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 life-style 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 American Dental Association’s CRA Forms. An assessment should be developed with each patient to determine their risk for dental caries. We know that patients who are at risk include those patients with certain socioeconomic factors (low education level, low income), patients with certain factors related to general health (diseases, physically or mentally compromised individuals), and 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). We know that multiple factors can contribute to 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 recall appointments we ensure their caries risk is current, as risk can change due to multiple variables, such as change in medications (contributing to xerostomia), oral hygiene, immunity, and bacterial transmission.

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 (sugary drinks such as soda, fruit juice, energy, and sports drink consumption)?
Microbial and Salivary Factors
  • Bacterial count?
  • 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 recall 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 protocol by the American Dental Association or CAMBRA. The ADA Chairside Guides are very helpful when calibrating the entire clinical team on caries treatment protocols. Schedule frequent fluoride varnish applications in your office, as well as prescribe fluoride toothpaste. Although the current ADA evidence-based practice guidelines does not indicate xylitol gum/mint therapy evidence is strong. The ADA considers xylitol therapy as an “Expert Opinion.” In other words, 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. Many sugarless chewing gum companies in the last couple years have xylitol as their first ingredient. One of my favorite flavored chewing gums is Peppermint Ice Breakers Ice Cubes. The flavor lasts a considerable time compared to other flavors and other different sugarless gum brands. As long as the patient does not have TMJ dysfunction, chewing gum is recommended by the American Dental Association and the American Academy of Pediatric Dentistry. There are also xylitol mints available over the counter. In fact, everyone can benefit from chewing sugarless xylitol gum, not just moderate- to high-risk caries patients.