Caries Prevention, Risk Assessment, Diagnosis, and Treatment

Caries Risk Classification Table

Modifying factors: Commonly include previous caries experience, age, family behaviors, diet, white spots/incipient lesions, tooth
morphology, fluoride exposure, oral hygiene, family socioeconomic status, frequency of dental visits, salivary properties, medical conditions,
medications, radiation, root exposure, Mutans streptococci levels, orthodontics, removable prosthetic appliances, and special assistance
requirements.
Age
Birth
to Age
4

Risk Category
Low
No active lesions of any type at
examination.

Age 5
and
Over

High
Any cavitated or white spot
lesions at examination,
continued bottle feeding after
age 12 months, or family caries
history.
Low
No active cavitated or noncavitated lesions at
examination.
Moderate
1 active cavitated smoothsurface lesion at examination,
or any number of pit-andfissure lesions.
High
25 active cavitated smoothsurface lesions at examination,
or 2 new lesions of any type
with a history of smooth-surface
lesions in permanent teeth.

Very High
6 or more active cavitated
smooth-surface lesions at
examination.

Preventive Strategies
Education and reinforcement
Fluoride toothpaste (supervised)**
Dental sealants (behavior permitting), if patient has deep or uncoalesced
pits and fissures**
Education and reinforcement
Fluoride toothpaste (supervised)**
Dental sealants (behavior permitting)**
Fluoride supplements PRN*
Professionally applied topical fluorides (varnish)**
Restorative treatment
Education and reinforcement
Fluoride toothpaste**
Dental sealants if newly erupted and deep or uncoalesced pits and fissures**
Fluoride supplements PRN*
Education and reinforcement
Fluoride toothpaste**
Dental sealants and preventive resin restoration (PRR)**
Fluoride supplements PRN*
Home-use fluoride rinses and professionally applied topical fluorides*
Restorative treatment
Education and reinforcement
Fluoride toothpaste**
Dental sealants and PRR**
Fluoride supplements PRN*
Home-use fluorides and professionally applied topical fluorides*
Dietary counseling (refer to nutritionist)
Xylitol gum, if available and patient chews gum
Restorative treatment
Chlorhexidine rinse*
Education and reinforcement
Fluoride toothpaste**
Dental sealants and PRR**
Fluoride supplements PRN*
Home-use fluorides and professionally applied topical fluorides**
Dietary counseling (refer to nutritionist)
Xylitol gum, if available and patient chews gum
Restorative treatment
Chlorhexidine rinse*
Eliminate cavitated lesions as soon as possible (2 or fewer appointments)
Assess compliance and/or Mutans streptococci levels

Recall
612 months

36 months

2436 months;
more often for
children and
adolescents
624 months

312 months

36 months

*Shown effective in smaller clinical trials.

**Shown effective in large clinical trials.
Source: Indian Health Service. 2003. Caries Diagnosis, Risk Assessment, and Management: A Practical Guide. Rockville, MD: Indian
Health Service.

Points to Consider

This table approaches dental caries as an infectious disease based upon a medical model, rather than a surgical model.
Most restorative treatments result in irreversible changes in those teeth involved. The goal is to avoid premature or unnecessary
placement of restorations.
If resources are limited, prioritize by planning procedures with a double asterisk first, then procedures with a single asterisk, and then
other procedures as time and resources allow.
Do not use an explorer on white spot lesions or in pit-and-fissure lesions, as it may cause cavitation of otherwise reversible lesions.
In the mixed dentition and during adolescence, even patients at low risk should be evaluated at shorter recall intervals for sealant
placement on erupting teeth with deep or uncoalesced pits and fissures.
Use clinical judgment to classify patients with only pit-and-fissure lesions. Treat with preventive and/or conservative restorative
techniques whenever possible.
Less than semi-annual professional topical fluoride treatments are not effective. Provide treatments a minimum of twice a year,
depending on the patients risk level.
Home-use fluorides include toothpaste, mouthrinses, gels, and systemic supplements. Professionally applied topical fluorides include
fluoride foams, varnishes, and gels.
In the very-high-risk category, the effectiveness of antimicrobials should be assessed and re-prescribed, if necessary, to control active
infection. These procedures should be implemented before definitive restorative treatment.
The Alternative Restorative Treatment (ART) technique is appropriate for young children as well as adults.

Source: Barzel R, Holt K, Siegal M, eds. 2009. Caries Prevention, Risk Assessment, Diagnosis, and Treatment. Washington, DC: National Maternal and Child
Oral Health Resource Center. http://www.ohiodentalclinics.com/curricula/caries