cda j ournal , vol 39, n

1 0
october 201 1 709
c r a s t u dy
authors
Sophie Domjean,
dds, phd, is with CHU
Clermont-Ferrand, Service
dOdontologie, Clermont-
Ferrand, France.
Joel M. White, dds, ms,
is a professor at the
University of California,
San Francisco, School of
Dentistry.
John D. B. Featherstone,
ms, phd, is dean and
professor at the
University of California,
San Francisco, School of
Dentistry.
or many ycars, thcrc has bccn a
nccd or cvidcnccbascd inorma
tion to assist dcntal practitioncrs
in thc diagnosis, dctcction, and
managcmcnt o dcntal carics.
r

In r,,, thc Journal of the American Dental
Association publishcd a supplcmcnt out
lining carics risk asscssmcnt and dcscrib
ing how dcntists should considcr man
aging paticnts according to thcir risk o
dcvcloping dcntal dccay.

Sincc thcn, two

carics risk asscssmcnt (CRA) approachcs
havc bccn dcvclopcd bascd on thc spccic
nccds o populations and individuals.

Onc mcthod is thc population approach
dcvclopcd within thc cld o cpidcmiol
ogy and public hcalth. Tis approach is
bascd on thc idcntication and quanti
cation o risk actors that signicantly
compromisc thc populations hcalth, with
intcrvcntion stratcgics that acct popula
tions, likc communal watcr uoridation.
Tc sccond approach is bascd on thc
individual and includcs thc prcscncc or
abscncc o actors involvcd in thc carious
proccss likc biological charactcristics,
pcrsonal and mcdical history, habits,
and licstylc. Tcsc variablcs inscrtcd
into statistical dccision modcls prcdict
thc pcrsons risk o discasc ovcr somc
uturc pcriod. Tis CRA paticntspccic
approach has two objcctivcs which arc
both undamcntal. CRA is currcntly a
ncccssary componcnt in thc practitioncrs
clinical dccisionmaking proccss and CRA
is an cducational and motivational tcch
niquc to cncouragc thc paticnt to adopt a
hcalthicr, prcvcntionoricntcd licstylc.
In .cc., a conscnsus concrcncc was
hcld in Sacramcnto, Cali., on thc topic
o Carics Managcmcnt By Risk Asscss
mcnt (CAMBRA).

Tc procccdings wcrc
publishcd and arc availablc onlinc in thc
Fcbruary and March .cc issucs o thc
Validation of the CDA
CAMBRA Caries Risk
Assessment A Six-Year
Retrospective Study
sophie domjean, dds, phd; joel m. white, dds, ms;
and john d. b. featherstone, ms, phd
abstractThe present manuscript presents the results of a six-year retrospective
study validating caries risk assessment in a caries management by risk assessment
program in a large predominantly adult patient population seeking dental care. CRA was
successful in accurately identifying patients at high caries risk. Caries risk assessment
in a CAMBRA program is a good clinical tool for everyday dental practice.
F
acknowledgment
The authors wish to
acknowledge, Tom Ferris
and his excellent sta in
Network and Information
Services for the extraction
of the electronic health
records. We also wish
to acknowledge Stuart
Gansky and Nancy Cheng
for their contribution in
translating the data for
analysis.
710october 201 1
cda j ournal , vol 39, n

1 0
Journal of the California Dental Association
(cdaoundation.orgjournal). A CRA orm
was proposcd bascd upon thc known litcr
aturc at that timc.
/
Tc variablcs includcd
in thc CRA orm wcrc a combination
o discasc indicators, pathological and
protcctivc actors that wcrc assumcd to bc
ablc to bc uscd in combination to asscss
ovcrall carics risk and to guidc thcrapy
and trcatmcnt planning. Subscqucntly,
thc CRA orm was modicd, improvcd
by a national working group callcd thc
CAMBRA Coalition, and this improvcd
vcrsion was publishcd in thc Journal of the
California Dental Association in Octobcr
.cc/ ollowing a sccond symposium.
8

For purposcs o this papcr, thc authors
will rccr to this orm as thc CLA CRA
orm. Tc orm is rcproduccd in table 1.
Tc discasc indicators or risk prc
dictors in this CLA CRA (table 1) arc
markcrs that arc indicativc o a cur
rcnt or past carious proccss but thcy
arc not causativc actors. Tc discasc
indicators arc clinical obscrvation that
rccognizc thc prcscncc o, or a rcccnt
history o, thc dcntal carics discasc.
visiblc cavitics or radiographic pcnctra
tion o thc dcntin, radiographic ap
proximal cnamcl lcsions, whitc spots
on smooth suracc and rcstorations
during thc last thrcc ycars. Tcy arc
rccognizcd to bc highly prcdictivc in
tcrms o dcvclopmcnt o uturc lcsions,
and that thc carics discasc proccss will
continuc in thc uturc. Liscasc indica
tors, by thcmsclvcs, givc a good idca o
thc risk lcvcl, but thcy do not hclp thc
practitioncr to undcrstand why a paticnt
has dcvclopcd thc discasc and how to
customizc thc trcatmcnt plan and thc
rccommcndations to bc dclivcrcd.
Tc risk actors or pathological ac
tors in thc CLA CRA arc dcscribcd as
variablcs rclatcd to thc probability o oc
currcncc and progrcssion o thc discasc,
including cxisting lcsions progrcssion
and thc ormation o ncw lcsions. Somc
risk actors arc part o thc causal chain.
mcdium and high mutans strcptococci
and lactobacilli counts, prcscncc o
visiblc hcavy plaquc on tccth, rcqucnt
snacking (grcatcr than thrcc timcs daily
bctwccn mcals), and inadcquatc saliva
ow (by obscrvation or mcasurcmcnt).
Somc othcrs cxposc thc individual to
thc causal chains. dccp pits and ssurcs
involvcd in plaquc rctcntion, rccrc
ational drug usc lcading to thc rcduction
o thc saliva ow, mcdicationsradia
tionsystcmic discascs rccognizcd to bc
salivarcducing actors, cxposcd roots,
and orthodontic applianccs that arc
both a hindrancc to good oral hygicnc
and also plaquc rctcntion actors.
Tc protcctivc actors in thc CLA
CRA arc biological or thcrapcutic ac
tors or mcasurcs that can collcctivcly
prcvcnt thc dcmincralization proccss,
cnhancc rcmincralization, or osct thc
challcngc prcscntcd by thc pathological
risk actors. Tc CLA CRA protcctivc
actors includc adcquatc saliva ow
(grcatcr than r mlmin stimulatcd),
uoridc (rom drinking watcr, tooth
pastc, varnish, gcl), antimicrobial rinscs
(c.r. chlorhcxidinc rccommcndcd usc
oncc a day or onc wcck cach month),
xylitol (gum, c./ gm or lozcngcs, r gm
rccommcndcd to bc uscd twicc daily or
modcratc risk or our timcs daily) or
high risk, and cascin phosphopcptitc
and amorphous calcium phosphatc pastc
(CPPACP) uscd twicc a day, morning
and at night. Usc o any o thc prcvcn
tivc products during thc last six months
arc considcrcd protcctivc actors.
Tc CAMBRA protocols and CLA
CRA orm wcrc introduccd into thc
prcdoctoral dcntal clinics at thc Univcr
sity o Caliornia, San Francisco, School
o Lcntistry in anuary .cc on a pilot
basis and ully implcmcntcd in uly .cc.
Tc aim o thc prcscnt study was to
rctrospcctivcly cvaluatc thc validity o CLA
CRA as rclatcd to cxisting carics and to dc
tcrminc its prcdictivc valuc or uturc carics.
Methods
Tis study was conductcd rctro
spcctivcly using clcctronic data and
papcr charts rom UCSF prcdoctoral
dcntal clinic paticnts. Tc study popula
tion consistcd o paticnts ovcr thc agc
o who had a basclinc CRA bctwccn
uly r, .cc, and unc c, .cc,. Tc
projcct rcccivcd thc approval o thc
Committcc on Human Rcscarch (thc
institutional rcvicw board) o UCSF.
Lata rom thc CRA pilot study wcrc
obtaincd by chart rcvicw. Flcctronic
CLA CRA data was cxtractcd rom thc
clcctronic hcalth rccord sotwarc sys
tcm (axiUm, Fxan, Vancouvcr, Brit
ish Columbia, Canada). All data wcrc
transormcd or analysis. Mcthods uscd
in this study ollowcd thc protocols
dcvclopcd in thc authors initial study.
,

In this study, initial CLA CRA data
wcrc obtaincd at cithcr thc comprchcn
sivc or pcriodic oral cxamination, with
ollowup CLA CRA data obtaincd at a
subscqucnt pcriodic oral cxamination.
\hcn availablc, bactcrial tcsting rcsults
wcrc also includcd in thc data analysis.
disease indicators,
by themselves, give a good
idea of the risk level; but they
do not help the practitioner
to understand why a patient
has developed the disease
c r a s t u dy
cda j ournal , vol 39, n

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october 201 1 711
TABLE 1
Caries Risk Assessment Form Children Age 6 and Over/Adults
Patient Name: ___________________________________________________________________________________Chart #:________________________________Date:________________________________________________________
Assessment Date: Is this (please circle)

baseline

or

recall
Disease Indicators
(Any one YES signifies likely High Risk and to do a bacteria test**)
YES = CIRCLE YES = CIRCLE YES = CIRCLE
Visible cavities or radiographic penetration of the dentin YES
Radiographic approximal enamel lesions (not in dentin) YES
White spots on smooth surfaces YES
Restorations last 3 years YES
Risk Factors (Biological predisposing factors) YES
MS and LB both medium or high (by culture**) 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
5,000 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 6 months YES
Xylitol gum/lozenges 4x daily last 6 months YES
Calcium and phosphate paste during last 6 months YES
Adequate saliva flow (> 1 ml/min stimulated) YES
**Bacteria/Saliva Test Results: MS: LB: Flow Rate: ml/min. Date:
VISUALIZE CARIES BALANCE
(Use circled indicators/factors above)
(EXTREME RISK = HIGH RISK + SEVERE SALIVARY GLAND HYPOFUNCTION)
CARIES RISK ASSESSMENT (CIRCLE): EXTREME HIGHMODERATE LOW
Doctor signature/#: _______________________________________________________________________________________________________________________ Date:_________________________________________________________
712october 201 1
cda j ournal , vol 39, n

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To asccrtain thc validity o thc CLA
CRA orm and its prcdictivc valuc,
dcscriptivc and bidimcnsional analyscs
wcrc pcrormcd using statistical sot
warc (SPSS r.c). Tc c
2
and McNcmar
Bowkcr tcsts wcrc uscd to tcst thc
rclationship bctwccn CRA variablcs
with a pcrccnt lcvcl o signicancc.
Tc odds ratios (ORs) wcrc calculatcd
to indicatc thc strcngth o thc rclation
ships as wcll as thc dircction. An OR lcss
than r.c indicatcd a ncgativc rclationship
(protcctivc ccct) with carics discasc
and an OR o morc than r.c indicatcd a
positivc rclationship with carics discasc.
\hcn thc OR was morc than r.c thc
highcr thc OR thc grcatcr is thc dcgrcc
o rclationship with carics discasc.
Results
Baseline CRA: Is the choice of the factors
listed in the CDA CRA form relevant?
\ithin thc sixycar inclusion pcriod o
thc study, r.,, paticnts had a basclinc
CLA CRA pcrormcd, 8,r CRA wcrc
pcrormcd using orms rom thc .cc
CLA vcrsion and ,8.c using thc .cc/
CLA vcrsion, which is currcntly uscd
at UCSF prcdoctoral dcntal clinics.
table 2 prcscnts thc dcmographic
charactcristics o thc study population.
Studcnts and supcrvising aculty wcrc
traincd to makc this ovcrall carics risk
asscssmcnt by taking into considcration
thc ycs and no answcrs to thc qucstions
on this CLA CRA orm and making a
clinical judgmcnt as to whcthcr thc carics
balancc swings toward thc appcarancc o
carious lcsions in thc uturc or whcthcr
thc protcctivc actors arc likcly to prcvail,
as dcscribcd in dctail prcviously.
8
Tc low
and modcratc risk dctcrmination was
bascd on thc numbcr o protcctivc ac
tors and numbcr o discasc risk actors.
Prcscncc o any discasc indicator auto
matically dctcrmincs high risk. Prcscncc
o any discasc indicator plus dry mouth
automatically dctcrmincs cxtrcmc risk.
An ovcrall carics risk was dctcrmincd by
thcir providcrs or rc,,/ paticnts bascd
on thc balancc bctwccn discasc indicators
pathological and protcctivc actors rc
cordcd in this CLA CRA orm. r. pcrccnt
wcrc classicd as low risk, .r., pcrccnt as
modcratc risk, c. pcrccnt as high risk
and ..r pcrccnt as cxtrcmcly high risk.
Almost pcrccnt o thc paticnts includcd
in thc study had visiblc cavitics or radio intcrvals (CIs) o thc discasc indicators,
thc pathological and protcctivc actors on
this CLA CRA orm. Tc largcst odds ra
tio or discasc indicators was 8..r or thc
association o approximal cnamcl lcsions
on radiographs. Tc largcst odds ratio or
pathological actors was .. or thc asso
ciation o visiblc hcavy plaquc. Tc stron
gcst (signicantly lcss than r.c) odds
ratios or protcctivc actors wcrc c.8r and
c.8c or thc ncgativc association o uo
ridc toothpastc and uoridc mouthwash.
Tc variablcs or which thc high ratc o
missing data was morc than .c pcrccnt
(applianccs, saliva rcducing actors and
CaPO pastc) wcrc not takcn into ac
count in thc bidimcnsional analysis.
Tc cross tabulations bctwccn visiblc
cavitation and carics into dcntin by
radiograph and thc ovcrall carics risk
lcvcl at basclinc arc prcscntcd in table 4.
Pcrccnt cavitation incrcascd as carics risk
lcvcl incrcascd. Paticnts wcrc morc likcly
to havc cavitics whcn thc ovcrall carics
risk scorcs wcrc dctcrmincd as high (/8.
pcrccnt) and cxtrcmc (/. pcrccnt).
Follow-up CRA: Can the CDA CRA Form
Be Considered as a Predictive Model?
Among thc r.,, paticnts who had a
basclinc CRA bctwccn uly r, .cc, and
unc c, .cc,, .,/r had at lcast onc ol
lowup CRA that was pcrormcd (avcragc
r+ r.. months atcr thc basclinc CRA).

TABLE 2
Demographic Characteristics of the
Study Population (n=12,954)
Gender Male: 47.7%
Female: 52.3%
Account type Cash: 58.9%
General assistance
(Denti-Cal and others): 27.4%
Insurance: 13%
Ethnicity Caucasian: 52.3%
Asian: 16.1%
African American: 12.2%
Hispanic: 18.8%
American Indian: 0.4%
Birth Year 1912-1994
Average 1958
the low and
moderate risk
determination was based
on the number of protective
factors and number of
disease risk factors.
graphic cvidcncc o carics pcnctration into
dcntin. Bactcria tcsts wcrc pcrormcd,
and thc bactcrial challcngc was dctcr
mincd by visual comparison to standard
izcd cxamplcs on a printcd photographic
shcct and rccordcd or . paticnts. Tc
bactcrial challcngc or mutans strcpto
cocci was low or .r pcrccnt and modcr
atc or high or ., pcrccnt o paticnts.
Tc bactcrial challcngc or lactobacillus
was low or /./ pcrccnt and modcr
atc or high or .. pcrccnt o paticnts.
Bascd on risk status, paticntspccic
homc trcatmcnt rccommcndations wcrc
givcn to . pcrccnt o thc paticnts.
rc
Spccic rcsponscs on this CLA CRA
orm wcrc analyzcd or thcir rclationship
to outcomc variablcs o visiblc cavita
tion and or carics into dcntin by radio
graph. table 3 prcscnts thc c
.
pvalucs,
thc ORs with , pcrccnt condcncc
c r a s t u dy
cda j ournal , vol 39, n

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october 201 1 713
As shown in table 5, visiblc cavita
tion and carics radiographic pcnctra
tion o thc dcntin and intcrproximal
cnamcl lcsions or radioluccncics at
ollowup wcrc signicantly rclatcd to
ovcrall carics risk at basclinc. O thosc
asscsscd as high or cxtrcmc risk at
basclinc, thc pcrccnt o paticnts who had
ncw cavitics at ollow was ,. and 88
pcrccnt, rcspcctivcly. \hitc spots at
ollowup wcrc not signicantly rclatcd
to thc ovcrall carics risk at basclinc.
Discussion
Tc prcscnt rctrospcctivc study
conrms thc validity o thc CLA CRA
orm dcvclopcd by thc \cstcrn CAM
BRA Coalition and uscd at thc UCSF
and othcr dcntal schools sincc .cc.
Although Moss and Zcro stipulatcd
in r,, that CRA approachcs should
bc validatcd in cvcryday practicc sct
tings, most o thc CRA survcys havc
bccn uscd undcr trial conditions and
among populations o childrcn or cldcrly
pcoplc.
rr,r.
Tis study prcscnts CLA
CRA outcomcs among a population o
oldcr childrcn and prcdominantly adults
with a mcan birth ycar o r,8 (mcdian
r,8, modc r,). Tc currcnt study
was undcrtakcn in a largc cducational
clinical cnvironmcnt with multiplc stu
dcnt providcrs and supcrvising aculty.
Tcrc arc morc than rc dcntal studcnt
providcrs and morc than c supcrvis
ing gcncral dcntal aculty, with a largc
dcgrcc o variability providing carc to
this paticnt population. Tc majority
o thc supcrvising aculty arc in gcn
cral practicc. It is cxpcctcd thc ndings
o this study will havc gcncralizability
to cvcryday clinical dcntal practicc.
Thc prcliminary study publishcd
in .cc alrcady had shown somc
strong rclationships bctwccn thc
actors (discasc indicators, pathologi
cal and protcctivc) listcd in thc orm
and visiblc cavitation or radiographic
pcnctration o thc dcntin at basc
linc, in a small samplc o paticnts.
,

Thc prcscnt rcsults conirmcd this
rclationship among thc largc paticnt
samplc. Thc prcliminary study involvcd
only 8, ollowup CRA appointmcnts
whcrcas thc prcscnt study includcs
.,/r ollowup CRA appointmcnts.
All o thc discasc indicators and
pathological actors idcnticd on thc
CLA CRA orm had statistically sig
nicant odds ratios grcatcr than r.c
(table 3) showing positivc rclation
ship to thc prcscncc o cavitation or
radiographic pcnctration into dcntin
at basclinc. Tcsc rcsults conrm thc
validity o using thcsc indicators and
actors in thc risk CLA CRA orm. For
scvcral o thcsc discasc indicators and
risk actors, thc odds ratios wcrc much
grcatcr than r.c indicating a vcry strong
rclationship. Convcrscly, thc protcctivc
actors cach had odds ratios lcss than
r.c (mostly statistically signicant) and
showcd ncgativc rclationships to thc
prcscncc o cavitation or radiographic
pcnctration into dcntin at basclinc.

TABLE 3
Cross Tabulation Visible Cavitation or Radiographic Penetration of the Dentin at CRA Baseline Versus Disease
Indicators, Pathological and Protective Factors at CRA Baseline (n=12,954)
Visible Cavitation or Radiographic Penetration of the Dentin at CRA* Baseline
Significance (c
2
p-value) OR* 95% CI*
Disease indicators Restorations last 3 years <0.001 1.46 1.35-1.58
Approximal enamel lesions
on X-rays

<0.001

8.21

7.41-9.09
White spots <0.001 2.77 2.52-3.05
Pathological factors Visible heavy plaque <0.001 2.55 2.35-2.76
Frequent snack <0.001 1.77 1.63-1.93
Inadequate saliva flow <0.001 1.27 1.12-1.43
Exposed roots <0.001 1.19 1.10-1.28
Deep pits and fissures <0.001 1.80 1.63-1.98
Recreational drugs <0.001 1.95 1.66-2.28
Protective factors Fluoridated community 0.011 0.85 0.76-0.97
Fluoride toothpaste 0.003 0.81 0.70-0.93
Fluoride mouthwash <0.001 0.80 0.73-0.88
Xylitol gum 0.103 0.86 0.72-1.03
Chlorhexidine 0.724 0.95 0.73-1.24

*CRA: caries risk assessment; OR: odds ratio; CI: confidence interval.
714october 201 1
cda j ournal , vol 39, n

1 0
havc not bccn analyzcd to dctcrminc
whcthcr thosc who wcrc providcd with
spccic rccommcndations had lcss
cavitics, but, on thc othcr hand, thc
data prcscntcd hcrc show that thc CRA
proccdurcs uscd wcrc at lcast as good
as /c pcrccnt accuratc, and bascd upon
thc cxtrcmc risk data, approximatcly ,c
pcrccnt accuratc cvcn atcr pcrccnt
rcccivcd trcatmcnt rccommcndations,
which could havc lowcrcd thc carics
outcomcs. In othcr words, i no trcat
mcnt was givcn, thc prcdictivc valuc
could quitc possibly bc cvcn highcr.
Tcsc rcsults providc convinc
ing cvidcncc that thc CLA carics risk
asscssmcnt tool is valid in an adult
population sccking carc. Tc prcscnt
data dcmonstratc that CLA CRA orm
can bc succcssully implcmcntcd and
utilizcd in cvcryday clinical dcntal prac
ticc as it accuratcly idcnticd paticnts
at high carics risk and cxtrcmc risk.
In conclusion, thc CLA CRA orm
prcscntcd hcrc is bascd on a combina
tion o actors rclatcd to thc carics
discasc occurrcncc that arc casy to
rccordasscss in cvcryday practicc. Tc
proccdurc to usc thc orm is straight
orward and ollows thc dcntal history
and clinical cxamination.
8
In thc prcscnt
study, simplc instructions wcrc uscd by
multiplc providcrs with thc outcomc
prcscntcd hcrc at ollowup cxamina
tions with vcry good succcss in idcntiy
ing high and cxtrcmc carics risk indi
viduals. Tc prcscnt rcsults, bascd on a
vcry largc population o adults, clcarly
show thc validation o thc CLA CRA
orm as bcing hclpul in scrccning pa
ticnts who arc at high or cxtrcmc risk o
dcvcloping urthcr carics lcsion unlcss
intcrvcntionprcvcntion thcrapy is uscd.
Futurc rcscarch is nccdcd to dctcrminc
i thosc who rcccivcd trcatmcnt had
lowcr carics ratcs on ollowup.
(All o thcsc carics risk paticnts should
havc rcccivcd prcvcntivc trcatmcnt
intcrvcntions, which would havc
providcd incrcascd protcctivc actors
and altcrcd thcir carics balancc morc
avorably.) Howcvcr, only pcrccnt
o thc 8 pcrccnt total atrisk paticnts
wcrc providcd with spccic homc carc
rccommcndations that wcrc capturcd
using thc clcctronic hcalth rccord. In our
cxpcricncc, thc majority o thc paticnts
who did not rcccivc thc prcvcntivc
intcrvcntions wcrc bccausc o paticnt
rcusals, i.c., thc paticnt did not want to
purchasc thc prcvcntivc products. Tis
may bc duc to providcrs not cxplaining
thc valuc o thc prcvcntion or simply pa
ticnt nancial rcasons. It was impossiblc
to know thc cxtcnt o providcr compli
ancc in rccommcnding to thc paticnts
thc prcvcntivc intcrvcntions. Tc data
Tc high and cxtrcmc carics risk lcv
cls prcdictcd by thc usc o thc CLA CRA
orm wcrc comparcd to outcomcs in
thc .,/r paticnts who wcrc asscsscd at
ollowup (table 5), with , pcrccnt and
88 pcrccnt or high and cxtrcmc risk,
rcspcctivcly, rcturning with ncw cavitics.
Convcrscly, / pcrccnt classicd as low
risk rcturncd with no cavitics. Tcsc
rcsults dcmonstratc thc prcdictivc valuc
o thc CLA CRA orm. Indccd, thc carics
risk scorc at basclinc was highly signi
cantly rclatcd to thc prcscncc o cavita
tion and radiographic pcnctration into
dcntin and approximal cnamcl lcsions
on Xrays at ollowup appointmcnts.
Tc total numbcr o paticnts clas
sicd as having carics risk was ap
proximatcly 8 pcrccnt (.r., pcrccnt
modcratc risk+c. pcrccnt high risk+..r
pcrccnt cxtrcmc risk8. pcrccnt).


TABLE 4
TABLE 5
Cross Tabulation Visible Cavitation or Radiographic Penetration of the
Dentin Versus Overall Caries Risk Level Both at Baseline (n=12,954)
Relationship Assessed Overall Caries Risk at Baseline Versus Visible
Cavitation or Radiographic Penetration of the Dentin, Interproximal Enamel
Lesions or Radiolucencies, and White Spots at Follow-Up (n=2,571)
Risk @ Baseline Cavitations
@ Baseline
P-value
Low 6.4% <0.001
Moderate 25.2%
High 78.4%
Extreme 74.4%
c
2
p-value <0.001 <0.001 0.163
Risk @ Baseline First Follow-up
Cavitations
Interproximal Lesions White Spots
Low 23.6% 9.9% 10.2%
Moderate 38.6% 12.4% 7.7%
High 69.3% 28.7% 9.6%
Extreme 88% 23.5% 2%
c
2
p-value <0.001 <0.001 0.163
c r a s t u dy
cda j ournal , vol 39, n

1 0
october 201 1 715
references
1. Diagnosis and management of dental caries throughout life.
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ence statement, March 26-28, 2001. J Dent Educ 65(10):1162-8,
2001.
2. Ismail AI, Hasson H, Sohn W, Dental caries in the second
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3. Pits NB, Are we ready to move from operative to non-
operative/preventive treatment of dental caries in clinical
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tive strategies and management. J Am Dent Assoc 126
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6. Featherstone JDB, Adair SM, et al, Caries management by
risk assessment: consensus statement, April 2002. J Calif
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7. Featherstone JDB, The caries balance: contributing factors
and early detection. J Calif Dent Assoc 31(2):129-33, 2003.
8. Featherstone JDB, Domejean-Orliaguet S, et al, Caries risk
assessment in practice for age 6 through adult. J Calif Dent
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9. Domejean-Orliaguet S, Gansky SA, Featherstone JDB,
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Educ 70(12):1346-54, 2006.
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to request a printed copy of this article, please contact
John D. B. Featherstone, MS, PhD, University of California, San
Francisco, Oce of the Dean, Box 0430, 513 Parnassus Ave.,
San Francisco Calif., 94143-0430.


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