While we have made some success with preventing, detecting, and treating dental caries and dental decay in the United States over the last 30 years, some sectors of the population with low access to oral health care continue to suffer enormously from the disease.
The National Institutes of Health (NIH) commissioned a Consensus Development Conference (CDC) on the Diagnosis and Management of Dental Caries to address this problem in 2001.(1) Whereas this is considered a historical document, some of the principles remain the same today, and we have made some progress in this area.
Not everyone has the same risk for dental decay, and to treat each individual in the same manner, such as exposing radiographs or administering fluoride treatments every six months, not only is unnecessary, but wastes valuable resources such as time and money. Evaluating risk is one way to individualize treatment based on need.
This issue will focus on Risk Assessment for Dental Caries, and include CAMBRA, Previser, the International Caries Detection and Assessment System (ICDAS), and American Academy of Pediatrics (AAP) oral health risk assessment (OHRA).
What are the best indicators for an increased risk of dental caries?
According to the NIH, most data pertaining to caries-risk assessment comes from accumulated caries experience rather than methodical, regulated study. There are a variety of risk assessment tools, and there are some consistent risk indicators: past caries experience, especially for assessing children’s risk; inadequate exposure to fluoride; any physical or mental illness and any oral application or restoration that compromises the maintenance of optimal oral health; fermentable carbohydrate consumption; lower salivary flow, associated with certain medical conditions and therapies; mutans streptococci; gingival recession, especially in elderly populations; and lower indices of socioeconomic status.(1)
Children and Infants
The American Academy Of Pediatrics (AAP) has a Policy Statement on Oral Health Risk Assessment Timing and Establishment of the Dental Home.(2) It should be noted that even the most thoughtfully designed and implemented caries risk assessment tool can fail to identify all infants at risk of early childhood dental caries. If an infant is assessed to be within one of the following risk groups, the care requirements would be significant and surgically invasive; therefore, certain infants should be referred to a dentist as early as 6 months of age and no later than 6 months after the first tooth erupts or 12 months of age (whichever comes first) for establishment of a dental home.
The risk groups are: children with special health care needs; children of mothers with a high caries rate; children with demonstrable caries, plaque, demineralization, and/or staining; children who sleep with a bottle or breastfeed throughout the night; later-order offspring; and children in families of low socioeconomic status.(2)
As well, not all individuals will all into the scientific mean. Therefore, the infectious and transmissible nature of bacteria that cause early childhood caries and methods of oral health risk assessment, anticipatory guidance, and early intervention should be included in the curriculum of all pediatric medical residency programs and postgraduate continuing medical education curricula at an appropriate time.
Every child should begin to receive oral health risk assessments by six months of age from a pediatrician or a qualified pediatric health care professional. The AAP also suggests that pediatricians, family practitioners, and pediatric nurse practitioners and physician assistants should be trained to perform an oral health risk assessment on all children beginning by six months of age to identify known risk factors for early childhood dental caries.
Many states offer risk assessment tools for children. First 5 California has a program called Healthy Teeth for Healthy Kids.(3) They have a project, First Smiles, which features a comprehensive Web site with information, resources and training for both parents and health care professionals in risk assessment. It includes free on-demand distance-learning courses for dental staff, a 5-minute video with basic oral care instructions for parents, presentation materials for health care professionals, and a parent brochure available in ten languages.(4)
In 2004, the CDA Foundation and Dental Health Foundation (now the Center for Oral Health) obtained a $7 million First 5 California Oral Health Education and Training Project Grant to educate dental and medical professionals in California about the value and methodology of using CAMBRA to combat early childhood caries.(5,6)
As of January 2006, First Smiles has reached 2,600 dental professionals; has visited over 1,300 physician offices and provided training to pediatricians, family practice physicians and obstetricians; there have been 53,000 visits to the First Smiles Web site and 730,000 copies of the brochure have been distributed to providers, subcontractors and First 5 County Commissions.
They discuss Caries Management by Risk Assessment using an interdisciplinary team approach. Understanding the caries process and the new paradigm in caries management, the latest science on caries risk assessment, the role of members of the oral health and medical teams, and how to implement caries risk assessment and caries management in practice, are keys to success.
The American Academy of Pediatric Dentistry (AAPD) has a Policy on Use of a Caries-risk Assessment Tool (CAT) for Infants, Children and Adolescents.(7) The caries risk potential of an infant can be determined by the use of the AAPD Caries Risk Assessment Tool (CAT). The NY Partners in Oral Health use this tool, and New Jersey uses the CAT as well.(8) To view the AAPD Caries-Risk Assessment Tool, go to CAT.
The American Academy of Pediatrics (AAP) oral health risk assessment (OHRA) provides a concise overview of how to perform an oral examination and conduct an oral health risk assessment and triage for infants and young children.(9) Many children live with oral health problems that could be addressed with timely, affordable access to effective preventive dental care and treatment. Even in the top-ranked state (Minnesota) on this indicator in a recent report, one of five children has oral health problems such as tooth decay, pain, or bleeding gums.(10)
Another tool is Caries Management by Risk Assessment (CAMBRA), which represents a paradigm shift in the management of dental decay and the caries process.(11) It treats dental caries as an infectious disease that is curable and preventable, and employs risk assessment techniques. The risk assessment and the weight of the entire disease process, not just the cavitated stage of lesion, make CAMBRA different from the traditional restorative approach in treating dental caries and dental decay.
The caries balance method was originally introduced by Featherstone as an evidence-based method to measure caries risk and determine effective treatment options.(12) The assessment of risk proposes the correct interceptive treatment strategies to prevent or reverse the caries process.(13) A randomized clinical trial has demonstrated the effectiveness of this type of assessment and intervention.(14)
A consensus conference held in 2002 resulted in two issues of the Journal of the California Dental Association (February and March 2003) dedicated to the science of CAMBRA. Future issues (October and November 2007) focused on the clinical implementation of CAMBRA.(15) Unfortunately, few offices employ CAMBRA.
PreViser is a program that produces analytic reports with scientifically validated risk scores for caries. Effective treatment planning should include a consideration of the risk of disease to compel preventive interventions, as well as appropriate reparative interventions once the disease process is identifiable.(16,17) It provides an objective and reproducible way to measure, understand, and communicate your patients’ risk and disease level as simple numeric scores.
International Caries Detection and Assessment System (ICDAS)
ICDAS is a peer-reviewed and internationally recognized visual assessment tool that allows a tooth’s health status to be graded numerically. ICDAS is a clinical scoring system for use in dental education, clinical practice, research, and epidemiology.
ICDAS is designed to: lead to better quality information to inform decisions about appropriate diagnosis, prognosis, and clinical management at both the individual and public health levels. It provides a framework to support and enable personalized total caries management for improved long-term health outcomes.
Significant differences persist among states regarding insurance coverage, affordability, and preventive care, based on 20 key indicators of children’s healthcare access, affordability of care, prevention, and treatment.(10) Children in low-income families have more than one-and-a-half times the prevalence of untreated cavities, pain, bleeding tissue, or other oral health concerns than higher-income children in most states. Perhaps risk assessment is one way to focus our efforts on those who need the care, versus a one size fits all approach.
Caries Management By Risk Assessment In A Practice-Based Research Network is a clinical trial conducted in dental offices.(18) The goal of this project is to create a Practice Based Research Network with 30 researcher dentists calibrated on the administration of a caries risk assessment and the treatment modalities recommended based on the caries risk assessment results (Caries Management by Risk Assessment – CAMBRA), and to conduct a 2-year interventional CAMBRA study in those dental offices.
Participating dentists will be a blend of general practitioners and pediatric dentists selected from private practice, part time university faculty, large group practices, or community clinics. Participating practices will collect baseline data and patient progress and report on patient acceptance and compliance, and the effectiveness of treatment.
The program’s duration is anticipated to be approximately four years. Year one will be dedicated to program, protocol and evaluation design, and recruitment, selection and calibration of researcher dentists. Years two and three will be the research and data collection time period, and year four will be dedicated to evaluation. The planned study, not yet recruiting, is a double blind practice-based clinical study. The California Dental Association Foundation will help to select the participating dentists.
More dental schools are emphasizing caries risk assessment.(19) The risk-based medical model, rather than a “drill and fill” or surgical approach, is gradually being embraced in undergraduate dentistry programs in the U.S. We also need dental hygiene schools to accept this new paradigm.
While this is progress, the authors state that a more integrated method of risk assessment is needed to clarify terminology, diagnosis, treatment, and communications with researchers, clinicians, teachers, patients, and third-party payers. The literature has expanded our understanding of the etiological factors for caries development and subsequent tooth decay, and the preventive measures that focus on preservation of tooth structure rather than surgical intervention. Clinicians need to move from knowledge and comprehension to the higher domains of application, analysis, synthesis, and evaluation if these principles are to be implemented in dental offices and other settings where oral care is delivered.
1. Diagnosis and Management of Dental Caries Throughout Life. NIH Consensus Statement Online 2001 March 26-28; [cited year, month, day]; 18(1): 1-24.
2. American Academy Of Pediatrics Policy Statement. Oral Health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics Vol. 111 No. 5 May 2003, p. 1113-1116.
10. S. K. H. How, A.-K. Fryer, D. McCarthy, C. Schoen, and E. L. Schor, Securing a Healthy Future: The Commonwealth Fund State Scorecard on Child Health System Performance, 2011, The Commonwealth Fund, Feb. 2011.
11. Young DA, Buchanan PM, Lubman RG, Badway NN. New Directions in Interorganizational Collaboration in Dentistry: The CAMBRA Coalition Model. J Dent Educ. 71(5): 595-600 2007.
12. Featherstone JD. The caries balance: contributing factors and early detection. J Calif Dent Assoc 2003; 31(2):129-33.
13. Young DA. New caries detection technologies and modern caries management: merging the strategies. Gen Dent 2002; 50(4):320-31.
14. Featherstone JDB, Gansky SA, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, et al. A randomized clinical trial of caries management by risk assessment. Caries Res 2005;39:295(Abstr #25).
18. CAMBRA – PBRN Caries Management By Risk Assessment In A Practice-Based Research Network (CAMBRA-PBRN). ClinicalTrials.gov
19. Yorty JS, Walls AT, Wearden S. Caries Risk Assessment/Treatment Programs in U.S. Dental Schools: An Eleven-Year Follow-Up. Journal of Dental Education, January 2011, Vol. 75:1, pp. 62-67.