Caries Risk Assessment

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In spite of decades of a significant decline in incidence, dental caries remains a global public health burden with statistics indicating approximately 44% of all people worldwide suffering from untreated caries in their primary and/or permanent teeth [1, 2]. It is therefore obvious that the focus and efforts on effective caries prevention and minimally invasive operative carious lesion management must be intensified. In this context, a caries risk/susceptibility assessment (CRA) of populations, groups and individuals is thought to be a cornerstone of preventive dentistry in order to allocate time and resources to those with the greatest need. Even though CRA is implicit in the daily delivery of good quality oral health care by many oral health care practitioners, questions still remain unanswered as to whether or not formalized, documented evidence-based CRA is possible, feasible or even desired in the environment of general oral healthcare practice. The aim of this chapter is to summarize the science and quality of evidence that exists for CRA and discuss some of the complexities associated with its use. Caries risk assessment (CRA) can be defined as “the clinical process of establishing the probability of an individual patient to develop carious lesions over a certain period of time or the likelihood that there will be a change in size or activity of lesions already present”. First of all, dental caries is classified by the World Health Organization (WHO) as a plaque (biofilm)-mediated, non-communicable disease (NCD), with a complex network of biological, genetic, behavioural, socioeconomic and lifestyle-related risk factors in common with other NCDs, for example, obesity and diabetes [2]. This means that one cannot expect one single risk factor alone, such as bacterial load, sugar intake or salivary secretion rate, to be individually useful in order to predict future caries incidence. The second issue is “probability over a certain period of time”. To establish this probability, any risk factor, or combination of risk factors, must be tested and validated in prospective trials in which defined cut-off points, or threshold values, are related to the true caries increment. The calculated probability for developing caries is often expressed in terms of sensitivity, specificity, receiver operating characteristics and/or area under the curve, terms that may not be easily digested by the clinician, and even less so by the patient. It should also be observed that the results are only valid for the particular age group and population in which the study was conducted. This means that the external validity may be limited and that the findings can seldom be generalized meaningfully to all patient groups or populations. Prospective risk assessment clinical trials are associated with an ethical dilemma since they must be performed without any form of intervention in order to truly reflect their predictive ability. The fourth issue deals with the methodology of caries detection. Caries development is not an “on/off” process but a continuum with a slow progression rate in most individuals. A final point is regarding the common terminology used. It may be considered a semantic point, but all dentate patients are subjected equally to the associated risk factors for caries process instigation—a suitable tooth surface, a dysbiotic cariogenic stagnating plaque biofilm  containing a diverse microbiota working  collectively to drive the caries process when conditions allow, a carbohydrate source for bacterial metabolism and time.

Regards
Sarah eve
Editorial Assistant
Journal of Oral Hygiene and Health