Cariogram

Assessment of Dental caries for better oral health

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2. C A R I O G R A M CARIOGRAM 2

3. The 'Cariogram' is a concept, conceived initially as an educational model, aiming at illustrating the multifactorial background of dental caries in a simple way. It is a graphical picture illustrating in an interactive way the individual's/patient's risk for developing new caries in the future , simultaneously expressing to what extent different etiological factors of caries affect the caries risk for that particular patient. 3

4. Cariogram as an interactive PC-program has been developed for educational, preventive and clinical purposes. However , the Cariogram does never specify a particular number of cavities that will or will not occur in the future. It rather illustrates a possible over-all risk scenario , based on what can be expected depending on our interpretation of available information. 4

5. Professor D. Bratthall in 1996 developed the concept and the formula for the Cariogram. The PC version was created in collaboration with Dr L. Allander and K-O. Lybegård . The Swedish version of the Cariogram(modified Cariogram) was first launched officially in November 1997 after extensive trials. 5

6. Cariogram – aims Expresses caries risk graphically. Illustrates the interaction of caries related factors. Illustrates the chance to avoid caries . Recommends targeted preventive actions . Can be used as an educational programme. 6

7. Original Cariogram CLOSED Where demineralization occurs resulting in cavities over a given time OPEN Where no caries lesions will occur because 'something is missing', in order to create demineralization. 7

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9. NEW CARIOGRAM -So what do the five sectors represent? 9

10. The dark blue sector ‘Diet ’ is based on a combination of diet contents and diet frequency. The red sector ‘Bacteria’ is based on a combination of amount of plaque and mutans streptococci. The light blue sector ‘susceptibility’ is based on a combination of fluoride program, saliva secretion and saliva buffer capacity. The yellow sector ‘Circumstances’ is based on a combination of caries experience and related diseases. The green sector shows an estimation of the ‘Chance of avoiding caries’. 10

11. Original Version Modified Version 11

12. Difference between old and new T he risk for future carious activity varies on a scale from 0% to 100% but it cannot be more than 100% i.e sectors do not over lap. The chance of avoidance is seen as green zone in new one where as in old one it was seen as Blank space/Gap. New sector, circumstances, was included . This sector includes factors such as caries experience and systemic diseases-factors to consider when the risk is calculated, in spite of the fact that these factors themselves do not participate directly in the development of the lesion. 12

13. What makes Sectors Small or Large? The Red sector increases if there is a lot of plaque, high proportion of extra cariogenic bacteria in the plaque (such as mutans streptococci and lactobacilli). The Red sector decreases if there is a good oral hygiene and if a low proportion of cariogenic bacteria in the plaque. 13

14. The Blue sector increases if there is a high and frequent intake of sugar and other easily fermentable carbohydrates. The Blue sector decreases if there is a low and infrequent intake of sugar and other easily fermentable carbohydrates. 14

15. The Light blue sector increases if susceptibility is high, for example due to low exposure to fluorides, low saliva secretion, low buffering capacity of saliva. The Light blue sector decreases if susceptibility is low, for example due to proper exposure to fluorides, normal saliva secretion, good buffering capacity of saliva. 15 Flouride

16. HOW TO OBTAIN A CARIOGRAM FOR A PATIENT?? 16

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19. Age in years Better than Normal (mean DMFT) Normal (mean DMFT) Worse than normal (mean DMFT) 20 8 10 12 30 10 12 15 40 14 18 21 50 18 21 23 60 21 22 24 70 22 24 25 80 23 25 26 19

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22. Cariogram model 23

23. The factors included in the Cariogram have been given different ‘weights’. This means that the key factors, which support the development of caries, or resist caries, have a stronger impact than the less important factors(socio- economic factors and past caries experience) when the program calculates the ‘Chance to avoid new cavities’. The factors are also weighted in relation to each other. Thus, different factors have different ‘weights’ in different situations and the number of combinations of factors is enormous. ‘Weights’ - the relative impact of factors

24. Is the Cariogram a risk model or a prediction model? Actually, it is both because it acts as a prediction model that predicts who is at high risk, and it is a risk model identifying the risk factors to facilitate planning of interventions. 25

25. Why are social factors not included in the Cariogram? A number of papers have clearly indicated the importance of social factors for caries risk. Still, the Cariogram does not address these factors directly. The reason is that social factors do not directly act on the tooth surface (if they had, there would be carious lesions everywhere, not just where there are bacteria). Social background can often explain reasons for factors such as neglected oral hygiene and increased sucrose consumption, factors that are already included in the Cariogram. Hence, social factors need not be taken into account separately when constructing the Cariogram. 26

26. What is the sensitivity and specificity of the Cariogram? Calculating such values demands ‘cut-off’ points and the Cariogram does not have such a point. According to Rodricks: Risk is the probability that some harmful event will occur. Because it is a probability, risk is expressed as a fraction, without units. It takes values from 0 (absolute certainty that there is no risk, which can never be shown) to 1.0, where there is absolute certainty that a risk will occur. In other words, the Cariogram expresses a probability. For example, ‘90% chance of avoiding caries’ means that most people with that particular combination of risk factors would stay without new cavities. If a person anyway developed caries with that probability, the program was not ‘wrong’ as it had not said ‘100%’. 27

27. International studies 28

28. 1. Caries Risk Profiles of 12-13 year-old Children in Laos and Sweden Purpose: To analyse caries risk factors of 12-13-year-old children living in Laos, using the computer program Cariogram to illustrate the caries risk profile. In addition, to compare the results with a study performed in Sweden. 100 Laotian and 392 Swedish children were included. Interviews were performed to obtain information on diet intake and fluoride use. Various risk factors in cariogram were evaluated Caries prevalence was recorded according to WHO. The data were entered into the Cariogram to determine each child’s caries risk, expressed as ‘the chance of avoiding caries’. The children were divided into five risk groups. Oral Health Prev Dent 2005; 3: 15–23. G. L. Tayanina /G. Hänsel Peterssona /D. Bratthalla 29

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31. Caries Risk Profiles of 12-13 Year-old Children in Laos and Sweden Results: Mean DMFT level of the Laotian children was 4.61 + 2.95 and 1.38 + 1.97 Only 6% of Laotian children belonged to the Cariogram low risk group versus 40% of the Swedish children. The mean chance of avoiding caries was 37.3% for the Laotians and 69.2% for the Swedish children (p < 0.001). 32

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35. 2. Caries risk profiles in schoolchildren over 2 years assessed by Cariogram Aim. To evaluate longitudinal changes in caries risk profiles in a group of schoolchildren in relation to caries development. Design. The Cariogram model was used to create caries risk profiles and to identify risk factors in 438 children being 10–11 years at baseline. The assessment was repeated after 2 years and the caries increment was recorded. The frequency of unfavourable risk factors were compared between those considered at the lowest and the highest risk. International Journal of Paediatric Dentistry 2010; 20: 341– 346 36 Gunnel haansel petersson, Pererik isberg & Svante twetman

36. Results. 50% of the children remained in the same risk category after 2 years. One third of the children were assessed in a higher-risk category while 18.4% showed a lower risk. Those with increased risk compared with baseline developed significantly more caries than those with an unchanged risk category. The most frequent unfavourable risk factors among those with high risk at baseline were high-salivary mutans streptococci and lactobacilli counts as well as frequent meals. 37

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39. Conclusion. Half of the children showed a change risk category after 2 years, for better or for worse, which suggests that regular risk assessments are needed in order to make appropriate decisions on targeted preventive care and recall intervals. 40

40. 3 .Caries risk profile using the Cariogram in governmental and private orthodontic patients at de-bonding Objectives -To analyze various caries-related factors in orthodontic patients at de-bonding between governmental and private orthodontic patients immediately after orthodontic treatment. Materials and Methods: A cross-sectional examination was carried out on 89 orthodontic patients aged 13–29 years, mean age 21.5 years. They were divided into two groups based on the center of treatment, governmental group (G -45) and private group (P-44). Angle Orthod 2012;82:267–274. Naif Abdullah Almosaa ; Anas H. Al- Mullab ; Dowen Birkhedc 41

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42. The investigation comprised a questionnaire, plaque scoring, caries examination, bitewing radiographs, salivary secretion rate, buffering capacity, and cariogenic microorganisms. Data were entered into the Cariogram PC program to illustrate caries risk profiles. 43

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45. Results: Findings revealed that ‘‘the chance of avoiding new cavities,’’ according to the Cariogram, was high in the P-group and low in the G-group (61% and 28%, respectively) (P 0.001). (DMFS), plaque index, mutans streptococcus and lactobacillus counts, and salivary buffer capacity were significantly higher in the G-group compared with the P-group. The total number of caries lesions at de-bonding in the G-group was more than two times higher than that in the P-group (Angle Orthod . 2012;82:267–274.) 46

46. CONCLUSIONS The null hypothesis was rejected. The chance to avoid new cavities in orthodontic patients at de-bonding appears to be more negative at governmental clinics than at private clinics. This study shows the importance of improving preventive measures used during orthodontic treatment, especially at governmental clinics. The Cariogram may be a useful tool for illustrating caries risk profiles for orthodontic patients.. 47

47. 4.Evaluation of the caries profile and caries risk in adults with endodontically treated teeth Objectives. The present study was set up to explore (1) a potential association between a person’s caries risk profile and the presence or absence of root-filled teeth, (2) the caries risk in endodontically treated teeth. Study design. 200 Saudi adults were divided into an Endodontic Group (EG) n-100 , with a minimum of 2 root-filled teeth, and a Non-Endodontic Group (NEG) n-100, without any root filling. Various caries risk factors were evaluated using a computer-based program (Cariogram). Clinical and radiographic examinations were also carried out. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:264-269) Merdad K, Sonbul H, Gholman M, Reit C, Birkhed D 48

48. Results. Cariogram findings showed that “the chance of avoiding caries” was low in both groups (35% in EG and 37% in NEG), and there was no statistically significant difference between the 2 groups. However, DMFS, recurrent caries, and mutans streptococcus count in saliva were significantly higher in the EG compared to the NEG ( P > 0.05). When teeth in the EG were evaluated independently, the proportion of recurrent caries to the total fillings associated with endodontically treated teeth was 31.6% versus 19.2% in the non-endodontically treated teeth. 49

49. Conclusions. Data were not in favor of an association between caries risk profile and presence of root-filled teeth, but supported the notion that root-filling procedures might make the tooth more susceptible to caries. 50

50. 5. Caries assessment in school children using a reduced Cariogram model without saliva tests Gunnel Hansel Petersson , Per-Erik Isberg and Svante Twetman Methods: The study group consisted of 392 school children, 10-11 years of age, who volunteered after informed consent. A caries risk assessment was made at baseline with aid of the computer-based Cariogram model and expressed as "the chance of avoiding caries" and the children were divided into five risk groups. The caries increment (ΔDMFS) was extracted from the dental records and bitewing radiographs after 2 years. The reduced Cariogram was processed by omitting the variables "salivary mutans streptococci", "secretion rate" and "buffer capacity" one by one and finally all three. Differences between the total and reduced models were expressed as area under the ROC-curve. BMC Oral Health 2010, 10:5 51

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53. Results: Both Cariogram models displayed a statistically relationship with caries development (p < 0.05) more caries was found among those assessed with high risk compared to those with low risk. Almost all children (99%) remained in the same risk group when the buffer and secretion rate values were aborted. The corresponding value for mutans streptococci elimination was 68% indicating that almost one third of the children changed their risk group, for better or for worse, without use of the salivary mutans streptococci enumeration. The vast majority (74%) were placed in a lower risk category. 54

54. Conclusion- the accuracy of caries prediction in school children was significantly impaired when the Cariogram model was applied without enumeration of salivary tests. The mutans streptococci enumeration seemed to be most important of the salivary variables. 55

55. Indian studies 56

56. 1. Caries risk profile of 12 year old school children in an Indian city using Cariogram Mamata Hebbal , Anil Ankola , Sharada Metgud The present study was conducted with an aim to assess the caries profile of 12 year old Indian children using Cariogram. Study design: 100 children were interviewed to record any illness, oral hygiene practices and fluoride exposure after obtaining a three day diet diary. Examination was done to record plaque and dental caries status. Stimulated saliva was collected and salivary flow rate, salivary buffering capacity, Streptococcus mutans and Lactobacillus were assessed. The information obtained was scored and Cariogram was created. Med Oral Patol Oral Cir Bucal . 2012 Nov 1;17 (6):e1054-61. 57

57. Differences between mean ( DMFT) and Cariogram risk groups were assessed using ANOVA. Spearman Correlation coefficients were used to explore correlation among Cariogram scores and individual variables. 58

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59. Results: Significant correlation was observed between Cariogram score and DMFT, diet content, diet frequency, plaque scores, Streptococcus mutans counts and fluoride programme. Conclusions: Cariogram model can identify the caries-related factors that could be the reasons for the estimated future caries risk, and therefore help the dentist to plan appropriate preventive measures. 60

60. 2. Evaluation of a preventive program based on caries risk among mentally challenged children using the cariogram model. Y.B. Patil , S. Hegde-Shetiya , P.V. Kakodkar , R. Shirahatti Objectives : To assess the caries risk and to evaluate the risk based preventive program at the end of 10 months amongst the mentally challenged children using the Cariogram model. Basic research design : Longitudinal field trial with before and after comparison. 54 children (7-17years old) with mild to severe mental disability from Brahmadutta School, for the mentally challenged children situated in Pimpri (Maharashtra) India. Community Dent Health. 2011 Dec;28(4):286-91 61

61. Interventions Phase I : Information of the Cariogram parameters (caries experience, diet content, diet frequency, plaque amount, mutans streptococci, fluoride program, saliva secretion and saliva buffer capacity) were collected, which were used to generate the individual caries profile, based on which the children were divided into 5 risk groups. Phase II : Risk based preventive program was implemented. 0-20% chance avoidance-APF gel 1.23% at beginning,3 months and at end of 6 months 21-100% chance of avoidance- avoidance-APF gel 1.23% at beginning, and end of 6 months Phase III : At the end of 10 months , caries profile was generated again. 62

62. The effectiveness of the preventive program was assessed by comparing the baseline and follow-up caries profile. Wilcoxon Signed Ranks test was used for statistical analysis. Results : As compared to the baseline, there was a 57% increase in the number of children in low caries risk group and for the caries risk factors diet content, diet frequency, plaque amount and Mutans streptococci count had significantly lower values. At follow-up, only 4 new carious lesions developed. 63

63. Conclusion: The preventive program was effective in improving the caries risk factors and increasing the chance to avoid caries from a mean of 44% to 87%. 64

64. 3. An evaluation of the Cariogram as a predictor model. Utreja D ,  Simratvir M ,  Kaur A ,  Kwatra KS ,  Singh P ,  Dua V . This study was conducted to evaluate the accuracy of the Cariogram in predicting the occurrence of caries in first permanent molars. Thirty children aged 8 years were included who were divided in two groups depending on presence of carious or non carious first permanent molars. Their Cariograms were plotted and the likelihood of caries as indicated by the Cariogram was compared to the actual occurrence of caries in first permanent molars. Results revealed that the Cariogram had a diagnostic accuracy of 63.33% thus emphasizing the need for better prediction models. Int Dent Journal  2010 Aug;60(4):282-4. 65

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66. Caries Risk Assessment is one of the cornerstones in patient centered caries management in order to assist the clinician in the decision making process concerning treatment, recall appointments and need for additional diagnostic procedures. Ideal Risk assessment tool -high precision and accuracy - should be easy to use in the daily practice -utilize inexpensive risk factors that can be scored in reliable way. -the process should be rapid and the outcome understandable so it can used as didactic tool in patient motivation. 67

67. Ultimately,predictive tool should be sensitive enough to catch as many as possible of those with a true caries risk but also correctly identify those with low risk. The cariogram model is truly comprehensive and illustrates the relative importance of various background factors in an individual risk profile but the increased costs and timely handling of salivary tests may have limited its use. 68

68. REFERENCES 69

69. References Caries Risk Profiles of 12-13-Year-old Children in Laos and SwedenG . L. Tayanina /G. Hänsel Peterssona /D. Bratthalla Oral Health Prev Dent 2005; 3: 15–23. Caries risk profiles in schoolchildren over 2 years assessed by cariogram Gunnel Ha¨ Nsel Petersson1, Per-erik Isberg2 & Svante twetman international journal of paediatric dentistry 2010; 20: 341– 346. Caries risk assessment-a comparison between the computer program ’Cariogram’, dental students and dental instructors G. H-el Petersson , I? Carlsson and D. Bratthall Eur Dent Educ 1998; 2: 184-190 70

70. Dental Caries: intervened - interrupted - interpreted. Concluding remarks and Cariography . Bratthall D. Eur J Oral Sci 1996; 104: 486-491. 1996. Caries risk profiles in schoolchildren over 2 years assessed by-Cariogram . Gunnel hansel petersson ,Per-erik isberg ,Svante twetman .International Journal of Paediatric Dentistry 2010; 20: 341– 346 Hansel Petersson G. Cariogram – a multifactorial risk assessment model for a multifactorial disease. Community Dent Oral Epidemiol 2005; 33: 256–64. 71

71. Caries risk profile of 12 year old school children in an Indian city using Cariogram Hebbal M, Ankola A, Metgud S.. Med Oral Patol Oral Cir Bucal . 2012 Nov 1;17 (6): Caries risk profile using the Cariogram in governmental and private orthodontic patients at de- bondingAlmosa NA, Al- Mulla AH, Birkhed D. Angle Orthod . 2012 Mar;82(2):267-74. Caries assessment in school children using a reduced Cariogram model without saliva tests Gunnel Hansel Petersson , Per-Erik Isberg and Svante Twetman BMC Oral Health 2010, 10:5 72

72. Thank you.!! 73