CARIES RISK ASSESMENT

Presented by:
Disha jandial
MDS 1st year
Deptt. Of pediatrics and preventive dentistry
CONTENTS
CARIES RISK ASSESSMENT

Terminology
 Goals of caries risk assessment
 Factors relevant to caries risk assessment
 Models used for caries risk assessment
CARIES RISK
ASSESSMENT
DENTAL CARIES:
 Shafer (1993) defined dental caries as an irreversible
microbial disease of the calcified tissues of the teeth,
characterized by demineralization of the inorganic portion and
dissolution of the organic substance of the tooth, which often
leads to cavitation.
TERMINOLOGY

 Caries risk: Probability of an individual to develop a carious

lesion.

 Caries risk factors: The conditions or characteristics influencing

the occurrence and progression of caries.

 Caries risk assessment: The determination of the likelihood of the

incidence of caries (i.e. the number of new carious lesions) during
a certain time period.(Reich 1999)or the likelihood that there will
be change in the size or activity of lesions already present.(Ismail
et al 2003)
 Caries activity: It is a measure of the speed of progression of
a carious lesion or increments of new carious lesions in an
individual over a given period of time.

 Caries susceptibility: The inherent tendency of the host

(tooth) to be afflicted by caries process.
 CARIES RISK ASSESMENT
 Acc. to AAPD, identifying risk factors for caries should be an
essential component of ethical dental practice.
 Caries assesment tools(CAT) can be used that will assist
clinicians not only with identifying individuals at risk but also
help managing the preventive protocol.
Goals of caries risk assesment
 Classify individuals into high/moderate/low risk after
screening.
 Make patient aware of their risk for developing caries, thus
motivating them for preventive care.
 Help design a preventive program.
 Assess impact of caries control measures.
 Aids in selection of patients for caries study.
 Factors Relevant to Caries Risk Assessment
High Risk low Risk
Social History
Low socio-economic status High socioeconomic status
High caries in siblings Low caries in siblings

Low knowledge of dental disease Dental awareness

Irregular attendee Regular attendee

Medical History
Medically compromised No medical problem
Handicapped No physical problem
Xerostomia Normal salivary flow
Long-term cariogenic medicine No long-term medication

Dietary Habits
Frequent sugar intake Infrequent sugar intake
Fluoride
non-fluoridated area Fluoridation area
No fluoride supplement Fluoride supplement used
No fluoride toothpaste Fluoride toothpaste used
Plaque Control

Infrequent ineffective cleaning Frequent effective cleaning

Poor manual control good manual control
Saliva
Low flow rate Normal flow rate
20
Low buffering capacity High buffering capacity
High Streptococcus Mutans
and lactobacillus count Low Streptococcus Mutans. and Lactobacillus counts
 MODELS USED FOR CARIES RISK
ASSESMENT:
A. CARIOGRAM
B. CAMBRA(caries management by risk
assessment)
C. Caries risk assessment tools.
D. ICDAS
E. ICCMS
F. Traffic light matrix model (TL-M)
G. Caries activity tests
 CARIOGRAM
 Developed By BRATHALL (1996).
 Computer based tool that depicts the interaction of caries
provoking factors and probability of developing new carious
lesion.
 Represented by pie chart in 5 sectors.
 Each category is assigned one colour.
 RED : Amount of plaque and S. Mutans
 DARK BLUE: Diet factor (diet contents and frequency).
 LIGHT BLUE: Salivary factors, their secretions, buffer
capacity.
 YELLOW: combination of past caries experience & other
related factors.
 GREEN: Chance to avoid new cavities.
 CASE REPORT

 Case : Patient ,Male, 28 years old, fireman.

 The patient is a 28 years old fireman with irregular working-
hours. He is fit and takes no medicines. He says that he
”always has had many holes (cavities) in his teeth”. Clinically,
one can see buccal lesions in the lower jaw. The x-rays show
proximal, incipient caries. He uses fluoride toothpaste and
brushes his teeth twice a day. Irregular food intake. Smoker.
Caries experience Many caries lesions.
5 years since last visit to a dentist.

Related diseases The patient is ‘healthy’, no medical

treatment
Diet, contents Improper diet from a caries
perspective. 10 cups of coffee
every day with sugar.

Diet, frequency Irregular food intake, snacks often

Bacteria, amount Brushes twice a day. No inter

proximal tooth cleaning. Plaque
index 2.
Mutans streptococci Class 2.
Fluoride programm Uses fluoride toothpaste, no other
fluoride treatment.

Saliva secretion Normal (2,2 ml/min).

Saliva buffer Reduced buffering capacity
capacity (green).
 AIMS

 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 dental clinic.
 Can be used as an educational programme.
 INTERPRETATIONS

 All the five factors are calculated from patients record and
examination.
 Bigger the GREEN color -- Better the dental health.
 Small GREEN color -- High Caries risk.
 For other categories, smaller the percentage, better the
dental health.
 Mieravet AR et al in 2007 said that the past caries experience,
Streptococcus mutans count, fluoridation programme and buffer
capacity of the saliva are the factors included in the Cariogram
that showed significant correlation with the caries risk determined
by the program.

Mieravet AR, Letra A, Rose EK, Brandon CA, Resick JM, Marazita ML, Vieira
AR. Inherited risks for susceptibility to dental caries. Caries Res. 2007;42:8–
13.
•Caries management by risk assessment (CAMBRA) is an

evidence-based approach towards preventing or treating the

cause of dental caries at the earliest stages rather than waiting
for irreversible damage to the teeth.
 In April 2002, A group of experts designed a caries risk
assessment form and proposed its use based upon the
known literature at that time.
 One form was designed for patients 6-years-old through
adulthood, and a second was for patients 0-5.
 Later on,the form was modified for infants and toddlers
targeting 0-5, and has added a treatment protocol.
CAMBRA TREATMENT GUIDELINES FOR >6YRS:

LOW CARIES RISK

 Dear (Patient X)

■ Brush twice daily with a fluoride-containing toothpaste.

■ Review your dietary and oral hygiene habits and receive

oral hygiene instructions. If good, continue with your

existing dietary and oral hygiene habits unless there is a

change in status, such as new medications.

■ Get a thorough professional cleaning as needed for your

periodontal health.

■ Return for a caries recall exam (when requested) in six to 12

months
■ Have new bitewing radiographs (X-rays) taken about every 24
to 36 months to check for cavities.
■ Consider using xylitol gum/candies and fluoride rinse (0.05
percent sodium fluoride) instead of regular gum/candy or
mouthwash
 Get fluoride varnish after teeth cleanings, base line bacterial
test, sealants if your dentist recommends it.
 Moderate caries risk
 ■ Review your dietary and oral hygiene habits with us and
receive oral hygiene instructions.
 ■ Brush twice daily with a fluoride-containing toothpaste,
following the oral hygiene instruction procedures you have
been given.
 ■ Purchase a fluoride rinse (0.05 percent sodium fluoride,
e.g. Fluoriguard) and rinse with 10 ml (one cap full) once
or twice daily after you have used your fluoride toothpaste.
 Get a thorough professional cleaning from us as needed
for your periodontal health.
 ■ Chew or suck xylitol-containing gum or candies four
times daily.
 ■ Return when requested for a caries recall exam in three
to six months to re-evaluate your progress and current
caries risk.
 ■ Get new bitewing radiographs (X-rays) about every 12-
18 months to check for cavities.
 Get a fluoride varnish treatment every four to six months at
your caries recall exams.
 You may also need a base line bacterial test and sealants
(depending on your situation and condition).
 High caries risk
 ■ Complete a caries bacterial test with us today (as a base line
before antibacterial therapy). We will have the results of this
test in three days.
 ■ Complete a saliva flow measurement to check for dry
mouth.
 Brush twice daily with a high fluoride toothpaste, either
Control RX or Prevident Plus toothpaste (5,000 parts per
million fluoride).
 ■ Rinse for one minute, once a day with a special antibacterial
mouthrinse that we will provide for you today. It is called
Peridex and has an active ingredient called chlorhexidine
gluconate at 0.12 percent
 Have the necessary restorative work done, such as fillings
or crowns.
 ■ Suck or chew xylitol candies or gum four times daily. .
 ■ Get sealants applied to all of the biting surfaces of your
back teeth to keep them caries free.
 Return when requested for a caries recall exam in three to
four months to re-evaluate your progress and current
caries risk.
 ■ Participate in another caries bacterial test at your caries
recall exam or earlier to compare results with your first
visit. This will allow us to check whether the
chlorhexidine is working satisfactorily.
 ■ Allow us to review your use of chlorhexidine and
Control RX/Prevident and oral hygiene at that visit.
 ■ Get a thorough professional cleaning as needed for your
periodontal health.
 ■ Get new bitewing radiographs (X-rays) about every six to
12 months to check for cavities.
 ■ Get a fluoride varnish treatment for all of your teeth every
three to four months at your caries recall exams
CARIES RISK ASSESSMENT TOOLS
 Caries Risk Assessment Tool (CAT): This tool
was developed by the American Academy of
Paediatric Dentistry (AAPD) in 2006.

 Depending on the age of children CAT

incorporates three factors in assessing caries
risk, namely, biological as well as protective
factors and clinical findings
FACTORS:

 Biological –

 Patient has >3 in between meal sugar-containing snacks or

beverages per day.
 Patient has special health care needs
 Patient is a recent immigrant (water-fluoride)
 Protective-

 Patient receives optimally-fluoridated drinking water

 Patient brushes teeth daily with fluoridated toothpaste
 Patient receives topical fluoride from health professional
 Patient has dental home/regular dental care
 Clinical Findings:

 Patient has >1 interproximal lesions

 Patient has active white spot lesions or enamel defects
 Patient has low salivary flow
 Patient has defective restorations
 Patient wearing an intraoral appliance
Caries risk assessment tools : 6-20 years
TRAFFIC LIGHT MATRIX(TL-M)
MODEL

 TL-M model offers a systemic approach to the

assessment of all the risk factors predisposing to
caries.
 Traffic light colours convey varying risk levels
(red=high, yellow=moderate and green=low).
 Concept is based on existing risk assessment models along
with an assessment of patient motivation and life style
activities.
 Matrix of the TL-M model is designed to assess the patient’s
present disease status and attitude to maintain their own dental
health
 Attitude towards dental health is scored as A, B or C
 The current disease status is scored as 1, 2 or 3
 MATRIX COMPONENT
CURRENT DISEASE STATUS:
1. No current disease

2. Need for repair

3. Active disease.

ATTITUDE TOWARS DENTAL HEALTH:

A. Yes

B. May be

C. No
 Sixteen risk factors, grouped under five headings, are:
SALIVA
 Ability of minor salivary glands to produce saliva.
 Consistency of Saliva
 PH of saliva
 Salivary flow rate
 Buffering capacity of saliva
DIET
 No. Of sugar exposures per day

 No. Of acid exposures per day

FLUORIDE
 Past and current exposure.

ORAL BIOFILM
 Differential staining
 Composition
 activity
 MODIFYING FACTORS
 Lifestyle

 Past and current dental status

 Past and current medical status

 Compliance

 Socioeconomic status
International Caries Detection and
Assessment System (ICDAS)

 The International Caries Detection and Assessment System

(ICDAS) was developed based on a systematic review of the
available clinical caries detection and assessment systems, to
provide an international system for caries detection that would
allow for comparison of data collected in different locations at
different points in time, and to bring forward the current
understanding of the process of initiation and progression of
dental caries to the fields of epidemiological and clinical
research.
ICDAS I (2002)
Include (D) component for caries detection and (A)
component for assessment of caries process (whether cavitated
or non-cavitated and active or arrested caries). Root caries
were not included due to lack of consensus and need for
further discussions.

ICDAS II (2005)
Modified by ICDAS coordinating committee in 2005 which
describes both coronal caries and root caries.

Sebastian ST, Johnson T. International Caries Detection and Assessment System

(ICDAS): An Integrated Approach. Int J Oral Health Med Res 2015;2(3):81-84.
Root Caries (New in ICDAS II)
 ICDAS has a 2-digit coding system (X-Y).
 I.The first decision (code X; lesion detection) is to classify
each tooth surface on whether it is sound, sealed, restored,
crowned, or missing.
 II.The second decision (attributed to code Y; lesion
assessment) that should be made for each tooth surface is the
classification of the carious status on an ordinal scale.
Decision I
DECISION 2
 Example
 A tooth restored with amalgam, which also exhibits an
extensive distinct cavity with visible dentin will be coded 4
(for an amalgam restoration) and 6 (for a distinct cavity).
International Caries Classification and Management
System (ICCMS™)
 The mission of the International Caries Classification and
Management System (ICCMS™) is to translate the current
international understanding of the pathogenesis, prevention
and control of dental caries in a holistic way through a
comprehensive assessment and personalized caries care plan.
This is in order to:
  prevent new lesions from appearing
  prevent existing lesions from advancing further
  preserve tooth structure with non-operative care at more
initial stages and conservative operative care at more
extensive carious stages
 ELEMENTS OF ICCMS
 HISTORY
 CLASSIFICATION –caries staging and assessment.
 MANAGRMENT-Personalised caries prevention and
control and tooth preserving operative care
1.History-patient level caries risk assessment
2.CLASSIFICATION-Risk assessment AND
STAGING
 ICMMS embrases the CAMBRA philosophy for
caries risk assessment
 Low risk
 Moderate risk
 High risk
CLINICAL
STAGING:
RADIOGRAPHIC
STAGING:
3.MANAGEMENT
 The ICCMS tooth preserving operative principles should
guide decisions for all restorative care.

 In the active extensive lesions where there is a risk of vital

pulpal exposure, stepwise or partial excavation of caries
should be carried out.
 Wherever possible, exposure of the dental pulp should be
avoided.
 Practitioners may choose from a package of non-operative
care (NOC) and TPOC interventions.
MANAGEMENT:
Sound NO TREATMENT
Initial Clinically applied topical fluoride
Oral hygiene with fluoridated dentifrice
(1000 ppm)
Mechanical removal of biofilm
Resin-based sealants
Moderate Resin based sealants
Determine cavitation for appropriate
management options
If no cavitation: NOC.
If cavitation: TPOC (minimally invasive
treatment with no or minimal dentin
removal)
Extensive TPOC(invasive caries management with
dentin removal)

NOC = Non-Operative Care

TPOC = Tooth-Preserving Operative Care
 CRA is still in a developmental stage, hence no single
model can be recommended for use in clinical setting at
this time.
 However, if used routinely in dental practice, there will be
a shift in the dental treatment from an operative to
preventive model.
 KEY RISK AGE GROUPS
 Key-risk age group 1:Ages 1 to 2 years
 • Kohler et al (1978,1982) showed that mothers with high
salivary MS levels frequently transmit MS to their babies as
soon as the first primary teeth erupt, leading to greater
development of caries •
 It was also shown that the practice of giving infants sugar
containing drinks in nursing bottles at night increases the
development of caries (Wendt and Birkhed, 1995).

 Axelsson P. Prediction of caries risk and risk profiles. Textbook on Diagnosis and
risk prediction of Dental caries; 1st Ed 2000, vol 2:151-174
 Key-risk age group 2: Ages 5 to 7 years
 • In a study by Carvalho et al (1989), plaque

reaccumulation was heavy on the occlusal surfaces of

erupting maxillary and mandibular molars.
 Axelsson P. The Effect of a Needs-Related Caries Preventive Program in Children and Young
Adults – Results after 20 Years. BMC Oral Health. 2006; 6( 1): S1-S7 .
 Key-risk age group 3: Ages 11 to 14 years
 • Normally, the second molars start to erupt at the age of 11 to
11.5 years in girls and at around the age of 12 years in boys.
Total eruption time is 16- 18 mon.
 • During this period, the proximal surfaces of the newly
erupted permanent posterior teeth are the most caries
susceptible

 Axelsson P. The Effect of a Needs-Related Caries Preventive Program in

Children and Young Adults – Results after 20 Years. BMC Oral Health.
2006; 6( 1): S1-S7
 Key-risk age groups in young adults •
 Under certain circumstances, young adults (19 to 22 year olds)
may also be regarded as a risk age group.
 Most have erupting or newly erupted third molars without full
chewing function and with highly caries-susceptible fissures
CARIES ACTIVITY TESTS
USES OF CARIES ACTIVITY TESTS

FOR CLINICIANS:-
 To determine the need for caries control measures.
 To act as an indicator of patient cooperation.
 To aid in the determination of prognosis.
 Orthodontists can be cautioned.

FOR RESEARCHERS
 Selection of cases for study of caries .
 To help in the screening of potential therapeutic agents.
REQUIREMENTS OF CARIES ACTIVITY
TESTS
 Test should be reproducible & valid
 There should be good correlation between the
caries activity scores & actual caries development
 Should be simple
 Results should be obtained rapidly, within hours or
few days
 Should be inexpensive, non-invasive & applicable
to any clinical setting
CARIES ACTIVITY TEST
 Lactobacillus count test
 Snyder test
 Alban test
 Swab test
 Salivary mutans level test-lab test
-chair side test
-adherence test
 Salivary buffer capacity test
 Salivary reductase test
 Fosdick’s calcium dissolution test
 Dewar test
 Cariostat test
 Ora test
 Streptococcus mutans dipslide test
 Modified dip-slide test
Lactobacillus colony count test
 It was introduced by Hadley in 1933.

 Basically evaluates the lactobacilli bacteria.

PROCEDURE
 LAB METHOD:
 Saliva is obtained by chewing a piece of paraffin

 Shaken with glass beads to break up aggregates of bacteria

 Saliva is then mixed with a buffer solution and 1 ml of the dilutions

is mixed with 10 ml melted SL agar

 10 ml is then poured into the petridish.

 Incubation at 37ºC for 4 days.

 Lactobacilli appear as whitish dots on the medium.

CHAIRSIDE TEST:

 Dentocult lb method.

 Aerobic incubation for 4 days at 37ºC.

 No.of lactobacilli is estimated by comparing the slides with a

model chart supplied by the manufacturer.
 No. of Caries activity Symbolic
lactobacilli per designation
ml saliva
Little or none +
0-1000

Slight +
1000-5000

5000-10,000 Moderate ++

Marked +++ or +++

> 10,000
+
 DISADVANTAGES:

1. It does not completely exclude the growth of other relatively

aciduric organisms .

2. Requires relatively complex equipment.

3.Result takes several days.

4.costly.
SNYDER’S TEST
 It was developed by Snyder in 1951.
 It is based on the rate of acid production by
acidogenic microorganisms eg lactobacillus
 The medium contains glucose and agar
having a pH of 4.7-5
 An indicator dye, bromocresol green is
present in the medium.
 This dye changes color from green at pH
4.7- 5 to yellow at pH 4.
 Salivary sample is collected by chewing paraffin.
 A tube of snyder glucose agar is melted and then cooled to
50 °C.
 0.2 ml of saliva is added into the tube .
 The agar is solidified and incubated.
 The rate of color change from green to yellow is indicative
of the degree of caries activity.
TIME HRS. 24 hrs 48h 72h

Colour YELLOW YELLOW YELLOW

Caries Marked Definite Limited

activity
Colour GREEN GREEN GREEN

Caries Continue Continue Caries

Activity to to inactive.
incubate incubate
 ADVANTAGES:
1. Easier and an acceptable method.
2. Cost is moderate.

DISADVANTAGES:
1. Time consuming
2. Color changes may not very clear
 ALBANS TEST
It is a simplified substitute for Snyder’s test.
 Use of simpler sampling procedures, in which, the patient
expectorates directly into tubes that contain the medium.
PROCEDURE
Color change Score
Beginning of color change ( top to +
medium)

One half color change (top to bottom) ++

Three fourth color change(top to +++

bottom)

Total color change to yellow ++++

Advantages
 Simplicity
 Low cost
 Ideal for Motivational and education.

Disadvantage
 More armamentarium required
THE SWAB TEST
This test was developed by GRAINGER et al in 1965.

PRINCIPLE:-
- Based on the same principle as the snyder test.
- Measure the aciduric-acidogenic component of oral flora
after the incubation period, by employing a color
indicator
 The change in the pH following a 48 hour incubation

is read on a pH meter or the color change is read by

the use of color comparator.
PROCEDURE
 pH Caries activity
4.1 and < 4.1 Marked

4.2 to 4.4 Active

4.5 to 4.6 Slightly active

4.6 and over Caries inactive

Advantage
 No collection of saliva is necessary.
 Predict caries activity in young and uncooperative
children.
 SALIVARY S. MUTANS LEVEL TEST

PRINCIPLE:
It measures the no. of S.mutans colony forming units for detecting and
quantitating S.mutans colonized on the teeth .

Several methods are available to measure the levels of mutans

streptococci in saliva and plaque and on individual tooth surfaces .
 LABORATORY METHOD
 CHAIR SIDE METHOD
 ADHERENCE METHOD
LABORATORY METHOD-

PROCEDURE:
• Sample is obtained by the use of tongue blades (wooden spatulas).
• These are then pressed against S.mutans selective Mitus Salivarius
Bacitracin(MSB)
• The agar plates are incubated at 37ºC for 48 hours in CO2 gas
mixture.
 The test is Interpreted as:
Level of streptococcus mutans >105 /ml of saliva-
unacceptable
CHAIR-SIDE METHOD
Dentocult SM Strip Mutans test

Bacitracin discs are added to the broth at least 15 min before use

Individual is asked to chew a piece of paraffin

Plastic strip is turned around in the mouth to become contaminated.

The strip is withdrawn through closed lips , leaving a thin layer of

saliva on the strip.

The strip is incubated in the selective broth

After incubation for 48 hours at 35-37◦c , the strip with attached

colonies is compared with chart, and given a score from 0 to 3
ADHERENCE TEST

 The test infers on the ability of Streptococcus mutans to

adhere to glass surface.
 Procedure:
 0.1 ml unstimulated saliva is inoculated in MSB broth at 37°C
for 24 hours.
 After bacterial growth, the medium is removed and the cells
adhering to the glass surface are examined microscopically.
 SALIVARY BUFFER CAPACITY
PRINCIPLE:

• Buffer capacity test can be quantitated using either a Ph meter or

color indicator.
• This test measures the quantity of acid in milliliters required to lower
the Ph of Saliva through an arbitrary Ph interval, ( from Ph 7.0 to 6.0)
or the amount of acid or base necessary to bring color indicators to
their end point.
 PROCEDURE:
10ml
Lactic
5ml of
of thisacid is then
is measured into a
beaker. After correcting the ph
added to the samplethe
stimulated
meter
10ml
Lactic
5ml
ph
of this
until
of saliva of
a acid
is measured
pH of saliva
to room temperature,
is 6.0
then
is adjusted
into a
to is
7.0 by
is collected.
beaker. After correcting the ph
added
reached.
addition
stimulated
meter
ofto the samplethe
base.
saliva
to room temperature,
until
ph a pH
of saliva of 6.0
is adjusted to is
7.0 by
is collected.
reached.
addition of base.

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 EVALUATION:

There is an inverse relationship between buffering capacity of

saliva and caries activity.

The saliva of individuals whose mouths contain a considerable

number of carious lesions frequently have a lower acid buffering
capacity than the saliva of those who are relatively caries free.
ADVANTAGES :
Simple to carry out
DISADVANTAGES:

Does not correlate adequately with caries activity.

SALIVARY REDUCTASE TEST

PRINCIPLE:
-Measures the activity of enzyme reductase in salivary bacteria.
PROCEDURE

(
)
FOSDICK’S CALCIUM DISSOLUTION
TEST
PRINCIPLE

 This test measures the milligram of powdered enamel dissolved in

4 hrs by acid formed when the patient’s saliva is mixed with
glucose and powdered enamel.
PROCEDURE
DISADVANTAGE

-The test is not simple and requires trained personnel.

-The cost involved is high.
-This test is not generally suited for office procedures.
 DEWAR TEST
 Dewar modified the enamel dissolution test
measuring pH of the saliva-glucose-enamel
mixture (instead of calcium dissolution, only
pH is measured).
 The procedure is not very common.
CARIOSTAT (CAT 21 TEST)

 The method, developed by Shimono and Sobue (1974), is a

colorimetric test that determines the acidogenicity of oral
microorganisms in the plaque through changes in pH.
 PROCEDURE
 The buccal cervical surfaces of maxillary teeth of any quadrant
are wiped twice with cotton swabs.
 The swab then shifted to a container, is incubated for 48 hours at
37°C.
 A color chart is provided and the scoring is carried out in daylight.
 A blue color infers pH 6.1 ± 0.3; green 5.4 ± 0.3; yellow-green
4.7 ± 0.3 and yellow being 4.0 ± 0.3.
 Advantages
 Method is simple, effective and inexpensive.
 Can be used individually or at large scale.
 ORA TEST

This test was developed by Rosenberg et al in 1989 for estimating oral

microbial levels.

PRINCIPLE:

•It is based on the rate of oxygen depletion by microorganisms in

expectorated milk samples. In normal conditions the bacterial enzyme,

the aerobic dehydrogenase transfers electrons or proton to oxygen .

 Once oxygen gets utilized by the aerobic organisms, methylene
blue acts as an electron acceptor and gets reduced to
leucomethylene blue. This reflects the metabolic activity of the
aerobic organisms.
 PROCEDURE:
o Mouth is rinsed vigorously with 10ml of sterile milk for 30 seconds
and the expectorate is collected.
o 3ml of this is transferred to the screw cap tube with the help of a
disposable syringe.
o To this ,0.12ml of methylene blue is added, thoroughly mixed and
placed on a stand in a well illuminated area.
o The tubes are observed every 10 minutes for any color change at
the bottom using a mirror.

o The time taken for the initiation of color change within 6mm
ring is recorded.

o The higher the infection ,lesser was the time taken for the
change in color of the expectorate reflecting higher oral
microbial levels.
ADVANTAGES:
 Less time consuming.
 Economic.
 Non-toxic vehicle.
 Can be easily learnt by auxiliary personnel.

DISADVANTAGES:
 Lack of specificity.
 S. MUTANS DIP SLIDE
METHOD TEST
This is a simple and inexpensive test. Undiluted saliva is flowed
over a plastic dip slide coated with agar.
This slide is placed in a sterile tube and incubated for four days at
35°C.
GRADE S. MUTANS CFU/ML
OF SALIVA
0 Negligible

1 Less than 1,00,000

2 1,00,000 – 1,000,000

3 More than 1,000,000

 Modified dip slide test
 This test estimates the count of three microorganisms, namely
mutans streptococci, lactobacilli and Candida.

 Procedure:
 Five milliliters of paraffin-stimulated saliva sample is collected
and poured over a three compartment slide containing Mitis-
salivarius,Bouitrain agar, Rogosa agar and Sabourand dextrose
agar.

 Slide is incubated in a 5% CO2 incubator for 48 hours.

 The salivary mutans streptococci,lactobacilli and Candida counts

are obtained.
 Advantages
 The test is simple and useful for the early selection of patients.
 It is a valuable educational aid for the motivation and dietary
counseling among children.
Caries activity DISCOVERY, PROCEDURE INCUBATION INTER RESULTS
tests YEAR -PRETATION
Lactobacillus Hadley.,1933
count test
Lab test 1ml stimulated 37°C 0-1000 Little or none
saliva+rogosa agar 1000—5000 Slight
medium 5000-10000 Moderate
>10000 Marked

Chair-side test stimulated saliva 37°C 0-1000 Little or none

on each side of 1000—5000 Slight
dipslide containing 5000-10000 Moderate
rogosa agar. >10000 Marked

Fosdick’s Fosdick,1937 saliva-glucose- Shaken for 4 hrs Amount of

dissolution test enamel mixture enamel
dissolution is _
increased with
increased caries
activity
Snyder test Snyder,1951 BCGdextrose 37°C GREEN TO After 24hrs.-
agar+0.2cc YELLOW color marked caries
stimulated saliva change 48hrs.-definite
72hrs.-limited

_
Swab test Graiger,1965 Swabbing of 37°C Qualitative Marked
buccal surfaces </=4.1 Active
4.2-4.4 Slightly active
4.5-4.6 Caries inactive
Caries activity DISCOVERY, PROCEDURE INCUBATION INTER RESULTS
tests YEAR -PRETATION
Streptococcus Jensen and bratthal
mucans level test
Lab test Sample collected 37°C <10000 Score-0
with tongue 10000-100000 Score- 1
blade+Mitus 100000-1000000 Score- 2
Salivarius >1000000 Score- 3
Bacitracin(MSB)
Chairside test Test strip in vial 37°C <10000 Score-0
containing 10000-100000 Score- 1
bacitracin 100000-1000000 Score- 2
>1000000 Score- 3
Adherece test 0.1 ml 37°C No growth 0(-)
unstimulated saliva Few 1-10(+)
is inoculated in Scattered deposits 10-20(++)
MSB broth Numerous >20(+++)

Alban’s test Arthur Alban,1970 is a simplified 37°C Beginning of color +

substitute for change ( top
Snyder’s test., in
which, the patient to Medium)
expectorates One half color ++
directly into tubes change (top
that contain the to bottom)
medium
Three fourth color +++
change(top to
bottom)
Total color change ++++
to yellow)
Salivary reductase Measures the _ Blue(15min) Caries inactive
test activity of enzyme Orchid(15min) Slightly active
reductase in Red(15min) Moderately active
salivary bacteria Red(immediately) Higly active
White/pink(immed Extremely active
iately)

Salivary buffering Quantity of acid in _ _ There is an inverse

capacity test milliliters required relationship
to lower the Ph of between buffering
Saliva through an capacity of saliva
arbitrary Ph and caries activity
interval, ( from Ph
7.0 to 6.0) or the
amount of acid or
base

Cariostat Shimono and Swabbing of 37°C pH

Sobue (1974) buccal cervical Blue 6.1 ± 0.3;
lesions Green 5.4 ± 0.3;
Yellow-green 4.7 ± 0.3
yellow 4.0 ± 0.3.

Ora test Rosenberg et al in 10ml of sterile 37°C 6mm ring formed The higher the
1989 milk for 30econds at the bottom infection ,lesser
and the expectorate was the time taken
is for the change in
collected+0.12ml color of the
of methylene blue expectorate
reflecting higher
oral microbial
levels.
Modified dip slide paraffin-stimulated 5%CO2 _ salivary mutans
test saliva sample + streptococci,lactob
three compartment acilli and Candida
slide containing counts are
Mitissalivarius, obtained.
Bouitrain agar,
Rogosa agar and
Sabourand
dextrose agar.
Thank you !!