28 Caries Risk Assessment
CM Marya
Caries is not the consequence of a single event (as is a classical
infectious disease for example) but it is rather a sequel of a
series of processes happening over a longer period of time.
The etiological factors which can be diagnosed today, that is,
the risk of caries, do not necessarily have to be identical with
the causative factors which led to the development of a carious
lesion.
In scientific studies various so-called ‘predictors’ for the
risk of caries have been investigated. These could be clinical
signs of caries or risk indicators, such as factors associated
with the development of caries. Their effects on the
development of caries can be either causative or modifying.
Causative relationships are often identified as risk factors. An
individual with an increased risk of caries may, therefore, be
a person with a higher than average exposure to the causative
risk factors mentioned below.
Several studies have attempted to determine risk factors
that can be reliably used to assess the level of risk of caries
progression in individual patients. Studies still are underway,
and there is no definitive formula yet available. It has been
established that high-risk patients include those who have a
high bacterial challenge, which may consist of a combination
of high numbers of mutans streptococci, lactobacilli or both.
Although fluoride has excellent properties in terms of balancing
caries challenge, if the challenge is too high, then fluoride—
even at increased concentrations, with increased use or both—
cannot balance that challenge. Therefore, in case of high
bacterial challenge, the bacterial infection must be dealt with,
typically with a chlorhexidine rinse, as well as the enhancement
of salivary action by topical delivery of fluoride. These
principles apply equally well to adults and children. Accurate
detection of early caries can increase the reliability of caries
risk assessment, particularly if those measurements are made
at three- or six-month intervals and caries progression can be
measured. In case of caries progression, obviously, intervention
is needed either antibacterially, with fluoride or with other
techniques.
Beck offered a definition for risk factors that was adopted
for the World Workshop on Periodontics
Risk factor: an environmental, behavioral, or biologic factor
confirmed by temporal sequence, usually in longitudinal
studies, which if present directly increases the probability of a
disease occurring, and if absent or removed reduces the
probability. Risk factors are part of the causal chain, or expose
the host to the causal chain. Once disease occurs, removal
of a risk factor may not result in a cure.
This definition is longer than the one offered by Last, but
it is much clearer.
The key contributions of this definition are (a) the emphasis
on a temporal sequence of events preceding the outcome; (b)
the unequivocal acceptance that a risk factor is part of a
causal chain; and (c) the acceptance that risk factors are
involved in the onset of disease but not necessarily in its
progression or resolution.
GOALS OF CARIES RISK ASSESSMENT
The goals of caries risk assessment can be summarized as
follows:
a. Screen out low risk patients (to allow safe recommendation
of long recall intervals).
b. Identify high risk patients before they become caries-active.
c. Monitor changes in disease status in caries-active patients.
The aim is to identify caries-active individuals and to
convert them to caries-inactive status, so that they become
low risk for the disease (Bevenius J, 1997)
CARIES DISEASE INDICATORS
Caries disease indicators are clinical observations that tell
about the past caries history and activity. They are indicators
or clinical signs that either disease is present or that there has
been recent disease. These indicators say nothing about what
caused the disease or how to treat it. They simply describe a
clinical observation that indicates the presence of disease.
These are neither pathological factors nor are they causative
in any way. They are simply physical observations (cavitations,
white spots, radiolucencies).
318 Section 3  Preventive Dentistry
The four caries disease indictors are: (1) frank cavita-
tions or lesions that radiographically show penetration into
dentine; (2) approximal radiographic lesions confined to the
enamel only; (3) visual white spots on smooth surfaces; and
(4) any restorations placed in the last three years.
CARIES RISK FACTORS
Caries risk factors are biological factors that contribute to the
level of risk for the patient of having new carious lesions in
the future or having the existing lesions progress. The risk
factors are the biological reasons or factors that have caused
or contributed to the disease, or will contribute to its future
manifestation on the tooth. These we can do something about.
The best indicators for increased risk of dental caries are:
• Medium or high MS and LB counts
• Visible heavy plaque on teeth: This indicates poor oral
hygiene and/or prolific plaque growth by the individual
and is an indirect indicator that there are likely to be high
levels of cariogenic bacteria.
• Inadequate exposure to fluoride
• Frequent (>three times daily) snacking between meals: If
a person is snacking greater than 3 times daily between
meals on foods or beverages that contain sucrose, glucose,
fructose, or cooked starch (cookies or bread), this increases
the acid challenge to the teeth to a high level. Xylitol-
containing gum or mints should be recommended as a
substitute for these snacks.
• Deep pits and fissures
• Lower socioeconomic status
• Recreational drug use
• Inadequate saliva flow by observation or measure-ment:
Saliva reducing factors (medications/radiation/systemic)
Saliva flow rate can be measured by having the patient
chew and spit into a measuring cup and calculate the
number of milliliters (mL) per minute. A value less than
0.7 mL/minute is low, whereas 1 to 4 mL/minute is normal
• Exposed roots
• Orthodontic appliances: The presence of fixed or removable
appliances in the mouth such as orthodontic brackets or
removable partial dentures leads to undue accumulation
of plaque and an increase in the percent of cariogenic
bacteria. These appliances will generally place the patient
at high risk of new carious lesion in the future.
• Any physical or mental illness and any oral application or
restoration that compromises the maintenance of optimal
oral health.
CARIES PROTECTIVE FACTORS
These are biological or therapeutic factors or measures that
can collectively offset the challenge presented by the previously
mentioned caries risk factors. The more severe the risk factors,
the higher must be the protective factors to keep the patient
in balance or to reverse the caries process. As industry responds
to the need for more and better products to treat dental caries,
the current list is sure to expand in the future.
The protective factors are:
1. Lives/work/school located in a fluoridated community.
2. Fluoride toothpaste at least two times daily.
3. Fluoride mouthrinse (0.05 percent NaF) daily.
4. 15,00 ppm fluoride toothpaste daily.
5. Fluoride varnish in last six months.
6. Office fluoride topical in last six months.
7. Chlorhexidine prescribed/used daily for one week each
for last six months.
8. Xylitol gum/lozenges four times daily in the last six
months.
9. Calcium and phosphate supplement paste during last
six months.
10. Adequate saliva flow (ml/min stimulated).
Fluoride toothpaste frequency is included since studies
have shown that brushing twice daily or more is significantly
more effective than once a day or less. Any or all of these
protective factors can contribute to keep the patient “in
balance” or even better to enhance remineralization, which is
the natural repair process of the early carious lesion.
Caries Susceptibility
This is the susceptibility (or resistance) of a tooth to a caries-
producing environment. The risk of developing a lesion,
however, is individual and varies, depending on the tooth, its
localization, surfaces, previous fluoride exposure etc.
Caries Activity
Caries activity is a measure of the speed of progression of a
carious lesion. Retrospectively it can be determined as caries
incidence, that is, new carious lesions over time of an individual
or population.
Caries-risk
Generally speaking, risk is defined as the probability of
incidence of an event within a certain period of time. The
caries-risk, therefore, is the risk of an individual developing a
carious lesion. Increased risk may be the result of several
caries-producing factors coinciding or of insufficient defense
mechanisms leading to different caries prevalence. By
definition, risk is aimed at assessing developments in the future.
It can, however, be assessed only on the basis of symptoms
present at, or having manifested themselves by, the time of
assessment.
The following factors should be considered when assessing
caries risk primarily for an adult as shown in Table 28.1 (Caries
risk assessment tool):
 Chapter 28  Caries Risk Assessment 319
Table 28.1: Caries risk assessment tool for an adult

Risk factors High risk Low risk

Clinical/oral evidence • Previous caries • Very few restoration

• New lesions • No new carious lesion
• Unsealed deep pits and fissures • Sealants in pits and fissures
• Fixed orthodontic appliances • No orthodontic appliances
• Prosthesis • No prosthesis to care for
• Exposed root surfaces • Exposed root surfaces with special fluoride
• Premature extraction of teeth application regularly
• Multiple restorations • Nil extraction for caries
• Caries in anterior teeth • Sound anterior teeth

Dietary habit • Frequent sugar intake • Infrequent sugar intake

• Frequent snack in between meal • Rare in between meals snacks
• Use of xylitol gum

Medical history • Medically compromised • No medical problems

• Physical disability/handicapped • No physical problems or handicaps
• Xerostomia • Normal salivary flow
• Radiation therapy • No long-term medication for chronic diseases

Social history • Low knowledge of dental disease • Dentally aware

• Irregular dental visits • Regular appointments with dentist
• Low dental aspiration • High dental aspiration
• High caries in sibling • Low caries in siblings
• General poor oral care in family • Good oral care by family

Plaque/biofilm control • Irregular brushing • Frequent effective cleaning using toothbrush

• Ineffective cleaning • Use of dental floss
• Poor manual dexterity or handicap • Good dexterity; no handicap
• High biofilm scores • Low biofilm scores
• Orthodontic appliance and prosthesis care • No orthodontic or prosthesis care requirement

Saliva • Low flow rate • Flow rate normal

• Low buffering capacity • High buffering capacity

Use of fluoride • No fluoride supplement • Use of fluoride supplement

• Non-fluoridated drinking water • Drinking water fluoridated
• Use of non-fluoridated toothpaste or irregular • Fluoride toothpaste used
brushing with a fluoridated toothpaste • Use of fluoride mouthwash
• Does not use a fluoridated mouthwash

Moderate risk • Individuals who do not clearly fit into high or low risk categories are considered to be at moderate risk.

Adapted from the table cpompiled by Professor Edwina Kidd for the Faculty of General Dental Practitioners Guidelines.

• Clinical evidence of previous disease caries could be detrimental to their general health. These
• Dietary habits, especially frequency of sugary food and patients should receive intensive preventive dental care.
drink consumption
• Social history, especially socio-economic status FACTORS RELEVANT TO ASSESSMENT OF
• Use of fluoride DENTAL CARIES
• Plaque control
• Saliva
Clinical Evidence
• Medical history
• Clinicians should be aware of individuals with a medical The patients with following oral characteristics are at high
or physical disability for whom the consequences of dental risk.
320 Section 3  Preventive Dentistry
• Multiple new lesions in past 12 months XEROSTOMIA
• Unsealed pits and fissures
• History of premature extraction for caries Xerostomia is defined as a subjective complaint of dry mouth
• Multiple restorations that may result from a decrease in the production of saliva.
• Exposed root surfaces To assess the risk for caries involvement due to
• Anterior caries or restorations xerostomia, the clinical evidence of hyposalivation must be
identified. Dry lips, dryness of buccal mucosa, absence of
Dietary Habits saliva in response to gland palpation, and a high number of
decayed, missing, or filled teeth have been cited as an easily
It is seen that all patients who have high sugar intake develop assessed set of clinical parameters for identifying most
dental decay. Frequent smokes in-between meal are also patients with salivary gland dysfunction
considered as risk factors.
XEROSTOMIA AND DENTAL CARIES
Medical History
A major complication of xerostomia is the promotion of dental
Medically compromized and handicapped people may be at
caries (Fig. 28.1). This process is accelerated owing to a
high risk of caries. Many medicaments, such as Antidepressants,
reduction in oral irrigation and an inability to clear foods from
Antipsychotic, Tranquilizers, Antihyper-tensive and Diuretics
the oral cavity rapidly, particularly if proteins and electrolytes
cause dry mouth. Patients who have radiotherapy in salivary
that inhibit cariogenic microorganisms and buffer oral acids,
gland region for head and neck malignancy or removal of
respectively, are diminished. The development of rampant caries,
salivary gland suffer from xerostomia. Patients with rheumatoid
particularly at the cervical area, has been observed within a
arthritis may also have Sjogren’s syndrome, which affect salivary
few weeks after radiation therapy to the head and neck.
and lacrimal gland, leading to dry mouth and dry eyes.
CAUSES OF XEROSTOMIA
Social History
The following features of social history may also be present Primary Sjögren’s syndrome
in high risk patient Secondary Sjögren’s syndrome
Surgical removal of glands due to neoplasm
• Caries in sibling is high
• The patient possesses little knowledge
CONNECTIVE TISSUE DISEASE
• Irregular dental visits to dentist and dental awareness are
low • Rheumatoid arthritis
• The patient’s access to snacks is high • Systemic lupus erythematosus
• Poor oral care in family. • Systemic sclerosis
• Mixed connective tissue disease
Plaque Control
OTHER CONDITIONS
Dental plaque is the most important risk factor for dental
caries. The patients who do not clean their teeth frequently • Radiation therapy
and effectively or have poor manual dexterity may be at high • Primary biliary cirrhosis
risk. Orthodontic appliances and dental prosthesis are a major • Vasculitis
source of plaque accumulation which needs to be cleaned • Chronic active hepatitis
• HIV
effectively to prevent plaque accumulation.
• AIDS
• Bone marrow transplantation
Saliva • Graft-vs-Host disease
• Renal dialysis
Many features of saliva affect the risk of dental caries like:
• Anxiety or depression.
• Low buffering capacity (as acids are not neutralized)
• Low quantity DRUGS THAT DECREASE SALIVARY FLOW
• High S. mutans and Lactobacillus count
• Xerostomia is a known predisposing factor. • Anticholinergics
• Antihistamines
Use of Fluorides • Antianxiety
• Diuretics
Fluoride has been a known factor which delays the progression • Antidepressants
of dental caries; thus patients who do not have fluoridated • Anticonvulsants
water or use fluoridated toothpaste may be at risk. • Narcotics

Fig. 28.1: Theoretical model of the relationship between medication,
salivary gland hypofunction, xerostomia and dental caries
Much progress has been achieved in the prevention of
dental decay over the past decades. Epidemiological studies
have demonstrated high caries active individuals in the same
population as moderate or low caries active individuals. Caries
prevalence indicators can be used for assessing either caries
activity or the risk of future caries. However, caries-risk does
not remain constant throughout life and may be modified by
preventive intervention both by the patient and by the dentist.
CLASSIFICATION
A ‘high caries-risk’ group is defined as a sub-group of the
population which is at greater risk of acquiring caries than
the average population. The borderline between low, moderate
or high risk is not precise, but depends on the prevalence
within the population and on additional factors. When there
are only a few caries-risk factors present, then the evaluation
is of a ‘low caries risk’, when there are many risk-factors
present the classification is of a ‘high caries-risk,’ and the
moderate caries-risk group falls in between (Box 28.1).
CARIES RISK ASSESSMENT
For individual patients, the objective clinical judgment of the
dentist, their ability to combine and use these risk factors and
their knowledge of the patient has been shown to be one of the
most powerful predictors of that individual’s caries risk. In
particular, the dentist’s subjective judgment of the size of the
‘Decayed’, ‘Missing’ and ‘Filled’ increment (newly developing
caries) over subsequent years is also a relatively strong predictor.
In diagnosing caries risk, no single test can simultaneously
measure host resistance, microbial pathogens, and cariogenicity
of the diet. Multiple predictor models (including mutans scores,
baseline caries prevalence, fissure retentiveness score, dietary
Chapter 28  Caries Risk Assessment 321
habit index, salivary buffering and flow rate) are necessary to
classify a person according to caries risk.
Several studies have attempted to determine risk factors that
can be reliably used to assess the level of risk of caries progression
in individual patients. Studies still are under way, and there is no
definitive formula yet available. It has been established that
high-risk patients include those who have a high bacterial
challenge, which may consist of a combination of high numbers
of mutans streptococci, lactobacilli or both. Although fluoride
has excellent properties in terms of balancing caries challenge, if
the challenge is too high, then fluoride—even at increased
concentrations, with increased use or both—cannot balance that
challenge. Therefore, in the case of high bacterial challenge, the
bacterial infection must be dealt with, typically with a
chlorhexidine rinse, as well as the enhancement of salivary action
by topical delivery of fluoride. These principles apply equally
well to adults and children. Accurate detection of early caries
can increase the reliability of caries risk assessment, particularly
if those measurements are made at three- or six-month intervals
and caries progression can be measured. In the case of caries
progression, obviously, intervention is needed either antibacterially,
with fluoride or with other techniques.
FACTORS IN LOW, MODERATE AND HIGH
CARIES RISK ASSESSMENT
Determination of caries-risk is important for:
• Assessment of the individual etiological factors of existing
carious lesions and of the caries risk situation
• Repeated determination of the caries-risk allows an
evaluation of the success of, or the need for, modification
of preventive measures
• Indications of an increased caries-risk in specific children
in community preventive programs will allow selection of
an individual preventive program in order to minimize the
development of carious lesions.
The prevalence and incidence of caries influences the
predictability of the caries-risk assessment. The identification
of subjects with high caries-risk is relatively accurate where
children and adolescents are concerned and when sufficient
base-line data is available. The situation is different where adults
are concerned because they receive more dental treatment but
lack preventive programs. Since secondary caries is the most
frequent cause of replacement of restorations and root caries
becomes a problem for adults, caries-risk assessment and, when
needed, preventive intervention is also necessary for adults.
In the clinical situation the accurate prediction of caries is
not as important as the assessment of the individual caries risk
and risk factors. Even with routinely available clinical and
sociodemographic information at clinical examination a dentist
can identify high caries risk subjects with good accuracy.
In order to arrest the development of caries as early as
possible it is important that caries-risk status be assessed. For
children in kindergarten a simple assessment of previously
acquired lesions will suffice.
322 Section 3  Preventive Dentistry

BOX 28.1: FACTORS IN CARIES RISK ASSESSMENT

Children Adults
Low risk Low risk
• No new or incipient carious lesions in the past year No new or incipient lesion
Moderate risk (any of the following) Moderate risk (any of the following)
• One new, incipient or recurrent carious lesion in the • One to two new, incipient or recurrent carious lesions
past year during the past three years
• Deep or noncoalesced pits and fissures. • History of numerous or severe caries
• High caries experience in siblings • Deep or noncoalesced pits and fissures
• History of pit and fissure caries • Frequent sugar exposures
• Early childhood caries • Decreased salivary flow
• Frequent sugar exposures • Irregular dental visits
• Decreased salivary flow • Inadequate fluoride exposure
• Compromised oral hygiene
• Irregular dental visits
• Inadequate fluoride exposure
• Proximal radiolucency

High risk High risk

Two or more new, incipient or recurrent carious lesions in Three or more carious lesions in the past three, or two
the past year, or two or more of the following: or more of the following:
• Deep or noncoalesced pits and fissures • History of numerous or severe caries
• Siblings or parents with high caries rate • Deep or noncoalesced pits and fissures
• History of pit and fissure caries • Frequent sugar exposures
• Frequent sugar exposures • Decreased salivary flow
• Decreased salivary flow • Irregular dental visits
• Compromised oral hygiene • Inadequate fluoride exposure
• Irregular dental visits • Compromised oral hygiene
• Inadequate fluoride exposure
• Proximal radiolucency

Caries management by risk assessment now is receiving

considerable attention, and software programs are being
developed that will aid practitioners in assessing risk and lead
them to the use of current and new technologies by specifying
treatments recommended for the various risk categories (Box
28.2).

CARIOGRAM (FIG. 28.2)

Cariogram is an interactive version for estimation of caries
risk and for understanding the interactions of various factors
causing caries. In simple terms, Cariogram is a way to illustrate
interactions between caries related factors, by a computer
version which presents a graphical picture that illustrates the
overall risk scenario. It was developed by D. Bratthall, L.
Allander and K. Lybegard in 1997.
The Cariogram serves the purpose of demonstrating the caries
Fig. 28.2: Cariogram
risk graphically in terms of:
• Risk for developing new caries in the future The idea is to:
• Chance to avoid new caries in the near future a. Identify those persons who will most likely develop caries
Cariogram helps to understand the multi-factorial aspects and
of dental caries and can be used as a guide in attempts to b. Provide these individuals proper preventive and treatment
estimate caries risk measures to stop the disease.
 Chapter 28  Caries Risk Assessment 323

BOX 28.2: CARIES RISK ASSESSMENT PROFORMA FOR CHILDREN

Factors Caries Risk

S No. Risk factor to consider High Moderate Low Finding

1. Child has visible decay Yes No

2. Caries restored (time lapsed in last restoration) <12 months 12-24 months >24 months
3. Visible heavy plaque/debris on teeth of child Yes No
4. Frequency of between meal snacks/sugars by the child >3 1-2 Meal time only
5. Presence of conditions that impairs/reduce saliva
(dry mouth) in child Yes No
6. Family socio-economic status Low Mid-level High
7. Child has orthodontic/oral appliance in the mouth Yes No
8. Deep pits & fissures/enamel defects Yes No
9. White spot lesion/areas of enamel demineralization >1 1 None
10. Gingivitis Present Absent
11. Levels of mutans streptococci or lactobacilli High Moderate Low
12. Child’s exposure to fluoride
A. Daily use of fluoride toothpaste No Yes Yes
B. Drinking water fluoridated No No Yes
C. Daily use of fluoride No No Yes
mouthwash or gel
D. Intake of fluoride supplements No No Yes
13. Child needs special health care Yes No
14. Childs’s frequency of tooth brushing per day Irregular or <1 1 2 Times

But the idea of caries risk assessment is highly varied, as
dental caries is a multi-factorial disease. On account of several
studies performed, one could define three main approaches
for risk assessment, which are based on:
i. past caries experience
ii. socioeconomic factors and
iii. biological factors
So, in view of the fact, a new model for understanding
the interactions of various factors was proposed and a
graphical model, the Cariogram, was drawn up to illustrate
the fact that caries can be controlled by several different means.
Cariogram was originally developed as an educational model
but later on served as a routine caries assessment tool.
The Cariogram presents caries risk profile of an individual
graphically, simultaneously taking into account the interaction
off different causative factors/parameters of caries. It also
provides recommendations for target preventive measures one
could implement, in order to overcome new caries formation.
APPLICATIONS
• Illustrates the interaction of caries related factors.
• Illustrates the chance to avoid caries.
• Expresses caries risk graphically.
• Recommends targeted preventive actions.
• Can be used in the clinic and as an educational program.
The Cariogram, a pie-circle diagram, is divided into five
sectors, in the following colors:
• The Dark blue sector ‘Diet’ - Based on a combination of
diet contents and diet frequency.
• The Red sector ‘Bacteria’ - Based on a combination of
amount of plaque and mutans streptococci.
• The Light blue sector ‘Susceptibility’- Based on a
combination of fluoride program, saliva secretion and
saliva buffer capacity.
• The Yellow sector ‘Circumstances’ - Based on a
combination of past caries experience and related diseases.
• The Green sector shows an estimation of the ‘Actual
chance to avoid new cavities’.
The bigger the green sector, the better from a dental
health point of view. Smaller the green sector means low
chance to avoid caries = high caries risk. For the other
sectors, the smaller the sector, the better from dental health
point of view.