Evaluating Caries Risk

No risks occur in isolation, and many have their roots in complex chains of events spanning long periods of time (WHO 2002) Public health strategies designed to help identify and tackle poor oral health e.g. NHS Dental Recall interval guidelines for Oral Health Assessment and Oral Health Review to determine risk categories/ prevention/treatment recommendations:
Low/controlled: 0-1 active lesion with no history of recent restorations Moderate/modifiable: >1/2 active/new/progress/filled lesions in 2-3yrs High/unmmodifiable: >1/2 active/new/progress/filled lesions in 2-3yrs

AAPD Caries-Risk Assessment Tool (CAT) traffic light system is this one used by NHS Dentists? Modifying factors have insuffienct evidence to assign a score so dentists must use their clinical judgement to weigh the risk/protective factors for individual patients

Medical History
Medical conditions causing xerostomia, reduce the rate at which cariogenic bacteria are eliminated, acids are neutralised and enamel is remineralised e.g.
Sjgrens syndrome Salivary Gland aplasia Trauma Leukaemia Psychological disorders

Some directly cause xerostomia, others indirectly via their treatment e.g.

Radiotherapy near salivary glands Long term medication use e.g. examples?
Amelogenesis imperfecta Diabetes - how exactly? Autoimmune diseases Gastric reflux Cleft lip how?h Check the BNF for dry mouth side effects and sugar content of medications Chronically sick cant care for themselves

Other medical disorders that increase dental caries risk include:

Additional things to consider:

Social & Demographic Factors

WHO recognises importance of social inequality in oral health outcomes Not the sole reason but socioeconomic factors, esp. educational levels, emerging as key external modifying factors related to dental caries, e.g:
Income/employment status Ethnicity/immigrant groups Family history Location Lifestyle behaviours Dental care attendance Industrialised vs developing countries

High risk group:

Socially deprived High caries in siblings Low knowledge of dental disease Irregular attendance Readily available snacks Low dental aspirations

Education level of parents is significantly related to caries incidence in children

ww.who.int/oral_health/media/orh_socio_beh_risks_CDOE2005.pdf

Diet Multiple studies shown link between diet and dental caries e.g. Tristan de Cunha (1930s), Vipeholm Hospital (1940s) Dietary counselling key to identifying appropriate habits to reduce risk of caries
Increased frequency of fermentable carbohydrates feeds cariogenic bacteria, increasing patients susceptibility to the carious process Frequent consumption of acidic fizzy drinks directly reduces pH in oral cavity causing demineralisation of enamel and weakening tooth structures e.g. phosphoric acid Behavioural or medical disorders relating to diet may increase a patients susceptibility to caries e.g. high sugar content of medications

Sugars in almost everything we eat but need to tackle exposure to non-milk extrinsic sugars (cariogenic sugars) where possible e.g.
Sucrose Dextrose Glucose syrup Fructose (ok in fresh fruits or vegetables)

Sugar substitutes can have extremely positive result on reducing caries risk e.g. Xylitol Education of diet is essential in helping reduce caries risk as shown by Sure Start programme, Choosing Better Oral Health, 5-a-day. E.g. Baby Ribena
Remember:
Avoid - high sugar content foods Limit - frequency of fermentable carbohydrates Encourage healthy food, drink and overall diet

Oral Hygiene

Saliva

Saliva has a protective role in the mouth and when compromised, can increase the risk of dental caries e.g. xerostomia or hyposalivation will increase susceptibility to dental caries (see medical history) Reduced saliva flow rate should be assessed to determine caries risk as can affect its buffering capability and compromise tooth integrity

Plaque Control
The patients oral hygiene will have a direct effect on their susceptibility to caries. Removal of bacterial plaque by brushing, flossing, washing is important in minimising the aetiological factors in caries e.g. reduce level of cariogenic bacteria in the oral cavity therefore reducing susceptibility to caries. Patient is more susceptible to caries in areas within the mouth that are more difficult to clean such as the interdental spaces or posterior teeth

Fluoride
Fluoride reduces the rate of demineralisation , enhances mineral uptake in enamel and reduces caries risk e.g. Colorado Springs (1901), U.S./British studies (1930s), U.S. study of 20 towns (1942) Fluoride exposure can therefore be used to assess patients susceptibility to caries Fluoride is found in multiple sources e.g. toothpaste, sea salt, seafood, Teflon pans etc. On-going arguments for and against roll-out of fluoride in UK water supply e.g.

Clinical Evidence

Best predictor of caries risk is caries experience and clinical examination is the best method of identifying this Detective work required including use of visual examination, bitewing radiographs, laser florescence, CariScreen Caries Susceptibility Test, Saliva-Check Mutans Multiple factors encourage development of the carious process e.g.
Poor restorations e.g. secondary caries in stagnation areas (defective margins/ditching), soggy bottom, residual caries following excavation, no fissure sealant Re-restorations e.g. Continuous restoration preparations, loss of tooth structure caution on full replacement Multiband orthodontics e.g. obstruction to cleaning by brackets and wires so build up of plaque on tooth surfaces Partial dentures e.g. Clasps obstruct cleaning and dentures trap foods and encourage plaque build up Anterior caries e.g. Indicates reduced salivary flow or possible gastric disorders as area of high salivary flow rate Premature extractions e.g. Risk of overcrowding creating inaccessible surfaces (children) or over eruption and possible root caries (adults) New lesions e.g. New lesions since last check-up Deep pits and fissures e.g. Occlusal morphology may allow for stagnation areas and speed up carious process Stages of development e.g. children (occlusal surface of erupting molars), adolescents (approximal surfaces esp. premolars and molars), adults (root surfaces)