Caries Risk Assessment

in Practice for Age

Through Adult


comcs rcscarch bascd upon thc usc o thc
proccdurcs in a largc cohort o paticnts at
thc School o Lcntistry at thc Univcrsity
o Caliornia, San Francisco, was rcccntly
publishcd, validating thc orm and procc
durcs.
.
c rcsults rom this study arc thc
basis or thc currcnt rcvisions to thc carics
risk asscssmcnt orm and proccdurcs prc
scntcd hcrc. c succcssul componcnts
o thc prcvious vcrsion havc bccn rc
groupcd according to thc outcomcs rcsults
and arc prcscntcd in . c orm can
bc rcadily adaptcd or usc in clcctronic
rccord systcms, as has bccn donc at UCSF.
c background, rationalc, and stcpby
stcp proccdurcs arc dcscribcd as ollows.
Background
Succcssul and accuratc carics risk
asscssmcnts havc bccn a drcam or
dccadcs. Numcrous rcscarch papcrs
havc bccn writtcn on thc topic, such
as thc rcvicws by Andcrson ct al. and
Anusavicc.
,
Scvcral orms and pro
ccdurcs havc bccn suggcstcd, somc
o which arc summarizcd in a rcccnt
rcvicw by Zcro ct al.

Individual contrib
1he aim cf lhis arlicle is lc presenl a praclical caries risk assessmenl
prccedure and fcrm fcr palienls whc are age lhrcugh adull 1he ccnlenl cf lhe fcrm
and lhe prccedures have been validaled by culccmes research aer several years cf
experience using lhe faclcrs and indicalcrs lhal are included

1ohn 0B Featherstone
is inlerim dean
niversily cf Califcrnia
San lranciscc Schccl cf
Denlislry and is a prcfes
scr Deparlmenl cf Pre
venlive and Reslcralive
Denlal Sciences al CSl
0ouglas A Young
is an asscciale
prcfesscr Deparlmenl
cf Denlal Praclice
niversily cf lhe Pacic
Arlhur A Dugcni Schccl cf
Denlislry
5ophie 0omejean0rli
aguet is an assislanl
prcfesscr Deparlmenl cf
Dperalive Denlislry and
Endcdcnlics niversil
dAuvergne Clermcnller
rand lrance
C
arics risk asscssmcnt is thc
rst stcp in carics managc
mcnt by risk asscssmcnt,
CAMBRA. c lcvcl o risk
should bc uscd to dctcrminc
thc nccd or thcrapcutic intcrvcntion and
is an intcgral part o trcatmcnt planning.
c managcmcnt o carics ollowing risk
asscssmcnt or ycarolds through adult
is dcscribcd in this issuc in dctail in thc
papcr by cnson ct al. A scparatc orm
and proccdurcs or usc or ncwborns
to ycarolds is prcscntcd in thc papcr
by RamosComcz ct al. in this issuc.
A group o cxpcrts rom across thc
Unitcd Statcs convcncd at a conscnsus
concrcncc hcld in Sacramcnto, Cali., in
April .cc.. is group produccd a carics
risk asscssmcnt orm and proccdurcs
bascd upon litcraturc availablc up to that
timc. c rcsults wcrc publishcd in .cc.
r

c conscnsus statcmcnt and supporting
rcvicw articlcs arc availablc on thc nct.
www.cdaoundation.orgjournal. is
orm, or somc variation o it, has bccn in
usc in dcntal schools and privatc practiccs
or as long as our ycars. Rcccnt out

Larry 1enson
is fcrmerly a heallh sci
ences clinical prcfesscr
Deparlmenl cf Prevenlive
and Reslcralive Denlal
Sciences niversily cf
Califcrnia San lranciscc
Schccl cf Denlislry
Mark Wol is a
prcfesscr and chair De
parlmenl cf Cariclcgy and
Ccmprehensive Care New
Ycrk niversily Ccllege cf
Denlislry New Ycrk

TALE
Caries Risk Assessment Form Children Age and 0verAdults
Palienl Name Charl Dale
Assessment 0ate Is this please circle base line

or

recall
0isease Indicators Any one YE5 signifies likely High Risk and to do a bacteria
test
YE5 CIRCLE YE5 CIRCLE YE5 CIRCLE
Visible cavilies cr radicgraphic penelralicn cf lhe denlin YE5
Radicgraphic apprcximal enamel lesicns ncl in denlin YE5
While spcls cn smcclh surfaces YE5
Reslcralicns lasl years YE5
Risk Factors Biological predisposing factors YE5
MS and lB bclh medium cr high by cullure YE5
Visible heavy plaque cn leelh YE5
lrequenl snack x daily belween meals YE5
Deep pils and fissures YE5
Recrealicnal drug use YE5
nadequale saliva flcw by cbservalicn cr measuremenl f measured ncle lhe flcw
rale belcw
YE5
Saliva reducing faclcrs medicalicnsradialicnsyslemic YE5
Expcsed rccls YE5
Drlhcdcnlic appliances YE5
Protective Factors
liveswcrkschccl flucridaled ccmmunily YE5
llucride lcclhpasle al leasl cnce daily YE5
llucride lcclhpasle al leasl x daily YE5
llucride mculhrinse Nal daily YE5
ppm l flucride lcclhpasle daily YE5
llucride varnish in lasl mcnlhs YE5
Dffice l lcpical in lasl mcnlhs YE5
Chlcrhexidine prescribedused cne week each cf lasl mcnlhs YE5
Xylilcl gumlczenges x daily lasl mcnlhs YE5
Calcium and phcsphale pasle during lasl mcnlhs YE5
Adequale saliva flcw mlmin slimulaled YE5
Bacteria5aliva Test Results M5 LB Flow Rate mlmin 0ate
VSAlZE CARES BAlANCE
se circled indicalcrsfaclcrs abcve
EX1REME RSK HCH RSK SEVERE SAlVARY ClAND HYPDlNC1DN
CARES RSK ASSESSMEN1 CRClE EX1REME HCH MDDERA1E lDW
Dcclcr signalure Dale

to dctcrminc thc lcvcl o risk that thc
sum o thcsc actors indicatcs.
/
Spccic
pathologic and protcctivc actors or
dcntal carics contributc to dctcrmin
ing thc balancc bctwccn progrcssion,
arrcstmcnt, or rcvcrsal o thc discasc.
For cxamplc, a young paticnt may havc
poor oral hygicnc but no othcr carics
risk actors. \c would want to addrcss
thc oral hygicnc issuc, but this, in and
o itscl, is not sucicnt to put thc
paticnt in a highrisk catcgory. \c know
that paticnts with high plaquc lcvcls
rcqucntly dcmonstratc no cvidcncc
o dcntal carics. On thc othcr hand, a
paticnt with a cavitatcd carics lcsion is
immcdiatcly put into thc highrisk cat
cgory bccausc this is a wclldocumcntcd
prcdictor o uturc carics lcsions.
anticipatc that, with thc updatcd orm
prcscntcd hcrc, thc succcss will bc cvcn
highcr as all o thc contributing ac
tors havc bccn validatcd and rankcd in
ordcr o thc odds ratios ound thcy wcrc
rclatcd to thc ormation o cavitics.
0etermining Caries Risk
Assigning a paticnt to a carics risk
lcvcl is thc rst stcp in managing thc
discasc proccss. A stcpbystcp guidc
how to do this is laid out latcr in this
articlc. Bcorc moving to thc dctails
somc ovcrall discussion and dcnition
o tcrms arc nccdcd. is asscssmcnt
occurs in two phascs. thc rst is to
dctcrminc spccic discasc indicators,
risk actors, and protcctivc actors
cach paticnt has. c sccond stcp is
uting actors to carics risk havc bccn
idcnticd ovcr thc last c ycars or so,
and a rcvicw o thcsc was publishcd in
two spccial issucs o thc oarnc| o/ ||e
Cc||/orn|c !en|c| Asso.|c||on, Fcbruary
and March .cc (www.cdaoundation.
orgjournal), togcthcr with thc conscn
sus statcmcnt rccrrcd to abovc.

Much
o thc inormation has bccn availablc
or rc to .c ycars or morc, but has not
bccn put into cvcryday clinical practicc,
primarily bccausc thc inormation has
not bccn gathcrcd togcthcr in a simplc
orm and proccdurc, and such combi
nations havc not bccn validatcd until
rcccntly.
.
Utilization o risk asscssmcnt
to dctcrminc thcrapcutic modalitics was
succcssul at a lcvcl o about /c pcrccnt
in an adult population. c authors
1he caries imbalance 1he balance amcngsl disease indicalcrs risk faclcrs and prcleclive faclcrs delermines whelher denlal caries prcgresses halls cr reverses
Refer lc and lhe lexl fcr mcre delail cn disease indicalcrs Caviliesdenlin refers lc frank cavilies cr lesicns lc lhe denlin by radicgraph Reslcralicns years means res
lcralicns placed in lhe previcus lhree years 1his gure has been updaled frcm previcus versicns cf lhe caries balance wilh lhe very impcrlanl addilicn cf lhe disease indicalcrs

f
lhese indicalcrs are presenl lhey weigh heavily cn lhe side cf predicling caries prcgressicn unless lherapeulic inlervenlicn is carried cul 1he leading leers lhal help lc remember
lhe imbalance WREC BAD SAlE have been added as well as sealanls as a prcleclive faclcr Dielary habils pccr indicales frequenl ingeslicn cf fermenlable carbchydrales
grealer lhan lhree limes daily belween meals
The Caries Imbalance

5 aliva sealants
Antibacterials
F luoride
E ective diet

ad bacteria
Absence of saliva
D ietary habits poor

W hite spots
P estorations years
E namel lesions
C avitiesdentin

c sccond phasc o carics risk as
scssmcnt is by no mcans a mathcmatical
ormula, it is bcttcr charactcrizcd as a
judgmcnt bascd on thc likcly balancc
bctwccn thc indicators and actors
idcnticd in thc risk asscssmcnt orm
( ) and illustratcd visually in
. c risk asscssmcnt orm ( )
is compriscd o a hicrarchy o discasc
indicators, risk actors, and protcc
tivc actors that arc bascd on thc bcst
scicntic cvidcncc wc havc at this timc.
As mcntioncd prcviously, thc risk asscss
mcnt proccdurcs publishcd in .cc havc
bccn asscsscd ovcr morc than thrcc ycars
and thc outcomcs lcd to thc climina
tion o somc itcms and to thc validation
o thosc includcd hcrc, togcthcr with
validation o thc tool to asscss carics
risk.
r,.
c dctcrmination o highrisk
status is airly clcar. c dccision to placc
somconc in thc modcratcrisk catcgory
is somctimcs not clcar and dicrcnt
practitioncrs may rcasonably comc to di
crcnt conclusions. It is bcttcr to crr on
thc conscrvativc sidc and placc a paticnt
in thc ncxt highcr catcgory i thcrc is
doubt. As wc gct morc clinical data thc
accuracy o thcsc risk asscssmcnt orms
will no doubt incrcasc cvcn urthcr.
Rationale and Instructions for Age
Through Adult Caries Risk Assessment
Form
c ollowing scction prcscnts thc
rationalc and instructions or thc usc o
thc orm prcscntcd in . 'Carics Risk
Asscssmcnt Form Childrcn Agc and
OvcrAdults.
Caries 0isease Indicators
Carics discasc indicators arc clinical
obscrvations that tcll about thc past car
ics history and activity. cy arc indica
tors or clinical signs that thcrc is discasc
prcscnt or that thcrc has bccn rcccnt
with rank cavitics has high lcvcls o
cariogcnic bactcria, and placing rcstora
tions docs not signicantly lowcr thc
ovcrall bactcrial challcngc in thc mouth.
8
Caries Risk Factors
Carics risk actors arc biological ac
tors that contributc to thc lcvcl o risk or
thc paticnt o having ncw carious lcsions
in thc uturc or having thc cxisting lcsions
progrcss. c risk actors arc thc biologi
cal rcasons or actors that havc causcd or
contributcd to thc discasc, or will con
tributc to its uturc manicstation on thc
tooth. csc wc can do somcthing about.
crc arc ninc risk actors rcccntly
idcnticd in outcomcs mcasurcs o car
ics risk asscssmcnt
.
listcd in . r)
mcdium or high MS and IB counts, .)
visiblc hcavy plaquc on tccth, ) rc
qucnt (. thrcc timcs daily) snacking
bctwccn mcals, ) dccp pits and ssurcs,
) rccrcational drug usc, ) inadcquatc
saliva fow by obscrvation or mcasurc
mcnt, /) saliva rcducing actors (mcdica
tionsradiationsystcmic), 8) cxposcd
roots, and ,) orthodontic applianccs.
I thcrc arc no positivc carics discasc
indicators (scc abovc), thcsc ninc ac
tors in sum bccomc thc dctcrminants
o carics activity, unlcss thcy arc osct
by thc protcctivc actors listcd bclow.
Caries Protective Factors
csc arc biological or thcrapcutic actors
or mcasurcs that can collcctivcly osct
thc challcngc prcscntcd by thc prcviously
mcntioncd carics risk actors. c morc
scvcrc thc risk actors, thc highcr must bc
thc protcctivc actors to kccp thc paticnt
in balancc or to rcvcrsc thc carics proccss.
As industry rcsponds to thc nccd or morc
and bcttcr products to trcat dcntal carics,
thc currcnt list in is surc to cxpand
in thc uturc. Currcntly, thc protcctivc
actors listcd in arc. r) livcswork
discasc. csc indicators say nothing
about what causcd thc discasc or how to
trcat it. cy simply dcscribc a clinical
obscrvation that indicatcs thc prcscncc
o discasc. csc arc not pathological
actors nor arc thcy causativc in any way.
cy arc simply physical obscrvations
(holcs, whitc spots, radioluccncics). c
outcomcs asscssmcnt dcscribcd prcvi
ously and prior litcraturc, highlight
that thcsc discasc indicators arc strong
indicators o thc discasc continuing un
lcss thcrapcutic intcrvcntion ollows.
c our carics discasc indictors
outlincd in arc. (r) rank cavita
tions or lcsions that radiographically
show pcnctration into dcntin, (.) ap
proximal radiographic lcsions conncd
to thc cnamcl only, () visual whitc spots
on smooth suraccs, and () any rcstora
tions placcd in thc last thrcc ycars. csc
our catcgorics arc strong indicators or
uturc carics activity and unlcss thcrc
is nonsurgical thcrapcutic intcrvcntion
thc likclihood o uturc cavitics or thc pro
grcssion o cxisting lcsions is vcry high.
A positivc rcsponsc to any onc o
thcsc our indicators automatically placcs
thc paticnt at high risk unlcss thcrapcu
tic intcrvcntion is alrcady in placc and
progrcss has bccn arrcstcd. A paticnt

lc err cn lhe
ccnservalive side
and place a palienl
in lhe nexl higher
calegcry if
lhere is dcubl

school locatcd in a fuoridatcd community,
.) fuoridc toothpastc at lcast oncc daily, )
fuoridc toothpastc at lcast two timcs daily,
) fuoridc mouthrinsc (c.c pcrccnt NaF)
daily, ) ,ccc ppm F fuoridc toothpastc
daily, ) fuoridc varnish in last six months,
/) occ fuoridc topical in last six months,
8) chlorhcxidinc prcscribcduscd daily or
onc wcck cach o last six months, ,) xylitol
gumlozcngcs our timcs daily in thc last
six months, rc) calcium and phosphatc
supplcmcnt pastc during last six months,
and rr) adcquatc saliva fow (. r mlmin
stimulatcd). Fluoridc toothpastc rcqucncy
is includcd sincc studics havc shown that
brushing twicc daily or morc is signicant
ly morc ccctivc than oncc a day or lcss.
,

Any or all o thcsc protcctivc actors can
contributc to kccp thc paticnt 'in balancc
or cvcn bcttcr to cnhancc rcmincralization,
which is thc natural rcpair proccss o thc
carly carious lcsion.
What to 0o
r. Takc thc paticnt dctails, thc paticnt
history (including mcdications) and
conduct thc clinical cxamination. cn
procccd with thc carics risk asscssmcnt.
.. Circlc or highlight cach o thc 'YFS
catcgorics in thc thrcc columns on thc
orm ( ). Onc can makc spccial
notations such as thc numbcr o carious
lcsions prcscnt, thc scvcrity or thc lack o
oral hygicnc, thc brand o fuoridcs uscd,
thc typc o snacks catcn, or thc namcs o
mcdicationsdrugs causing dry mouth.
. *GUIFBOTXFSJTiZFTwUPBOZPOFPG
UIFGPVSEJTFBTFJOEJDBUPSTJOUIFmSTU
QBOFMUIFOBCBDUFSJBMDVMUVSFTIPVME
CFUBLFOVTJOH thc Carics Risk Tcst
(CRT) markctcd by Vivadcnt, (Amhcrst,
N.Y.). ('Scc bclow or cquivalcnt tcst.)
. Makc an ovcrall judgmcnt as to
whcthcr thc paticnt is at high, modcr
atc or lowrisk dcpcndcnt on thc bal
ancc bctwccn thc discasc indicatorsrisk
tions in thc orm o a lcttcr, bascd
on clinical obscrvations and thc
Carics Risk Asscssmcnt rcsult.
8. Civc thc paticnt thc shcct that
cxplains how carics happcns ( )
and thc lcttcr with your rccommcnda
tions. Samplc lcttcrs arc givcn. Morc
dctails about thcsc rccommcndations and
proccdurcs arc laid out in cnson ct al. in
this issuc. Products that should bc uscd
arc dcscribcd in dctail in Spolsky ct al.
,. Copy thc rccommcndations and thc
lcttcr or thc paticnt chart (or i you havc
clcctronic rccords thc various orm lcttcrs
and rccommcndations can bc gcncratcd to
bc printcd out custom or cach paticnt).
rc. Inorm thc paticnt o thc rcsults
o any tcsts. c.g., showing thc paticnt
thc bactcria grown rom thcir mouth
(CRT tcst rcsult') can bc a good motiva
tor so havc thc culturc tubc or digital
photograph o thc tcst slidc handy at
thc ncxt visit (or schcdulc onc or this
purposc thc culturc kccps satisacto
rily or somc wccks), or givcscnd thcm
a picturc (digital camcra and cmail).
rr. Atcr thc paticnt has bccn ollow
ing your rccommcndations or thrcc to six
months, havc thc paticnt back to rcasscss
how wcll thcy arc doing. Ask thcm i thcy
arc ollowing your instructions, how otcn.
I thc bactcrial lcvcls wcrc modcratc or
high initially, rcpcat thc bactcrial culturc
to scc i bactcrial lcvcls havc bccn rcduccd.
Somc clinicians rcport improvcd paticnt
motivation whcn a sccond bactcrial tcst
is donc initially immcdiatcly atcr thc
rst month o antibactcrial trcatmcnt.
Locumcnting a 'win in your column carly
on is a valuablc tool to cncouragc paticnts.
Makc changcs in your rccommcndations
or rcinorcc protocol i rcsults arc not as
good as dcsircd, or thc paticnt is not com
pliant. Rccr to cnson ct al. this issuc or
morc dctail on protocols and proccdurcs.
actors and thc protcctivc actors using
thc carics balancc conccpt (scc bottom
o and ). Lctcr
mining thc carics risk or an individual
rcquircs cvaluating thc numbcr and
scvcrity o thc discasc indicatorsrisk
actors. An individual with carics lcsions
prcscntly or in thc rcccnt past is at
high risk or uturc carics by dcault. A
paticnt with low bactcrial lcvcls would
nccd to havc scvcral othcr risk actors
prcscnt to bc considcrcd at modcratc
risk. Somc clinical judgmcnt is nccdcd
whilc also considcring thc protcc
tivc actors in dctcrmining thc risk.
. *GBQBUJFOUJTIJHISJTLBOEIBT
TFWFSFTBMJWBSZHMBOEIZQPGVODUJPOPS
TQFDJBMOFFETUIFOUIFZBSFBUiFYUSFNF
SJTLwBOESFRVJSFWFSZJOUFOTJWFUIFSBQZ
. Complctc thc thcrapcutic rccom
mcndations scction as dcscribcd in thc
papcr by cnson ct al. this issuc, bascd
on thc asscsscd lcvcl o risk or uturc
carious lcsions and ongoing carics
activity. Usc thc thcrapcutic rccom
mcndations as a starting point or thc
trcatmcnt plan. c products that can
bc uscd arc dcscribcd in dctail in cnson
ct al. and Spolsky ct al. in this issuc.
/. Providc thc paticnt with thcra
pcutic and homc carc rccommcnda

frequency is included
since sludies have
shcwn lhal brushing
lwice daily cr mcre is
significanlly
mcre effeclive lhan
cnce a day cr less

Test procedures 5aliva Flow Rate
and Caries Bacteria Testing
`.. 3c||.c F|ou Pc|e. Havc thc paticnt
chcw a paran pcllct (includcd with
thc CRT tcst scc bclow) or thrcc to
vc minutcs (timcd) and spit all saliva
gcncratcd into a mcasuring cup. At thc
cnd o thc thrcc to vc minutcs, mca
surc thc amount o saliva (in millilitcrs
ml) and dividc that amount by timc to
dctcrminc thc mlminutc o stimulatcd
salivary fow. A fow ratc o r mlmin
and abovc is considcrcd normal. A lcvcl
o c./ mlmin is low and anything at c.
mlmin or lcss is dry, indicating scvcrc
salivary gland hypounction. Invcstigation
o thc rcason or thc low fow ratc is an
important stcp in thc paticnt trcatmcnt.
`.. Fc.|er|c| |es||ng. An cxamplc (othcrs
arc currcntly availablc) o a currcntly avail
ablc chairsidc tcst or cariogcnic bactcrial
challcngc is thc Carics Risk Tcst (CRT)
markctcd by Vivadcnt. It is sucicntly
scnsitivc to providc a lcvcl o low, mcdi
um, or high cariogcnic bactcrial challcngc.
It can also bc uscd as a motivational tool
or paticnt adhcrcncc with an antibactcrial
rcgimcn. Othcr bactcrial tcst kits will likcly
bc availablc in thc ncar uturc. c ollow
ing is thc proccdurc or administcring thc
currcntly availablc CRT tcst. Rcsults arc
availablc atcr /. hours (notc. thc manu
acturcr's instruction statcs 8 hours, but
morc rcliablc rcsults arc achicvcd i thc
incubation timc is /. hours). c kit comcs
with a twosidcd sclcctivc mcdia stick that
asscss mutans strcptococci on thc bluc
sidc and lactobacilli on thc grccn sidc.
a) Rcmovc thc sclcctivc mcdia stick
rom thc culturc tubc. Pccl o thc plastic
covcr shcct rom cach sidc o thc stick.
b) Pour (do not strcak) thc col
lcctcd saliva ovcr thc mcdia on
cach sidc until it is cntircly wct.
c) Placc onc o thc sodium bicar
bonatc tablcts (includcd with thc
kit) in thc bottom o thc tubc.
d) Rcplacc thc mcdia stick in thc
culturc tubc, scrcw thc lid on and labcl
thc tubc with thc paticnt's namc, rcgistra
tion numbcr, and datc. Placc thc tubc in
thc incubator at /dcgrccs Cclsius or /.
hours. Incubators suitablc or a dcntal
occ arc also sold by thc company.
c) Collcct thc tubc atcr /. hours
and comparc thc dcnsitics o bactc
rial colonics with thc picturcs providcd
in thc kit indicating rclativc bactcrial
lcvcls. c dark bluc agar is sclcctivc or
mutans strcptococci and thc light grccn
agar is sclcctivc or lactobacilli. Rccord
thc lcvcl o bactcrial challcngc in thc
paticnt's chart, as low, mcdium or high.
Somc nd it hclpul or documcntation
to numbcr thc picturcs r through .
5ample Patient Leers
Recommendations for Control of
0ental 0ecay Age and 0verAdult
Onc o thc ollowing lcttcrs (
)including homc carc rccommcnda
tions should go to cach paticnt dcpcnd
ing on thc risk catcgory and thc ovcrall
trcatmcnt plan (rccr to cnson ct al.
this issuc or trcatmcnt plan dctails).


1cclh decay is caused by cerlain lypes cf bacleria mulans slreplccccci
and laclcbacilli lhal live in ycur mculh When lhey allach lhemselves lc
lhe leelh and mulliply in denlal plaque lhey can dc damage 1he bacleria
feed cn whal ycu eal especially sugars including fruil sugars and cccked
slarch bread pclalces rice pasla elc Wilhin |usl a few minules afler
ycu eal cr drink lhe bacleria begin prcducing acids as a byprcducl cf lheir
digesling ycur fccd 1hcse acids can penelrale inlc lhe hard subslance cf
lhe lcclh and dissclve scme cf lhe minerals calcium and phcsphale f lhe
acid allacks are infrequenl and cf shcrl duralicn ycur saliva can help lc
repair lhe damage by neulralizing lhe acids and supplying minerals and fluc
ride lhal can replace lhcse lcsl frcm lhe lcclh Hcwever if ycur mculh is
dry ycu have many cf lhese bacleria cr ycu snack frequenlly lhen lhe
lcclh mineral lcsl by allacks cf acids is lcc greal and canncl be repaired
1his is lhe slarl cf lcclh decay and leads lc cavilies
Hcw lcclh decay happens lc be given lc each palienl
How Tooth 0ecay Happens

Dear Palienl X
Ccngralulalicns ycu have been assessed al lcw risk fcr fulure denlal decay We wanl lc help ycu slay lhal way Ycu will find lhal ycu will be able
lc mainlain ycur currenl level cf cral heallh if ycu dc lhe fcllcwing

Brush lwice daily wilh an cverlheccunler flucrideccnlaining lcclhpasle

Review wilh us ycur dielary and cral hygiene habils and receive cral hygiene inslruclicns f gccd ccnlinue wilh ycur exisling dielary and cral
hygiene habils unless lhere is a change in slalus such as new medicalicns

Cel a lhcrcugh prcfessicnal cleaning as needed fcr ycur pericdcnlal heallh We will be happy lc prcvide lhese cleanings fcr ycu

Relurn fcr a caries recall exam when requesled in six lc mcnlhs lc reevaluale ycur currenl caries risk

Have new bilewing radicgraphs Xrays laken abcul every lc mcnlhs lc check fcr cavilies

Ccnsider using xylilcl gumcandies and cverlheccunler flucride rinse percenl scdium flucride inslead cf regular gumcandy cr mculh
wash

Cel flucride varnish afler leelh cleanings base line baclerial lesl sealanls if ycur denlisl reccmmends il Ycu may cr may ncl need lhis l
depends cn ycur cral ccndilicns

Dlher reccmmendalicns
lcw caries risk
Dear Palienl Y
Ycu have been assessed lc be al mcderale risk fcr new denlal decay in lhe near fulure because ycu have fill in lhe blank We wanl ycu lc mcve
inlc a safer silualicn lc avcid new decay in lhe fulure Here are scme ways lc acccmplish lhis gcal

Review ycur dielary and cral hygiene habils wilh us and receive cral hygiene inslruclicns

Brush lwice daily wilh an cverlheccunler flucrideccnlaining lcclhpasle fcllcwing lhe cral hygiene inslruclicn prccedures ycu have been
given

Purchase an cverlheccunler flucride rinse percenl scdium flucride eg llucrigard cr AC1 and rinse wilh ml cne cap full cnce cr
lwice daily afler ycu have used ycur flucride lcclhpasle Ccnlinue daily unlil ycur nexl denlal exam

Cel a lhcrcugh prcfessicnal cleaning frcm us as needed fcr ycur pericdcnlal heallh

Chew cr suck xylilclccnlaining gum cr candies fcur limes daily

Relurn when requesled fcr a caries recall exam in fcur lc six mcnlhs lc reevaluale ycur prcgress and currenl caries risk

Cel new bilewing radicgraphs Xrays abcul every mcnlhs lc check fcr cavilies

Cel a flucride varnish lrealmenl every fcur lc six mcnlhs al ycur caries recall exams

Ycu may alsc need a base line baclerial lesl and sealanls depending cn ycur silualicn and ccndilicn

Dlher reccmmendalicns
Mcderale caries risk

Dear Palienl Z
Dur assessmenl reveals ycu are al a high risk cf having new denlal decay in lhe near fulure because ycu have fill in lhe blank We wanl lc help
ycu lc mcve lc a safer silualicn lc avcid new decay if al all pcssible We slrcngly reccmmend lhe fcllcwing

Ccmplele a caries baclerial lesl wilh us lcday as a base line befcre anlibaclerial lherapy We will have lhe resulls cf lhis lesl in lhree days

Ccmplele a saliva flcw measuremenl lc check fcr dry mculh 1his is a very simple lesl lhal we will dc lcday as parl cf lhe baclerial assessmenl

Review wilh us ycur dielary and cral hygiene habils and receive inslruclicns cn bclh 1he mcsl impcrlanl lhing is lc reduce lhe number cf
belweenmeal sweel snacks lhal ccnlain carbchydrales especially sugar Subslilulicn by snacks rich in prclein such as cheese will alsc help
as well as lhe xylilcl gum cr candies described belcw

Brush lwice daily wilh a high flucride lcclhpasle eilher Ccnlrcl RX cr Previdenl Plus lcclhpasle parls per millicn flucride We will
prcvide scme fcr ycu lcday 1his is lc be used lwice daily in place cf ycur regular lcclhpasle

Rinse fcr cne minule cnce a day wilh a special anlibaclerial mculhrinse we will prcvide fcr ycu lcday l is called Peridex cr Pericgard and
has an aclive ingredienl called chlcrhexidine gluccnale al percenl Ycu shculd use lhis cnce daily |usl befcre bed al nighl ml fcr cne
minule bul cnly fcr cne week each mcnlh Ycu musl use lhis al leasl cne hcur afler brushing wilh lhe ppm flucride lcclhpasle

Have lhe necessary reslcralive wcrk dcne such as fillings cr crcwns as needed in a minimally invasive fashicn

Suck cr chew xylilcl candies cr gum fcur limes daily Ycu can cblain supplies frcm us lcday cr we can help ycu buy lhese elsewhere

Cel sealanls applied lc all cf lhe biling surfaces cf ycur back leelh lc keep lhem frcm being reinfecled wilh lhe bacleria lhal cause denlal
decay We will be happy lc dc lhis fcr ycu

Relurn when requesled fcr a caries recall exam in lhree lc fcur mcnlhs lc reevaluale ycur prcgress and currenl caries risk

Parlicipale in anclher caries baclerial lesl al ycur caries recall exam cr earlier lc ccmpare resulls wilh ycur firsl visil 1his will allcw us lc
check whelher lhe chlcrhexidine is wcrking salisfaclcrily

Allcw us lc review ycur use cf chlcrhexidine and Ccnlrcl RXPrevidenl and cral hygiene al lhal visil

Cel a lhcrcugh prcfessicnal cleaning as needed fcr ycur pericdcnlal heallh

Cel new bilewing radicgraphs Xrays abcul every six lc mcnlhs lc check fcr cavilies

Cel a flucride varnish lrealmenl fcr all cf ycur leelh every lhree lc fcur mcnlhs al ycur caries recall exams

Dlher reccmmendalicns
High caries risk

lealherslcne 1D Adair SM el al Caries managemenl by

risk assessmenl ccnsensus slalemenl April ! Cci Dent
Asscc March
Dcme|eanDrliaguel S Cansky SA lealherslcne 1D Caries
risk assessmenl in an educalicnal envircnmenl ! Dent Educ

Anderscn MH Bales D1 Dmnell KA Mcdern managemenl
cf denlal caries lhe cuing edge is ncl lhe denlal bur ! Am
Dent Asscc
Anusavice K1 Ecacy cf ncnsurgical managemenl cf lhe
inilial caries lesicn ! Dentci Educcticn
Zerc D1 lcnlana M lenncn AM Clinical applicalicns and
culccmes cf using indicalcrs cf risk in caries managemenl !
Dent Educ
lealherslcne 1D 1he caries balance ccnlribuling faclcrs and
early deleclicn ! Cci Dent Asscc lebruary
lealherslcne 1DB 1he caries balance lhe basis fcr caries
managemenl by risk assessmenl Drci Hecitn Prev Dent
Suppl
lealherslcne 1D Cansky SA el al A randcmized clinical
lrial cf caries managemenl by risk assessmenl Ccries Res

Curncw MM1 Pine CM el al A randcmized ccnlrclled lrial
cf lhe ecacy cf supervised lcclhbrushing in highcariesrisk
children Ccries Res 1ulyAugusl

1chn DB lealherslcne MSc PhD niversily cf
Califcrnia San lranciscc Deparlmenl cf Prevenlive and
Reslcralive Denlal Sciences Parnassus Ave Bcx
San lranciscc Calif

Dear Palienl Z
Dur assessmenl indicales lhal ycu are al exlreme risk cf new denlal decay in lhe near fulure because ycu have fill in lhe blank and ycu have
severe dry mculh due lc fill in lhe blank We wanl ycu lc mcve lc a safer silualicn lc avcid new decay if al all pcssible Please dc lhe fcllcwing
righl away

Ccmplele a caries baclerial lesl wilh us lcday as a base line befcre anlibaclerial lherapy We will kncw lhe resulls cf lhis lesl in lhree days

Ccmplele a saliva flcw measuremenl lc ccnfirm ycur exlreme dry mculh 1his is a very simple lesl lhal we will ccmplele lcday as parl cf lhe
baclerial assessmenl

Review ycur dielary and cral hygiene habils wilh us and receive inslruclicns abcul hcw lc imprcve lhem bclh 1he mcsl impcrlanl lhing is lc
reduce lhe number cf belweenmeal sweel snacks lhal ccnlain carbchydrales especially sugar Subslilulicn by snacks rich in prclein such as
cheese will alsc help as well as lhe xylilcl gum cr candies reccmmended belcw

Brush lwice daily wilh a new slrcng lcclhpasle eilher Ccnlrcl RX cr Previdenl Plus lcclhpasle parls per millicn flucride We will prc
vide ycu wilh scme lcday 1his is lc be used lwice daily in place cf ycur regular lcclhpasle

Rinse fcr cne minule cnce a day wilh a special anlibaclerial mculhrinse lhal we will prcvide ycu wilh lcday l is called Peridex cr Pericgard
and has an aclive ingredienl called chlcrhexidine gluccnale al percenl Ycu will use lhis cnce daily |usl befcre gcing lc bed al nighl ml
fcr cne minule bul cnly fcr cne week each mcnlh Ycu musl use lhis al leasl cne hcur afler brushing wilh lhe ppm flucride lcclhpasle

Cel a flucride varnish lrealmenl fcr all cf ycur leelh every lhree mcnlhs al ycur caries recall exams

Receive lhe necessary reslcralive wcrk such as fillings and crcwns as needed in a minimally invasive fashicn

Suck cr chew xylilcl candies cr gum fcur limes daily Ycu can cblain supplies frcm us lcday cr we can help ycu buy lhese elsewhere

se a special pasle lhal ccnlains calcium and phcsphale eg M pasle Apply il several limes daily lc ycur leelh We will leach ycu hcw lc dc
lhis prcperly

Dblain a lhcrcugh prcfessicnal cleaning during ycur currenl visil

Cel a sealanl lrealmenl cn all cf lhe biling surfaces cf ycur back leelh lc keep lhem frcm being reinfecled wilh lhe bacleria lhal cause denlal
decay

se a baking scda rinse cr similar neulralizing prcducl fcur lc six limes daily during lhe day Ycu can make lhis ycurself by shaking up lwc lea
spccns cf baking scda in an eighlcunce bcllle cf waler

Please relurn when called fcr a reevalualicn in abcul cne mcnlh

Please relurn when requesled fcr a caries recall exam in lhree mcnlhs

Cel new bilewing radicgraphs Xrays abcul every six mcnlhs unlil nc cavilaled lesicns are evidenl

Ccme in fcr anclher caries baclerial lesl al lhe lhreemcnlh visil cr sccner lc ccmpare resulls wilh ycur firsl visil lc check whelher lhe
chlcrhexidine is wcrking salisfaclcrily

Receive a review cf ycur use cf chlcrhexidine and Ccnlrcl RXPrevidenl and cral hygiene al lhal visil

Ccme in fcr a lhcrcugh prcfessicnal cleaning as needed fcr ycur pericdcnlal heallh

Cel anclher flucride varnish lrealmenl cf all leelh again al lhreemcnlh caries recall visil and anclher sel cf bilewing Xrays al six mcnlhs
We will prcvide ycu wilh a limelable lc help ycu lc remember all cf lhese prccedures
Allhcugh lhis scunds like a lcl cf lhings lc dc and lc remember lhis inlensive lherapy is necessary lc slcp lhe rapid deslruclicn cf ycur leelh
l can really wcrk and if ycu are willing lc pul in lhe lime and effcrl ycu can clear up ycur mculh gums and leelh and avcid ccslly reslcralive
denlal wcrk in lhe fulure Please help us lc help ycu
Praclilicner signalure Dale
Palienl signalure Dale
Exlreme caries risk high risk plus severe salivary gland hypcfunclicn