Phosphate Precipitation from Human Parotid Saliva. J. Biol. Chem.
252:1689-1695 (1977).

IMMUNE SYSTEM AND CARIES RISK
•Salivary immunoglobulin are mucosal antibodies that act as
the first line of defense, and they include two major antibodies,
namely, secretory IgA and IgG.
• Higher caries prevalance in preschool children with higher
level of microbes such as mutans streptococci, C.
albicans and Prevotellaspp., salivary protein including IgA,
IgG immunoglobulins, PRP and histatin peptides, in saliva
compared with caries free individuals.
Huang R et al. Salivary proteins and microbiota as biomarkers for early childhood caries risk
assessment. International Journal of Oral Science (2017), 1–8

INHERITED RISK SUSCEPTIBILITY
• Racial characteristics predispose particular groups to dental
caries.
•American Indians and Inuit (Eskimo) have showel shaped
incisors, barrel shaped incisors, deep buccal pits on molars, plaque
accumulation from a cariogenic diet will predispose these areas to
caries.

•Whites have a higher prevalence of cusp of Carabelli and hence are
predisposed to caries in maxillary molars. (Dahlberg, 1961)
Dahlberg AA. The physical anthropology of the American Indian. New York
•Schuler CF et al in 2001 found that inherited disorders of tooth
development with altered enamel structure and altered immune
response to cariogenic bacteria increase the risk of dental caries.
However the evidence supporting an inherited susceptibility to
dental caries is limited and does not provide a predictable basis for
predicting future decay rates.
Shuler CF. The Changing Face of Dental Education: The Impact of PBL. J Dent Edu 2001;10:1038-1045

CARIES RISK INDICATORS
• Caries risk indicators broadly divided into pathological factors and
protective factors
• Pathological factors are-
• 1- Past caries experience
• 2- Dietary habits
• 3- Socioeconomic status
• 4-Fluoride exposure
• 5-Medical factors

1)PAST CARIES EXPERIENCE
• Most powerful single predictor for future caries incidence in
children and young adults.
• Represent the sum result of all the etiologic and modifying risk
factors to which individuals have been exposed
• Criticized because the aim should be to determine the high risk
individuals before there are any signs of past caries experience.
Axelsson P. Diagnosis and risk prediction of dental caries. 2004.
Bratthall D et al. Community Dent Oral Epidemiol 2005; 33: 256–64

Pathological factors:
2) Dietary factors
• Frequent between meal
snacking
• Prolonged night-time or
at will bottle/breast
feeding of infant
• Multiple sugar exposures
through the day
• Infant Ready availability
of cariogenic snacks
Protective factors are:
• Dietary factors:
• Sugar exposures are limited to
meal times
• Preference for non-cariogenic
snacks
• No deleterious bottle/breast
feeding of the infant

Socioeconomic factors
• High caries risk in
siblings/parents
• Socioeconomically Children
deprived or immigrant
backgrounds
• High maternal MS levels
• Low dental aspirations especially
on the importance of maintaining
caries free primary dentition
Socioeconomic factors;
• Good oral hygiene in
parents with adequate
knowledge about dental
health & prevention
• Regular access to a well-
established dental home

• Fluoride exposure
• No exposure to fluoridated
drinking water
• No access to professionally
applied topical fluorides
especially when permanent
molars erupt delaying
post-eruptive maturation
Fluoride exposure:
• Presence of continuous, low
concentration of free F- ions
around teeth especially at the
time of a cariogenic acid attack.
• Daily use of a fluoridated
dentifrice
• Living in an area with community
water fluoridation

• Medical factors
• Special child (i.e. a child with a
physical,mental, or medically
compromising condition that may
limit oral health care measures or
make the child more susceptible
to caries.)
• Salivary dysfunction caused by
medications, radiation therapy or
general systemic conditions
• Long term cariogenic medication
Medical factors
•Institution & maintenance
of an intensive preventive
regimen in the special child
•Saliva substitutes
•sugar-free medications

• Salivary factors
• High salivary MS &
Lactobacilli counts
• Poor salivary flow
rate impeding
clearance
• Salivary factors
• Salivary buffers that aid in
neutralizing acids
• Salivary proteins and lipids that
form pellicle & protect tooth
surface Salivary Calcium &
Phosphate ions can enhance
remineralization & delay
demineralization

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

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

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

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

Other risk groups
• 1.Persons who work in occupations where frequent food
sampling is required
• 2. Persons who are obese
• 3. Persons who abuse recreational drugs
• 4. Persons who have systemic diseases and are taking regular
medication
• 5. Women who are pregnant

• Niessen L et al (1996) Based on the clinical evaluation and
information derived from a patient’s medical and dental
history, he or she can be classified as being at low, moderate or
high risk.
Niessen LC, DeSpain B. Clinical strategies for prevention of oral diseases. J Esthet Dent
1996;8(1):3-11.

USES OF CARIES RISK ASSESSMENT
 Evaluate the degree of patient’s risk of developing caries to
determine the intensity of treatment.
 Help identify main etiologic agents - to determine the type of
treatment
 Determine if additional diagnostic procedures are required –
salivary flow rate analysis, diet analysis
 Improve the reliability of the prognosis of the planned treatments
 Assess the efficacy of proposed management and preventive
treatment plan at recall visits.

TESTS IN CRA
 Bacterial challenge- determination of Mutans streptococcus as
an indicator of relative risk.
 Diet- determination of lactobacilli as an indicator of sugar
content in diet.
 Remineralization potential- salivary flow rate and buffer
capacity as an indicator of potential biologic repair.
 Host susceptibility- caries experience as an indicator of past
activity.

Microbial tests for mutans streptococci detection
• Several methods are available to measure the levels of mutans
streptococci in saliva and plaque and on individual tooth
surfaces .
 LABORATORY METHOD
 CHAIR SIDE METHOD
 SURVEY METHOD
 SELECTIVE METHOD
 ADHERENCE METHOD

Wooden spatula contaminated
with saliva and pressed on Agar
S mutans colonies on the
surface of agar
LABORATORY METHOD

 Saliva is collected from the individual to be sampled
 Mixed with proper transport medium
 After incubation using a selective medium, mutans colonies on
the plates are counted and the results are expressed as no. of
colony forming per units per ml saliva.
 A common type of selective agar plate for mutans streptococci
is the mitis salivarious bacitracin agar, MSB agar.

For screening surveys using agar plates, a simplified method
has been described in which wooden spatulas are
contaminated by saliva and then directly pressed against
selective agar plates.
After incubation the no. of colonies on a predetermined area
of the agar is calculated

• Dentocult SM Strip Mutans test
• Bacitracin discs are added to the broth at least 15 min before
use
• Individual is asked to chew a piece of paraffin for 1 minute
• Plastic strip is turned around in the mouth to become
contaminated.

• The strip is withdrawn through closed lips , leaving a thin
layer of saliva on the strip.
• The strip is incubated in the selective broth
• After incubation for 48 hours at 35-37◦c, the strip with attached
colonies is compared with chart, and given a score from 0 to 3

• SURVEY METHOD:-
• Plates can be placed into plastic bags containing expired air,
which are then sealed and incubated at 37◦ c.
• Counts of more than 100 CFU by this method are proportional
to greater than 108 CFU of S.mutans per ml of saliva by
conventional methods.

• SELECTIVE METHOD:
• Plaque samples are collected from gingival third of buccal tooth
surface
• Toothpicks are inserted into approximal spaces
• Place into Ringer’s solution
Shake to homogeneity

Contaminated sides are then pressed into the approximal spaces
Incubation at 37◦c for 72 hours
Sites with or without mutans streptococci can be identified

• ADHERENCE METHOD
• Unstimulated saliva is inoculated in MSB Broth
• Inoculated tubes are set at 60◦ angle and incubated aerobically
at 37◦ c for 24 hrs
• After growth has been observed, the supernatant medium is
removed.

+++ S.Mutans is present at level higher than 105
CFU per ml of whole saliva
- S.Mutans is present at less than 104
CFU per ml of whole saliva
value inference
- No growth expressed
+ A few deposits ranging from 1-10
++ Scattered deposits of smaller size
+++ Numerous minute deposits with more than 20 large size
deposits
Results

Microbial tests for Lactobacilli count
LABORATORY METHOD:
• Saliva is obtained by chewing a piece of paraffin
• Shaken with glass beads to break up aggregates of bacteria
• Saliva is then mixed with a buffer solution and 1 ml of the
dilutions 10-2 and 10-3
• 10 ml is poured into the Petri dish
• Plates are incubated at 37◦ c for 4 days. Lactobacilli appear
as whitish dots

Chair side- Dentocult LB method aerobic incubation
for 4◦ days no. of lactobacilli is estimated by
comparing the slides with a model chart
Results
No. of Lactobacilli/ ml Caries activity
0-1000 Little or no activity
1000-5000 Slight activity
5000-10,000 Moderate activity
>10,000 Marked activity

Synder Test
• Saliva is collected before breakfast by chewing paraffin wax
• A tube of Snyder glucose agar is melted and then cooled to 50 ◦ c
• Saliva specimen is shaken vigorously for 3 minutes.
• 0.2ml of saliva is pipetted into the tube of agar and immediately
mixed by rotating the tube.

Agar is allowed to solidify in the tube and is incubated at 37 ◦ c
Color change of the indicator is observed after 24, 48, and 72
hours of incubation by comparison with an uninoculated tube
against a white background.

Alban Test
• 60 grams of Synder test agar is placed in 1 liter of water
• Suspension is brought to boil over a low flame
• After suspension has melted the agar is distributed using about 5 ml per tube
• Tubes should be autoclaved for 15 minutes; allowed to cool in refrigerator

• 2 tubes are taken from the refrigerator and patient is asked to
expectorate a small amount of saliva directly into the tubes.
• Tubes are labeled and incubated at 98.6◦F for 4 days
• Tubes are observed daily for color change

Color change score
No color change 3/4
Beginning color change +
One half color change ++
Three fourths color change +++
Total color change to yellow ++++
Results of Alban test

CONCLUSION
• Caries risk assessment as a prerequisite for appropriate
preventive and treatment intervention decisions and provide
some practical information on how general practitioners can
incorporate caries risk assessment into the management of
caries
• A caries risk assessment tool can be used to identify dietary
habits that may contribute to caries risk

• The multifactorial etiology of dental caries makes it likely that
even the most sophisticated risk models will be of limited
value in predicting future caries development very accurately.
• Prevention is still the least costly alternative treatment hence
the saying Prevention is better than cure which holds good for
dental caries too.

References
• Young DA, Fontana M, Wolff MS. Current concepts in cariology.
Dent Clin North Am 2010;54:479-493.
• Norman O Harris, Franklin Garcia Godoy. Primary preventive
Dentistry. New Jersey: Pearson Prentice Hall; 2004. p. 285-316.
• Axelsson P. Diagnosis and risk prediction of dental caries. Slovakia
Quintessence International 2004; p. 29.
• Bratthall D et al. Cariogram a multifunctional risk assessment model
for a multifactorial disease. Community Dent Oral Epidemiol 2005;
33: 256–64.

• Fontana M, Zero D. Assessing patient’s caries risk. J Am Dent Assoc
2006;137:1231-1239.
• Bowden GH. Dose assessment of microbial composition of
plaque/saliva allow for diagnosis of disease activity of individuals?
Community Dent Oral Epidemiol 1997;25: 76–81.
• Beighton D. The complex oral microflora of high risk individuals
and groups and its role in the caries process. Community Dent Oral
Epidemiol 2005;33:248-255.
• Pearce EIF, YM Dong, Yue L, Gao XJ, Purdie GL, Wang JD.
Plaque minerals in the prediction of caries activity. Community Dent
Oral Epidemiol 2002;30:61-9.

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