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Current Concepts in Preventive Dentistry

Course Number: 334

Methods to Determine Caries Risk

By definition, caries risk assessment is to predict future caries development before the clinical onset of the disease. Risk factors are the lifestyle and biochemical determinants that contribute to the development and progression of the disease. There are two caries risk assessment plans that I utilize when teaching caries: CAMBRA and the ADA’s CRA Forms. However, dental providers can create customized caries risk assessments. For example, just one variable “dental caries in the last three years” can automatically place your patient in the high-risk category. This patient would be treated as a high-risk caries patient until they no longer have dental caries in three years. As with all caries risk assessments, individual assessment should be developed for each patient. We know that patients who are at risk for dental caries include those patients with certain factors related to general health (diseases, physically or mentally compromised individuals), those patients with epidemiologic factors (living in a high-caries family or having a past caries experience, especially new caries in the last three years), and patients with certain socioeconomic factors (low education level, low income), However, the most current research conducted by the National Institute for Dental and Craniofacial Research indicates White adult patients (20-64 years of age) and White seniors (65 years and older) and those living in families with higher incomes and more education have had more dental caries. For example, we have seen an increase in energy drinks in the U.S. population.

We also know there are other contributing factors in caries development. The key to preventing or arresting caries is to determine potential risk factors and establish an individual treatment plan for each patient. By updating our patients’ caries risk assessment at future dental appointments, we ensure their caries risk is current, as risk can change due to multiple variables, e.g., change in medications affecting saliva production, oral hygiene (removal of plaque and bacteria), the patient (host) immunity, and bacterial transmission from family members.

Table 1. Methods to Determine Caries Risk.

Oral Risk Factors
  • New carious lesions?
  • Previous carious lesions in the last three years?
  • Recurrent caries around restorations?
  • Deep pits and fissures?
  • Orthodontic treatment?
Home Care: Oral Hygiene and Fluoride Exposure
  • Plaque present?
  • Current understanding of plaque control and the patient’s motivation?
  • Brushes with fluoridated toothpaste daily?
  • Drinks city-added or naturally occurring fluoridated water?
Dietary Analysis
  • Carbohydrate intake, including frequency (consumption of sugar-sweetened beverages, e.g., soda, fruit drinks, energy drinks, and sports drinks)?
Microbial and Salivary Factors
  • Bacterial count? (saliva testing)
  • Xerostomia?
  • Physiological conditions?
  • Prescription drugs affecting saliva rate?
  • Salivary stones?
Family or Social Risk Factors
  • Multiple in-between carbohydrates/day ingested?
  • Dental fear?
  • Family caries history?
Immunity/Medical Risk Factors
  • Chronic diseases?
  • Medically or physically challenged?

Each of these categories must be addressed at each dental examination to determine risk assessment, as a patient’s oral condition may be different due to physiological changes or self-care practices. Two significant factors that indicate a patient is at high-risk include caries in the last three years and past restorative care, thereby indicating a higher bacterial count. A current caries assessment should be performed at future dental appointments. Oral and written instructions should be given to the patient indicating their individual home/self-care instructions. Do not assume the patient is an expert in their own preventive care. Spend time with your patients so that they understand the importance of daily plaque control and how frequent carbohydrate intake influences the daily demineralization-remineralization process.

Moderate to High-risk Caries Diagnoses

If a patient is diagnosed as moderate- to high-risk caries, follow the recommended treatment protocols as utilizing evidence-based dentistry recommendations by the ADA and the AAPD. The current ADA’s Evidence-based Dentistry Clinical Practice Guidelines should be utilized when calibrating the entire clinical team on caries treatment protocols and other forms of treatment. The current ADA Clinical Guidelines include: nonrestorative treatments for carious lesions, topical fluoride, non-fluoride caries preventive agents, sealants, oral cancer, fluoride toothpaste for young children, prosthetic joint, and infective endocarditis, and nonsurgical treatment of chronic periodontitis.

With moderate to high-risk caries patients, schedule frequent fluoride varnish applications in your office, as well as prescribe fluoride toothpaste. Although the current ADA evidence-based practice guidelines do not indicate xylitol gum/mint therapy evidence is strong. The ADA considers xylitol therapy as an “Expert Opinion.” The ADA believes that even though there is a lack of evidence about xylitol, they recommend it be chewed by their patients for 10-20 minutes after meals and snacks as it buffers saliva and stimulates saliva to assist with hyposalivation. Read the product labels to find xylitol as one of the first ingredients. As long as the patient does not have TMJ dysfunction, chewing gum is recommended by the ADA and the AAPD. There are also xylitol mints available over-the-counter. In fact, everyone can benefit from sugarless xylitol gum and mints, not just moderate- to high-risk caries patients, e.g., stimulating saliva and the sugar alcohol benefits.