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Review Article

An Overview of Caries Risk Assessment: Rationale,

Risk Indicators, Risk Assessment Methods, and Risk‑based
Caries Management Protocols
Ekta Singh Suneja, Bharat Suneja1, Bhuvanesh Tandon, Nebu Ivan Philip2
Departments of Conservative Dentistry and Endodontics and 1Pediatric and Preventive Dentistry, BJS Dental College and Hospital, Ludhiana, Punjab,
2
Department of Pediatric and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Kothamangalam, Kerala, India

Abstract
The paradigm shift in our understanding of the dynamic, multifactorial nature of dental caries and the resultant change in caries preventive
and treatment strategies necessitates that caries risk assessment (CRA) should be an integral part of any caries management protocol. This
review discusses the rationale for CRA and the role various risk indicators play in the fluctuating demineralization‑remineralization cycle
of dental caries. It also provides an overview of different CRA methods and a risk‑based clinical protocol for dental caries management in
infants and children.

Keywords: Caries risk, management protocol, risk assessment

Caries Risk Assessment – Rationale standardized preventive and treatment recommendations

(e.g.,  frequency of recall visits, number of diagnostic
For a long time, the diagnosis and treatment of dental caries
radiographs needed, fluoride treatment modalities,
was based on identifying demineralization or cavitation on the
anticipatory guidance protocols, etc.) according to each
tooth surface, and its treatment by “surgical” removal of the
patient’s caries risk status. Risk assessment can thus also
carious tooth structure and placement of a suitable restoration.
contribute to a more efficient allocation of time and resources
However, it is now well‑recognized that a caries management
for oral health programs by eliminating many unnecessary
protocol that is limited to surgical treatment of the chronic
interventions (e.g., professional topical fluoride application
infectious disease of dental caries, without addressing the risk
in a low caries risk child).
factors responsible for the disease, will eventually only result
in new carious lesions appearing and failure of any treatment CRA can be used as a valuable motivating tool for patients,
rendered.[1] encouraging them to undertake measures that will move them
from a high/moderate‑risk category to a low‑risk category.
Hausen has defined caries risk as the probability that an individual
Besides this, CRA can potentially promote caries prevention
will develop a certain number of carious lesions (cavitated or
at the primary level itself, i.e., even before the initiation of
noncavitated) or reach a given level of disease progression,
the disease process. This could enable even high caries risk
over a specific period of time, provided his or her exposure
children to reach adulthood caries free – a goal every pediatric
status remains the same during this period.[2] Assessing a
dentist strives to achieve for their patients.
patient’s caries risk status is an essential component in the
modern day management of dental caries, where the emphasis Address for correspondence: Dr. Ekta Singh Suneja,
is on a nonoperative/preventive approach, rather than just the Department of Conservative Dentistry and Endodontics, BJS Dental College
surgical/restorative intervention to the disease process.[3,4] and Hospital, Ludhiana, Punjab, India.
E‑mail: ektasingh.suneja@gmail.com
Incorporation of caries risk assessment (CRA) into regular
clinical practice can assist the dental professional in making This is an open access article distributed under the terms of the Creative Commons
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Access this article online and build upon the work non-commercially, as long as the author is credited and the new
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Website:
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How to cite this article: Suneja ES, Suneja B, Tandon B, Philip NI.
DOI: An overview of caries risk assessment: Rationale, risk indicators, risk
10.4103/IJDS.IJDS_49_17 assessment methods, and risk‑based caries management protocols. Indian
J Dent Sci 2017;9:210-4.

210 © 2017 Indian Journal of Dental Sciences | Published by Wolters Kluwer - Medknow
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Suneja, et al.: CRA: Rationale, indications, methods, protocol
Caries Risk Assessment ‑ Risk Indicators
Keyes triad of the primary factors responsible for dental
caries  (fermentable substrate, cariogenic bacteria, and a
susceptible host)[5] still holds true, however it is now well
established that dental caries is a multifactorial, chronic
infectious disease, with fluctuating cycles of demineralization and
remineralization.[6] The dynamic interplay between pathologic
factors that favor demineralization (e.g., high MS levels) and
protective factors that promote remineralization (e.g., presence
of free F −ion in the oral environment) will ultimately determine
whether caries lesions develop/progress or not.[7]
Caries risk indicators are thus multivariate between pathological
factors that cause the disease directly  (e.g.,  frequent sugar
exposures, high MS counts), variables that may be considered
protective (e.g., topical fluoride exposure, adequate plaque control),
and those factors that may play a contributing role (e.g., deep
pits and fissures, salivary factors, and socioeconomic status).
A summary of the various caries risk indicators broadly divided
into pathological and protective factors is shown in Table 1.[8-36]
After an extensive review of literature on caries risk indicators,
Zero, Fontana, and Lennon concluded that no single indicator
or combination of risk indicators could consistently be a good
predictor of caries risk status when applied across different
populations and age groups.[37] In general, however, the best
indicator of future caries risk is the past caries experience,
although this may not be particularly useful in children where
it is vital to determine caries risk status before any caries
lesions develop.
Caries Risk Assessment Methods
A number of CRA methods have been proposed for use in
clinical practice as follows:
1. Caries Questionnaire in combination with Clinical
Observations[38]
2. AAPD’s Caries-risk Assessment Form.[39]
3. The Cariogram Model[40]
4. Caries Assessment and Risk Evaluation (CARE) test[41]
5. Caries management by risk assessment (CAMBRA)[42]
6. Traffic Light Matrix (TLM).[43]
Caries questionnaire in combination with clinical
observations
Based on the concept that dental caries is an infectious
disease where there is a dynamic balance or imbalance
between pathological factors (that cause demineralization)
and protective factors (that favor remineralization), [7]
Featherstone et al.[38] evolved a consensus statement to assess
individual caries risk from a questionnaire that addresses
issues such as maternal dental history, family dynamics,
socioeconomic factors, oral hygiene measures, fluoride
exposure, and frequency of sugar exposures. Along with the
questionnaire, clinical observations were made by visual,
tactile, and radiographic examination of teeth. Once individual
risk status was determined, they suggested using a minimally
Indian Journal of Dental Sciences  ¦  Volume 9  ¦  Issue 3  ¦  July-September 2017
invasive caries management protocol that included appropriate
preventive and therapeutic recommendations.
American Academy of Pediatric Dentistry’s caries risk
assessment form
Incorporating the most recent evidence and expert/consensus
opinion,[44‑47] the AAPD modified its original Caries‑risk
Assessment Tool (CAT),[48] into a more sensitive and practical
tool to assist dental practitioners, physicians, and nondental
health‑care providers in assessing the levels of risk for
caries development in infants, children, and adolescents.[39]
Caries‑risk Assessment forms were formulated that can be
used by dentists to assess caries risk status for 0–5‑year‑old and
≥6‑year‑old children. Risk assessment categorization of low,
moderate, or high is based on the preponderance of factors for
the individual. However, clinical judgment may justify the use
of one factor (e.g., frequent exposure to cariogenic snacks, ≥1
interproximal lesions, and low salivary flow) in determining
the overall risk.[39]
The Cariogram model
The Cariogram model was first presented by Brathall as a
graphical illustration of an individual’s risk of developing new
caries lesions in the future. It also simultaneously expresses the
extent to which the different etiological factors of dental caries
affect caries risk for that particular individual.[40]
The original Cariogram pie chart had three differently
colored sectors representing the primary factors in
caries etiology  –  bacteria  (red), sugars  (blue), and host
susceptibility  (light blue). This was later modified to
include two more sectors  –  a yellow sector representing
circumstances  (past caries experience and general health
status), while a green sector representing “Percent Chance
to Avoid Cavities.” The size of the green “Chance” sector
is determined by the size of the other four sectors, and by
reducing or modifying the size of these sectors, one can
increase the “Percent Chance to Avoid Cavities.”
The Cariogram is an interactive computer‑based program
that calculates the “Percent Chance to Avoid Cavities”
after entering a number of scores for different risk factors.
The results come out based on “weighted” values. These
“weights” are a result of literature reviews using an
evidence‑based approach, in combination with clinical
experience of evaluating dental caries including the use of
saliva tests.
The Cariogram model is a valuable educational tool to
demonstrate to patients the different etiological factors of
dental caries and how the patient’s caries risk status can change
as a result of various preventive actions he/she may undertake.
A  study to assess caries risk in schoolchildren using the
Cariogram concluded that it predicted caries increment more
accurately than any other single‑factor model.[49]
Caries Assessment and Risk Evaluation test
While the above‑mentioned risk indicators are still of primary
importance in assessing individual caries risk status, several
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Suneja, et al.: CRA: Rationale, indications, methods, protocol
Table 1: Caries risk indicators: Pathological vs. protective factors
Pathological factors
Dietary factors
Frequent between meal snacking[8]
Prolonged night‑time or at will bottle/breast feeding of infant[9,10]
Multiple sugar exposures through the day[11]
Infant Ready availability of cariogenic snacks[12]
Socioeconomic factors
High caries risk in siblings/parents[13]
Children from socioeconomically deprived or immigrant
backgrounds[14,15]
High maternal MS levels[16,17]
Low dental aspirations especially on the importance of maintaining
caries free primary dentition
Fluoride exposure
No exposure to fluoridated drinking water[19]
No access to professionally applied topical fluorides especially when
permanent molars erupt delaying post‑eruptive maturation[20]
Medical factors
Special child (i.e. a child with a physical,mental, or medically
compromising condition that may limit oral health care measures or
make the child more susceptible to caries.)[25]
Salivary dysfunction caused by medications, radiation therapy or
general systemic conditions[26]
Long term cariogenic medication[27]
Salivary factors[28]
High salivary MS & Lactobacilli counts
Poor salivary flow rate impeding clearance
Clinical factors
Early colonization of infants teeth by MS[29,30]
Presence of dental appliances[31] or restorations[32]
Deep retentive pits and fissures
New carious lesions or white spot lesions every 6 months
studies have also shown a strong, statistically significant,
genetic component determining caries experience.[50,51] This
may be especially important in developed societies that have
a good dental coverage, adequate fluoride exposure, and
where gross malnutrition and negligent oral hygiene are rare;
increasing the role a child’s genes may play in determining
his or her caries susceptibility. Evaluating a child’s genetic
susceptibility to dental caries may thus play a vital role in
assessing the child’s overall caries risk status.
Researchers at the Division of Diagnostic Sciences of the
University of Southern California School of Dentistry
developed a novel salivary test for genetic CRA called the
CARE test[41] based on the high correlations they found between
caries history and quantities of specific oligosaccharides
in whole saliva.[52] Certain salivary oligosaccharides are
known to facilitate bacterial attachment and colonization of
the salivary pellicle, while other salivary sugar chains promote
212
Protective factors
Sugar exposures are limited to meal times
Preference for non‑cariogenic snacks
No deleterious bottle/breast feeding of the infant
Good oral hygiene in parents with adequate knowledge about dental
health & prevention
Regular access to a well‑established dental home[18]
Presence of continuous, low concentration of free F‑ ions around teeth
especially at the time of a cariogenic acid attack[21]
Daily use of a fluoridated dentifrice[22]
Living in an area with community water fluoridation[23,24]
Institution & maintenance of an intensive preventive regimen in the
special child
Saliva substitutes
Alternate sugar‑free medications
Salivary buffers that aid in neutralizing acids
Salivary proteins and lipids that form pellicle & protect tooth surface
Salivary Calcium & Phosphate ions can enhance remineralization & delay
demineralization
Early sealant application in all susceptible pits & fissures[33]
Use of antibacterial compounds (e.g. xylitol, chlorhexidine, povidone
iodine, sodium bicarbonate) in children with active caries lesions[34,35]
Measures to interfere with vertical (mother to child) transmission of
cariogenic bacteria[36]
agglutination and removal of free bacteria. In the case of the
former, there is a positive correlation with caries experience,
while for the latter, a negative correlation is seen.[53,54] Since the
pattern of these salivary oligosaccharides is 100% genetically
determined,[55] identifying individual salivary oligosaccharide
concentrations can help determine the genetic risk of the child
to develop caries. It was also established that, just like blood
group types, the salivary oligosaccharide patterns remain
quantitatively consistent over time and across age groups.[56]
The CARE test is probably the only CRA method that can
potentially promote caries prevention at the primary level
itself (before any carious lesions have appeared), by identifying
high caries risk children early and instituting a preemptive
aggressive preventive regimen in them. The widespread
incorporation of the CARE test in clinical practice and its use
in conjunction with other more traditional risk assessment
methods is probably the future of dental CRA.
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Suneja, et al.: CRA: Rationale, indications, methods, protocol
Caries management protocol for infants and children
In the modern day clinical practice, the focus of any caries
management protocol should rely more on a “medical” rather
than solely on a “surgical” approach to the treatment of dental
caries.[1] This change has occurred due to a paradigm shift in
our understanding of two important aspects:
• The principal mechanisms by which fluorides bring about
their cariostatic action, where its topical role is emphasized
over any presumed systemic benefit[57,58]
• The chronic, infectious, transmissible, and multifactorial
nature of dental caries where the interplay between
demineralization/remineralization factors will determine
whether caries progresses or not.[7]
The AAPD has developed one of the best clinical protocols for
the management of caries in different age groups of infants and
children. These protocols were evolved from evidence‑based
peer‑reviewed literature, considered judgment of expert panels,
and clinical experience. Following these protocols will enable
dentists treating children to make standardized diagnostic,
preventive, and restorative recommendations depending on
child’s risk status and the compliance expected from parents.[39]
Caries management protocols need to be constantly evolving
based on the latest evidence‑based research and should also
reflect newer therapeutic modalities. The application of casein
phosphopeptide‑amorphous calcium phosphate products for
its positive effect on the demineralization/remineralization
caries cycle,[59] using more effective fluoride compounds such
as silver diamine fluoride,[60] or the potential of antimicrobials
to reverse caries[35] are some of the innovative technologies that
may be included in the future caries management protocols.
On the other hand, some of the current recommendations such
as use of systemic fluoride supplements may be avoided in the
future protocols.[61]
Caries Management by Risk Assessment
The science of CAMBRA deals with caries management
using risk assessment protocols for diagnosis, treatment, and
prevention, including nonsurgical means for repairing or
remineralizing tooth structure. So, with CAMBRA methodology,
evidence‑based CRA is followed by specific treatment
recommendations, for example, behavioral, chemical, and
minimally invasive procedures. This will further establish
the balance of pathologic and protective factors back to favor
health.[42] The introduction of CAMBRA involved the production
of CRA forms for clinicians to use in practice. One form was
designed to use with newborns to children aged 5 years[44] and
the second for patients aged 6 years through adulthood.[47]
Traffic light matrix
This is a commonly used CRA tool in Australia. It uses color
codes such as red, green, and orange to convey specific
threshold values for data obtained in the analysis. The objective
is to alert the clinician regarding the current risk status. The
model is designed to keep the visual interpretation simple and
easily communicable to the patient. It is based on 19 criteria
in 5 different categories including saliva (6 criteria), plaque
Indian Journal of Dental Sciences  ¦  Volume 9  ¦  Issue 3  ¦  July-September 2017
(3 criteria), diet (2 criteria), fluoride exposure (3 criteria), and
modifying factors (5 criteria).[43]
• Saliva:  (a) Resting: Hydration, viscosity, and pH
(b) stimulated: Quantity/rate, pH, and buffering capacity
• Plaque: PH, maturity, and bacteria – mutans count
• Diet: Number of sugar and acid exposures in‑between
meals/day
• Fluoride: Exposure to fluoride through water/toothpaste/
professional treatment
• Modifying factors: Drugs that reduce salivary flow,
diseases resulting in dry mouth, fixed/removable
appliances, recent active caries, and poor compliance.
The specific threshold values for the data obtained in the
analysis of the aforementioned factors are conveyed in traffic
light color codes conveying varying risk levels (red = high,
yellow = moderate, and green = low). This color code model
keeps the visual interpretation simple and communicable to
the patient as well.
Conclusion
The paradigm change in our understanding of dental caries and
its prevention and treatment makes it mandatory for all dentists
treating infants, children, adolescents, and adults to incorporate
CRA into their clinical practice and utilize risk‑based caries
management protocols to make diagnostic, preventive, and
restorative recommendations for their patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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