Preventive Dentistry Assis. Prof.

Alhan Ahmed
College of Dentistry \ University of Baghdad
5th Grad Lec. 10
Identification of High-Risk Groups for Dental Caries
Modern caries management is based on evidence-based dentistry, with a more
intense focus on prevention .
Comprehensive caries control involves focusing on the whole patient to manage the
individual risk factors of the patient to promote and maintain optimum oral health.
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.
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.
Assessment of the individual patient's current caries activity and risk of future
caries progression is an important part of recent dental practice. Always the dentist
must remember that treat patients not just individual lesions.
Risk factor
1. Risk factors: part of the causal chain or expose the host to the causal chain.
(Environmental, behavioral, biologic). Identifying these risk factors consider a good
practice to list the factors thought to be responsible for the individual's caries risk
status.
2. Risk indicators: marker that is indicative of the disease process but is not thought
to be etiological for that disease. such a previous caries experience.
Important biological and environmental risk factors include salivary flow, level
of oral hygiene, some dietary aspects and fluoride exposure, all of which are the
determinants of the disease.
Identifying biological and environmental risk factors. It is good practice to list the
factors thought to be responsible for the individual's caries risk status. This defines
what should be modified for that particular individual. It may also define factors
that cannot be modified, e.g. a dry mouth consequent to destruction of the salivary
glands. Such a patient will always be a high caries risk.
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.

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 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.
CARIES DISEASE INDICATORS
Caries disease indicators are clinical observations that tell about the past caries
history and activity.
The four caries disease indictors are:
(1) frank cavitations or lesions that radiographically show penetration into dentine.
(2) approximal radiographic lesions confined to the enamel only.
(3) visual white spots on smooth surfaces.
(4) any restorations placed in the last three years.
CARIES RISK FACTORS
The best indicators for increased risk of dental caries are:
1. Medium or high MS and LB counts.
2. Visible heavy plaque on teeth: This indicates poor oral hygiene.
3. Inadequate exposure to fluoride.
4. Frequent (>three times daily) snacking between meals.
5. Deep pits and fissures.
6. Lower socioeconomic status.
7. Inadequate saliva flow by observation or measure-ment: Saliva reducing factors
(medications/radiation/systemic)
8. 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.
9. Any physical or mental illness and any oral application or restoration that
compromises the maintenance of optimal oral health.
CARIES PROTECTIVE 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.
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. Fluoride varnish in last six months.
5. Office fluoride topical in last six months.
6. Chlorhexidine prescribed/used daily for one week each for last six months.
7. Xylitol gum/lozenges four times daily in the last six months.
8. Calcium and phosphate supplement paste during last six months.
9. Adequate saliva flow rate.
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.

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 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. '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.
1. low caries risk (few caries-risk factors present).
2. moderate caries-risk group.
3. high caries-risk.
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.
FACTORS IN CARIES RISK ASSESSMENT
Children
Low risk
• No new or incipient carious lesions in the past year.
Moderate risk (any of the following)
• One new, incipient or recurrent carious lesion in the past year.
• Deep or noncoalesced pits and fissures. •
• High caries experience in siblings •
• History of pit and fissure caries •
• Early childhood caries •
• Frequent sugar exposures •
• Decreased salivary flow •
• Compromised oral hygiene
• Irregular dental visits
• Inadequate fluoride exposure
• Proximal radiolucency
High risk

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Two or more new, incipient or recurrent carious lesions in Three or more carious
lesions in the past
• Deep or noncoalesced pits and fissures •
• Siblings or parents with high caries rate •
• History of pit and fissure caries •
• Frequent sugar exposures •
• Decreased salivary flow •
• Compromised oral hygiene •
• Irregular dental visits •
Adults
Low risk: No new or incipient lesion.
Moderate risk (any of the following):
One to two new, incipient or recurrent carious lesions during the past three years.
History of numerous or severe caries.
Deep or noncoalesced pits and fissures
Frequent sugar exposures.
Decreased salivary flow.
Irregular dental visits
Inadequate fluoride exposure.
High risk
three, or two the past year, or two or more of the following:
History of numerous or severe caries.
Deep or noncoalesced pits and fissures.
Frequent sugar exposures.
Decreased salivary flow.
Irregular dental visits.
Inadequate fluoride exposure.
Compromised oral hygiene.
Caries Risk in Children
a.Early childhood caries
Children in the age group 12-30 months have a special caries pattern that differs
from older children. Caries affects the maxillary primary incisors first primary
molars in a way that reflects the pattern of eruption.
The longer the tooth has been present and exposed to the caries challenge, the more
it will be affected. The upper incisors are most vulnerable, while the mandibular
incisors are protected by the tongue and saliva from submandibular and sublingual
glands.
b. Children
The most consistent predictor of caries risk in children is past caries experience.
There is evidence of matrilineal transmission of mutans streptococci in early
childhood. Hence, the presence of caries in the mother and siblings increases risks
for the child.
Management in Children

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 Regular brushing of tooth surfaces using a fluoride-containing dentifrice, reduces
caries risk. Conversely, inadequate exposure to fluoride confers increased risk.
Conditions that compromise the long-term maintenance of good oral hygiene are
also positively associated with caries risk. These include
1- certain illnesses.
2- physical and mental disabilities.
3- and the presence of existing restorations or oral appliances.
✓ Children with orthodontic treatment
Children undergoing orthodontic treatment with fixed appliances have an additional
risk for caries development, especially where there is frequent consumption of
sugar-containing soft drinks.
Daily tooth brushing with fluoride-containing toothpaste, combined with use of a
fluoride mouth rinse, is also the basic prevention method in this group.
✓ Patients with active caries are at special risk and consideration should be given to
the use of professional tooth cleaning with fluoride applications during visits . It
is also reasonable to suggest that orthodontic treatment is unwise in those where
current caries status designates them as high risk.