Caries risk assessment in detail description

CARIES RISK ASSESSMENT

1. CARIES RISK ASSESSMENT PRESENTER – ZADENO KITHAN PERCEPTOR- DR. ABHIK MUKHERJEE 18.06.22

2. TABLE OF CONTENTS INTRODUCTION DEFINITIONS CARIES RISK FACTORS CARIES RISK GROUPS CARIES RISK CATEGORIES CARIES RISK ASSESSMENT TOOLS CARIES RISK ASSESSMENT SYSTEMS - ICDAS - ADA - CARIOGRAM - AAPD - CAMBRA - TRAFFIC LIGHT MATRIX -CARE TEST MICROBIAL TEST FOR MUTANS STREPTOCOCCI DETECTION CARIES ACTIVITY TESTS

3. In many countries the prevalence of dental caries has markedly regressed over the past years. Epidemiological studies show an uneven distribution of dental caries. Approximately 25 per cent of the population exhibits significantly more caries than the rest of the population. A systemic review and meta-analysis on the prevalence of dental caries In Indian population revealed tha overall prevalence of 54.16% and there exists a remarkable variation in dental caries prevalence rates as per age, diagnostic criteria, dentition, and geographical region. In reference to prevalence of dental caries across different types of dentition, highest overall prevalence was noted in the mixed dentition (58%) category, followed by the primary (54%).

4. Dental caries is an irreversible microbial disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic part and destruction of the organic substance of the tooth, which often leads to cavitation. DENTAL CARIES Shafers textbook of oral pathology 8 th edition Complex and dynamic process Effects all geographic areas of the world Latin word meaning 'rot' or' decay Efforts at prevention have been partially successful

5. Dental caries/tooth decay occur when microbial biofilm (plaque) formed on the tooth surface converts the free sugars contained in food and drinks into acids that dissolve tooth enamel and dentine over time. With continued high intake of free sugars, inadequate exposure to fluoride and without regular microbial biofilm removal, tooth structures are destroyed, resulting in development of cavities and pain, impacts on oral-health-related quality of life, and, in the advanced stage, tooth loss and systemic infection.

6. Caries risk assessment (CRA)

7. CRA refers to an approach to establish the probability of a future(new or incident) enamel or dentine lesion, i.e. predicting caries after some period of follow-up Identification of individuals with an increased risk of the occurrence or progression of caries over a specified period of follow-up AIM Naichuan Su, Maxim D. Lagerweij, Geert J.M.G. van der Heijden, Assessment of predictive performance of caries risk assessment models based on a systematic review and meta-analysis, Journal of Dentistry, Volume 110, 2021

8. Caries-risk assessment is the  determination of the likelihood of the increased incidence of caries  (i.e., 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 . AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

9. CRA CONTRIBUTES TO DETERMINE THE NEED AND EXTENT OF PERSONALIZED PREVENTIVE MEASURES MOTIVATION OF PATIENT IDENTIFY HIGH RISK GROUPS ESTABLISH CRITERIA FOR SUCCESS OF THERAPEUTIC MEASURES MONITOR EFFECTIVENESS OF PROGRAM DETERMINE THE NEED FOR CARIES CONTROL MEASURES AIDS IN ESTABLISHING RECALL PROTOCOL

10. FACTORS AFFECTING CARIES PREVALENCE RACE AGE GENDER FAMILIAL Region wise data shows that South Indian five-year-old had a higher mean deft compared to their North Indian counterparts. However, among the 12-year-old, the highest mean DMFT was observed among West Indian children followed by North India and others. studies done in Eastern region of India reported the least DMFT

11. CARIES RISK FACTORS Is defined as factor that which plays an essential role in the etiology and occurrence of the disease, like the lifestyle and the biochemical determinants to which the tooth is directly exposed and which contribute to the development or progression of the lesion.

12. PLAQUE Enamel caries begin beneath the dental plaque Important to estimate The number of surfaces affected The amount of plaque accumulated Age of the plaque Whether its presence is associated with carious lesions in those same sites . Role of pH of Dental Plaque According to Stephan (1940)-The pH of plaques in different persons varied, but averaged about 7.1 in caries-free persons and about 5.5 in persons with extreme caries activity.

13. Tooth factor Composition Morphologic Characteristics Position

14. Saliva Factor Calcium and Phosphate Concentrations pH of Saliva IAP = Ksp and SI= 0 Buffer Capacity of Saliva CRITICAL PH = 5.5 Bicarbonate carbonic acid (HCO3/H2CO3) & phosphate (HPO4 or H2PO4) Quantity of Saliva salivary gland aplasia/ xerostomia = Rampant caries

15. The retrieved studies show a highly significant correlation between higher caries prevalence in preschool children with higher levels of microbials, such as mutans streptococci,  C. albicans  and  Prevotella  spp., and salivary proteins, including IgA, IgG immunoglobulins, PRP and histatin peptides, in saliva compared with caries-free individuals. Therefore, based on the results of these studies, these saliva components may be used as biomarkers for ECC

16. Objectives:  The aim of this cross-sectional study was to investigate how the level of metabolic control affects salivary function, xerostomia prevalence and incidence of caries, in children and adolescents with type 1 diabetes. Results:  Higher caries levels, higher prevalence of xerostomia and a decreased unstimulated salivary flow rate were recorded in poorly-controlled diabetics. The average caries indexes were DMFT(poor c) 3.6, DMFT(well controlled)1.2, DMFT(healthy) 1.5, p < 0.05). Salivary status and caries index were not found to be significantly different between well-controlled patients and healthy controls.

17. The Diet Factor Physical Form soft, refined foods tend to cling tenaciously to the teeth and are not removed because of the general lack of roughage The carbohydrate content of the diet has been almost universally accepted as one of the most important factors in the dental caries process

18. Infants and toddlers - regularly bottle fed with sweet drinks at night or breast fed for > twelve months- risk factors for caries. T eenagers and young adults - ex c e s sive consumption of s oft drinks-risk factors for caries

19. CARIES RISK GROUPS

20. Key-risk age group 1: Ages 1 to 2 years Kohler et al (1978,1982) showed that mothers with high salivary MS levels frequently transmit MS to their babies as soon as the first primary teeth erupt, leading to greater development of caries It was also shown that the practice of giving infants sugar containing drinks in nursing bottles at night increases the development of caries (Wendt and Birkhed, 1995 ) Axelsson P. Prediction of caries risk and risk profiles. Textbook on Diagnosis and risk prediction of Dental caries; 1st Ed 2000, vol 2:151-174

21. Key-risk age group 2: Ages 5 to 7 years In a study by Carvalho et al (1989), plaque reaccumulation was heavy on the occlusal surfaces of erupting maxillary and mandibular molars, particularly in the distal and central fossae Axelsson P. The Effect of a Needs-Related Caries Preventive Program in Children and Young Adults – Results after 20 Years. BMC Oral Health . 2006; 6( 1): S1-S7.

22. Key-risk age group 3: Ages 11 to 14 years Normally, the second molars start to erupt at the age of 11 to 11.5 years in girls and at around the age of 12 years in boys. Total eruption time is 16- 18 mon. During this period, the approximal surfaces of the newly erupted posterior teeth are most caries susceptible Axelsson P. The Effect of a Needs-Related Caries Preventive Program in Children and Young Adults – Results after 20 Years. BMC Oral Health . 2006; 6( 1): S1-S7.

23. Key-risk age groups in young adults Under certain circumstances, young adults (19 to 22 year olds) may also be regarded as a risk age group. Most have erupting or newly erupted third molars without full chewing function and with highly caries-susceptible fissures

24. CARIES RISK CATEGORIES Niessen L et al (1996) Based on the clinical evaluation and information derived from a patient’s medical and dental history, he or she can be classified as Low, Moderate High Risk Niessen LC, DeSpain B. Clinical strategies for prevention of oral diseases. J Esthet Dent 1996;8(1):3-11.

25. Low risk Moderate risk High risk Caries inactive/ caries controlled No active lesion, no history of recent restorations. The protective factors outweigh the risk factors Can develop caries in the near future if an imbalance occurs between the protective factors and risk factors Caries active but all relevant risk factors can be potentially changed (eg: plaque control, fluoride, diet) Caries control can be achieved through changes in risk factors. Patients in whom the caries balance is tilted towards demineralization. Caries active but some risk factors cannot be changed (eg:dry mouth, medications) or risk factors cannot be identified

26. WHY THE NEED FOR CARIES RISK ASSESSMENT Knowing which patients are at high risk for developing caries provides an opportunity to implement specific preventive strategies that may prevent caries. These strategies are specific to highrisk individuals and are not intended for all patients For patients at low risk for caries, preventive measures may be limited to oral hygiene

27. CARIES RISK ASSESSMENT TOOLS

28. 1.PATIENT HISTORY AGE GENDER FLUORIDE EXPOSURE SMOKING HABITS ALCOHOL INTAKE DIETARY HABITS ECONOMIC AND EDUCATIONAL STATUS Medications

29. 2.CLINICAL EXAMINATION Inadequate salivary functioning Inflammation of soft tissues plaque accumulation cavitated lesions poor oral hygiene Existing restoration

30. 3. Nutritional Analyses Frequent exposure to sucrose increases the likelihood of plaque development by the more cariogenic MS organisms. 4. Salivary Analyses Analyzing saliva may provide important information about appropriateness of secretion rates and buffering capacity and numbers of MS and lactobacilli

31. 5 . Social, Economic, and Education Status Affect the expression and management of the caries disease predictive at the population level but are generally inaccurate at the individual level

32. 6. Radiographic Assessment The minimal depth of a detectable lesion on a radiograph is about 500 μm Approximately 60% of teeth with radiographic proximal lesions in the outer half of dentin are likely to be noncavitated. Early detection of incipient caries, limitation of caries activity before significant tooth destruction has occurred, and identification of high-risk patients are primary goals of an effective diagnosis and treatment program.

33. 7. Past caries experience Most powerful single predictor for future caries incidence in children and young adults Represent the sum result of all the etiologic and modifying risk factors to which individuals have been exposed

34. CARIES RISK ASSESSMENT SYSTEMS

35. Developed in the year 2001. It is an Evidence-based, preventively oriented strategy that classifies the visual appearance of a lesion and culminates in diagnosis. A two digit coding system ( X-Y) Code X (lesion detection) - classify each tooth surface on whether it is sound, sealed, restored, crowned or missing. Code Y (lesion assessment ) - classification of the carious status on an ordinal scale T he International Caries Detection and Assessment System (ICDAS 1 & Ⅱ )

36. ICDAS 1(2001) ICDAS Ⅱ(2009) Includes D and A Component. Root caries were not included due to lack of consensus. Describes both coronal caries and caries associated with restorations and sealants (CARS) and root caries

37. Description and clinical examples of each score of ICDAS. ( Jablonski -Momeni et al . Caries Res 2008) PIT AND FISSURES & SMOOTH SURFACE

38. CARIES ADJACENT TO RESTORATIONS AND SEALANTS ( CARS )

39. ROOT CARIES 1 2 3-4 5-6

40. This systematic review discovered a number of root caries risk predictors in different categories. People who are older, in lower socio-economic status or tobacco users, and those with more root caries experience, gingival recession and poor oral hygiene have higher risk of developing new root caries.

41. ADA SYSTEM The American Dental Association offers caries assessment forms for patients 0 to 6 years old, and those older than 6 years.

42. CARIOGRAM A computer program showing a graphical picture that illustrates a possible overall caries risk scenario. The program contains an algorithm that presents a ‘weighted’ analysis of the input data, mainly biological factors. It expresses as to what extent different etiological factors of caries affect caries risk

43. PURPOSE OF CARIOGRAM 1. To determine the caries risk graphically , expressed as the “Chance to avoid new caries” (i.e . to avoid getting new cavities or holes) in the near future. 2. To exemplify to what extent different factors affect this “Chance”. 3. To encourage preventive measures to be introduced before new cavities could develop.

44. ADVANTAGES OF CARIOGRAM AFFORDABLE USER FRIENDLY EASY TO UNDERSTAND serve as a support for clinical decision making when selecting preventive strategies for the patient

45. Methods:  A prospective study recording root caries incidence was conducted on 334 dentate older adults. Data were collected on participant's medical history, fluoride exposure, and diet. Saliva samples were collected to measure salivary flow rate, buffer capacity and bacterial counts. Clinical examination was completed to record decayed, missing and filled teeth (DMFT) and also exposed, filled and decayed root surfaces (RDFS). This was repeated after 12 and 24 months. Scores were entered into the Cariogram and baseline risk category was recorded. R esults:  280 participants were examined at two year follow up. 55.6% of those in the highest risk group developed new caries compared to 3.8% in the lowest risk group. Conclusion:  Within the limitations of this study, the Cariogram was clinically useful in identifying individuals with a high risk of developing root caries.

46. Caries Risk Assessment Tool (CAT): This tool was developed by the American Academy of Paediatric Dentistry (AAPD) in 2006. Depending on the age of children CAT incorporates three factors in assessing caries risk, namely, biological as well as protective factors and clinical findings

47. Biological Factors Patient is of low socioeconomic status Patient has >3 between-meal sugar-containing snacks or beverages per day Patient has special health care needs Patient is a recent immigrant Protective Factors Patient receives optimally-fluoridated drinking water Patient brushes teeth daily with fluoridated toothpaste Patient receives topical fluoride from health professional Patient has dental home/regular dental care Clinical Findings Patient has >1 interproximal lesions Patient has active white spot lesions or enamel defects Patient has low salivary flow Patient has defective restorations Patient wearing an intraoral appliance

48. CAMBRA Caries management by risk assessment (CAMBRA) is an evidence-based approach to preventing, reversing and, when necessary, repairing early damage to teeth. Evaluation of the etiologic and protective factors Establishment of the risk of future disease (risk assessment) Development of a patient centered evidence based caries management plan. INVOLVES

49. The 4 caries disease indictors making up the reminder “WREC” White spots visible on smooth surfaces Restorations placed in the last 3 years as a result of caries activity Enamel radiographic proximal lesions Cavitations/dentin indicating cavities or radiographic lesions that show penetration into dentin. Caries risk assessment

50.   CAMBRA, Cariogram, American Dental Association (ADA), and American Academy of Pediatric Dentistry (AAPD) CRAs CRA methods for ages 0–6 years and 6 years-adult were compared using 26 hypothetical patients (13 per age group).

51. Comparison results show that Cariogram and CAMBRA categorized patients into identical risk categories. Each of the ADA and AAPD tools gave different results than CAMBRA and Cariogram in several comparison examples. Both the Cariogram and the CAMBRA CRA methods are equally useful for identifying the future risk of dental caries

52. TRAFFIC LIGHT MATRIX commonly used CRA tool in Australia uses color codes such as red, green, and orange to convey specific threshold values for data obtained in the analysis.    Based on 19 criteria in 5 different categories S aliva (6 criteria) P laque (3 criteria) Fuoride exposure (3 criteria) modifying factors (5 criteria D iet (2 criteria)

53. CARE TEST Researchers at the University of Southern California School of Dentistry developed a novel salivary test for genetic CRA called the CARE test B ased on the high correlations they found between caries history and quantities of specific oligosaccharides in whole saliva P robably the only CRA method that can potentially promote caries prevention at the primary level itself (before any carious lesions have appeared), by identifying high caries risk children early and instituting a preemptive aggressive preventive regimen in them.

54. The pattern of these salivary oligosaccharides is 100% genetically determined, identifying individual salivary oligosaccharide concentrations can help determine the genetic risk of the child to develop caries . Lloyd KO. The chemistry and immunochemistry of blood group A, B, H, and Lewis antigens: Past, present and future. Glycoconj J 2000;17:531‑41. Leffler et al stated that just like blood group types, the salivary oligosaccharide patterns remain quantitatively consistent over time and across age groups. Leffler H, Prakobphol A, Fisher SJ. The high‑molecular‑weight human mucin is the primary salivary carrier of ABH, Lea, and Leb blood group antigens. Crit Rev Oral Biol Med 1993;4:325‑33.

55. Tooth genes Tuftelin interacting protein11   associated with the enamel surface's ability to uptake fluoride in very low concentrations, thus decreasing individual susceptibility to demineralization at subclinical levels -Shimuzu  et al Taste genes polymorphisms in the sweet taste receptor ( TAS1R2) and glucose transporter ( GLUT2) genes individually and in combination are associated with caries risk - Kulkarni  et al

56. Saliva salivary receptor gp-340, which mediates adhesion of  S. mutans , showed more caries experience in subjects positive for both gp-340 I variant and Db positive allele. - Jonasson  et al Immunity B eing positive for the HLA DR 4 allele increases the risk for early childhood caries 10 times more compared to the caries-free group. - Bagherian  et al H igh levels of  Streptococcus mutans  were positively associated with the presence of DR3 and DR4 alleles - Acton  et al

57. MICROBIAL TESTS FOR MUTANS STREPTOCOCCI DETECTION Laboratory Method To measure the levels of mutans streptococci in saliva and plaque and on individual tooth surfaces Chair-side Method Survey Method Selective Method Adherence Method

58. Laboratory Method Saliva (or dental plaque) is collected Mixed with a proper transport medium and sent to a microbiological laboratory Incubation using a selective medium mutans colonies on the plates are counted and the results are expressed as number of colony-forming units per ml saliva For screening surveys

59. Chair-side Method

60. Adherence method Categorizes salivary samples based on ability of S. mutans to adhere to glass surfaces when grown in sucrose containing broth.

61. The aim of the present study was to validate and establish a cut­off point and the predictive value of an adhesion test (AA­MSMG), as a microbiological method for evaluating cariogenic risk. This method used in a population of 154 people showed that levels of MGS counts higher than the cut­off point (1.68 x 105 CFU/ml), increase the microbiological risk of developing caries up to 5 times Polystyrene flask with mutants streptococci adhered colonies

62. Selective method Described by Kristoffersson and Bratthall. For the demonstration of mutans streptococci at specific sites

63. Survey method For field studies the plates can be placed into plastic bags containing expired air, which are then sealed (Seal-aMeal) and incubated at 37°C Counts of more than 100 colony-forming units (CFU) by this method are proportional to greater than 108 CFU of S. mutans per mL of saliva by conventional methods.

64. MICROBIAL TESTS FOR LACTOBACILLI DETECTION Introduced by Hadley in 1933.

65. Estimates the number of acidogenic and aciduric bacteria in the patient’s saliva by counting the number of colonies appearing on LBS agar (Rogosa). The total number of colonies on this medium reflects the proportion of the aciduric flora in the saliva

66. ORA TEST Chair side simple caries activity test B ased on the rate of oxygen depletion by micro organisms. Under aerobic conditions the bacterial enzyme, aerobic dehydrogenase transfers electrons or protons to oxygen. Once oxygen gets utilized by the aerobic organisms and an anaerobic environment is attained, methylene blue [redox indicator] acts as an electron acceptor and gets reduced to leucomethylene blue. The metabolic activity of the aerobic microorganism is reflected by the reduction of methylene blue to leucomethylene blue.

67. RESULT when the time taken for the change in color increases, the ICDAS-LAA scores decrease, which proves that a negative correlation exists between the two groups and the difference is highly statistically significant, T he mean time taken for the color change in OT was found to be higher in Group A whereas Group B had a lower mean value  

68. CARIES ACTIVITY TESTS Snyder test Alban test Reductase test Swab test

69. Snyder Test measures the ability of salivary microorganisms to form organic acids from carbohydrate medium.

70. ALBAN TEST Simplified substitute for the Snyder test. Scoring is based on the depth in medium to which color has changed

71. Aim To evaluate CRAFT as a tool for caries risk prediction among 3-years to 6-years-old children and to validate it against Alban test. Materials and methods A pilot study was conducted, including forty 3-years to 6-years-old children. Salivary samples were collected and inoculated on B.C.G.-Dextrose Agar. Caries activity was assessed using Alban test. Their parents/guardians completed the CRAFT assessment in entirety. Results Conclusion CRAFT scores were highly correlated with Alban scores in 3- to 6-year-old children. CRAFT could be successfully employed as a reliable, economical, chairside, and clinically feasible risk assessment tool with further research on a larger sample size.

72. REDUCTASE TEST measures the ability of reductase enzyme present in salivary bacteria.

73. SWAB TEST Developed by Grainger et al. in 1965 can be used in young and uncooperative patients as there is no need for salivary collection oral flora is sampled by swabbing the buccal surfaces of the teeth with a cotton applicator which is subsequently incubated for 48 hours

74. CONCLUSION Caries risk assessment as a prerequisite for appropriate preventive and treatment intervention decisions and provide some practical information on how general practitioners can incorporate caries risk assessment into the management of caries A caries risk assessment tool can be used to identify dietary habits that may contribute to caries risk Caries risk assessment as a prerequisite for appropriate preventive and treatment intervention provides some practical information on how general practitioners can incorporate caries risk assessment into the management of caries A caries risk assessment tool can be used to identify dietary habits that may contribute to caries risk

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