Caries Risk Assessment and Management

Dental caries, or tooth decay, is one of the most prevalent diseases in humans, affecting 97% of the population worldwide during their lifetimes.¹ The term “dental caries” can be used to describe both the disease process and the lesion (noncavitated or cavitated) that is formed as a result of the disease process.² One definition of caries is “a biofilm-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues.”³

The process of caries is multifactorial and, over time, can culminate in localized destruction of hard dental tissues by the weak acids produced by bacterial carbohydrate fermentation.² Microbiological shifts within the oral biofilm upset the balance of the tooth enamel remineralization/demineralization process; this balance is also affected by salivary flow and composition, fluoride exposure, consumption of dietary sugars, and preventive behaviors (e.g., brushing teeth).² Whether dental caries progresses, is halted, or reverses depends on a balance between protective and pathogenic factors.⁴

Caries is a continuum of disease states of increasing severity and tooth destruction, ranging from subclinical changes at the molecular level to lesions involving the dentin, either with an intact surface or obvious cavitation.² The formerly practiced paradigm of “drill and fill,” drilling out pits and fissures or surgically removing decayed and diseased tissue and placing permanent restorations, does not address the full continuum of the caries disease process.^{2, 5} Arresting or preventing the caries process from resulting in cavitated lesions requires careful and systematic methods for documenting and monitoring disease at early stages and intervening prior to the development of advanced lesions.

Caries Detection

Obvious caries lesions may be seen on simple visual clinical examination.² Tactile methods, e.g., the use of an explorer or ball-tipped dental probe, provide adjunctive information on evidence of enamel roughness and softening of dentin, although there are concerns about the potential, when the probe is used under force, for iatrogenic damage to the enamel surface and promotion of caries progression.^{2, 6} Radiographs, e.g., bitewings, can detect lesions on contacting approximal surfaces;² however, this method has varying sensitivity and specificity, depending on the stage of the lesion.⁷

Newer Detection Technologies

CDT 2017 contains a code⁸ that enables dentists to document techniques for detection and diagnosis of decay without the use of ionizing radiation.  This code, titled “nonionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum,” anticipates that the dentist delivering the procedure will determine the equipment and protocol best suited for the patient.

Examples of detection technologies for which this code might be applicable are laser fluorescence, transillumination or a combination of noncontacting modulated laser luminescence and photothermal radiometry. Devices may have specific applications for which their technology may be especially well suited or they may have more broad utility.

The 2015 ADA CSA Report on the ADA Caries Classification System (CCS, discussed below) notes that evidence-based adjunctive aids to detect caries lesions, such as fluorescence-based techniques or other light-based caries diagnostic tools, are “emerging and, as they are developed, clinically tested and validated, they may contribute to a more precise placement of caries lesions within the ADA CCS categories.”⁹

Classification and Risk Assessment Systems

Risk assessment is a valuable tool for the prevention and management of dental caries. Dentistry has entered an era of personalized care in which targeting care to individuals or groups based on their risk has been advocated. There are many risk tools and models in the literature. Some examples are provided in the following section.

The International Caries Detection and Assessment System is an evidence-based, preventively oriented strategy that classifies the visual appearance of a lesion (i.e., detection, whether or not disease is present), characterization/monitoring of the lesion once detected (i.e., assessment), and culminates in diagnosis.¹⁰  The system is scored on clean, dry teeth and cautions against using sharp explorers or probes in order to prevent iatrogenic damage to the tooth.¹⁰

The classification criteria, and associated estimates of caries activity, are based upon the histological extension of lesions spreading into tooth tissue.¹¹ The scores are on a 7-point rating scale, as follows:

0	Clinically sound
1 to 2	Clinically detected “intact” enamel lesions (initial stage decay)
3 to 4	Clinically detectable early, shallow, or microcavitations (moderate decay)
5 to 6	Clinically detectable late or deep cavitations (extensive decay)

• Initial patient assessments (collecting personal and risk-based information through histories and systematic data collection);
• Lesion detection, activity, and appropriate risk assessment (detection and staging of lesions, assessment of caries activity, and caries risk assessment);
• Synthesis and decision making (integrating patient-level and lesion-level information); and
• Clinical treatments (surgical and nonsurgical) with prevention (ensuring that the treatment planning options available are prevention oriented and include nonsurgical options whenever appropriate).

ADA CCS⁹ incorporates the ICDAS and other classification systems into a broader classification system that also incorporates radiographic presentation of the approximal surface and the clinical presentation. The ADA CCS is conducted on clean teeth, using compressed air, adequate lighting, and a rounded explorer or ball-end probe. Radiographs should also be available. The ADA CCS is designed to include both noncavitated and cavitated lesions and to “describe them by clinical presentation without reference to a specific treatment approach.” In addition, the ADA CCS—contrasted with some caries classification systems—links “clinical lesion presentation to radiographic findings and provides an approach to identify, when possible, caries lesion activity over time.”

ADA Caries Risk Assessment forms^{12, 13} categorize a patient’s overall risk of developing caries, based on history and clinical examination.  The forms are designated for patients ages 0 to 6 years¹⁴ and older than 6 years.¹³ Characteristics that place a patient at high caries risk include:

• Sugary Foods or Drinks: Bottle or sippy cup with anything other than water at bedtime (ages 0 to 6 years) or frequent or prolonged between meal exposures/day (ages >6 years)
• Eligible for Government Programs: WIC, Head Start, Medicaid or SCHIP (ages 0 to 6)
• Caries Experience of Mother, Caregiver and/or other Siblings: Carious lesions in the last 6 months (ages 0 to 14 years)
• Special Health Care Needs: developmental, physical, medical or mental disabilities that prevent or limit performance of adequate oral health care by themselves or caregivers (ages 0 to 14 years)
• Chemo/Radiation Therapy (ages >6 years)
• Visual or Radiographically Evident Restorations/Cavitated Carious Lesions: Carious lesions or restorations in last 24 months (ages 0 to 6 years)
• Noncavitated (incipient) Carious Lesions: New lesions in the last 24 months (ages 0 to 6 years)
• Cavitated or Noncavitated (incipient) Carious Lesions or Restorations (visually or radiographically evident): 3 or more carious lesions or restorations in last 36 months (ages >6 years)
• Teeth Missing Due to Caries: Any (ages 0 to 6 years) or in the past 36 months (ages >6 years)
• Severe Dry Mouth (Xerostomia; ages >6 years) or Visually Inadequate Salivary Flow (ages 0 to 6 years)

Behavioral Modification: Oral Hygiene and Diet

Patients, especially those at high risk of caries development, should be instructed to reduce the amount and frequency of carbohydrate consumption.¹⁴ Patients should limit sugary snacks between meals¹⁵ and eat a healthy diet that limits added sugars and high-acid foods that can affect mineralization of enamel.¹⁵ Encourage patients to chew sugar-free gum with xylitol, which can promote salivary flow, remineralization, and cannot be metabolized by cariogenic bacteria.¹⁶ All patients should be educated in optimal oral hygiene practices, including brushing with fluoride toothpaste twice a day and cleaning between teeth daily. Although some caries prevention recommendations⁵ include use of topical antimicrobials (e.g., chlorhexidine rinse) in patients 6 years of age and older who are at high risk of caries, a 2015 Cochrane systematic review found no trials for the use of antimicrobial chlorhexidine mouth rinses, sprays, gels, or chewing gums to prevent caries in children and adolescents.¹⁷

Topical Fluoride Application for Caries Prevention or Arrest

A 2013 systematic review¹⁸ from the ADA CSA Expert Panel on Topical Fluoride Caries Preventive Agents provided evidence-based clinical recommendations regarding professionally applied and prescription-strength, home-use topical fluoride agents for caries prevention. Evidence was sought from clinical trials of professionally applied and prescription-strength topical fluoride agents—including mouthrinses, varnishes, gels, foams and pastes—reporting on caries increment outcomes.  Clinical recommendations included the following for people at risk of developing dental caries:

The panel recommends the following for people at risk of developing dental caries:  2.26% fluoride varnish or 1.23% fluoride (acidulated phosphate fluoride) gel, or a prescription-strength, home-use 0.5% fluoride gel or paste or 0.09% fluoride mouthrinse for patients 6 years or older. Only 2.26% fluoride varnish is recommended for children younger than 6 years. The strengths of the recommendations for the recommended products varied from “in favor” to “expert opinion for.” As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.

Another form of topical fluoride application, Silver Diamine Fluoride 38% (Advantage Arrest™, Elevate Oral Care, L.L.C. or Riva Star, SDI, Inc.) has been cleared for marketing by the U.S. Food and Drug Administration for treating dentinal hypersensitivity in adults.¹⁹ A CDT code²⁰ adopted in 2016 is D1354—interim caries arresting medicament application: “Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure.” This new code allows for coding the off-label use of silver diamine fluoride for caries arrest.²¹

Pit-and-Fissure Sealants

Anatomical grooves, or pits and fissures on occlusal surfaces of permanent molars can trap food particles and promote the presence of bacterial biofilm, increasing the risk of developing caries lesions. Effectively penetrating and sealing these surfaces with a dental material, e.g., pit-and-fissure sealants, can prevent lesions and is part of a comprehensive caries management approach.²² From a secondary prevention perspective, there is evidence that sealants also can inhibit the progression of non-cavitated caries lesions.²³ The use of sealants to arrest or inhibit the progression of caries lesions is important to the clinician when determining the appropriate intervention for non-cavitated caries lesions.

Based on a systematic review, a 2016 guideline panel convened by the ADA CSA and the American Academy of Pediatric Dentistry (AAPD) came to the following evidence-based clinical recommendations for the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars in children and adolescents.^{24, 25}

• sealants are effective in preventing and arresting pit-and-fissure occlusal caries lesions of primary and permanent molars in children and adolescents compared to the non-use of sealants or use of fluoride varnishes; and
• sealants can minimize the progression of non-cavitated occlusal caries lesions (also referred to as initial lesions) that receive a sealant.

Based on available limited evidence, the panel was unable to provide specific recommendations on the relative merits of one type of sealant material over the others, so the choice of sealant type used depends on provider preference and experience. The report defined pit-and-fissure sealant materials as follows: 1) resin-based sealants, 2) glass ionomer cements or sealants, 3) polyacid-modified resin sealants, and 4) resin-modified glass ionomer sealants.²²

2018 ADA Clinical Practice Guideline on Nonrestorative Treatments for Carious Lesions

In 2018, the ADA Center for Evidence-Based Dentistry conducted a systematic review and network meta-analysis²⁶ informing a clinical practice guideline²⁷ on nonrestorative treatments for carious lesions. The expert panel formulated 11 clinical recommendations, each specific to lesion type (i.e., cavitated, noncavitated), tooth surface (i.e., coronal, root surface [in adults]) and dentition (i.e., primary or permanent), each recommendation with an associated strength or certainty of the evidence (please refer to the clinical practice guideline for specific recommendations, strength of those recommendations, and the certainty of the evidence associated with them). The panel provided recommendations for the use of the most effective treatment options, including 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide–amorphous calcium phosphate. The chairside guides for primary; and permanent dentition are available for download, and clinicians may also consult the online tool for personalized clinical recommendations based on the clinical parameters of the lesion.

PREVENTION AND CONTROL OF EARLY CHILDHOOD CARIES
(Trans.2014:507)

1. The American Dental Association recognizes Early Childhood Caries (ECC) as the presence of one or more decayed, noncavitated or cavitated lesions, missing due to caries, or filled tooth surfaces in any primary tooth in a child under the age of six. In children younger than three years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages three through five, one or more cavitated, missing (due to caries) or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of greater than or equal to four at age 3, greater than or equal to five at age 4, or greater than or equal to six at age 5 surfaces also constitutes S-ECC.
2. The Association recognizes that oral health is an important part of overall health. ECC is a health problem throughout the population that poses a significant health burden in specific at-risk communities.
3. The Association recommends health professionals and the public recognize that a child’s teeth are susceptible to decay as soon as they begin to erupt and that ECC is a multifactorial, transmissible disease that is reversible in its early stages and its progression is affected by many different risk and protective factors.
4. The Association recommends parents and guardians, as a child’s first tooth erupts, to:
   • Schedule the child’s first dental visit. Children should have a Dental Home before age one.
   • Begin brushing twice daily with no more than a smear (rice-sized amount) of fluoride toothpaste for children younger than 3 years old and a pea- sized amount of fluoride toothpaste for children 3 to 6 years old. This recommendation is taken from the ADA Council on Scientific Affairs Fluoride Toothpaste Use for Young Children, JADA, February 2014.
5. The Association recommends its members educate parents, including expectant parents, and caregivers about establishing a Dental Home before age one, provide them with oral health education based on the child's developmental needs and explain methods for reducing the risk for ECC, including specific details of how to reduce risk factors and promote protective factors.
6. The Association recommends state and local dental societies act as a resource for the medical community and public health programs (e.g., Women, Infants and Children [WIC] and Head Start). Dentistry can be instrumental in educating other health professionals and the public about risk factors for ECC and the importance of the establishment of a Dental Home before age one.
7. The Association recognizes that the unique characteristics of ECC should be considered in selecting treatment protocols that are based on a child’s individual risk.
8. The Association, recognizing that the science surrounding ECC continues to evolve, encourages research activities to study risk factors, preventive practices, disease management strategies and new technologies to address the challenges posed by this multifactorial disease.

1. Berg JH. The marketplace for new caries management products: dental caries detection and caries management by risk assessment. BMC Oral Health 2006;6 Suppl 1:S6.
2. Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369(9555):51-9.
3. Pitts NB, Zero DT, Marsh PD, et al. Dental caries. Nat Rev Dis Primers 2017;3:17030.
4. Featherstone JD. Caries prevention and reversal based on the caries balance. Pediatr Dent 2006;28(2):128-32; discussion 92-8.
5. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc 2000;131(7):887-99.
6. Pitts NB. Diagnostic tools and measurements--impact on appropriate care. Community Dent Oral Epidemiol 1997;25(1):24-35.
7. Bader JD, Shugars DA, Bonito AJ. A systematic review of the performance of methods for identifying carious lesions. J Public Health Dent 2002;62(4):201-13.
8. American Dental Association. ADA News: Committee adds 11 new codes to CDT.  March 15, 2016. Accessed May 27, 2021.
9. Young DA, Novy BB, Zeller GG, et al. The American Dental Association Caries Classification System for clinical practice: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(2):79-86.
10. Young DA, Featherstone JD, Roth JR. Curing the silent epidemic: caries management in the 21st century and beyond. J Calif Dent Assoc 2007;35(10):681-5.
11. Pitts NB, Ekstrand KR. International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) - methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 2013;41(1):e41-52.
12. American Dental Association. Caries Risk Assessment Form (Age 0-6). Accessed May 27, 2021.
13. American Dental Association. Caries Risk Assessment Form (Age >6). Accessed May 27, 2021.
14. Maheswari SU, Raja J, Kumar A, Seelan RG. Caries management by risk assessment: A review on current strategies for caries prevention and management. J Pharm Bioallied Sci 2015;7(Suppl 2):S320-4.
15. Sanders TA. Diet and general health: dietary counseling. Caries Res 2004;38 Suppl 1:3-8.
16. Fontana M, Gonzalez-Cabezas C. Are we ready for definitive clinical guidelines on xylitol/polyol use? Adv Dent Res 2012;24(2):123-8.
17. Walsh T, Oliveira-Neto JM, Moore D. Chlorhexidine treatment for the prevention of dental caries in children and adolescents. Cochrane Database Syst Rev 2015(4):Cd008457.
18. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc 2013;144(11):1279-91.
19. Featherstone JDB, Horst JA. Fresh approach to caries arrest in adults.  October 5, 2015. Accessed May 27, 2021.
20. American Dental Association. CDT 2016: Dental Procedure Codes. Chicago, IL: American Dental Association; 2015.
21. Horst JA, Ellenikiotis H, Milgrom PL. UCSF protocol for caries arrest using silver diamine fluoride: rationale, indications and consent. J Calif Dent Assoc 2016;44(1):16-28.
22. Anusavice KJ, Shen C, Rawls RR. Phillip's Science of Dental Materials. Missouri, US: Elsevier/Saunders; 2013.
23. Splieth C, Forster M, Meyer G. Additional caries protection by sealing permanent first molars compared to fluoride varnish applications in children with low caries prevalence: 2-year results. Eur J Paediatr Dent 2001;3:133-37.
24. Wright JT, Tampi MP, Graham L, et al. Sealants for preventing and arresting pit-and-fissure occlusal caries in primary and permanent molars: A systematic review of randomized controlled trials-a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc 2016;147(8):631-45 e18.
25. Wright JT, Crall JJ, Fontana M, et al. Evidence-based clinical practice guideline for the use of pit-and-fissure sealants: A report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc 2016;147(8):672-82 e12.
26. Urquhart O, Tampi MP, Pilcher L, et al. Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis. J Dent Res 2018:22034518800014.
27. Slayton RL, Urquhart O, Araujo MWB, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. J Am Dent Assoc 2018;149(10):837-49.e19.

ADA Publications and Resources

• ADA Oral Health Topics

Dental Sealants
Fluoride: Topical and Systemic Supplements
Home Oral Care
Silver Diamine Fluoride

• Search JADA for articles related to dental caries
• Search the ADA Store for products related to dental caries
• ADA Library Services
• ADA Professional Product Review: Caries Detection Devices
• ADA Health Policy Institute analysis: Untreated caries rates: children, adults, seniors

ADA Caries Risk Assessment Forms

• Download Instructions (PDF)
• Caries Risk Form (Patients Ages 0-6 Years) (PDF)
• Caries Risk Form (Patients Over 6 Years) (PDF)

ADA Caries Risk Assessment Forms (For Dental Education Use Only)

• Caries Risk Form (Patients Ages 0-6 Years) (PDF)
• Caries Risk Form (Patients Over 6 Years) (PDF)

Early Childhood Caries Symposium

• Panel Report: Symposium on Early Childhood Caries in American Indian and Alaska Native Children (PDF)

ADA Public Service Announcements

• 7 Toothbrushing Tunes Kids (and Parents) Will Love

Evidence-Based Clinical Recommendations

• Clinical Practice Guideline and Systematic Review/Network Meta-Analysis: Nonrestorative Treatments for Carious Lesions (2018)
• Clinical Practice Guideline and Systematic Review: Sealants for Preventing and Arresting Pit-and-Fissure Occlusal Caries in Primary and Permanent Molars (2016)
• Topical Fluoride for Caries Prevention (2013)
• Non-Fluoride Caries Preventive Agents (2011)

Patient Education Resources

• ADA MouthHealthy Topics:

• Baby Bottle Tooth Decay
• Cavities
• Decay
• Sealants

• JADA “For the Patient” pages:

How do sealants protect your teeth? (February 2021)
Fluoride helps fight cavities (February 2021)
Choices for fixing cavities (May 2020)
Helping your child fight tooth decay (February 2020)

• ADA Store: Tooth Decay Brochure (Item #W30320)
• ADA Public Service Announcements: Dudley and Friends Educational Videos

External Resources

• Mayo Clinic: Cavities/Tooth Decay
• MEDLINE Plus (U.S. National Library of Medicine): Tooth Decay
• National Institute for Dental and Craniofacial Research: Tooth Decay (Caries)
• Smiles for Life Oral Health App