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comes research based upon the use of the
procedures in a large cohort of patients at
the School of Dentistry at the University
of California, San Francisco, was recently
published, validating the form and proce-
dures.
2
e results from this study are the
basis for the current revisions to the caries
risk assessment form and procedures pre-
sented here. e successful components
of the previous version have been re-
grouped according to the outcomes results
and are presented in . e form can
be readily adapted for use in electronic
record systems, as has been done at UCSF.
e background, rationale, and step-by-
step procedures are described as follows.
Successful and accurate caries risk
assessments have been a dream for
decades. Numerous research papers
have been written on the topic, such
as the reviews by Anderson et al. and
Anusavice.
3,4
Several forms and pro-
cedures have been suggested, some
of which are summarized in a recent
review by Zero et al.
5
Individual contrib-
aries risk assessment is the
first step in caries manage-
ment by risk assessment,
CAMBRA. e level of risk
should be used to determine
the need for therapeutic intervention and
is an integral part of treatment planning.
e management of caries following risk
assessment for 6-year-olds through adult
is described in this issue in detail in the
paper by Jenson et al. A separate form
and procedures for use for newborns
to 5-year-olds is presented in the paper
by Ramos-Gomez et al. in this issue.
A group of experts from across the
United States convened at a consensus
conference held in Sacramento, Calif., in
April 2002. is group produced a caries
risk assessment form and procedures
based upon literature available up to that
time. e results were published in 2003.
e consensus statement and supporting
review articles are available on the net:
www.cdafoundation.org/journal. is
form, or some variation of it, has been in
use in dental schools and private practices
for as long as four years. Recent out-
TABLE 1
to determine the level of risk that the
sum of these factors indicates.
7
Specific
pathologic and protective factors for
dental caries contribute to determin-
ing the balance between progression,
arrestment, or reversal of the disease.
For example, a young patient may have
poor oral hygiene but no other caries
risk factors. We would want to address
the oral hygiene issue, but this, in and
of itself, is not sufficient to put the
patient in a high-risk category. We know
that patients with high plaque levels
frequently demonstrate no evidence
of dental caries. On the other hand, a
patient with a cavitated caries lesion is
immediately put into the high-risk cat-
egory because this is a well-documented
predictor of future caries lesions.
anticipate that, with the updated form
presented here, the success will be even
higher as all of the contributing fac-
tors have been validated and ranked in
order of the odds ratios found they were
related to the formation of cavities.
Assigning a patient to a caries risk
level is the first step in managing the
disease process. A step-by-step guide
how to do this is laid out later in this
article. Before moving to the details
some overall discussion and definition
of terms are needed. is assessment
occurs in two phases: the first is to
determine specific disease indicators,
risk factors, and protective factors
each patient has. e second step is
uting factors to caries risk have been
identified over the last 30 years or so,
and a review of these was published in
two special issues of the Journal of the
California Dental Association, February
and March 2003 (www.cdafoundation.
org/journal), together with the consen-
sus statement referred to above.
6
Much
of the information has been available
for 0 to 20 years or more, but has not
been put into everyday clinical practice,
primarily because the information has
not been gathered together in a simple
form and procedure, and such combi-
nations have not been validated until
recently.
2
Utilization of risk assessment
to determine therapeutic modalities was
successful at a level of about 70 percent
in an adult population. e authors
S
A
F
E
B
A
D
W
R
E
C
e second phase of caries risk as-
sessment is by no means a mathematical
formula; it is better characterized as a
judgment based on the likely balance
between the indicators and factors
identified in the risk assessment form
() and illustrated visually in
. e risk assessment form ()
is comprised of a hierarchy of disease
indicators, risk factors, and protec-
tive factors that are based on the best
scientific evidence we have at this time.
As mentioned previously, the risk assess-
ment procedures published in 2003 have
been assessed over more than three years
and the outcomes led to the elimina-
tion of some items and to the validation
of those included here, together with
validation of the tool to assess caries
risk.
,2
e determination of high-risk
status is fairly clear. e decision to place
someone in the moderate-risk category
is sometimes not clear and different
practitioners may reasonably come to dif-
ferent conclusions. It is better to err on
the conservative side and place a patient
in the next higher category if there is
doubt. As we get more clinical data the
accuracy of these risk assessment forms
will no doubt increase even further.
e following section presents the
rationale and instructions for the use of
the form presented in : “Caries Risk
Assessment Form — Children Age 6 and
Over/Adults.”
Caries disease indicators are clinical
observations that tell about the past car-
ies history and activity. ey are indica-
tors or clinical signs that there is disease
present or that there has been recent
with frank cavities has high levels of
cariogenic bacteria, and placing restora-
tions does not significantly lower the
overall bacterial challenge in the mouth.
8
Caries risk factors are biological fac-
tors that contribute to the level of risk for
the patient of having new carious lesions
in the future or having the existing lesions
progress. e risk factors are the biologi-
cal reasons or factors that have caused or
contributed to the disease, or will con-
tribute to its future manifestation on the
tooth. ese we can do something about.
ere are nine risk factors recently
identified in outcomes measures of car-
ies risk assessment
2
listed in : )
medium or high MS and LB counts; 2)
visible heavy plaque on teeth; 3) fre-
quent (> three times daily) snacking
between meals; 4) deep pits and fissures;
5) recreational drug use; 6) inadequate
saliva flow by observation or measure-
ment; 7) saliva reducing factors (medica-
tions/radiation/systemic); 8) exposed
roots; and 9) orthodontic appliances.
If there are no positive caries disease
indicators (see above), these nine fac-
tors in sum become the determinants
of caries activity, unless they are offset
by the protective factors listed below.
ese are biological or therapeutic factors
or measures that can collectively offset
the challenge presented by the previously
mentioned caries risk factors. e more
severe the risk factors, the higher must be
the protective factors to keep the patient
in balance or to reverse the caries process.
As industry responds to the need for more
and better products to treat dental caries,
the current list in is sure to expand
in the future. Currently, the protective
factors listed in are: ) lives/work/
disease. ese indicators say nothing
about what caused the disease or how to
treat it. ey simply describe a clinical
observation that indicates the presence
of disease. ese are not pathological
factors nor are they causative in any way.
ey are simply physical observations
(holes, white spots, radiolucencies). e
outcomes assessment described previ-
ously and prior literature, highlight
that these disease indicators are strong
indicators of the disease continuing un-
less therapeutic intervention follows.
e four caries disease indictors
outlined in are: () frank cavita-
tions or lesions that radiographically
show penetration into dentin; (2) ap-
proximal radiographic lesions confined
to the enamel only; (3) visual white spots
on smooth surfaces; and (4) any restora-
tions placed in the last three years. ese
four categories are strong indicators for
future caries activity and unless there
is nonsurgical therapeutic intervention
the likelihood of future cavities or the pro-
gression of existing lesions is very high.
A positive response to any one of
these four indicators automatically places
the patient at high risk unless therapeu-
tic intervention is already in place and
progress has been arrested. A patient
school located in a fluoridated community;
2) fluoride toothpaste at least once daily; 3)
fluoride toothpaste at least two times daily;
4) fluoride mouthrinse (0.05 percent NaF)
daily; 5) 5,000 ppm F fluoride toothpaste
daily; 6) fluoride varnish in last six months;
7) office fluoride topical in last six months;
8) chlorhexidine prescribed/used daily for
one week each of last six months; 9) xylitol
gum/lozenges four times daily in the last
six months; 0) calcium and phosphate
supplement paste during last six months;
and ) adequate saliva flow (> ml/min
stimulated). Fluoride toothpaste frequency
is included since studies have shown that
brushing twice daily or more is significant-
ly more effective than once a day or less.
9
Any or all of these protective factors can
contribute to keep the patient “in balance”
or even better to enhance remineralization,
which is the natural repair process of the
early carious lesion.
. Take the patient details, the patient
history (including medications) and
conduct the clinical examination. en
proceed with the caries risk assessment.
2. Circle or highlight each of the “YES”
categories in the three columns on the
form (). One can make special
notations such as the number of carious
lesions present, the severity or the lack of
oral hygiene, the brand of fluorides used,
the type of snacks eaten, or the names of
medications/drugs causing dry mouth.
3. If the answer is “yes” to any one of
the four disease indicators in the first
panel, then a bacterial culture should
be taken using the Caries Risk Test
(CRT) marketed by Vivadent, (Amherst,
N.Y.). (*–See below or equivalent test.)
4. Make an overall judgment as to
whether the patient is at high-, moder-
ate- or low-risk dependent on the bal-
ance between the disease indicators/risk
tions in the form of a letter, based
on clinical observations and the
Caries Risk Assessment result.
8. Give the patient the sheet that
explains how caries happens ()
and the letter with your recommenda-
tions. Sample letters are given. More
details about these recommendations and
procedures are laid out in Jenson et al. in
this issue. Products that should be used
are described in detail in Spolsky et al.
9. Copy the recommendations and the
letter for the patient chart (or if you have
electronic records the various form letters
and recommendations can be generated to
be printed out custom for each patient).
0. Inform the patient of the results
of any tests. e.g., showing the patient
the bacteria grown from their mouth
(CRT test result*) can be a good motiva-
tor so have the culture tube or digital
photograph of the test slide handy at
the next visit (or schedule one for this
purpose — the culture keeps satisfacto-
rily for some weeks), or give/send them
a picture (digital camera and e-mail).
. After the patient has been follow-
ing your recommendations for three to six
months, have the patient back to reassess
how well they are doing. Ask them if they
are following your instructions, how often.
If the bacterial levels were moderate or
high initially, repeat the bacterial culture
to see if bacterial levels have been reduced.
Some clinicians report improved patient
motivation when a second bacterial test
is done initially immediately after the
first month of antibacterial treatment.
Documenting a “win in your column” early
on is a valuable tool to encourage patients.
Make changes in your recommendations
or reinforce protocol if results are not as
good as desired, or the patient is not com-
pliant. Refer to Jenson et al. this issue for
more detail on protocols and procedures.
factors and the protective factors using
the caries balance concept (see bottom
of and ). Deter-
mining the caries risk for an individual
requires evaluating the number and
severity of the disease indicators/risk
factors. An individual with caries lesions
presently or in the recent past is at
high risk for future caries by default. A
patient with low bacterial levels would
need to have several other risk factors
present to be considered at moderate
risk. Some clinical judgment is needed
while also considering the protec-
tive factors in determining the risk.
5. If a patient is high risk and has
severe salivary gland hypofunction or
special needs, then they are at “extreme
risk” and require very intensive therapy
6. Complete the therapeutic recom-
mendations section as described in the
paper by Jenson et al. this issue, based
on the assessed level of risk for future
carious lesions and ongoing caries
activity. Use the therapeutic recom-
mendations as a starting point for the
treatment plan. e products that can
be used are described in detail in Jenson
et al. and Spolsky et al. in this issue.
7. Provide the patient with thera-
peutic and home care recommenda-
*. Saliva Flow Rate: Have the patient
chew a paraffin pellet (included with
the CRT test — see below) for three to
five minutes (timed) and spit all saliva
generated into a measuring cup. At the
end of the three to five minutes, mea-
sure the amount of saliva (in milliliters
= ml) and divide that amount by time to
determine the ml/minute of stimulated
salivary flow. A flow rate of ml/min
and above is considered normal. A level
of 0.7 ml/min is low and anything at 0.5
ml/min or less is dry, indicating severe
salivary gland hypofunction. Investigation
of the reason for the low flow rate is an
important step in the patient treatment.
*2. Bacterial testing: An example (others
are currently available) of a currently avail-
able chairside test for cariogenic bacterial
challenge is the Caries Risk Test (CRT)
marketed by Vivadent. It is sufficiently
sensitive to provide a level of low, medi-
um, or high cariogenic bacterial challenge.
It can also be used as a motivational tool
for patient adherence with an antibacterial
regimen. Other bacterial test kits will likely
be available in the near future. e follow-
ing is the procedure for administering the
currently available CRT test. Results are
available after 72 hours (note: the manu-
facturer’s instruction states 48 hours, but
more reliable results are achieved if the
incubation time is 72 hours). e kit comes
with a two-sided selective media stick that
assess mutans streptococci on the blue
side and lactobacilli on the green side.
a) Remove the selective media stick
from the culture tube. Peel off the plastic
cover sheet from each side of the stick.
b) Pour (do not streak) the col-
lected saliva over the media on
each side until it is entirely wet.
c) Place one of the sodium bicar-
bonate tablets (included with the
kit) in the bottom of the tube.
d) Replace the media stick in the
culture tube, screw the lid on and label
the tube with the patient’s name, registra-
tion number, and date. Place the tube in
the incubator at 37-degrees Celsius for 72
hours. Incubators suitable for a dental
office are also sold by the company.
e) Collect the tube after 72 hours
and compare the densities of bacte-
rial colonies with the pictures provided
in the kit indicating relative bacterial
levels. e dark blue agar is selective for
mutans streptococci and the light green
agar is selective for lactobacilli. Record
the level of bacterial challenge in the
patient’s chart, as low, medium or high.
Some find it helpful for documentation
to number the pictures through 4.
One of the following letters (
)including home care recommenda-
tions should go to each patient depend-
ing on the risk category and the overall
treatment plan (refer to Jenson et al.
this issue for treatment plan details).
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J Cal Dent
Assoc
J Dent Educ
J Am
Dent Assoc
J Dental Education
J
Dent Educ
J Cal Dent Assoc
Oral Health Prev Dent
Caries Res
Caries Res
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