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Question: How Critical is Risk Assessment in the Management of Caries?
Joel Berg, DDS, MS; Kevin J. Donly, DDS, MS; Constance M. Killian, DMD
Dental caries is the most prevalent disease in humans, and affects 97% of the population in their lifetime. Yet, dental professionals are mostly using antiquated methods to determine which of our youngest and most vulnerable patients are most susceptible to this infectious disease. Recently, new ways of assessing a patient’s future risk of dental caries have been proposed, and several new products have been introduced. It is anticipated that the progression of this most significant technological development in dentistry, detailed below, will do more to change the way we practice than any other development in recent decades. Technologies that can assess the risk for future dental caries include various scanning devices that “survey” the surface of teeth and estimate a collective amount of demineralization that has already occurred. Such early demineralization, if identified in an infant or young toddler, should lead to the more frequent use of medicinal therapeutic interventions, including fluoride varnishes, to prevent the patient from actually manifesting caries lesions later. Other technologies include microbiological identification and treatment based on understanding the quantity and virulence of the particular bacterial composition within the child’s plaque. Less known is the effect of various possible salivary compositions and consistencies on the future caries experience of the child. Combining behavioral modification techniques with pharmaceutical approaches will make a dramatic difference in the progression of caries in infants and toddlers deemed to be at high risk. It is also important to note that manufacturers of therapeutic intervention products will have an increased interest in developing new solutions to prevent caries given the presence of validated predictive approaches.
It is imperative that we complete a risk assessment no later than the first birthday, as recommended by the American Academy of Pediatric Dentistry (AAPD), American Dental Association, and the American Academy of Pediatrics. Initial exposure to a dentist for risk assessment at this early age can allow an appropriate preventive dentistry plan to be initiated. This could include oral hygiene instruction, diet counseling, fluoride varnish application, dental recall appointments at frequencies deemed necessary to prevent caries, and referring parents/ siblings for needed dental care.
Standard diagnostic criteria in assessing the risk of caries development includes the presence of caries, levels of intraoral Streptococcus mutans bacteria, gingivitis, early enamel demineralization (white-spot lesions), presence of orthodontic appliances, and deep pits/fissures on molars. These clinical diagnostic criteria, in addition to pertinent medical history, socioeconomic status, and minority status, can be useful in identifying patients who require increased caries control measures.
The concept of risk assessment is not focused on restoring early tooth demineralization so that an oral equilibrium can be re-established. Certainly, the remineralization of natural tooth structure is desirable, but when enamel cavitation warrants restoration placement, minimally invasive restorative techniques can be implemented.
The “dental home” can provide this ongoing risk assessment evaluation. A dental home is described by the AAPD as “the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral healthcare delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate.” Establishment of a healthy oral environment is the only effective way to provide long-term preventive dental care.
“Attached to every tooth there is a person.” One of my dental school professors wore a button with this expression and it has always been a reminder to me that each patient is unique in terms of their needs and in terms of how they respond to our therapy.
The caries process is impacted by a variety of factors—genetics, diet, special healthcare needs, fluoride use, access to care, dental defects, and the presence of dental appliances, among others. These factors all contribute to the caries risk of each patient, which can be assessed using a caries risk-assessment tool such as that developed by the AAPD.1 In my practice, at every recare visit I use this tool to assign caries risk (low, moderate, or high) to each patient. The following cases illustrate how the consideration of caries risk can impact the choice of restorative therapy.
Case 1: A 3-year-old with a developmental disability presents for a first examination with occlusal caries and buccal decalcification affecting all four primary first molars. Home care is inconsistent; the child does not receive regular dental care, and is rewarded with frequent snacks. The caries risk assessment for this child is high. Because of the child’s age and developmental disability, restorative dental treatment must be done under sedation or general anesthesia. Stainless-steel crown restorations are more likely to be successful for this patient.
Case 2: A healthy 3-year-old with good oral hygiene and regular preventive care presents for routine recare with an occlusal defect related to localized hypoplasia on a newly erupted second primary molar. After consideration of all caries risk factors, it is determined that the child’s overall risk is low. This child can be considered for conservative restorative therapy consisting of excavation of caries with hand instruments and/or a slow-speed handpiece, using a round bur, followed by restoration using resin-modified, glass-ionomer restorative material. This interim therapeutic restoration can be done without sedation or general anesthesia.
Because the risk factors for each child are different, the caries process will progress differently and successful therapy should be customized to the child’s risk. The use of caries risk assessment in that customization provides a more scientific approach for the practitioner and a more effective outcome for the patient.
1. AAPD Reference Manual. Use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. Pediatr Dent. 2008; 30(7): 29-33.
About the Authors
Joel Berg, DDS, MS
Lloyd and Kay Chapman Chair for Oral Health
Department of Pediatric Dentistry
University of Washington School of Dentistry
Department of Dentistry
Seattle Children’s Hospital
Kevin J. Donly, DDS, MS
Professor and Chair of Pediatric Dentistry
University of Texas Health Science Center
Constance M. Killian, DMD
Adjunct Associate Professor of Pediatric Dentistry
University of Pennsylvania