Caries risk assessment: How and when?
Professor Svante Twetman
Head of Department of Odontology at the Faculty of Health Sciences, University of Copenhagen, DEN
Risk assessment is an essential component in the decision-making process for the prevention and management of dental caries. Multiple risk factors and indicators based on diet, oral hygiene and past caries experience have been proposed as predictors for future caries, varying with the age group at which they are targeted.
How?? Systematic reviews have concluded that there is a strong body of evidence to support that caries experience is the single best predictor for future caries development and that the usefulness of additional risk factors is questionable in schoolchildren and adolescents. In preschool children however, prediction models which include a variety of risk factors seem to increase the accuracy of the prediction. Family caries experience, transmission-related behavior, mutans streptococci counts, dietary habits, health beliefs, low family income and inadequate exposure to fluoride are important factors to consider for a comprehensive risk assessment in toddlers and preschool children.
When?? Longitudinal clearly show that less than half of the children remain in the same risk category over a period of time. Consequently, regular risk assessments are needed in order to make appropriate decisions on recall intervals and to develop an individualized and targeted preventive management plan.
Key messages from the lecture
- Risk assessment is an essential component for the prevention and management of caries.
- Definition of Risk Factors & Risk Indicators
- Risk Factors: variables that are of proven value for detection of disease, established in prospective studies.
- Risk Indicators: variables established in cross-sectional studies as being associated with disease.
- Why is this important? Because even if risk factors exhibit a very strong association with the disease, they are not necessarily useful as predictors! In most cases not!
- Caries Risk Assessment(CRA) models include a combination of risk factors:
- Fluoride exposure
- Behavior factors
- Social factors
- Genetics
- Diet
- Biofilm activity
- Saliva
- But...the perfect method is missing!
- The best, but far from optimal, predictor is still past caries history
- Risk Category is determined by: Case History + Clinical Findings + Supplementary Tests (Biochemical findings)
- Simple, user-friendly protocols:
- CAT
- CAMBRA
- CariFree
- These are just examples, many clinics have their own but very few are validated. The key thing is to keep it quick and simple, otherwise dental professionals will skip it.
- The predictive accuracy is higher for preschool children than at higher ages.
- In toddlers and preschool children prediction models should include a variety of risk factors (family caries experience, transmission-related behavior, mutant streptococci load, dietary habits, health beliefs, family income and exposure to fluoride) for increased accuracy of prediction.
- Caries Risk Assessment has 70% sensitivity and 80% specificity (more accurate for low risk). These are average values for schoolchildren but both sensitivity and specificity can be higher for prediction models in preschoolers.
- When should Caries Risk Assessment be performed? More than 50% of children change risk category over 2 years, therefore regular risk assessment is necessary. Caries Risk Assessment should be performed in the following time points:
- 1-3 years (20 new teeth)
- 5-7 years (4 new surfaces)
- 12-15 years (76 new surfaces including 32 proximal)
- Before onset of orthodontic treatment
- At onset of chronic disease (e.g. asthma, diabetes Type I)
Free computer-based programs (such as Cariogram) are available for performing CRA. They do not increase the accuracy but the process can be handled by the whole dental team (dentist, dental hygienist, assistant..). In addition, these programs appeal to patient and allow interactive understanding and motivation
