Caries risk assessment By: Dr. Amany Moussa

Definition of Dental Caries Is a chronic ,transmissible mal-nutrition disease. Caries clinically manifested by three microbial events: 1-primary infection by S.Mutans. 2-formation of complex biofilm (dental plaque). 3-demeralization of enamel &cavitation.

Risk factors of Dental caries 1- diet &nutrition: -cariogenic diet as freely fermentable carbohydrates -malnutrition during period of teeth development. 2- age: -the highest peak is at age 4-8 years. -11-19 years (pit &fissures). -35-45 years (proximal caries). -55-65 yeaars (root caries).

4-emotional disturbances: 3- gender: Females have a higher incidence than males 4-emotional disturbances: Stress was found to be associated with high caries incidence. 5- role of microorganisms: Streptococcus Mutans is the main microorganisms that is responsible for caries initiation.

Definition of Caries Risk Assessment It is a qualitative and quantitative procedure to predict future caries development and introduce appropriate measures before the clinical onset of irreversible lesions of the disease.

Aim Is to predict whether the disease is likely to develop in caries-free individual. To determine the rate of progression in a patient who already has some caries experience . To create a specific model for treatment of cases which are suitable for each case. To direct effort and money to those that are in need for prevention.

Important Terms Risk: defined as the probability that an unwanted or even a harmful event will occur. Caries susceptibility: it is the possibility to develop caries in a caries producing environment. Caries activity: is a measure of the speed of progression of a carious lesion. Caries activity test: it is our tool to estimate the actual state of disease activity (progression or regression).

Caries Risk Assessment Models AAPD (The American Academy of Pediatric Dentistry ) Caries – Risk Assessment Tool Cariogram CAMBRA ( Caries Management By Risk Assessment)

Caries risk assessment is the determination of the likelihood of the incidence of caries (ie, the number of new cavitated or incipient lesions) during a certain time period or the likelihood that there will be a change in the size or activity of lesions already present. With the ability to detect caries in its earliest stages (ie, white spot lesions), health care providers can help prevent cavitation.

AAPD Caries- Risk Assessment Tool The American Academy of Pediatric Dentistry (AAPD) recognizes that caries- risk assessment and management protocols can assist clinicians with decisions regarding treatment based upon caries risk and patient compliance and are essential elements of contemporary clinical care for infants , children, and adolescents. This guideline is intended to educate healthcare providers and aid in clinical decision making regarding diagnostic , fluoride, dietary, and restorative protocols.

Aim of AAPD Risk Assessment Fosters the treatment of the disease process instead of treating the outcome of the disease. Gives an understanding of the disease factors for a specific patient and aids in individualizing preventive discussions. Individualizes, selects, and determines frequency of preventive and restorative treatment for a patient. Anticipates caries progression or stabilization.

Factors influencing Caries Risk Age: Newly erupted teeth are more susceptible to decay particularly at pits and fissures due to the difficulty to clean the tooth until they have reached the occlusal plane. Gender: controversial opinions, however women’s oral hygiene is better, they have less missing teeth. Yet they might have DMF values as they seek more dental care and higher number of filled teeth.

Behavior: eating habits and oral hygiene measures are important factors that influence cares susceptibility. Social, genetic and occupational factors are related to oral health knowledge attitude and practices. General medical factors: the long term use of sugary liquid medications, increase caries prevalence. Psycho-pharmaceutical products (anti-depressants) reduce the flow of saliva and thus increase the caries risk. Cytotoxic chemotherapy disrupts the mineralization of teeth and thereby raises the caries prevalence.

Dental Therapy: the type of treatment delivered by the dentist depends on: Dentist’s education and clinical experience. Knowledge of preventive measures. Use of recent techniques. Convenience of the cost to the patient.

Cariogram It is a graphical picture illustrating in an interactive way the individual’s / patient’s risk for developing new caries at some point in the future.

The five sectors of cariogram 1.The green sector shows an estimation of the ‘Actual chance to avoid new cavities’. .The green sector is ‘what is left’ when the other factors have taken their share. 2.The dark blue sector ‘Diet’ is based on a combination of diet contents and diet frequency. 3.The red sector ‘Bacteria’ is based on a combination of amount of plaque and mutans streptococci. 4.The light blue sector ‘Susceptibility’ is based on a combination of fluoride program, saliva secretion and saliva buffer capacity. 5.The yellow sector ‘Circumstances’ is based on a combination of past caries experience and related diseases.

CAMBRA (Caries Management By Risk Assessment) Caries management by risk assessment (CAMBRA) is an evidence- based approach to preventing or treating the cause of dental caries at the earliest stages rather than waiting for irreversible damage to the teeth. The clinician identifies the cause of the disease by assessing each patient’s risk factors. Then the clinician corrects the problem by managing the risk factors & using specific treatment recommendations.

According to CAMBRA analysis , patients are divided to four categories to determine the type of treatment strategy needed : Low risk Moderate risk High risk Extremely high risk

Levels of prevention Primary Secondary Tertiary

caries prevention Primary prevention: It means stop occurrence of the dental caries By: 1- plaque control which essentially is the instruction of proper home care for the mechanical removal of the plaque. 2- use of fluorides either systemic or local to increase the resistance of the tooth towards decay. Prevention of initiation of the disease-implement program –procedures &measures to prevent the disease as fluoridation the community drinking water –application of topical fluorides, tooth brushing , flossing, diet control, sealent application

3-Dietary control through limitation of frequent intake of sucrose & other food stuffs which enable micro-organism to grow 4- use of sealants which act as a plastic like mechanical barrier on occlusal surfaces of teeth to prevent caries

Secondary prevention: is the prevention of progression &recurrence of the caries process through Remineralization , the use of certain dental compounds which will help the dentin to remineralize Operative dentistry techniques to remove the caries Pulp capping procedures Removal of initial stages of the disease

Tertiary prevention: That is to prevent total loss of function Extensive prevention & intervention to replace some or all of the teeth in indentation

Services provided by the dental professional Primary Provision of oral hygiene aids; patient education Plaque control Program recall reinforcement Topical fluoride application Correction of tooth mal-alignment prophylaxis Preventive orthodontics

Secondary Periodic examination Attention to developmental defects Prompt treatment of incipient lesions Scaling and curettage Corrective restorative and orthodontic treatment Treatment of well developed lesions Pulp capping Root canal therapy Deep curettage Root planning Extractions

Tertiary Replacement of tooth structure by appliances (removable or fixed prosthodontics)

Preventive level Primary Secondary Tertiary Health promotion Specific protection Secondary Early diagnosis Prompt treatment Tertiary Disability limitation Rehabilitation

Services provided by the individual Primary Periodic visits to dental office Demand for preventive services Oral hygiene measures Avoidance of sticky food, particularly between meals. Secondary Self-examination and referral ;use of dental services Periodic screening and referral Tertiary Disability limitation Provision of dental services Use of dental services

Services provided by community Primary Dental health education programs. Promotion of research efforts. Dental prophylaxis. Supervised school brushing programs Fluoridation of public water Secondary Provision of dental services

Health Education To teach patients how to take care of their teeth & develop sound dental habits is the goal of patient education program; Health education program can be achieved by lectures, group discussion, individual instructions & distribution of pamphlets. The most effective mean of health education is individual instruction