Introduction

Dental caries is now widely recognized as a noncommunicable, diet-mediated chronic disease, rather than a classical infectious disease. This reflects an updated understanding of its multifactorial etiology, which involves the interplay between host susceptibility, the oral microbiome, dietary behaviors (particularly sugar consumption), fluoride exposure, and broader social determinants of health.^1,2 Unlike diseases caused by a single pathogen, caries results from a dysbiosis of the dental biofilm driven by environmental and behavioral factors, particularly frequent sugar intake and inadequate oral hygiene.

Despite improvements in fluoride access and public health initiatives, dental caries remains one of the most prevalent noncommunicable diseases globally and in the United States, disproportionately affecting low-income and underserved populations.³

Risk assessment is an essential part of caries management and should be performed for every patient. It is not only a method to evaluate the likelihood of future caries development or progression of existing lesions, but more importantly, it helps identify why an individual is at risk. Understanding the specific biological, behavioral, or environmental contributors allows clinicians to design personalized, preventive treatment plans tailored to each patient's unique needs. This individualized approach to caries management is the foundation of minimally invasive dentistry. By using caries risk assessment tools, dental professionals can implement targeted interventions, such as dietary counseling, behavior change support, optimized oral hygiene, professional fluoride therapies, and sealants.^4-6

Moreover, when patients are made aware of their caries risk and contributing factors, they are more likely to adopt health-promoting behaviors and engage more actively in their oral health care. Educating patients about their risk empowers them to make informed decisions, supports shared decision-making, and leads to improved long-term oral health outcomes.

Clinical Significance Snapshot

What is the point of undertaking risk assessment for a patient? Isn’t everyone who has natural teeth at risk of dental caries?

Yes, everyone with natural teeth is at some risk of developing dental caries. However, caries is a preventable and manageable disease, and patients do not all have the same level of risk. Caries risk assessment (CRA) is a structured, evidence-based process used to identify patients at low, moderate, or high risk for developing caries, based on a combination of risk factors, protective factors, and clinical findings.

In the past, caries was typically treated only after visible tooth damage had occurred, often leading to a cycle of repeated restorative treatments. CRA allows dental professionals to move from a surgical-restorative model to a personalized, preventive approach. By identifying high-risk individuals, targeted interventions - such as dietary counseling, behavior change support, improved oral hygiene practices, fluoride therapies, and sealant application - can be implemented to reduce risk and prevent the progression of dental caries.

Patients at low risk still require ongoing monitoring and preventive care to ensure their risk remains low. High-risk patients, on the other hand, should be recalled more frequently, monitored more closely, and provided with a more intensive preventive care plan designed to modify risk factors and support protective behaviors.

Which are the strongest indicators of risk?

Presence of active caries lesions (cavitated or non-cavitated lesions).
History of caries in the past 12-24 months.
Frequent consumption of fermentable carbohydrates.
Poor oral hygiene practices, including infrequent or ineffective toothbrushing
Use of appliances or restorations that retain plaque (e.g., orthodontic devices, partial dentures)
Low salivary flow or impaired salivary function (e.g., due to medications, medical conditions, or radiation therapy)
Inadequate fluoride exposure (e.g., not using fluoride toothpaste daily or living in a non-fluoridated area)
Socioeconomic or behavioral factors that limit access to dental care, fluoride exposure, oral health education, or the ability to maintain daily oral hygiene routines

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