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Caries management by riskassessment

Young DA, Featherstone JDB. Caries management by risk assessment.Community Dent Oral Epidemiol 2013; 41: 112.2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd

Abstract Caries disease is multifactorial. Whether caries disease will beexpressed and damage dental hard tissue is dependent on the patients ownunique make-up of pathogenic risk factors and protective factors.Objectives:This manuscript will review the science of managing caries disease

based on assessing caries risk.Methods:The caries balance/imbalance modeland a practical caries risk assessment procedure for patients aged 6 yearsthrough adult will illustrate how treatment options can be based on caries risk.Results:Neither the forms nor the clinical protocols are meant to imply there iscurrently only one correct way this can be achieved, rather are used in thismanuscript as examples only.Conclusions:It is important to have the forms andprotocols simple and easy to understand when implementing cariesmanagement by risk assessment into clinical practice. The science of CAMBRA

based on the caries balance/imbalance model was reviewed and an exampleprotocol was presented.

Douglas A. Young1 and

John D. B. Featherstone2

1

Department of Dental Practice, Universityof the Pacific, San Francisco, CA, USA,2School of Dentistry, University ofCalifornia, San Francisco, CA, USA

Key words: caries; caries management;caries protocols; caries risk assessment;CAMBRA; remineralization

Douglas A. Young, Department of DentalPractice, University of the Pacific, SanFrancisco, 2155 Webster St. Rm. 400, SanFrancisco, CA 94115, USATel.: +1 415 749 3308Fax: +1 415 749 3339e-mail: dyoung@pacific.edu

The caries management by risk assessment (CAM-BRA) philosophy is built on the understanding that

dental caries is a disease initiated by a complex

biofilm (rather than any one pathogen), which

changes dynamically with its environment and the

local chemistry of the tooth site, pellicle, and saliva.

This is in stark contrast to the classic medical

model of one pathogen-one disease, thus, rather

than focusing on the elimination of any one patho-

gen, caries management must determine which of

many factors is causing the expression of disease

and takes corrective action. For purposes of this

paper, the phrase caries management by riskassessment or CAMBRA will be used to describe

this risk-based approach to prevent, reverse and,

when necessary, repair damage to teeth using min-

imally invasive methodologies (1). CAMBRA is not

a trade name for products or a company, nor is it a

caries risk assessment (CRA) form, it is a concept

for managing dental caries and its manifestations.

In its simplest form, it means (i) assessing the risk

for future caries lesions, (ii) reducing the pathologi-

cal factors, (iii) enhancing the protective factors,

and (iv) minimally invasive restorative care result-ing in control of the disease.

The caries balance/imbalance model

The caries balance/imbalance model is a visual

representation of the multifactorial nature of the

dental caries disease. It illustrates the determining

factors of caries disease, and it is the dynamic inter-

action of the biofilm with the oral environment. It

is the local environment that determines how the

biofilm will behave at any given tooth site and ifthe disease is severe enough to result in demineral-

ization and visible changes to the tooth site. By col-

lecting actual patient information about the

patients unique caries balance an astute clinician

can assess the risk of future demineralization

based on weighing all the disease indicators and

risk factors against existing protective factors. This

is process is called a CRA.

The caries balance/imbalance (Fig. 1) is the bal-

ance among disease indicators, risk factors and

doi: 10.1111/cdoe.12031 e53

Community Dent Oral Epidemiol 2012; 41; e53e63All rights reserved

2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd

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protective factors and determines whether dental

caries progresses, halts, or reverses. Refer to

Appendix and the text below for more detail on

disease indicators. Cavities/dentin refers to frankcavities or lesions well into the dentin by radio-

graph. Restorations

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research has proven to be causative of caries

lesions (given a pathogenic environment) and can

be easily remembered because their first letters

spell the word BAD. They are as follows:

Bad bacteria (meaning cariogenic bacteria),

Absence of saliva (hyposalivation),

Destructive lifestyle habits (e.g., poor dietary

habits, frequent ingestion of fermentablecarbohydrates, recreational drugs, etc.).

The CRA form shown in Appendix lists several

other risk factors (totaling nine) identified in out-

comes measures of CRA (5, 6). They are as follows:

(i) medium or high MS (mutant streptococci) and

LB (lactobacillus species) counts, (ii) visible heavy

plaque on teeth, (iii) frequent (>3 times daily)

snacking between meals, (iv) deep pits and fis-

sures, (v) recreational drug use, (vi) inadequate sal-

iva flow by observation or measurement, (vii)

saliva reducing factors (medications/radiation/

systemic), (viii) exposed roots, and (ix) orthodonticappliances.

Caries protective factors

Caries protective factors are biological or therapeu-

tic factors that can collectively offset the pathologic

challenge presented by the above caries risk factors

(also refer to Appendix). The more severe the car-

ies risk factors are, the higher the intensity of pro-

tective factors must be to keep the patient inbalance or to reverse the caries process. Figure 1

only lists a few that are known to be highly protec-

tive and can be remembered by SAFER. They are

as follows:

Saliva and sealants

Antibacterials

Fluoride and calcium/phosphate (as supportive

to fluoride not a replacement) (9)

Effective lifestyle habits

Risk-based reassessment

Industry is responding to the need for more and

better products to treat dental caries disease andthe current list in Appendix is sure to expand in

the near future. Currently, the protective factors

listed in Appendix are as follows: (i) lives/work/

school located in a fluoridated community, (ii)

fluoride toothpaste at least once daily, (iii) fluoride

toothpaste at least two times daily, (iv) fluoride

mouthrinse (0.05% NaF) daily, (v) 5000 ppm F

fluoride toothpaste daily, (vi) fluoride varnish in

last 6 months, (vii) office fluoride topical in last

6 months, (viii) chlorhexidine prescribed/used

daily for 1 week each of last 6 months or other

antibacterial agent of choice based on current evi-

dence. (ix) xylitol gum/lozenges four times daily

in the last 6 months, (x) calcium and phosphate

supplement paste during last 6 months, and (xi)

adequate saliva flow (>1 ml/min stimulated).

Fluoride toothpaste frequency is included as stud-

ies have shown that brushing twice daily or moreis significantly more effective than once a day or

less (10). Any or all of these protective factors can

contribute to keep the patient in balance and to

enhance remineralization, which is the natural

repair process of the early carious lesion.

Hard tissue exam and charting (bylocation, severity, and activity)

The existence of previous or current disease is the

highest predictor of future disease. Therefore acareful hard tissue exam must precede the CRA to

detect signs of previous or existing caries disease

(disease indicators). There are many ways to

record hard tissue findings. The following example

is a simple approach that mimics clinical practice

and considers both precavitated and cavitated car-

ies lesions.

Occlusal: chart ICDAS Codes (11) noting deep

pits or fissures. See Table 2 (For description

of ICDAS for clinical practice see http://

www.icdas.org/clinical-practice) Approximal: chart depth of lesions noted on

bitewing radiographs as E1, E2, D1, D2, or D3

and note activity if possible (see approximal

lesion management later this article)

Facial/Lingual; visual and tactile exam (round

end of explorer or ball ended probe) noting:

(i) active white spots (dull, rough surface)

(ii) inactive white spots (smooth, shiny and

hard)

(iii) active brown spots (tan to tooth colored,

dull, rough surface)

(iv) inactive brown spots (smooth, shiny, andhard)

(v) cavitations still in enamel

(vi) cavitations extending into dentin

Caries risk assessment

A CRA is simply a way to formalize and expand

upon the patients caries balance/imbalance in the

most predicable fashion to diagnose current caries

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disease, to help predict future disease, and to

determine what factors are out of balance so evi-

dence-based clinical decisions can be made (8, 12).

The CRA may draw upon relevant historical data

of the patient such as medical history (medications

and systematic disease), dental history (previous

caries experience), social history (recreational

drugs, alcohol, smoking), dietary history, and anyother personal or cultural habits that could contrib-

ute to caries disease. Lastly, a CRA may also

include additional tests such as saliva/pH/buffer

assessment and bacterial load assessment. These

test all have lower levels of evidence, yet the real

benefit may be as a teaching and motivating tool to

help modify patient behaviors.

Implementation of a CRA in clinical practice is

best carried out by the use of a CRA form, insuring

each patient will be systematically assessed in the

same manner, which is based on the best available

research. The CRA form presented here is basedupon published science and outcomes measures of

the use of the form (5, 6). The items in the form

have been trimmed to include only those that had

significant relationships to the onset of future cavi-

tation in thousands of patients. The aim is to keep

the form and procedure as simple and rapid as

possible for use in practice, to keep to one page,

and to have only proven components included.

The CRA form presented here is based on the car-

ies balance/imbalance theory, and the factors eval-

uated were discussed previously. Although thereare several published CRA forms, the one shown

in Appendix was chosen to use as an example in

this manuscript because the content of the form

and the procedures have been validated by pub-

lished outcomes research using a large cohort of

patients (5, 6). The included items all had statisti-

cally significant odds ratios relating to the future

onset of cavitation.

To use the form (Appendix): Simply circle the

Yes answers, count them up and visualize how

these will affect the balance at the bottom of the

form. Some clinicians have reported improvedresults by engaging the patient early by handing

out the form in the reception room and letting

them self-select answers for questions they are

familiar with. This allows the practitioner to read-

ily determine low, moderate, high, or extreme risk

while saving valuable time as well. Extreme risk is

high risk plus major salivary dysfunction (hyposal-

ivation). Low risk should indicate that there is a

very low risk of future dental caries disease, pro-

vided no deleterious changes are made. On the

other hand, high risk indicates the high likelihood

of new caries lesions in the near future (a year or

2). If there is doubt about low or high risk, then the

classification is moderate.

There are several other versions of CRA forms

available, and clinical outcomes of using many risk

indicators and factors are summarized in a system-

atic review by Zero et al. (13). In addition, there aredifferences in the relative predictive value given to

different factors in the literature (e.g., according the

2001 NIH Consensus Conference on Dental Caries,

presence of mutant streptococci alone is no more

than weakly predictive of clinical caries activity) (14).

However, none of these other forms have published

outcomes results. The ADA offers caries assessment

forms for patients 06 years old, and those over

6 years of age. The forms can be found here:

http://www.ada.org/sections/professionalRe-

sources/pdfs/topic_caries_over6.pdf. In addition,

the AAPD also offers their form for children under6 at: http://www.ada.org/sections/professionalRe-

sources/pdfs/topics_caries_under6.pdf.

All these forms vary from each other in some

way or another; however, all of them agree that

caries experience is the strongest predictor of

future caries disease, even though they may use

different variables to describe caries experience. In

addition, they all measure the other etiological fac-

tors involved in the disease in some manner; the

weight that these other factors receive varies from

form to form, in part because the literature on riskassessment (except for past caries experience) is

very limited.

Any CRA form should systematically weigh

the factors research has proven to be pathogenic

against the protective factors that are known to

protect from caries disease. The astute clinician

can then manipulate these environmental factors

via treatment interventions that will tip the car-

ies balance to favor health. As not all factors

have equal predictive value, the questions used

in any CRA form must be weighted is some

fashion. The weighting system shown in Appen-dix is a visual weighting system created by the

three-column format based on outcomes research

and statistical odds ratios mentioned previously.

Other forms may use a mathematical weighting

system.

The end result of any CRA is to combine histori-

cal and current clinical data, information from the

CRA form, including any additional test such as

saliva or pH assessment and bacterial load assess-

ment, to ultimately allow a determination of an

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overall caries risk for your patient. This will help

establish a caries disease diagnosis and disease

activity level (caries active or caries inactive). Car-

ies risk changes with time and needs to be reas-

sessed as time goes on.

Chemical intervention protocolsOnce caries risk diagnosis is made (low, moderate,

high, or extreme risk), there must be therapeutic

intervention protocols attached to the risk level for

that patient, so that treatment options along with

prognosis can be presented to the patient and a

treatment plan formulated. The level and type of

risk is used to determine the level and type of

corrective therapeutic intervention. Note that cur-

rently there is no consensus on correct treatment

protocol, just as there is no one correct way to

assess the caries risk of the patient. The process ofmanagement based on caries risk was recently vali-

dated by a randomized clinical trial where the test

group using CRA, based on salivary fluoride levels

and bacterial load (MS and LB), to drive chemical

treatment decisions (chlorhexidine and/or fluo-

ride) had lower mean caries increment compared

to the control group, which did not employ risk

assessment or chemical based treatments (restor-

ative only) (8). The fact that multiple treatment

interventions may be necessary to treat a complex

multifactorial disease, by nature does not lenditself well to future randomized clinical trials and

systematic reviews. With that said, Table 1 lists an

example protocol of interventions that could be

used based on the caries risk level of the patient.

Table 1 is a modified version of an example proto-

col previously published for age 6 to adult based

on caries risk category (10). The eight interventions

summarized in Table 1 are the following: (i) seal-

ants (resin-based or glass ionomer), (ii) saliva

assessment (flow and bacterial load measurement),

(iii) antibacterials, (iv) fluoride, (v) factors favor-

able for remineralization (pH control calcium-phosphate topical supplements), (vi) effective life-

style habits, (vii) frequency of radiographs, and

(viii) frequency of caries recare exams (Table 1).

Minimally invasive restorativeoptions

Caries risk assessment should be a mandatory part

of every initial examination and every caries

re-care appointment, because caries risk is likely to

change with time. If an interventive therapy is

applied successfully, the aim is to lower the caries

risk. Once a caries risk diagnosis is made, appro-

priate prevention or therapeutic protocols are

started based on caries risk (low, moderate, high or

extreme risk). If caries lesions (precavitated or cavi-

tated) are present, the decision to treat chemicallyversus surgically based on the site, extent, and

activity of the caries lesion must be made (see sum-

mary Table 3). This requires early detection and

precise terminology (refer to previous mentioned

Hard Tissue Exam and Charting). Bacteria are physi-

cally too large to fit into diffusion channels of intact

enamel; thus, intact enamel prevents bacterial

ingress into the dentin. In contrast, cavitation

through the enamel should trigger surgical proce-

dures.

Caries risk status may or may not have any bear-

ing on the restorative phase of treatment; it is notan absolute requirement. At the occlusal site, the

ICDAS system may help determine the extent of

preventive and/or restorative treatment (see

Table 2). Caries risk status may help drive the deci-

sion to place a sealant or not (e.g., sealants are a

recommended option for high caries risk patients)

(15).

On the approximal surface, most dentists rely

heavily on the bitewing radiograph (conventional

or digital). Based on a review of the scientific lit-

erature American Dental Association Council onScientific Affairs determined that the diagnostic

quality of digital images is comparable to that of

conventional films (1618). One way to record

radiographic radiolucency depth is to divide the

enamel in half (E1 = outer of enamel.

E2 = inner of enamel) and dentin into thirds

(D1 = outer 1/3 of dentin, D2 = middle 1/3 of

dentin, and D3 = inner 1/3 of dentin). Radio-

graphic radiolucency in the enamel (E1, E2) have

low chance of being cavitated (14) and should be

treated chemically. If left untreated therapeuti-

cally, the likelihood of progressing to cavitationis high (6). Radiographic radiolucency well into

dentin (D2, D3) is more likely cavitated (14) and

should be restored. It is the radiographic radiolu-

cencies that just penetrate the dentinal enamel

junction (D1), which trouble many dentists. Many

were taught in dental school that early D1 lesions

are the ideal board patient, yet most of these

lesions may not be cavitated. In the US, activity

of these lesions is rarely considered and the use

of elastomeric separation to confirm cavitation is

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even more rare. At this site, caries risk status

may not help in treatment decision. In other

words, you should not justify surgical treatmentbased on high-risk status. All risk categories

should receive the benefit of remineralization

therapy on noncavitated lesions.

On the facial and lingual surfaces, direct visual

and tactile examination is possible, making the

decision easy. It is also much easier to assess

lesion activity and to monitor the progress of

remineralization therapy. If restoration is neces-

sary on the root area, a high-risk status may

preclude one to use a fluoride releasing material

such as conventional glass ionomer cement

(Tables 2 and 3) (19).

Treatment planning and behavioralchange

Individualized, evidence-based treatment options

along with prognosis is presented to the patient

and decisions are made based on the patients

wants and needs. Implementation of the treatment

phase requires the clinician to assist the patient in

modification of behaviors that favor health. This

Table 2. Example occlusal protocolabased on ICDAS code and caries risk level

a

All sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confinedto enemel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part ofthe preparation in dentin and the preparation extends to a second surface (note: the second surface does not have to bein dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamelis immature, or where fissure preparation is not desired, or where rubber damn isolation is not practical. Patients should

be given a choice in sealant placement and material selection.bPatients withone(or more) cavitated lesion(s) are high risk patients.cPatients withone(or more) cavitated lesion(s)andxerostomia are extreme risk patients.Adapted from Jenson et al. (11).

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Table 3. Site specific risk-based management

SITE SPECIFIC RISK-BASED MANAGEMENT

SITE EXTENT

(non-surgical approach)

Initial caries management stage

(*** minimal removal of caries and tissue)

Moderate caries management stage Severe caries

management

stage

(conventional

restorative

approach)

OCCLUSAL SITE ICDAS code 0 ICDAS code 1 ICDAS code 2 ICDAS code 3 ICDAS code 4 ICDAS code 5 ICDAS code 6

Management Low Risk: Sealants not indicated for inactive lesions;

continue nonsurgical preventive maintenance; however

sealants may be considered optional for primary

prevention of at risk (deep) pits and fissures.

Moderate Risk: sealants recommended

*High or ** Extreme Risk: sealants recommended

All Risk Levels:

Minimal removal of tooth structure to ensure adequate

seal for dental material used.

All Risk Levels:

Conservative

caries removal

when near the

pulp; ensure

adequate seal for

dental material

used.

APPROXIMAL SITE Radiographic E0

****

Radiographic E1 Radiographic D1 Radiographic D2

(outer 1/3 dentin) (middle 1/3 dentin)

Radiographic D3

(inner 1/3 dentin)

Management Chemical treatment or preventive

maintenance.

Chemical or preventive therapy.

Demonstration of lesion

progression or regression and/or

elastomeric tooth separation

Minimally invasive

restoration probable

(but not absolute) based

on lesion progression,

Minimally invasive restoration

needed. Conservative caries

removal when near the pulp;

ensure adequate seal for dental

preferred before surgical

intervenon is considered.

regression, or tooth

separaon.

material used.

FACIAL/LINGUAL

SITE

Non-cavitated lesions

Inacve Acve

(shiny, smooth) (matt, rough)

Parally cavitated les ions Fully cavitated les ions Ful ly cavitated les ions

Management

Non-cavitated lesions

Acve white or brown spot lesions

receive chemical therapies based on

caries risk assessment (CRA).

Parally cavitated lesions

May receive nonsurgical chemical

therapy or minimally invasive

restoraon depending on clinician

and paent discussion of

treatment opons.

Fully cavitated lesions

Minimally invasive

restoraon

Fully cavitated lesions

Conservave caries removal

when near the pulp; ensure

adequate seal for dental

material used.

Lesion activity assessment (adapted from Kim Ekstrand) (Parameters in red indicate activity; in black, no activity) Ini-tial caries risk status: high, moderate, or low; Visual appearance: cavitation/shadow, whitish, or brownish; Location ofthe lesion: plaque stagnation area, natural, or not; Tactile feeling: rough enamel/soft dentin, or smooth enamel/harddentin; Gingival status (if the lesion is located near the gingiva): inflammation, bleeding on probing, or no inflammation,

no bleeding on probing; surface luster: matt, shiny; Plaque: sticky, not sticky; Age of the lesion: 3 years.aAll sealants and restorations to be done with a minimally invasive philosophy in mind. Sealants are defined as confinedto enamel. Restoration is defined as in dentin. A two surface restoration is defined as a preparation that has one part ofthe preparation in dentin and the preparation extends to a second surface (Note: the second surface does not have to bein dentin). A sealant can be either resin-based or glass ionomer. Glass ionomer should be considered where the enamelis immature, or where fissure preparation is not desired, or where rubber dam isolation is not practical. Patients should

be given a choice in sealant placement and material selection.bPatients with one (or more) cavitated lesion(s) are high risk patients.cPatients with one (or more) cavitated lesion(s) and xerostomia and/or hyposalivation are extreme risk patients.dNotations system used here: on bitewing radiographs as E1 (outer of enamel), E2 (inner of enamel), D1 (outer 1/3of dentin), D2 (middle 1/3 of dentin), or D3 (inner 1/3 of dentin) and note the progression/regression from previousradiographs if possible #33.

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will require skill in obtaining patient cooperation

in use of the recommended therapeutic interven-

tions. In doing so, it is important to give patients

encouragement and clear instructions on what they

need to do (20).

SummaryDental caries is a complex multifactorial disease

that cannot be controlled by restoration alone

(8). A CRA is a way to predict risk of future

disease, but it is also a systematic way to iden-

tify factors that are out of balance that could

lead to demineralization on a susceptible patient.

To assist the clinician in assessing caries risk,

several forms and procedures are in existence, of

which one form and one example protocol was

used in this paper to illustrate the science of car-

ies management by risk assessment, CAMBRA.CAMBRA is not a trade name for products or a

company, nor is it a CRA form, it is a concept

for managing dental caries and its manifesta-

tions. In its simplest form it means (i) assessing

the risk for future cries lesions, (ii) reducing the

pathological factors, (iii) enhancing the protective

factors, and (iv) minimally invasive restorative

care resulting in control of the disease.

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J Calif Dent Assoc 2007;35:799805.2. Featherstone JD, Domejean-Orliaguet S, Jenson L,

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3. Featherstone JD. The caries balance: contributing fac-tors and early detection. J Calif Dent Assoc2003;31:12933.

4. Featherstone JD. Prevention and reversal of dentalcaries: role of low level fluoride. Community DentOral Epidemiol 1999;27:3140.

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6. Domejean S, White JM, Featherstone JD. Validationof the cda cambra caries risk assessment a six-year

retrospective study. J Calif Dent Assoc 2011;39:70915.

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8. Featherstone JD, White JM, Hoover CI, Rapozo-HiloM, Weintraub JA, Wilson RS et al. A randomizedclinical trial of anticaries therapies targeted accord-

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based clinical recommendations. J Am Dent Assoc2011;142:106571.

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How tooth decay happens (to be given to eachpatient)Tooth decay is caused by acid-producing bacteria

that live in your mouth. The bacteria feed on what

you eat, especially sugars (including fruit sugars)

and cooked starch (bread, potatoes, rice, pasta,

etc.). Within just a few minutes after you eat, or

drink, the bacteria begin producing acids as a by-

product of their digesting your food. Those acids

can penetrate and dissolve the minerals (calcium

and phosphate) in your teeth. If the acid attacks are

infrequent and of short duration, your saliva can

AppendixAppendix 1. Caries risk assessment form for ages 6 years through adult. Adapted from Featherstone JD et al. (2)

Patient Name: CHART #: DATE:Assessment Date: Is this (please circle) Baseline or Recall

Disease Indicators (Any one YES signifies likely HighRisk and to do a bacteria load test**)

YES =CIRCLE

YES =CIRCLE

YES=CIRCLE

New/Progressing visible cavitations or radiolucencies intodentin

YES

New/Progressing approximal enamel Lesions by radiograph YES

New/Active White spots on smooth surfaces YES

Restoration for caries lesion in the last 3 years (for initialexam or within the last 1 year for recall/POE exam)

YES

Risk Factors (Biological predisposing factors)

MS and LB both medium or high (by culture or ATPbioluminescence**)

YES

Visible heavy plaque on teeth YES

Frequent snack (> 3x daily between meals) YES

Deep pits and fissures YES

Recreational drug use YES

Inadequate saliva flow by observation or measurement (**If

measured note the flow rate below)

YES

Saliva reducing factors (medications/radiation/systemic) YES

Exposed roots YES

Orthodontic appliances YES

Protective Factors

Lives/work/school fluoridated community YES

Fluoride toothpaste at least once daily YES

Fluoride toothpaste at least 2x daily YES

Fluoride mouthrinse (0.05% NaF) daily YES

5000 ppm F fluoride toothpaste daily YES

Fluoride varnish in last 6 months YES

Office F topical in last 6 months YES

Chlorhexidine prescribed/used one week each of last 6months

YES

Xylitol gum/lozenges 4x daily last 6 months YESCalcium and phosphate paste during last 6 months YES

Adequate saliva flow (> 1 ml/min stimulated) YES

** Biofilm Assessment:ATP bioluminescence: _______ or culture MS:_______LB:_______Stimulated Salivary Flow Rate:_______ ml/min. Stimulated pH______ Date: _________

Resting Salivary Flow Rate: _______ ml/min. Resting pH ________ Date: _________Buffering Capacity test:______________Consistency of resting saliva: thick-stringy-ropey vs watery

VISUALIZE CARIES BALANCE(Use circled indicators/factors above)(EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION)CARIES RISK ASSESSMENT (CIRCLE): EXTREME HIGH MODERATE LOW

Doctor signature/#: Date:

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help to repair the damage by neutralizing the acids

and supplying minerals and fluoride that can

replace those lost from the tooth. However if:

(i) your mouth is dry, (ii) you have too much acid

exposure, or (iii) you snack frequently, then the

tooth mineral lost by attacks of acids is too great

and cannot be repaired. This is the start of tooth

decay and leads to cavities.

Methods of controlling tooth decay

Saliva. Saliva is critical for controlling tooth decay.

It neutralizes acids and provides minerals and pro-

teins that protect the teeth. If you cannot brush after

a meal or snack, you can rinse or chew some sugar-

free gum. This will stimulate the flow of saliva to

help neutralize acids and bring lost minerals back to

the teeth. Sugar-free candy or mints could also be

used, but some of these contain acids themselves.

These acids will not cause tooth decay, but they can

slowly dissolve the enamel surface directly overtime (a process called erosion). Some sugar-free

gums are designed to help fight tooth decay and are

particularly useful if you have a dry mouth (many

medications can cause a dry mouth). Some gums

contain baking soda that neutralizes the acids pro-

duced by the bacteria in plaque.

Sealants. Sealants are plastic or glass ionomer

coatings bonded to the biting surfaces of back teeth

to protect the deep grooves from decay. In some

people, the grooves on the surfaces of the teeth aretoo narrow and deep to clean with a toothbrush, so

they may decay in spite of your best efforts. Seal-

ants are an excellent preventive measure used for

children and young adults at risk for this type of

decay. They do not last forever and should be

inspected once a year and replaced if needed.

Antibacterial mouth rinses. Rinses that your dentist

can prescribe are able to reduce the numbers of

bad bacteria that cause tooth decay and can be use-

ful in patients at high risk for tooth decay.

Fluorides. Fluorides help to make the tooth more

resistant to being dissolved by the bacterial acids.

Fluorides are available from a variety of sources

such as drinking water, toothpaste, over-the-coun-

ter rinses, and products prescribed by your dentistsuch as brush-on gels or high-fluoride toothpastes

used at home or gels, foams, and varnishes applied

in the dental office. Daily use is very important to

help protect against the acid attacks.

Factors favorable for remineralization. Calcium and

phosphate at the proper pH is necessary for tooth

repair. Normally, this is carried out by your saliva

but when you have a lack of saliva (dry mouth) or

when fluoride alone is not effective, you may con-

sider supplementing with calcium/phosphate and

acid-neutralizing products.

Effective lifestyle habits. Improving dietby reducing

the number of sugary and starchy foods, snacks,

drinks, or candies can help reduce the develop-

ment of tooth decay. That does not mean you can

never eat these types of foods, but you should limit

their consumption particularly when eaten

between main meals. Gum that contains xylitol as

its first listed ingredient will stimulate saliva and is

the gum of choice. If you have a dry mouth, you

could also fill a drinking bottle with water and adda couple teaspoons ofbaking sodafor each 8 ounces

of water and swish and spit with it frequently

throughout the day. Toothpastes containing baking

soda are also available by several companies.

Effective oral hygiene practices plaque removal:

Removing the plaque from your teeth on a daily

basis is helpful in controlling tooth decay. Plaque

can be difficult to remove from some parts of your

mouth especially between the teeth and in grooves

on the biting surfaces of back teeth. If you have an

appliance such as an orthodontic retainer or partialdenture, remove it before brushing your teeth.

Brush all surfaces of the appliance also.

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Caries management by risk assessment