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Caries risk assessment ppt

This document discusses caries risk assessment tools and factors. It introduces several tools used to assess caries risk: the Caries Risk Assessment Tool (CAT), Caries Management by Risk Assessment (CAMBRA), Cariogram, and the Traffic Light Matrix. It describes the various factors each tool considers like biological factors, protective factors, clinical findings, plaque, specific microbes, diet, eating patterns, and saliva. The goal of these tools is to improve oral health by introducing preventive measures before irreversible lesions develop based on a patient's caries risk level and factors.

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CONTENTS • Introduction • Caries imbalance • Objectives • Caries risk assessment tool • Cambra • Cariogram • Traffic light matrix • Caries risk factors
• Microbial tests for mutans streptococci detection • Microbial tests for lactobacilli detection • Caries activity tests • Caries risk indicators • Key risk groups • Uses • Conclusion • References
INTRODUCTION • DENTAL CARIES:- Acc to Shafers in 1993 Dental caries is an irreversible microbial disease of the calcified tissue of the teeth, characterized by demineralization of inorganic portion and destruction of organic substance of tooth which often leads to cavitation.
• CARIES RISK ASSESSMENT:- can be defined as a procedure to predict future caries development before the clinical onset of the diseases. • 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. It also involves the probability that there will be a change in the size or activity of the lesion in the mouth. Guideline on Caries-risk Assessment and Management for Infants, Children, and Adolescents Reference manual 2011; 37( 6): 15 -16.
• CARIES ACTIVITY TEST:- Estimate the actual state of disease activity (progression/regression). • RISK FACTOR:- 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.
• RISK INDICATOR:- is a factor or circumstance that is indirectly associated with the disease like socioeconomic factors and epidemiologic factors.
Disease indicators: •White spots •Restorations >3 years •Enamel lesions •Cavities/ dentin Risk Factors •Bad bacteria •Absence of saliva •Dietary habits(poor) Protective factors: •Saliva & sealants •Antibacterial •Fluorides •Effective diet Caries progression No caries CARIES IMBALANCE
OBJECTIVES  To improve the oral health in children, adolescents and adults  Introduce causal measures before irreversible lesions have become established  Utilize resources in a cost effective way
• Caries Risk Assessment Tools 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
Factors Biological 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 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
FACTORS low moderate high Caries activity none With in 24 months With in 12 months Demineralized areas No white spots 1 white spot >1 white spot Family history- mother, father, siblings No caries activity Low caries rate High caries rate Presence of plaque none moderate Visible plaque on anterior teeth Fluoride exposure optimal Low to optimal low Sugar consumption With meals only 1-2 b/w meals >3 b/w meals Dental home Established Irregular use none Special conditions Enamel hypoplasia impaired salivary flow Caries risk assessment tool- age 6 months through 35 months
FACTORS low moderate high Caries activity none With in 24 months With in 12 months Demineralized areas No white spots Inactive white spot Active white spots Parent/primery caregiver No decay Low caries rate High caries rate Family history No caries activity Low caries rate High caries rate Presence of plaque none moderate Visible plaque on anterior teeth Fluoride exposure optimal Low to optimal low Sugar consumption With meals only 1-2 b/w meals >3 b/w meals Dental home Established Irregular use none Special conditions Special needs patient Enamel hypoplasia impaired salivary flow Caries risk assessment tool- age 3 through 5 years
FACTORS low moderate high Caries activity none Incipient lesion >1 cavitated lesion Demineralized areas No white spots Inactive white spot Active white spots Parent/primery caregiver None Low caries rate High caries rate Restoration or missing teeth None 1 or 2 restorations with in last 36 mnths 3 or more restorations or extracted tooth in last 36 months Presence of plaque none moderate heavy Fluoride exposure optimal Low to optimal low Sugar consumption With meals only 1-2 b/w meals >3 b/w meals Dental home Established Irregular use none Special conditions Dental/ ortho applianceSpecial needs patient Enamel hypoplasia impaired salivary flow Caries risk assessment tool- age 6 through 20 years
• The CAMBRA philosophy was first introduced nearly a decade ago when an unofficial group called the Western CAMBRA Coalition was formed that included stakeholders from education, research, industry, governmental agencies and private practitioners based in the western region of the United States Caries Management by Risk Assessment (CAMBRA):
• 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. • Essentially based on the same factors as CAT to assess caries risk
Cariogram • Cariogram is a new way in which to illustrate the interaction between caries related factors. • This educational interactive program has been developed for better understanding of the multifactorial aspects of dental caries and to act as a guide in the attempts to estimate the caries risk.
• Peterson G et al in 2003 gave the opinion that the Cariogram predicted caries increment more accurately than any included single-factor model. • Petersson GH. Assessing caries risk-using the Cariogram model. Swed Dent J Suppl. 2003;(158):1-65
• Mieravet AR et al in 2007 said that the past caries experience, Streptococcus mutans count, fluoridation programme and buffer capacity of the saliva are the factors included in the Cariogram that showed significant correlation with the caries risk determined by the program. Other factors that the Cariogram does not include directly, such as, DMFT, DMFS and the plaque index, also showed high correlation with risk. • Mieravet AR, Letra A, Rose EK, Brandon CA, Resick JM, Marazita ML, Vieira AR. Inherited risks for susceptibility to dental caries. Caries Res. 2007;42:8–13.
Factors and relevant information required to create a cariogram
• Traffic Light Matrix (TLM): • This is a commonly used CRA tool. • TLM is based on 19 criteria in 5 different categories including saliva (6 criteria), plaque (3 criteria), diet (2 criteria), fluoride exposure (3 criteria) and modifying factors (5 criteria).
• traffic light colours convey varying risk levels (red=high, yellow=moderate and green=low). • The objective is to alert the clinician regarding the current risk status. • This color code model keeps the visual interpretation simple and communicable to the patient as well.
• Saliva: a) Resting: hydration, viscosity and pH b) Stimulated: quantity/rate, pH and buffering capacity • Plaque: pH, maturity and bacteria – Mutans count • Diet: number of sugar and acid exposures in between meals/ day
• Fluoride: water Toothpaste professional treatment • Modifying factors: drugs that reduce salivary flow, diseases resulting in dry mouth, fixed/removable appliances, recent active caries and poor compliance
• The system scores Red, yellow & green light for each risk factors depending on predetermined criteria. • Tests are carried for each risk factors independently and scores are generated. • The scores are compared with predetermined criteria. based on theis criteria Red for- high risk yellow for- moderate risk green for- low risk
• Eg- for diet
CARIES RISK FACTORS 1)- 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.
RISK AREAS FOR PLAQUE ACCUMULATION • Mesiolingual and distolingual mandibular surfaces of molars • Mesiobuccal and distobuccal surfaces of maxillary and mandibular molars. • Plaque accumulation on the palatal surfaces of maxillary teeth is low
2)- SPECIFIC MICROBES AND CARIES RISK • Can readily estimate bacterial levels in saliva, and dentists can identify patients with a high bacterial load • A high count in saliva more than 1 million colony forming units per ml of saliva indicates that most teeth are colonized by bacteria i.e. many tooth surfaces are subject to increased risk.
3)-DIET • Diet rich in fermentable carbohydrates (frequent sugar intake) is a very powerful external risk factor and prognostic risk factor for dental caries in populations with poor oral hygiene habits and associated lack of regular topical fluoride exposure from tooth pastes • In populations with good oral hygiene and daily use of fluoride toothpaste, sugar is a very weak RF and PRF
4)- EATING PATTERN • Fall in plaque pH after consumption of sugary foods may be modified by the consumption of less fermentable foods before, concurrently or afterward egs: cheese.
•Infants and toddlers - regularly bottle fed with sweet drinks at night or breast fed for > twelve months- risk factors for caries. •Teenagers and young adults- excessive consumption of soft drinks risk factors for caries
5) SALIVA •Saliva plays an important role in the health of soft and hard tissues in the oral cavity. SALIVARY FLOW RATE • Chronically low salivary flow rate one of the strongest salivary factors increased risk of developing caries. • caries is extreme absence of saliva.
Navazesh (1992) et al found that unstimulated salivary flow rates have the strongest predictive validity of estimating caries risk. The normal unstimulated values vary from 0.3-0.4 ml/min and values less than 0.1ml/ min are considered as abnormal. Navazesh, M., Christensen, C. & Brightman, V. 1992a, "Clinical criteria for the diagnosis of salivary gland hypofunction", Journal of dental research, vol. 71, no. 7, pp. 1363-1369.
• Grindefjord et al (1995) studied the relative risk (odds ratio) that 1year-old infants would develop caries by the age of 3.5 years: Those with poor oral hygiene, bad dietary habits, salivary MS, little or no exposure to fluoride, and parents with a low educational level or an immigrant background were at 32 times greater risk than were children without the corresponding etiologic and external risk factors. Grindefjord M, Dahllöf M, Modéer T. Caries development in children from 2.5 to 3.5 years of age: a longitudinal study. Caries Res. 1995;29:449–454.
Leone CW et al (2001), performed a literature review on the physical and chemical aspects of saliva as indicators of risk for dental caries. ‘the review showed that normal salivary output as quantified by flow rate is an intrinsic host factor providing protection against caries and the evidence shows that pathologically diminished flow rate is a significant risk factor for caries development.’ Leone CW et al. Physical and Chemical Aspects of Saliva as Indicators of Risk for Dental Caries in Humans J Dent Edu 2001;10:1054-1062.
DEMINERALIZATION AND REMINERALIZATION •Main factors governing stability of enamel are the pH and concentration of Ca, PO3 4-, and F in solution which are all derived from saliva. •The role of saliva in this process is highly dependent on accessibility, which is closely related to thickness of plaque.
•The ability of saliva to remineralize demineralized enamel crystals stems from its ability to supply bioavailable calcium and phosphate ions to the tooth. At physiological pH, unstimulated and stimulated parotid, submandibular, and whole saliva are supersaturated with respect to most solid calcium phases (Larsen and Pearce, 2003) Larsen, M.J., and Pearce, E.I.F. (2003). Saturation of human saliva with respect to calcium salts, Arch. Oral Biol., 48: 317-322.
•Precipitation of calcium phosphate phases in saliva normally does not occur, due to the presence of salivary proteins, particularly statherin (Schlesinger and Hay, 1977) Schlesinger, D. H. and D. I. Hay: Complete Covalent Structure of Statherin, a Tyrosine-Rich Acidic Peptide Which Inhibits Calcium Phosphate Precipitation from Human Parotid Saliva. J. Biol. Chem. 252:1689-1695 (1977).
IMMUNE SYSTEM AND CARIES RISK •Salivary immunoglobulin are mucosal antibodies that act as the first line of defense, and they include two major antibodies, namely, secretory IgA and IgG. • Higher caries prevalance in preschool children with higher level of microbes such as mutans streptococci, C. albicans and Prevotellaspp., salivary protein including IgA, IgG immunoglobulins, PRP and histatin peptides, in saliva compared with caries free individuals. Huang R et al. Salivary proteins and microbiota as biomarkers for early childhood caries risk assessment. International Journal of Oral Science (2017), 1–8
INHERITED RISK SUSCEPTIBILITY • Racial characteristics predispose particular groups to dental caries. •American Indians and Inuit (Eskimo) have showel shaped incisors, barrel shaped incisors, deep buccal pits on molars, plaque accumulation from a cariogenic diet will predispose these areas to caries.
•Whites have a higher prevalence of cusp of Carabelli and hence are predisposed to caries in maxillary molars. (Dahlberg, 1961) Dahlberg AA. The physical anthropology of the American Indian. New York •Schuler CF et al in 2001 found that inherited disorders of tooth development with altered enamel structure and altered immune response to cariogenic bacteria increase the risk of dental caries. However the evidence supporting an inherited susceptibility to dental caries is limited and does not provide a predictable basis for predicting future decay rates. Shuler CF. The Changing Face of Dental Education: The Impact of PBL. J Dent Edu 2001;10:1038-1045
CARIES RISK INDICATORS • Caries risk indicators broadly divided into pathological factors and protective factors • Pathological factors are- • 1- Past caries experience • 2- Dietary habits • 3- Socioeconomic status • 4-Fluoride exposure • 5-Medical factors
1)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 • Criticized because the aim should be to determine the high risk individuals before there are any signs of past caries experience. Axelsson P. Diagnosis and risk prediction of dental caries. 2004. Bratthall D et al. Community Dent Oral Epidemiol 2005; 33: 256–64
Pathological factors: 2) Dietary factors • Frequent between meal snacking • Prolonged night-time or at will bottle/breast feeding of infant • Multiple sugar exposures through the day • Infant Ready availability of cariogenic snacks Protective factors are: • Dietary factors: • Sugar exposures are limited to meal times • Preference for non-cariogenic snacks • No deleterious bottle/breast feeding of the infant
Socioeconomic factors • High caries risk in siblings/parents • Socioeconomically Children deprived or immigrant backgrounds • High maternal MS levels • Low dental aspirations especially on the importance of maintaining caries free primary dentition Socioeconomic factors; • Good oral hygiene in parents with adequate knowledge about dental health & prevention • Regular access to a well- established dental home
• Fluoride exposure • No exposure to fluoridated drinking water • No access to professionally applied topical fluorides especially when permanent molars erupt delaying post-eruptive maturation Fluoride exposure: • Presence of continuous, low concentration of free F- ions around teeth especially at the time of a cariogenic acid attack. • Daily use of a fluoridated dentifrice • Living in an area with community water fluoridation
• Medical factors • Special child (i.e. a child with a physical,mental, or medically compromising condition that may limit oral health care measures or make the child more susceptible to caries.) • Salivary dysfunction caused by medications, radiation therapy or general systemic conditions • Long term cariogenic medication Medical factors •Institution & maintenance of an intensive preventive regimen in the special child •Saliva substitutes •sugar-free medications
• Salivary factors • High salivary MS & Lactobacilli counts • Poor salivary flow rate impeding clearance • Salivary factors • Salivary buffers that aid in neutralizing acids • Salivary proteins and lipids that form pellicle & protect tooth surface Salivary Calcium & Phosphate ions can enhance remineralization & delay demineralization
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
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.
Key-risk age group 3: Ages 11 to 14 years • Normally, the second molars start to erupt at the age of 11 to 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.
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
Other risk groups • 1.Persons who work in occupations where frequent food sampling is required • 2. Persons who are obese • 3. Persons who abuse recreational drugs • 4. Persons who have systemic diseases and are taking regular medication • 5. Women who are pregnant
• 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 being at low, moderate or high risk. Niessen LC, DeSpain B. Clinical strategies for prevention of oral diseases. J Esthet Dent 1996;8(1):3-11.
USES OF CARIES RISK ASSESSMENT  Evaluate the degree of patient’s risk of developing caries to determine the intensity of treatment.  Help identify main etiologic agents - to determine the type of treatment  Determine if additional diagnostic procedures are required – salivary flow rate analysis, diet analysis  Improve the reliability of the prognosis of the planned treatments  Assess the efficacy of proposed management and preventive treatment plan at recall visits.
TESTS IN CRA  Bacterial challenge- determination of Mutans streptococcus as an indicator of relative risk.  Diet- determination of lactobacilli as an indicator of sugar content in diet.  Remineralization potential- salivary flow rate and buffer capacity as an indicator of potential biologic repair.  Host susceptibility- caries experience as an indicator of past activity.
Microbial tests for mutans streptococci detection • Several methods are available to measure the levels of mutans streptococci in saliva and plaque and on individual tooth surfaces .  LABORATORY METHOD  CHAIR SIDE METHOD  SURVEY METHOD  SELECTIVE METHOD  ADHERENCE METHOD
Wooden spatula contaminated with saliva and pressed on Agar S mutans colonies on the surface of agar LABORATORY METHOD
 Saliva is collected from the individual to be sampled  Mixed with proper transport medium  After incubation using a selective medium, mutans colonies on the plates are counted and the results are expressed as no. of colony forming per units per ml saliva.  A common type of selective agar plate for mutans streptococci is the mitis salivarious bacitracin agar, MSB agar.
For screening surveys using agar plates, a simplified method has been described in which wooden spatulas are contaminated by saliva and then directly pressed against selective agar plates. After incubation the no. of colonies on a predetermined area of the agar is calculated
Chair side method
• Dentocult SM Strip Mutans test • Bacitracin discs are added to the broth at least 15 min before use • Individual is asked to chew a piece of paraffin for 1 minute • Plastic strip is turned around in the mouth to become contaminated.
• The strip is withdrawn through closed lips , leaving a thin layer of saliva on the strip. • The strip is incubated in the selective broth • After incubation for 48 hours at 35-37◦c, the strip with attached colonies is compared with chart, and given a score from 0 to 3
• SURVEY METHOD:- • Plates can be placed into plastic bags containing expired air, which are then sealed and incubated at 37◦ c. • Counts of more than 100 CFU by this method are proportional to greater than 108 CFU of S.mutans per ml of saliva by conventional methods.
• SELECTIVE METHOD: • Plaque samples are collected from gingival third of buccal tooth surface • Toothpicks are inserted into approximal spaces • Place into Ringer’s solution Shake to homogeneity
Contaminated sides are then pressed into the approximal spaces Incubation at 37◦c for 72 hours Sites with or without mutans streptococci can be identified
• ADHERENCE METHOD • Unstimulated saliva is inoculated in MSB Broth • Inoculated tubes are set at 60◦ angle and incubated aerobically at 37◦ c for 24 hrs • After growth has been observed, the supernatant medium is removed.
+++ S.Mutans is present at level higher than 105 CFU per ml of whole saliva - S.Mutans is present at less than 104 CFU per ml of whole saliva value inference - No growth expressed + A few deposits ranging from 1-10 ++ Scattered deposits of smaller size +++ Numerous minute deposits with more than 20 large size deposits Results
Microbial tests for Lactobacilli count LABORATORY METHOD: • Saliva is obtained by chewing a piece of paraffin • Shaken with glass beads to break up aggregates of bacteria • Saliva is then mixed with a buffer solution and 1 ml of the dilutions 10-2 and 10-3 • 10 ml is poured into the Petri dish • Plates are incubated at 37◦ c for 4 days. Lactobacilli appear as whitish dots
Chair side- Dentocult LB method aerobic incubation for 4◦ days no. of lactobacilli is estimated by comparing the slides with a model chart Results No. of Lactobacilli/ ml Caries activity 0-1000 Little or no activity 1000-5000 Slight activity 5000-10,000 Moderate activity >10,000 Marked activity
Synder Test • Saliva is collected before breakfast by chewing paraffin wax • A tube of Snyder glucose agar is melted and then cooled to 50 ◦ c • Saliva specimen is shaken vigorously for 3 minutes. • 0.2ml of saliva is pipetted into the tube of agar and immediately mixed by rotating the tube.
Agar is allowed to solidify in the tube and is incubated at 37 ◦ c Color change of the indicator is observed after 24, 48, and 72 hours of incubation by comparison with an uninoculated tube against a white background.
Alban Test • 60 grams of Synder test agar is placed in 1 liter of water • Suspension is brought to boil over a low flame • After suspension has melted the agar is distributed using about 5 ml per tube • Tubes should be autoclaved for 15 minutes; allowed to cool in refrigerator
• 2 tubes are taken from the refrigerator and patient is asked to expectorate a small amount of saliva directly into the tubes. • Tubes are labeled and incubated at 98.6◦F for 4 days • Tubes are observed daily for color change
Color change score No color change 3/4 Beginning color change + One half color change ++ Three fourths color change +++ Total color change to yellow ++++ Results of Alban test
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
• The multifactorial etiology of dental caries makes it likely that even the most sophisticated risk models will be of limited value in predicting future caries development very accurately. • Prevention is still the least costly alternative treatment hence the saying Prevention is better than cure which holds good for dental caries too.
References • Young DA, Fontana M, Wolff MS. Current concepts in cariology. Dent Clin North Am 2010;54:479-493. • Norman O Harris, Franklin Garcia Godoy. Primary preventive Dentistry. New Jersey: Pearson Prentice Hall; 2004. p. 285-316. • Axelsson P. Diagnosis and risk prediction of dental caries. Slovakia Quintessence International 2004; p. 29. • Bratthall D et al. Cariogram a multifunctional risk assessment model for a multifactorial disease. Community Dent Oral Epidemiol 2005; 33: 256–64.
• Fontana M, Zero D. Assessing patient’s caries risk. J Am Dent Assoc 2006;137:1231-1239. • Bowden GH. Dose assessment of microbial composition of plaque/saliva allow for diagnosis of disease activity of individuals? Community Dent Oral Epidemiol 1997;25: 76–81. • Beighton D. The complex oral microflora of high risk individuals and groups and its role in the caries process. Community Dent Oral Epidemiol 2005;33:248-255. • Pearce EIF, YM Dong, Yue L, Gao XJ, Purdie GL, Wang JD. Plaque minerals in the prediction of caries activity. Community Dent Oral Epidemiol 2002;30:61-9.
Caries risk assessment ppt

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In this document
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Introduction to caries, risk assessments and various tools like CAMBRA and Cariogram.

Definition of dental caries and risk factors. Discussion on caries balance and indicators like white spots.

Aims to improve oral health, implement preventive measures, and utilize resources efficiently.

Discussion on the Caries Risk Assessment Tool (CAT), focusing on biological, protective, and clinical factors.

Risk assessment criteria based on caries activity, demineralized areas, family history, and plaque presence.

Introduction to CAMBRA principles and evidence-based strategies for early caries prevention.

Explanation of Cariogram as a tool for visualizing caries risk and discussing factors influencing risk.

Introduction of Traffic Light Matrix (TLM) for assessing caries risk levels with a color-coded system.

Identifying risk factors like plaque, microbial counts, diet, and saliva's role in caries risk.

Discussion on racial and genetic predisposition impacting caries risk and its variability.

Classification of caries risk indicators into pathological and protective factors including socioeconomic elements.

Identifying key childhood and young adult groups most susceptible to dental caries development.

Purpose of caries risk assessments in treatment planning, identifying etiologic agents, and establishing preventive measures.Methods for detecting mutans streptococci and lactobacilli through various laboratory and chair-side techniques.

Importance of caries risk assessment in preventing dental caries and reinforcing value in preventive care.

Citations of key literature supporting the presentation and caries research.

Caries risk assessment ppt

  • 3.
    CONTENTS • Introduction • Cariesimbalance • Objectives • Caries risk assessment tool • Cambra • Cariogram • Traffic light matrix • Caries risk factors
  • 4.
    • Microbial testsfor mutans streptococci detection • Microbial tests for lactobacilli detection • Caries activity tests • Caries risk indicators • Key risk groups • Uses • Conclusion • References
  • 5.
    INTRODUCTION • DENTAL CARIES:-Acc to Shafers in 1993 Dental caries is an irreversible microbial disease of the calcified tissue of the teeth, characterized by demineralization of inorganic portion and destruction of organic substance of tooth which often leads to cavitation.
  • 6.
    • CARIES RISKASSESSMENT:- can be defined as a procedure to predict future caries development before the clinical onset of the diseases. • 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. It also involves the probability that there will be a change in the size or activity of the lesion in the mouth. Guideline on Caries-risk Assessment and Management for Infants, Children, and Adolescents Reference manual 2011; 37( 6): 15 -16.
  • 7.
    • CARIES ACTIVITYTEST:- Estimate the actual state of disease activity (progression/regression). • RISK FACTOR:- 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.
  • 8.
    • RISK INDICATOR:-is a factor or circumstance that is indirectly associated with the disease like socioeconomic factors and epidemiologic factors.
  • 9.
    Disease indicators: •White spots •Restorations>3 years •Enamel lesions •Cavities/ dentin Risk Factors •Bad bacteria •Absence of saliva •Dietary habits(poor) Protective factors: •Saliva & sealants •Antibacterial •Fluorides •Effective diet Caries progression No caries CARIES IMBALANCE
  • 10.
    OBJECTIVES  To improvethe oral health in children, adolescents and adults  Introduce causal measures before irreversible lesions have become established  Utilize resources in a cost effective way
  • 11.
    • Caries RiskAssessment Tools 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
  • 12.
    Factors Biological Patient is oflow 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
  • 13.
    Protective Patient receives optimally-fluoridateddrinking water Patient brushes teeth daily with fluoridated toothpaste Patient receives topical fluoride from health professional Patient has dental home/regular dental care
  • 14.
    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
  • 15.
    FACTORS low moderatehigh Caries activity none With in 24 months With in 12 months Demineralized areas No white spots 1 white spot >1 white spot Family history- mother, father, siblings No caries activity Low caries rate High caries rate Presence of plaque none moderate Visible plaque on anterior teeth Fluoride exposure optimal Low to optimal low Sugar consumption With meals only 1-2 b/w meals >3 b/w meals Dental home Established Irregular use none Special conditions Enamel hypoplasia impaired salivary flow Caries risk assessment tool- age 6 months through 35 months
  • 16.
    FACTORS low moderatehigh Caries activity none With in 24 months With in 12 months Demineralized areas No white spots Inactive white spot Active white spots Parent/primery caregiver No decay Low caries rate High caries rate Family history No caries activity Low caries rate High caries rate Presence of plaque none moderate Visible plaque on anterior teeth Fluoride exposure optimal Low to optimal low Sugar consumption With meals only 1-2 b/w meals >3 b/w meals Dental home Established Irregular use none Special conditions Special needs patient Enamel hypoplasia impaired salivary flow Caries risk assessment tool- age 3 through 5 years
  • 17.
    FACTORS low moderatehigh Caries activity none Incipient lesion >1 cavitated lesion Demineralized areas No white spots Inactive white spot Active white spots Parent/primery caregiver None Low caries rate High caries rate Restoration or missing teeth None 1 or 2 restorations with in last 36 mnths 3 or more restorations or extracted tooth in last 36 months Presence of plaque none moderate heavy Fluoride exposure optimal Low to optimal low Sugar consumption With meals only 1-2 b/w meals >3 b/w meals Dental home Established Irregular use none Special conditions Dental/ ortho applianceSpecial needs patient Enamel hypoplasia impaired salivary flow Caries risk assessment tool- age 6 through 20 years
  • 18.
    • The CAMBRAphilosophy was first introduced nearly a decade ago when an unofficial group called the Western CAMBRA Coalition was formed that included stakeholders from education, research, industry, governmental agencies and private practitioners based in the western region of the United States Caries Management by Risk Assessment (CAMBRA):
  • 19.
    • Evidence-based approachto preventing or treating the cause of dental caries at the earliest stages rather than waiting for irreversible damage to the teeth. • Essentially based on the same factors as CAT to assess caries risk
  • 20.
    Cariogram • Cariogram isa new way in which to illustrate the interaction between caries related factors. • This educational interactive program has been developed for better understanding of the multifactorial aspects of dental caries and to act as a guide in the attempts to estimate the caries risk.
  • 23.
    • Peterson Get al in 2003 gave the opinion that the Cariogram predicted caries increment more accurately than any included single-factor model. • Petersson GH. Assessing caries risk-using the Cariogram model. Swed Dent J Suppl. 2003;(158):1-65
  • 24.
    • Mieravet ARet al in 2007 said that the past caries experience, Streptococcus mutans count, fluoridation programme and buffer capacity of the saliva are the factors included in the Cariogram that showed significant correlation with the caries risk determined by the program. Other factors that the Cariogram does not include directly, such as, DMFT, DMFS and the plaque index, also showed high correlation with risk. • Mieravet AR, Letra A, Rose EK, Brandon CA, Resick JM, Marazita ML, Vieira AR. Inherited risks for susceptibility to dental caries. Caries Res. 2007;42:8–13.
  • 25.
    Factors and relevantinformation required to create a cariogram
  • 28.
    • Traffic LightMatrix (TLM): • This is a commonly used CRA tool. • TLM is based on 19 criteria in 5 different categories including saliva (6 criteria), plaque (3 criteria), diet (2 criteria), fluoride exposure (3 criteria) and modifying factors (5 criteria).
  • 29.
    • traffic lightcolours convey varying risk levels (red=high, yellow=moderate and green=low). • The objective is to alert the clinician regarding the current risk status. • This color code model keeps the visual interpretation simple and communicable to the patient as well.
  • 30.
    • Saliva: a)Resting: hydration, viscosity and pH b) Stimulated: quantity/rate, pH and buffering capacity • Plaque: pH, maturity and bacteria – Mutans count • Diet: number of sugar and acid exposures in between meals/ day
  • 31.
    • Fluoride: water Toothpaste professionaltreatment • Modifying factors: drugs that reduce salivary flow, diseases resulting in dry mouth, fixed/removable appliances, recent active caries and poor compliance
  • 32.
    • The systemscores Red, yellow & green light for each risk factors depending on predetermined criteria. • Tests are carried for each risk factors independently and scores are generated. • The scores are compared with predetermined criteria. based on theis criteria Red for- high risk yellow for- moderate risk green for- low risk
  • 33.
  • 34.
    CARIES RISK FACTORS 1)-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.
  • 35.
    RISK AREAS FORPLAQUE ACCUMULATION • Mesiolingual and distolingual mandibular surfaces of molars • Mesiobuccal and distobuccal surfaces of maxillary and mandibular molars. • Plaque accumulation on the palatal surfaces of maxillary teeth is low
  • 36.
    2)- SPECIFIC MICROBESAND CARIES RISK • Can readily estimate bacterial levels in saliva, and dentists can identify patients with a high bacterial load • A high count in saliva more than 1 million colony forming units per ml of saliva indicates that most teeth are colonized by bacteria i.e. many tooth surfaces are subject to increased risk.
  • 37.
    3)-DIET • Diet richin fermentable carbohydrates (frequent sugar intake) is a very powerful external risk factor and prognostic risk factor for dental caries in populations with poor oral hygiene habits and associated lack of regular topical fluoride exposure from tooth pastes • In populations with good oral hygiene and daily use of fluoride toothpaste, sugar is a very weak RF and PRF
  • 38.
    4)- EATING PATTERN •Fall in plaque pH after consumption of sugary foods may be modified by the consumption of less fermentable foods before, concurrently or afterward egs: cheese.
  • 39.
    •Infants and toddlers- regularly bottle fed with sweet drinks at night or breast fed for > twelve months- risk factors for caries. •Teenagers and young adults- excessive consumption of soft drinks risk factors for caries
  • 40.
    5) SALIVA •Saliva playsan important role in the health of soft and hard tissues in the oral cavity. SALIVARY FLOW RATE • Chronically low salivary flow rate one of the strongest salivary factors increased risk of developing caries. • caries is extreme absence of saliva.
  • 41.
    Navazesh (1992) etal found that unstimulated salivary flow rates have the strongest predictive validity of estimating caries risk. The normal unstimulated values vary from 0.3-0.4 ml/min and values less than 0.1ml/ min are considered as abnormal. Navazesh, M., Christensen, C. & Brightman, V. 1992a, "Clinical criteria for the diagnosis of salivary gland hypofunction", Journal of dental research, vol. 71, no. 7, pp. 1363-1369.
  • 42.
    • Grindefjord etal (1995) studied the relative risk (odds ratio) that 1year-old infants would develop caries by the age of 3.5 years: Those with poor oral hygiene, bad dietary habits, salivary MS, little or no exposure to fluoride, and parents with a low educational level or an immigrant background were at 32 times greater risk than were children without the corresponding etiologic and external risk factors. Grindefjord M, Dahllöf M, Modéer T. Caries development in children from 2.5 to 3.5 years of age: a longitudinal study. Caries Res. 1995;29:449–454.
  • 43.
    Leone CW etal (2001), performed a literature review on the physical and chemical aspects of saliva as indicators of risk for dental caries. ‘the review showed that normal salivary output as quantified by flow rate is an intrinsic host factor providing protection against caries and the evidence shows that pathologically diminished flow rate is a significant risk factor for caries development.’ Leone CW et al. Physical and Chemical Aspects of Saliva as Indicators of Risk for Dental Caries in Humans J Dent Edu 2001;10:1054-1062.
  • 44.
    DEMINERALIZATION AND REMINERALIZATION •Mainfactors governing stability of enamel are the pH and concentration of Ca, PO3 4-, and F in solution which are all derived from saliva. •The role of saliva in this process is highly dependent on accessibility, which is closely related to thickness of plaque.
  • 46.
    •The ability ofsaliva to remineralize demineralized enamel crystals stems from its ability to supply bioavailable calcium and phosphate ions to the tooth. At physiological pH, unstimulated and stimulated parotid, submandibular, and whole saliva are supersaturated with respect to most solid calcium phases (Larsen and Pearce, 2003) Larsen, M.J., and Pearce, E.I.F. (2003). Saturation of human saliva with respect to calcium salts, Arch. Oral Biol., 48: 317-322.
  • 47.
    •Precipitation of calciumphosphate phases in saliva normally does not occur, due to the presence of salivary proteins, particularly statherin (Schlesinger and Hay, 1977) Schlesinger, D. H. and D. I. Hay: Complete Covalent Structure of Statherin, a Tyrosine-Rich Acidic Peptide Which Inhibits Calcium Phosphate Precipitation from Human Parotid Saliva. J. Biol. Chem. 252:1689-1695 (1977).
  • 48.
    IMMUNE SYSTEM ANDCARIES RISK •Salivary immunoglobulin are mucosal antibodies that act as the first line of defense, and they include two major antibodies, namely, secretory IgA and IgG. • Higher caries prevalance in preschool children with higher level of microbes such as mutans streptococci, C. albicans and Prevotellaspp., salivary protein including IgA, IgG immunoglobulins, PRP and histatin peptides, in saliva compared with caries free individuals. Huang R et al. Salivary proteins and microbiota as biomarkers for early childhood caries risk assessment. International Journal of Oral Science (2017), 1–8
  • 49.
    INHERITED RISK SUSCEPTIBILITY •Racial characteristics predispose particular groups to dental caries. •American Indians and Inuit (Eskimo) have showel shaped incisors, barrel shaped incisors, deep buccal pits on molars, plaque accumulation from a cariogenic diet will predispose these areas to caries.
  • 50.
    •Whites have ahigher prevalence of cusp of Carabelli and hence are predisposed to caries in maxillary molars. (Dahlberg, 1961) Dahlberg AA. The physical anthropology of the American Indian. New York •Schuler CF et al in 2001 found that inherited disorders of tooth development with altered enamel structure and altered immune response to cariogenic bacteria increase the risk of dental caries. However the evidence supporting an inherited susceptibility to dental caries is limited and does not provide a predictable basis for predicting future decay rates. Shuler CF. The Changing Face of Dental Education: The Impact of PBL. J Dent Edu 2001;10:1038-1045
  • 51.
    CARIES RISK INDICATORS •Caries risk indicators broadly divided into pathological factors and protective factors • Pathological factors are- • 1- Past caries experience • 2- Dietary habits • 3- Socioeconomic status • 4-Fluoride exposure • 5-Medical factors
  • 52.
    1)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 • Criticized because the aim should be to determine the high risk individuals before there are any signs of past caries experience. Axelsson P. Diagnosis and risk prediction of dental caries. 2004. Bratthall D et al. Community Dent Oral Epidemiol 2005; 33: 256–64
  • 53.
    Pathological factors: 2) Dietaryfactors • Frequent between meal snacking • Prolonged night-time or at will bottle/breast feeding of infant • Multiple sugar exposures through the day • Infant Ready availability of cariogenic snacks Protective factors are: • Dietary factors: • Sugar exposures are limited to meal times • Preference for non-cariogenic snacks • No deleterious bottle/breast feeding of the infant
  • 54.
    Socioeconomic factors • Highcaries risk in siblings/parents • Socioeconomically Children deprived or immigrant backgrounds • High maternal MS levels • Low dental aspirations especially on the importance of maintaining caries free primary dentition Socioeconomic factors; • Good oral hygiene in parents with adequate knowledge about dental health & prevention • Regular access to a well- established dental home
  • 55.
    • Fluoride exposure •No exposure to fluoridated drinking water • No access to professionally applied topical fluorides especially when permanent molars erupt delaying post-eruptive maturation Fluoride exposure: • Presence of continuous, low concentration of free F- ions around teeth especially at the time of a cariogenic acid attack. • Daily use of a fluoridated dentifrice • Living in an area with community water fluoridation
  • 56.
    • Medical factors •Special child (i.e. a child with a physical,mental, or medically compromising condition that may limit oral health care measures or make the child more susceptible to caries.) • Salivary dysfunction caused by medications, radiation therapy or general systemic conditions • Long term cariogenic medication Medical factors •Institution & maintenance of an intensive preventive regimen in the special child •Saliva substitutes •sugar-free medications
  • 57.
    • Salivary factors •High salivary MS & Lactobacilli counts • Poor salivary flow rate impeding clearance • Salivary factors • Salivary buffers that aid in neutralizing acids • Salivary proteins and lipids that form pellicle & protect tooth surface Salivary Calcium & Phosphate ions can enhance remineralization & delay demineralization
  • 58.
    Key-risk age group1: 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
  • 59.
    Key-risk age group2: 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.
  • 60.
    Key-risk age group3: Ages 11 to 14 years • Normally, the second molars start to erupt at the age of 11 to 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.
  • 61.
    Key-risk age groupsin 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
  • 62.
    Other risk groups •1.Persons who work in occupations where frequent food sampling is required • 2. Persons who are obese • 3. Persons who abuse recreational drugs • 4. Persons who have systemic diseases and are taking regular medication • 5. Women who are pregnant
  • 63.
    • Niessen Let 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 being at low, moderate or high risk. Niessen LC, DeSpain B. Clinical strategies for prevention of oral diseases. J Esthet Dent 1996;8(1):3-11.
  • 64.
    USES OF CARIESRISK ASSESSMENT  Evaluate the degree of patient’s risk of developing caries to determine the intensity of treatment.  Help identify main etiologic agents - to determine the type of treatment  Determine if additional diagnostic procedures are required – salivary flow rate analysis, diet analysis  Improve the reliability of the prognosis of the planned treatments  Assess the efficacy of proposed management and preventive treatment plan at recall visits.
  • 65.
    TESTS IN CRA Bacterial challenge- determination of Mutans streptococcus as an indicator of relative risk.  Diet- determination of lactobacilli as an indicator of sugar content in diet.  Remineralization potential- salivary flow rate and buffer capacity as an indicator of potential biologic repair.  Host susceptibility- caries experience as an indicator of past activity.
  • 66.
    Microbial tests formutans streptococci detection • Several methods are available to measure the levels of mutans streptococci in saliva and plaque and on individual tooth surfaces .  LABORATORY METHOD  CHAIR SIDE METHOD  SURVEY METHOD  SELECTIVE METHOD  ADHERENCE METHOD
  • 67.
    Wooden spatula contaminated withsaliva and pressed on Agar S mutans colonies on the surface of agar LABORATORY METHOD
  • 68.
     Saliva iscollected from the individual to be sampled  Mixed with proper transport medium  After incubation using a selective medium, mutans colonies on the plates are counted and the results are expressed as no. of colony forming per units per ml saliva.  A common type of selective agar plate for mutans streptococci is the mitis salivarious bacitracin agar, MSB agar.
  • 69.
    For screening surveysusing agar plates, a simplified method has been described in which wooden spatulas are contaminated by saliva and then directly pressed against selective agar plates. After incubation the no. of colonies on a predetermined area of the agar is calculated
  • 70.
  • 71.
    • Dentocult SMStrip Mutans test • Bacitracin discs are added to the broth at least 15 min before use • Individual is asked to chew a piece of paraffin for 1 minute • Plastic strip is turned around in the mouth to become contaminated.
  • 72.
    • The stripis withdrawn through closed lips , leaving a thin layer of saliva on the strip. • The strip is incubated in the selective broth • After incubation for 48 hours at 35-37◦c, the strip with attached colonies is compared with chart, and given a score from 0 to 3
  • 73.
    • SURVEY METHOD:- •Plates can be placed into plastic bags containing expired air, which are then sealed and incubated at 37◦ c. • Counts of more than 100 CFU by this method are proportional to greater than 108 CFU of S.mutans per ml of saliva by conventional methods.
  • 74.
    • SELECTIVE METHOD: •Plaque samples are collected from gingival third of buccal tooth surface • Toothpicks are inserted into approximal spaces • Place into Ringer’s solution Shake to homogeneity
  • 75.
    Contaminated sides arethen pressed into the approximal spaces Incubation at 37◦c for 72 hours Sites with or without mutans streptococci can be identified
  • 76.
    • ADHERENCE METHOD •Unstimulated saliva is inoculated in MSB Broth • Inoculated tubes are set at 60◦ angle and incubated aerobically at 37◦ c for 24 hrs • After growth has been observed, the supernatant medium is removed.
  • 77.
    +++ S.Mutans ispresent at level higher than 105 CFU per ml of whole saliva - S.Mutans is present at less than 104 CFU per ml of whole saliva value inference - No growth expressed + A few deposits ranging from 1-10 ++ Scattered deposits of smaller size +++ Numerous minute deposits with more than 20 large size deposits Results
  • 78.
    Microbial tests forLactobacilli count LABORATORY METHOD: • Saliva is obtained by chewing a piece of paraffin • Shaken with glass beads to break up aggregates of bacteria • Saliva is then mixed with a buffer solution and 1 ml of the dilutions 10-2 and 10-3 • 10 ml is poured into the Petri dish • Plates are incubated at 37◦ c for 4 days. Lactobacilli appear as whitish dots
  • 79.
    Chair side- DentocultLB method aerobic incubation for 4◦ days no. of lactobacilli is estimated by comparing the slides with a model chart Results No. of Lactobacilli/ ml Caries activity 0-1000 Little or no activity 1000-5000 Slight activity 5000-10,000 Moderate activity >10,000 Marked activity
  • 81.
    Synder Test • Salivais collected before breakfast by chewing paraffin wax • A tube of Snyder glucose agar is melted and then cooled to 50 ◦ c • Saliva specimen is shaken vigorously for 3 minutes. • 0.2ml of saliva is pipetted into the tube of agar and immediately mixed by rotating the tube.
  • 82.
    Agar is allowedto solidify in the tube and is incubated at 37 ◦ c Color change of the indicator is observed after 24, 48, and 72 hours of incubation by comparison with an uninoculated tube against a white background.
  • 84.
    Alban Test • 60grams of Synder test agar is placed in 1 liter of water • Suspension is brought to boil over a low flame • After suspension has melted the agar is distributed using about 5 ml per tube • Tubes should be autoclaved for 15 minutes; allowed to cool in refrigerator
  • 85.
    • 2 tubesare taken from the refrigerator and patient is asked to expectorate a small amount of saliva directly into the tubes. • Tubes are labeled and incubated at 98.6◦F for 4 days • Tubes are observed daily for color change
  • 86.
    Color change score Nocolor change 3/4 Beginning color change + One half color change ++ Three fourths color change +++ Total color change to yellow ++++ Results of Alban test
  • 88.
    CONCLUSION • Caries riskassessment 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
  • 89.
    • The multifactorialetiology of dental caries makes it likely that even the most sophisticated risk models will be of limited value in predicting future caries development very accurately. • Prevention is still the least costly alternative treatment hence the saying Prevention is better than cure which holds good for dental caries too.
  • 90.
    References • Young DA,Fontana M, Wolff MS. Current concepts in cariology. Dent Clin North Am 2010;54:479-493. • Norman O Harris, Franklin Garcia Godoy. Primary preventive Dentistry. New Jersey: Pearson Prentice Hall; 2004. p. 285-316. • Axelsson P. Diagnosis and risk prediction of dental caries. Slovakia Quintessence International 2004; p. 29. • Bratthall D et al. Cariogram a multifunctional risk assessment model for a multifactorial disease. Community Dent Oral Epidemiol 2005; 33: 256–64.
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    • Fontana M,Zero D. Assessing patient’s caries risk. J Am Dent Assoc 2006;137:1231-1239. • Bowden GH. Dose assessment of microbial composition of plaque/saliva allow for diagnosis of disease activity of individuals? Community Dent Oral Epidemiol 1997;25: 76–81. • Beighton D. The complex oral microflora of high risk individuals and groups and its role in the caries process. Community Dent Oral Epidemiol 2005;33:248-255. • Pearce EIF, YM Dong, Yue L, Gao XJ, Purdie GL, Wang JD. Plaque minerals in the prediction of caries activity. Community Dent Oral Epidemiol 2002;30:61-9.

Editor's Notes