years earlier and may no longer be actively progressing.

Alternatively, even one small, initial lesion may represent the

beginning of very rapid loss of structure at that site as well as
many others. Determining accurately and quickly the difference
between these two circumstances is extremely important to the
well‐being of the patient. By knowing, with a reasonable degree
of certainty, the level of activity, the most effective treatment of
the disease can be designed and delivered.
Historically, one way of determining caries activity state was
to observe the progress of individual lesions over time through
either visual or radiographic examination. Such observations
were made at intervals of six months or more, sufficient time for
lesion progression to be clearly apparent. However, waiting for a
lesion to develop further is now hard to justify ethically, because
biochemical reversal of an early lesion has a predictable clinical
outcome. Ethical care now requires a very different and much
more nuanced approach.
Whether an individual lesion is active is based on many factors
but a single evaluation may reveal some indication of the
lesion’s progression. Carious lesions that appear frosty, feel
rough, show loss of lustre and appear opaque are signs of ongoing
acid exposure and are probably lesions that are active. These
signs in the presence of plaque or gingival inflammation from
plaque (that the patient may have just brushed off) are indications
of active lesions requiring risk‐based interventions (not
necessarily surgical). Conversely, lesions that are brownish or
black in colour, even when cavitated, may not be active and may
not require surgical intervention [3, 4].
As is the case with prediction of future disease risk, disease
activity can be estimated by inquiring into or by measuring multiple
factors that are known to contribute to, or are likely to contribute
to, the disease, then adding the resultant data together
to create a summative index of disease activity. Indicators of
activity may include clinical observations as well as medical
and social data. The act of gathering data is itself an intervention
of value to future oral health because it is likely to influence
patient understanding and behaviour. If a determination
is made that the disease is active, the data can be used to design
targeted advice and intervention with a much higher degree of
confidence than would otherwise be the case. Conversely, if a
determination is made that there is no active disease, time and
resources can be better applied to other tasks.
Methods of Assessing Activity and Risk
This chapter will include descriptions of three methods of caries
activity and risk assessment: (i) one that is primarily focused
on the assessment of future risk of developing caries; (ii) one
that provides information about both present caries activity
state and future risk; and (iii) one that is primarily focused on
the immediate caries activity state. Each of the methods to be
described is designed to help both the patient and the dental
team focus on modifying those factors that are most likely to
contribute to the disease.
The three methods have in common a focus on at least five
primary factors that are known to contribute to caries activity
and caries risk. These five factors are:
• the microbial mix in biofilm, or plaque;
• the frequency of daily exposures of the biofilm to simple, fermentable
sugars;
• past and current exposure to fluoride;
• the observed, stimulated salivary flow rate, and factors that
may reduce salivary flow;
• recent caries experience.
Each of the three assessment methods uses these parameters in
slightly different ways, and each considers other related factors
as well. Each of the three can be a very beneficial addition to the
ethical and effective care of dental patients.
The Cariogram
The Cariogram is a computer‐assisted assessment system that
uses nine weighted parameters to help identify patients at high
risk of developing caries. It is expressed graphically as the percentage
chance of avoiding caries in the future, ranging from 0%
(a very low chance of avoiding caries in the future, that is, a very
high caries risk) to 100% (a very high chance of avoiding future
caries, that is, a very low caries risk). Developed at the Dental
School in Malmo, Sweden, building on earlier work in Sweden
and elsewhere, a ‘Cariogram Manual’ was first published in 1997
[5] and later became available as an internet version (Version
2.01, 2004).
The reader is referred to the internet version of the Cariogram
Manual. It is freely available and very clearly expressed.
The brevity of the following description is a tribute to the quality
and detail of that published material, which we shall not attempt
to replicate.
In brief, the system measures or estimates and then records
the following nine factors [6]:
• General health
• Diet/consumption of refined carbohydrates
• Oral hygiene
• The use of fluoride
• Mutans streptococci and lactobacilli counts in saliva
• Salivary buffering capacity
• Stimulated salivary secretion rate
• Caries to the dentino‐enamel junction, assessed radiographically
• Decayed, missing and filled surfaces/decayedare told that, while they remain low risk, they will be better
candidates for, say, elective cosmetic procedures.
• Patients at high risk may require therapeutic intervention in
the form of oral rinses, gels, gums, and sprays, as well as restoration
of any existing carious lesions. High risk patients may
also receive recommendations to put off elective cosmetic
dental procedures or orthodontic treatment until risk levels
can be controlled. The dental intervention will include treating
the disease in addition to restoring defects or improving
aesthetics, the former actions being based on the patient’s
specific risk factors.
• Patients who are assessed as high or extremely high risk are
told that they are more likely to have failures of expensive
dental work due to recurrent caries. They are encouraged to
delay such work until the disease risk becomes low.
The CAMBRA system is designed to be presented as a service
that dental teams can provide, in a similar way to providing
dental hygiene services. It is well recognized that dental hygiene
services will reduce the risk of periodontal disease, and that, at
the same time as promoting good health overall, will reduce or
avoid the cost of either periodontal surgery or tooth replacement.
In a similar way, the CAMBRA approach can ethically
and appropriately be advocated to patients and their caregivers
as something that will reduce the risk of restorative or cosmetic
failure due to recurrent caries, and therefore has immediate
and long‐term financial value to the patient or their family. In
addition, it will lead to the less readily quantifiable benefits of
improved dental health throughout life.
The Traffic Light‐Matrix (TL‐M) System
The Traffic Light‐Matrix model was first described in 2005, having
been developed independently of Cariogram or CAMBRA,
to address the question of how best to treat patients with active
dental caries using an individualized, patient‐centred approach
[9]. While apparently more complex than either Cariogram or
CAMBRA in the number and extent of parameters considered,
it is also, like them, both a useful tool for treatment planning and
a focused communication tool to explain the issues with each
patient or their caregiver. It offers a systematic approach to assess
all the factors that might contribute to caries activity, as part of
a complete oral examination and history‐taking, then to design
targeted or individualized preventative and curative therapy, and
finally to monitor the outcomes of that therapy over time.
The Traffic Light allocates a ‘threshold value’ for each risk
factor. If the information elicited from questioning or by
clinical testing yields results that exceed the predetermined
threshold values, then the model alerts the clinician and the
patient to a problem area that needs to be addressed. The system
does not make any assumptions about either the relative
importance of individual risk factors or their relationship to
each other.
The system scores a ‘red light’, a ‘yellow light’ or a ‘green light’
for each risk factor depending upon predetermined criteria.
Tests can be carried out either by a dentist or an auxiliary, who
has been trained to collect the data, and recorded on a form, see
Figure 3.18 on p. 000). The use of auxiliary personnel to assist in
data gathering makes the model more economically attractive
for everyday clinical practice.
The Matrix is designed as a means of assessing the patients’
present disease status relative to their attitude to maintaining
their own dental health. It is not intended to be anything more
than a subjective assessment by the clinician on a particular
day based on the clinician’s instinctive understanding of that
patient. However, collecting and re‐collecting this information
over a period of time gives the clinician a very useful
measure of the patient’s ability, or willingness, to comply with
treatment advice. It is also a simple way to provide information
about the potential for patient compliance between
different operators in the same practice or upon referral to
another practitioner.
Attitude towards dental health is scored as A, B or C and
recorded on the vertical axis of the grid shown in Figure 3.2.
Current disease status is scored as 1, 2 or 3 and is recorded on
the horizontal axis. The two scores position the patient within
the grid (Figure 3.2).
The scoring criteria for the Matrix are listed below.
Attitude
A Self‐motivated, dentally aware and maintaining dental health
is a high priority.
B Dentally aware but still dependent on the dental team for
motivation and help in staying healthy.
C Unmotivated, a low level of dental awarenessmodification
in salivary function has detrimental effects on both
hard and soft tissues as well as a negative impact on the quality
of life of the patient (see Chapter 1). Sreebny published an
excellent review of the literature on this topic and the design of
the assessment of saliva in TL‐M was based on this paper [10].
Although caries risk is strongly associated with only stimulated
salivary flow rate, the other salivary factors described may
contribute to caries risk; all are clearly relevant to overall oral
health and/or comfort; and focusing attention on a broader
set of indices may well have value in patient motivation. The
broader group of salivary tests is therefore described in detail
below.
Regular investigation of the following is recommended as
part of an overall oral examination and, with the caveat noted
above, as part of a focused investigation into caries activity state.
• Unstimulated saliva: (to be undertaken before the stimulated
saliva test)
• functional efficiency of the minor salivary glands
• consistency of unstimulated saliva
• pH of unstimulated saliva
• Stimulated saliva (which is more directly relevant to caries
activity state)
• flow rate
• buffering capacity
Minor salivary glands
Unstimulated saliva is very important for oral comfort, as
stimulated saliva is only produced during the short periods of
mastication. The minor salivary glands account for 7% of the
daily saliva production and the submandibular glands are the
major contributor (Table 3.1). There is wide variation in the flow
rate from the minor salivary glands located in different