Caries Risk Assessment

• Oral Health Assessment and Review (OHAR) involves a comprehensive patient assessment in primary dental care.
• The OHAR assessment considers social factors, dental health, medical histories, and oral health status.
• OHAR leads to diagnosis, risk assessment, personalized care planning, and ongoing review.
• Oral Health Assessments for adults and children should be done either every 24 months or every 12 months.
• As patient circumstances are constantly changing, reassessment at the start of each treatment course is important.

Components of Diagnosis and Risk Assessment

• Oral cancer risk
• Tooth surface loss
• Periodontal disease risk
• Caries risk

Caries Risk Assessment

• It's a systematic process evaluating potential risks or protective factors.
• Identifies a patients future disease risk before it occurs.
• It needs to pre-empt disease rather than waiting for it to occur.
• It takes into account risks and positive protective factors.
• Anything with potential does not necessarily need to be happening now.

Caries Development Influencing Factors

• Social History
• Oral Hygiene
• General Health Conditions
• Clinical Conditions
• Diet

Research Factors

• Diet relates to future caries incidence as noted by Gustafsson BE et al in 1954.
• Water fluoridation can cut DMFT by 35% in deciduous dentition and 26% in permanent dentition (Cochrane, 2015).
• Topical fluoride, increased brushing frequency, and supervision reduce caries incidence (Cochrane, 2003).
• Caries prevalence has been recorded as higher in patients with special needs, indicating a higher risk per Shyma M 2001 and Morgan J 2012
• Previous caries found in deciduous teeth is a strong indicator of future caries in both deciduous and permanent teeth (Tagliaferro EP et al 2006, Steiner M et al 1992, Li Y, Wang W 2002).
• Parental education and socioeconomic status relate to caries incidence in children (Radford JR et al 2000, Tagliaferro E et al 2006).

Structured Caries Risk Assessment Tools (CRA)

• American Dental Association CRA tool <6
• American Dental Association CRA tool >6
• Caries management by risk assessment (CAMBRA) CRA tool Part 1 and Part 2
• American Academy of Paediatric Dentistry (AAPD) CRA tool
• Dundee CRA tool
• Cariogram

Unstructured Approches to Caries Risk Assessment

• Diet
• Dental History
• Examination
• Medical Histroy
• Social History
• Oral Hygiene

Factors to assess without a tool:

• Assess everything routinely; just need to apply them to caries risk assessments
• Medical history: Diabetes, sugar-containing meds, xerostomia/radiotherapy, limited opening.
• Diet history: timing, frequency, and sugars.
• Social history: familial caries for children, drug/alcohol use, and age.
• Dental history: previous caries experience, regular attendance, and appliance use.
• Oral hygiene: fluoride use, brushing frequency, quality, and access to fluoridated water.
• Examination: poor plaque control, local plaque retentive factors, current caries, restorations, and exposed roots.
• Risk factors include poor oral hygiene, smoking 10+ a day, medical history note, and caries/restorations present
• Protective factors involve fluoride toothpaste use, good oral hygiene non-smoker, no medical history note, or caries/restorations.

Protective Factors

• Good oral hygiene
• Use of fluoride
• Regular Attendance
• No medical history
• No current or history of decay

Managing Risk

• Allocate patients to a risk category
• High Risk
• Moderate Risk
• Low Risk
• Further, identify risk-based review intervals in adults and children.
• This will influence preventative advice and treatment needs.
• It will also effect the ability to access more complex treatment, radiographic assessment and recall assessment.

Local Guidance

• DBOH (2021) refers to patient caries risk level when considering fluoride concentration in toothpaste.
• The DBOH also refers to fluoride varnish application and fluoride mouth rinse based on caries risk level.
• NICE (2004) recall guidelines refer to patient caries risk.
• NICE's guide also addresses children (3-12 months) and adults (3-24 months).
• Selection criteria for dental radiography refer to patient caries risk.
• High-risk children require bitewings every 6 months, while moderate or low-risk children need them every 12 months.
• Adults at high risk need bitewings every 6 months, moderate risk every 12 months, and low risk every 24 months.

Treatment Goals

• Risk assessment aids with treatment phasing.
• Stabilize disease initially.
• Risk assessment should be reviewed.
• Undertake more complex treatment if you moved from high to low risk.

Record Keeping:

• All work should be justifiable with supporting records.
• Documenting a process of risk assessment will help justify treatment plans and recall periods.

Key points:

• Risk assessment requires a systematic approach.
• Patients change in relation to their risk over time so needs review.
• Cannot judge risk from just one element - need all the information.
• Risk assessment is key for informed care and planning.
• Multiple tools are available to assist with this.