Colgate Dental Education Programs | Special topic No.

10

Australian Research Centre for Population Oral Health

Caries Risk Assessment for Children:
Information for Oral Health Practitioners
There has been a reduction of dental caries experience in Australia Risk Indicators:
over the last half century. It is no longer unusual for children to have no
dental caries experience. The use of fluoride in public water supplies, > Past caries experience: This has been the most consistent
dentifrices and professional products, improvement of oral hygiene predictive factor observed in caries risk assessment studies3.
practices as well as increased access to dental care have played a However, it is not particularly useful in young children as determining
major role in this dramatic improvement1. However, dental caries still caries risk before the disease manifests is much important in them.
remains one of the most prevalent chronic diseases in children. White spot lesions are considered good indicators to predict future
caries development in young children4.
The skewed distribution of dental caries underpins the usefulness of
caries risk assessment (CRA) both for individuals and groups. Early > Socioeconomic status (SES): Most dental studies use,
identification of subjects with different caries risk levels is important for low, middle or high socioeconomic advantage as a measure of
planning appropriate preventive measures for individual needs whereas SES. Research shows an inverse association between caries and
CRA-driven dental care programs, at population level, may be more SES levels indicating a higher caries experience in both primary
efficient and cost-effective. and permanent teeth among children who are socioeconomically
disadvantaged5.
One of the aims of the CRA for children is to maintain good oral health
of the low-risk individuals while trying to improve the oral health of > Sugar consumption: The quantity of sugar consumption as well
high-risk children by providing targeted oral care usually through more as the frequency of sugar intake contributes to dental caries. The
frequent visits. relationship between sugar consumption and caries in developed
countries has long been viewed as a positively linear one – the

Why CRA should be used? more the consumption and the higher the frequency the greater the
caries severity. Since the last decade, this linear relationship has
Categorising patients by their risk of caries has been advocated as been affected by fluoride exposure with most studies reporting a
an initial step in determining appropriate preventive and treatment moderate or weak relationship between sugar consumption and
interventions. Identifying and determining risk should be a component caries6. However, consumption of beverages with high sugar content
in the clinical decision-making process because2: such as soda pop or powdered beverage concentrates made with
> CRA and clinical examination provide an overview of exposures to sugar was associated with progression of dental caries7,8. Recently,
potential caries risk/protective factors such as plaque, frequency WHO guideline on sugar intake for adults and children concluded
of sugar intake, and exposure to fluoride while encouraging that even a small reduction in risk of dental caries due to less
management strategies developed specifically for the patient. consumption of sugar in childhood is of significance in later life9.

> CRA is useful to evaluate the degree of the patient’s risk of > Oral hygiene habits: The available evidence does not
developing caries to determine the intensity of the treatment and demonstrate a clear and consistent relationship between oral
frequency of recall appointments or treatments. hygiene and dental caries prevalence10. The reported association
with tooth brushing frequency is more likely due to use of fluoridated
> CRA helps in identifying the main aetiological agents that contribute toothpaste11.
to the disease and/or in determining the type of treatment and
in making restorative treatment decisions including whether to > Bacteria: Streptococcus Mutans and Lactobacilli, the main
intervene or not, preparing cavity designs and selecting dental bacteria that are involved in the caries process, are constituents
materials. of the normal flora. Therefore caries is considered as a bacterial
ecologic imbalance rather than as an exogenous infection5. At
> CRA can improve the reliability of the prognosis of the planned a population (group) level, total bacterial count has been weakly
treatment and assess the efficacy of the proposed management and associated with caries experience12 . At the individual level, bacterial
preventive treatment plan at recall visits. count is a poor predictor of future caries13. Mutans Streptococci
CRA models currently involve a combination of risk indicators and levels and the age of colonization with cariogenic flora are valuable in
protective factors that interplay with a variety of social, cultural, and assessing caries risk, particularly in very young children14.
behavioural factors.

seek LIGHT
> Saliva: No variation in a single salivary component in a healthy > Modifying factors: drugs that reduce salivary flow, diseases
population has been shown to be a significant predictive factor. resulting in dry mouth, fixed/removable appliances, recent
Nevertheless decreased salivary function, as manifested by extreme active caries and poor compliance
xerostomia, is a consistent predictor of high caries risk10. Despite the Figure 3 shows a modified form developed by GC Asia Dental Pty Ltd
fact that normal salivary flow is an extremely important intrinsic host (2007) to assess caries risk using TLM incorporating patient motivation
factor providing protection against caries, there is little information and compliance22.
about the prevalence of low salivary flow in children15.

Protective factors: Recommendations

> Fluoride: The protective effect of water fluoridation has been well > Dental caries-risk assessment, based on a child’s age, biological
documented in major systematic reviews and fluoridated toothpaste factors, protective factors, and clinical findings, should be a routine
has been accepted as a benchmark intervention for the prevention component of new and periodic examinations by oral health
of dental caries16. Professional topical fluoride applications and practitioners.
fluoride varnishes are also effective in reducing caries17.
> Oral health practitioners should determine the types and frequency
> Fissure sealants: Sealants are universally recognized as an of diagnostic, preventive, and restorative care for their patients.
evidence-based method to boost the tooth’s resistance to carious Clinical management of caries should be based on child’s age and
lesions in pits and fissures of the teeth. Extensive research has caries risk level.
shown a caries protective benefit from fissure sealants18.
> As none of these CRA tools are unequivocally accepted,
practitioners are advised to use their own clinical experience and
What CRA tools are available in the market? judgement in choosing a tool, assessing caries risk and making
clinical decisions.
Currently there are four commonly used CRA tools.

> Caries Risk Assessment Tool (CAT): This tool was

Table 1. Caries risk assessment form based on CAT19
developed by the American Academy of Paediatric Dentistry
(AAPD)19. Depending on the age of children CAT incorporates Factors Risk
High Moderate Low
three factors in assessing caries risk, namely, biological as well as
Biological
protective factors and clinical findings (Table 1).
Mother/primary caregiver has active caries (for Yes
> Caries Management by Risk Assessment (CAMBRA): child only)
This has been designed to use with newborns to children aged five Parent/caregiver/patient is of low SES Yes
years20. CAMBRA is essentially based on the same factors as CAT Child has >3 between meal sugar-containing Yes
snacks or beverages per day
to assess caries risk (Figure 1).
Child is put to bed with a bottle containing Yes
> Cariogram: This graphically illustrates as a pie-circle diagram natural or added sugar
a patient’s risk of developing new caries while simultaneously Child/patient has special health care needs Yes
expressing the contribution of different factors on the caries risk for Child/patient is a recent immigrant Yes
that particular patient21. A cariogram is divided into five colour-coded
Protective
sectors – green, dark blue, red, light blue and yellow – representing
Child/patient receives optimally-fluoridated Yes
factors that of relevance for caries. These factors are assigned a drinking water or fluoride supplements
score based on a stipulated scale and entered into an interactive Child/patient brushes teeth daily with fluoridated Yes
PC-program, which produces a pie-diagram. Table 2 indicates the toothpaste
factors and the relevant information required to create a cariogram. Child/patient receives topical fluoride from health Yes
professional
Figure 2 shows an example of a cariogram.
Child/patient has regular dental care Yes
> Traffic Light Matrix (TLM): This is a commonly used Patient has additional home measures (e.g., Yes
CRA tool in Australia22. TLM is based on 19 criteria in 5 different xylitol, MI paste, antimicrobial)
categories including saliva (6 criteria), plaque (3 criteria), diet (2
Clinical findings
criteria), fluoride exposure (3 criteria) and modifying factors (5 criteria)
Child has >1 decayed/missing/filled surfaces Yes
where traffic light colours convey varying risk levels (red=high,
Child/patient has active white spot lesions or Yes
yellow=moderate and green=low). enamel defects

> Saliva: a) Resting: hydration, viscosity and pH b) Stimulated: Child has elevated mutans streptococci levels Yes

quantity/rate, pH and buffering capacity Child has plaque on teeth Yes

Patient has ≥1 interproximal lesions Yes
> Plaque: pH, maturity and bacteria – Mutans count
Patient has low salivary flow Yes
> Diet: number of sugar and acid exposures in between meals/ Patient has defective restorations Yes
day Patient wearing an intraoral appliance Yes

> Fluoride: exposure to fluoride via water/toothpaste/professional

Child= aged <6 years Patient= aged ≥6 years
treatment
Overall caries risk assessment: High Moderate Low
 u p dat e d p r oto c o l
c da j o u r n a l , vo l 3 8 , n º 1 0

Figure 1. CAMBRA risk assessment form20 Figure 2. Example of a cariogram indicating high caries risk21
tAble 2

cambRa — caries Risk assessment Form for age 0 to 5 years

Patient Name:________________________________________________________________________________________________ ID#_________________________ Age: ________________________ Date: __________________________

Assessment Date: ________________________________________________________________ Please circle: BASELINE, three-month follow-up or six-month follow-up

1 2 3
nOtE: any one yes in column 1 signifies likely “high Risk” and an Yes Yes Yes Comments:
indication for bacteria tests =CIRCLE =CIRCLE =CIRCLE
1. Risk Factors (biological Predisposing Factors)
(a) Mother or primary caregiver has had active dental decay in the past Yes
12 months*
(b) Bottle with fluid other than water, plain milk and/or plain formula Yes Type of fluid:
(c) Continual bottle use Yes
(d) Child sleeps with a bottle, or nurses on demand Yes
(e) Frequent (>3 times/day) between-meal snacks of sugars/cooked Yes #times/day:
starch/sugared beverages
(F) Saliva-reducing factors are present, including: Yes
1. medications (e.g., some for asthma [albuterol] or hyperactivity)
2. medical (cancer treatment) or genetic factors
(g) Child has developmental problems/CSHCN (child with special health Yes
care needs)
(h) Caregiver has low health literacy, is a WIC participant and/or child Yes
participates in Free Lunch Program and/or Early HeadStart
2. Protective Factors
(a) Child lives in a fluoridated community or takes fluoride supplements Yes
by slowly dissolving or as chewable tablets (note resident ZIP code)
(b) Child drinks fluoridated water (e.g., use of tap water) Yes
(c) Teeth brushed with fluoridated toothpaste (pea size) at least once daily Yes
(d) Teeth brushed with fluoride toothpaste (pea size) at least 2x daily Yes
(e) Fluoride varnish in last six months Yes
(f) Mother/caregiver chews/dissolves xylitol chewing gum/lozenges Yes
2–4x daily
3. disease indicators/Risk Factors – clinical Examination of child
(a) Obvious white spots, decalcifications enamel defects or obvious decay Yes Figure 3. TLM form for assessing caries risk22 (adapted from GC Asia Dental Pty Ltd 2007)
present on the child’s teeth*
(b) Restorations present (past caries experience for the child)* Yes
(c) Plaque is obvious on the teeth and/or gums bleed easily Yes
(d) Visually inadequate saliva flow Yes
Child’s Overall Caries Risk* (circle): High Moderate Low
Child: Bacteria/Saliva Test Results: MS: LB: Flow Rate: Ml/min: Date:
Caregiver: Bacteria/Saliva Test Results: MS: LB: Flow Rate: ml/min: Date:
Self-management goals:
1)_________________________________________________________________________ visualizE
caRiEs balancE
2)_________________________________________________________________________
*Assessment based on provider’s judgment of balance between risk factors/disease indicators and protective factors.

750 o c to b e r 2 0 1 0
Table 2. Factors and relevant information required to create a cariogram21

Factor Comment Information needed

Caries Past caries experience, including DMFT, DMFS, new
experience cavities, fillings and missing caries
teeth because of caries. Several experience in the past
new cavities definitely appearing 1 year
during preceding year should
give a high score even if number
of fillings is low
Related General diseases or conditions Medical history,
diseases associated with dental caries medications

Diet, contents Estimation of the cariogenicity Diet history,

of the food, in particular sugar lactobacillus test count
contents

Diet, frequency Estimation of number of meals Questionnaire results,

and snacks per day, mean for 24- hour recall or
‘normal days’ dietary recall (3 days)

Mutans Estimation of levels of mutans Strip mutans test or

streptococci streptococci (Streptococcus other laboratory tests
mutans, Streptococcus giving comparable
sobrinus) results
in saliva, for example using
Strip mutans test
Fluoride Estimation of to what extent Fluoride exposure,
program fluoride is available in the oral interview patient
cavity over the coming period
of time

Saliva secretion Estimation of amount of saliva, Stimulated saliva test –

e.g., using paraffin-stimulated secretion rate
secretion and expressing
results as milliliter saliva per
minute

Saliva buffer Estimation of capacity of saliva Dentobuff test or other

capacity to buffer acids, e.g., using the laboratory tests giving
Dentobuff test comparable results

Clinical Opinion of dental examiner, Opinion of dental

judgement ‘clinical feeling’. Examiners own examiner, ‘clinical
clinical and personal score for feeling’. A pre-set score
the individual patient of 1 comes automatically
Acknowledgement:

Dr Ramos-Gomez Francisco and the Journal of California Dental

Association for granting permission to use CAMBRA risk assessment
form, Dr Gunnel Hänsel Petersson and GC AUSTRALASIA DENTAL
PTY LTD, respectively, for granting permission to use a figure of
Cariogram and a TLM form for assessing caries risk.

References

1. Spencer AJ . Skewed distributions--new outcome measures. Community Dent Oral

Epidemiol 1997;25: 52-59.

2. Zero D, Fontana M and Lennon AM. Clinical applications and outcomes of using indicators
of risk in caries management. J Dent Educ 2001;65:1126-1132.

3. Tagliaferro EP, Pereira AC, Meneghim Mde C and Ambrosano GM . Assessment of dental
caries predictors in a seven-year longitudinal study. J Public Health Dent 2006;66:169-173.

4. Nuttall N and Deery C. Predicting the experience of dentinal caries or restorative dental
treatment in adolescents using D1 and D3 visual caries assessments. Community Dent Oral
Epidemiol 2002;30: 329-334.

5. Burt BA, Eklund SA. Dentistry, dental practice, and the community. 6th ed. Elsevier
Saunders: St. Louis, 2005.

6. Burt BA, Eklund SA, Morgan KJ, Larkin FE, Guire KE, Brown LO and Weintraub JA. The
effects of sugars intake and frequency of ingestion on dental caries increment in a three-
year longitudinal study. J Dent Res 1988;67:1422-1429.

7. Levy SM, Warren JJ, Broffitt B, Hillis SL and Kanellis MJ. Fluoride, beverages and dental
caries in the primary dentition. Caries Res 2003;37: 157-165.

8. Warren JJ, Weber-Gasparoni K, Marshall TA, Drake DR, Dehkordi-Vakil F, Dawson DV and
Tharp KM. A longitudinal study of dental caries risk among very young low SES children.
Community Dent Oral Epidemiol 2009;37: 116-122.
9. Guideline: Sugars intake for adults and children. Geneva: World Health Organisation, 2015.

10. Newbrun E. Risk assessment dental caries working group summary statement. Risk
assessment in dentistry, University of Chapel Hill: North Carolina, 1990.

11. Ainamo J and Parviainen K. Occurrence of plaque, gingivitis and caries as related to self
reported frequency of toothbrushing in fluoride areas in Finland. Community Dent Oral
Epidemiol 1979;7:142-146.
12. Kohler B, Bjarnason S, Care R, Mackevica I and Rence I. Mutans streptococci and dental
caries prevalence in a group of Latvian preschool children. Eur J Oral Sci 1995;103: 264-
266.
13. Petti S and Hausen HW. Caries prediction by multiple salivary mutans streptococcal counts
in caries-free children with different levels of fluoride exposure, oral hygiene and sucrose
A joint program by
intake. Caries Res 2000;34: 380-387. Colgate Oral Care and The University of Adelaide
14. Grindefjord M, Dahllof G, Nilsson B and Modeer T. Prediction of dental caries development
in 1-year-old children. Caries Res 1995; 29:343-348.
15. Vanobbergen J, Martens L, Lesaffre E, Bogaerts K and Declerck D. The value of a baseline
caries risk assessment model in the primary dentition for the prediction of caries incidence For further enquiries
in the permanent dentition. Caries Res 2001;35: 442-450.
Dental Practice Education Research Unit
16. NHMRC. A systematic review of the efficacy and safety of fluoridation. National Institute of ARCPOH, School of Dentistry
Health and Medical Research Council: Canbera, 2007.
The University of Adelaide, SA 5005
17. Marinho VC, Worthington HV, Walsh T and Clarkson JE. Fluoride varnishes for preventing
dental caries in children and adolescents. Cochrane Database Syst Rev 2013;7:
CD002279. Phone: +61 8 8313 4235
18. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H and Makela M. Pit and fissure Enquiries: [email protected]
sealants for preventing dental decay in the permanent teeth of children and adolescents. Web: adelaide.edu.au/arcpoh/dperu
Cochrane Database Syst Rev 2004;3:CD001830.

19. American Academy of Pediatric Dentistry . Guideline on caries risk assessment and adelaide.edu.au
management for infants, children, and adolescents. Pediatr Dent 2010;32:101–108.
facebook.com/uniofadelaide
20. Ramos-Gomez F, Ng MW. Into the Future: Keeping Healthy Teeth Caries Free: Paediatric
CAMBRA Protocols. J Calif Dent Assoc 2011;39:723-733. twitter.com/uniofadelaide
21. Bratthall D, Petersson GH . Cariogram – a multifactorial risk assessment model for a
youtube.com/universityofadelaide
multifactorial disease. Community Dent Oral Epidemiol 2005;33: 256-264.

22. Australian Dental Council. Oral Health Committee Report. ADC, 2012. URL: http:// DisCLAiMER: The information in this publication is current as at the date of printing and is
subject to change. You can find updated information on our website at adelaide.edu.au
www.ada.org.au/app_cmslib/media/lib/1206/m416626_v1_nb%20(july%202012)%20 With the aim of continual improvement the University of Adelaide is committed to regular
cambra%20principals.pdf. Accessed January 2015. reviews of the degrees, diplomas, certificates and courses on offer. As a result the specific
programs and courses available will change from time to time. Please refer to adelaide.edu.au
for the most up to date information or contact us on 1800 061 459. The University of Adelaide
assumes no responsibility for the accuracy of information provided by third parties.
Diep Ha, Najith Amarasena, Ratilal Lalloo, Karen Peres.
Australian Research Centre for Population Oral Health (ARCPOH),
CRICOS 00123M © The University of Adelaide. Published Sep 2015
School of Dentistry, Faculty of Health Sciences, The University of Adelaide.