Caries Risk Assessment and Personalized Interventions

Fiona Collins BDS, MBA, MA, FPFA

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Caries Risk Assessment and Personalized Interventions

Figure 1. Prevalence of dental caries in the United States3Fleming E, Afful J. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016. NCHS Data Brief 2018;307. Available at: https://www.cdc.gov/nchs/data/databriefs/db307.pdf. ,4Dye B, Thornton-Evans G, Li X, Iafolla T. Dental caries and tooth loss in adults in the United States, 2011-2012. NCHS Data Brief. 2015;197.

Dental caries is a multifactorial infectious disease, endemic worldwide, and the most common chronic childhood disease1U.S. Department of Health and Human Services. Oral health in America: A report of the Surgeon General, Executive summary. Rockville, MD: National Institutes of Health, National Institute of Dental and Craniofacial Research. 2000.. In one systematic review, the prevalence of early childhood caries across 37 countries ranged from 23% to 90% and was >50% for more than two-thirds of these.2Chen KJ, Gao SS, Duangthip D, Lo ECM, Chu CH. Prevalence of early childhood caries among 5-year-old children: A systematic review. J Investig Clin Dent 2019;10(1):e12376. doi:10.1111/jicd.12376 In the United States, a caries prevalence of 45.8% was found for individuals 2 to 19 years-of-age for 2015-2016, with a greater prevalence in 12 to 19 year-olds.3Fleming E, Afful J. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016. NCHS Data Brief 2018;307. Available at: https://www.cdc.gov/nchs/data/databriefs/db307.pdf. For 2011-2012, the prevalence of dental caries among adults 20 to 64 years-of-age was 91% and 96% among older individuals.4Dye B, Thornton-Evans G, Li X, Iafolla T. Dental caries and tooth loss in adults in the United States, 2011-2012. NCHS Data Brief. 2015;197. (Figure 1)

Cariogenic bacteria and fermentable carbohydrates are prerequisites for dental caries.5Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al. Dental caries. Nat Rev Dis Primers 2017;25(3):17030. Bacterial metabolism of fermentable carbohydrates results in acid production, lowering of the intraoral pH and loss of calcium and phosphate from tooth structure. Dental caries is a dynamic process, with repeated cycles of demineralization and remineralization. Whether or not dental caries occurs depends on the balance between destructive factors (risk factors) and protective factors. Risk factors are defined as “any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury.”6World Health Organization. Risk factors. Available at: https://www.who.int/topics/risk_factors/en/ When protective factors outweigh risk factors, disease is inhibited.

Caries risk assessment (CRA) is performed to determine an individual patient’s risk level, which informs recommended interventions. The patient’s caries risk factors, protective factors, and medical and dental history are considered, and a full-mouth examination is performed, including radiographs as appropriate. The American Academy of Pediatric Dentistry (AAPD) recommends that patients’ first CRA be performed by 6 months of age. In addition, periodic re-assessment is indicated as risk level can change over time. Past dental caries experience remains the strongest predictor of dental caries.7Tagliaferro E, Pardi E, Ambrosano V, Meneghim G, Pereira, MAC. An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007). Braz J Oral Sci 2008;7(27):7.

CRA is performed to determine an individual patient’s risk level, which informs interventions.

Risk Factors

Caries risk factors include poor oral hygiene (visible plaque) and frequent consumption of fermentable carbohydrates, in particular free sugars.5Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al. Dental caries. Nat Rev Dis Primers 2017;25(3):17030. ,8Bibby BG, Krobicka A. An in vitro method for making repeated pH measurements on human dental plaque. J Dent Res 1984;63:906-9. Other risk factors include reduced/absent salivary flow, unfavorable tooth morphology (e.g., fissure anatomy), exposed root surfaces, a familial history positive for dental caries, low socioeconomic status, fixed orthodontic and other appliances, substance abuse, enamel hypoplasia, defective restorations, iatrogenic damage to tooth structure, and genetics.3Fleming E, Afful J. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016. NCHS Data Brief 2018;307. Available at: https://www.cdc.gov/nchs/data/databriefs/db307.pdf. ,9American Dental Association. Caries Risk Assessment Form (Age 0-6). Available at: https://www.ada.org/~/media/ADA/Member%20Center/FIles/topics_caries_under6.pdf. ,10American Dental Association. Caries Risk Assessment Form (Age >6). Available at: http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6.ashx. ,11AAPD. Caries-risk Assessment and Management for Infants, Children, and Adolescents. Latest revision, 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf ,12AAPD. Best Practices. Perinatal and Infant Oral Health Care. 2016.. Available at: https://www.aapd.org/globalassets/media/policies_guidelines/bp_perinataloralhealthcare.pdf. ,13Dasanayake AP, Warnakulasuriya S, Harris CK, Cooper DJ, Peters TJ, Gelbier S. Tooth decay in alcohol abusers compared to alcohol and drug abusers. Int J Dent 2010;2010:786503.,14Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B. Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res 2005;39(1):41-7.,15Opal S, Garg S, Jain J, Walia I. Genetic factors affecting dental caries risk. Aust Dent J 2015;60:2-11. (Figure 2) A shift in the biofilm with more acidogenic and aciduric bacteria, fostered by a low-pH environment, influences disease. It is also hypothesized that the oral microbial community favoring dental caries may be associated with absence of host genome adaptation.16Gomez A, Espinoza JL, Harkins DM, Leong P, Saffery R, Bockmann M et al. Host genetic control of the oral microbiome in health and disease. Cell Host Microbe 2017;22:269-78 e263.

CRA Tools

Figure 2. Caries risk factors

CRA can be performed using published tools, digital programs, a form created in the office, or be subjective. Formal CRA tools offer standardization, and digital tools offer the ability to easily store and compare risk over time and outcomes. CRA forms are available from the American Dental Association (ADA) for patients age 6 and under, and over age 6.9American Dental Association. Caries Risk Assessment Form (Age 0-6). Available at: https://www.ada.org/~/media/ADA/Member%20Center/FIles/topics_caries_under6.pdf. ,10American Dental Association. Caries Risk Assessment Form (Age >6). Available at: http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6.ashx. These provide a list of contributing conditions (protective and destructive), general health conditions that increase caries risk, and clinical conditions. Forms available from the AAPD are similar except that the age groups are 0-5 and age 6 and above, and the categories are named slightly differently.11AAPD. Caries-risk Assessment and Management for Infants, Children, and Adolescents. Latest revision, 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf Elements in each category are scored as low, moderate or high risk and the patient’s caries risk level is obtained based on the overall results. CAries Management By Risk Assessment (CAMBRA) includes now-updated assessment forms for under age 6, and age 6 and over, with disease indicator, risk factor and protective factor categories.17Featherstone JDB, Alston P, Chaffee BW, Rechmann P. Caries Management by Risk Assessment (CAMBRA)*: An Update for Use in Clinical Practice for Patients Aged Through Adult. In: CAMBRA® Caries Management by Risk Assessment A Comprehensive Caries Management Guide for Dental Professionals. (2019) Available at: https://www.cdafoundation.org/Portals/0/pdfs/cambra_handbook.pdf. Recommendations based on age and risk level are included.

Digital/Electronic Tools
Digital/electronic tools include Cariogram, the Oral Health Information Suite (OHIS; PreViser), and DEPPA. The University of Toronto also developed an online CRA, as has the National University of Singapore18Cagetti MG, Bontà G, Cocco F, Lingstrom P, Strohmenger L, Campus G. Are standardized caries risk assessment models effective in assessing actual caries status and future caries increment? A systematic review. BMC Oral Health 2018;18(1):123. doi: 10.1186/s12903-018-0585-4. . (Table 1)

Table 1. CRA Tools
ADA forms – age 6 and under; over age 6
AAPD forms – age 0 to 5; age 6 and above
CAMBRA – under age 6; age 6 and over
Cariogram digital CRA
OHIS digital CRA
DEPPA digital CRA
University of Toronto CRA
National University of Singapore

Figure 3. Cariogram diagram and data input scores

Cariogram was developed in Sweden and can be used online or downloaded at no cost.19Malmö University. Cariogram – Download. Available at: https://www.mah.se/fakulteter-och-omraden/Odontologiska-fakulteten/Avdelning-och-kansli/Cariologi/Cariogram/. Nine data points are entered, plus a clinical judgment score, after which a pie chart with the contribution of various factors is generated along with caries risk. In the example shown, the patient has a 55% likelihood of new dental caries (‘45% chance of avoiding new cavities’) which represents a moderate caries risk level (0-40%, 41-80% and 81-100% chance of avoiding new cavities, respectively, represent high, moderate and low caries risk)20Petsi G , Gizani S, Twetman S, Kavvadia K. Cariogram caries risk profiles in adolescent orthodontic patients with and without some salivary variables. Angle Orthod 2014;84(5):891-5. doi:10.2319/080113-573.1.. (Figure 3)

OHIS provides risk assessment scores for PD, dental caries and oral cancer and utilizes green-amber-red visuals to denote risk level, and individualized patient reports, suggested interventions and outcomes assessment are generated. OHIS was incorporated into the North East Delta Dental’s pilot oral health and wellness dental benefit plan.21Martin J, Mills S, Foley ME. Innovative models of dental care delivery and coverage. Patient-centric dental benefits based on digital oral health risk assessment. Dent Clin N Am 2018;62:319-25. Patients can sign up, complete a personal risk assessment online, obtain an oral health and wellness score and receive pre-determined additional prevention care based on risk level. An online tool in the United Kingdom has been developed (DEPPA) that includes OHIS, and clinician and patient feedback on satisfaction, perception on function, comfort and aesthetics.22Chapple L, Yonel Z. Oral Health Risk Assessment. Dent Update 2018;45:841-7. Cariogram, OHIS and DEPPA provide individualized patient information and suggested interventions.

Use and validity
A risk assessment tool should at a minimum be compliant with privacy regulations and consistent with current scientific knowledge, and ideally validated clinically.23American Dental Association. Electronic oral health risk assessment tools. SCDI White Paper No. 1074, 2013. Available at: http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/ADAWhitePaperNo1074.pdf?la=en. It should be easy to use and understand, efficient, precise, accurate and aid decision-making. Based on a recent publication, there is insufficient evidence to favor a particular CRA tool, none are completely accurate, and there are no validated tools for root caries risk.24Twetman S, Banerjee A. (2020) Caries Risk Assessment. In: Chapple I, Papapanou P. (eds) Risk Assessment in Oral Health. Springer, Cham. However, it was also reported that the predictive accuracy of CRA can be >80% for pre-school and school-age children and that the use of CRA tools can reduce incremental caries lesions.

A risk assessment tool should at a minimum be compliant with privacy regulations and consistent with current scientific knowledge, and ideally validated clinically.

Recent individual studies are promising. In a randomized, controlled, double-blind two-year clinical trial in a large practice-based group, caries risk level and indicators were reduced with CAMBRA interventions compared to standard treatment.25Rechmann P, Chaffee BW, Rechmann BMT, Featherstone JDB. Caries Management by Risk Assessment: Results From a Practice-Based Research Network Study. J Calif Dent Assoc 2019;47(1):15-24. In addition, clinicians and assistants have reported belief in its scientific basis, use and its utility for motivating patients.26Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Based Dent Pract 2017;17(1):1-12. In a study in adolescents wearing fixed orthodontic appliances, the use of Cariogram with and without assessing salivary buffering capacity resulted in no statistically significant difference in computed risk levels.20Petsi G , Gizani S, Twetman S, Kavvadia K. Cariogram caries risk profiles in adolescent orthodontic patients with and without some salivary variables. Angle Orthod 2014;84(5):891-5. doi:10.2319/080113-573.1. Omitting this test would save resources. Similarly, in a 2-year study in adults 18 to 29 years-of-age, no statistically significant difference in risk level was found when salivary buffering capacity was omitted.27Dou L, Luo J, Fu X, Tang Y, Gao J, Yang D. The validity of caries risk assessment in young adults with past caries experience using a screening Cariogram model without saliva tests. Int Dent J 2018;68(4):221-6. doi: 10.1111/idj.12378 Actual caries experience matched the assessed level of caries risk, with higher risk individuals developing more new lesions than low-risk individuals. Barriers to risk assessment tools include limited validation in dental office settings, time and reimbursement constraints, limited training, and the need to change behavior and to understand how these tools will help reduce an individual’s risk level.28Thyvalikakath T, Song M, Schleyer T. Perceptions and attitudes toward performing risk assessment for periodontal disease: a focus group exploration. BMC Oral Health 2018;18(1):90.,29Riley JL 3rd, Gordan VV, Ajmo CT, Bockman H, Jackson MB, Gilbert GH. Dentists’ use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network. Community Dent Oral Epidemiol 2011;39(6):564-73.

There is insufficient evidence to favor a particular CRA tool. However, the predictive accuracy of CRA can be >80% for pre-school and school-age children and CRA tools can reduce incremental caries lesions.

Risk-based Interventions

Knowing a patient’s risk level helps to determine, plan and implement appropriate recommended interventions. For patients at elevated risk for caries, increasing protective factors and reducing modifiable risk factors helps shift the balance in favor of caries prevention. Examples of protective factors include fluoride exposure, adequate salivary flow, sealants and a healthy lifestyle.

Topical fluorides for caries prevention
Topical fluorides are a key component of caries prevention. For patients under age 6 at increased risk for dental caries, application of 5% sodium fluoride (NaF) varnish at least every 3 to 6 months is recommended.30Weyant RJ, Tracy SL, Anselmo T, Frantsve-Hawley J, Meyer DM, Beltrán-Aguilar ED et al. Topical fluoride for caries prevention. J Am Dent Assoc 2013;144(11):1279-91. doi.org/10.14219/jada.archive.2013.0057 While an off-label use, evidence supports its safety and efficacy as an anti-caries agent. For patients age 6 and over, 5% NaF varnish or a 4-minute application of 1.23% APF gel is recommended. In addition, twice-daily use of 5,000 ppm fluoride paste/gel is recommended at age 6 and over, or weekly rinsing with 0.2% NaF. (Table 2) These home-use topical fluorides are not recommended for younger children unless clinical judgment suggests the benefit will outweigh the harm; in this age group, there is a risk of fluorosis associated with inadvertent ingestion of fluoride. Adjunctive interventions such as xylitol or erythritol gum, antimicrobial rinses, and calcium and phosphate may also be considered, in the absence of contraindications.

For patients under age 6 at increased risk for dental caries, application of 5% sodium fluoride varnish at least every 3 to 6 months is recommended.

For patients at low risk for caries, twice-daily use of fluoride toothpaste may be sufficient.30Weyant RJ, Tracy SL, Anselmo T, Frantsve-Hawley J, Meyer DM, Beltrán-Aguilar ED et al. Topical fluoride for caries prevention. J Am Dent Assoc 2013;144(11):1279-91. doi.org/10.14219/jada.archive.2013.0057 To optimize caries prevention and minimize the risk of fluorosis, no more than a smear of toothpaste – the size of a grain of rice – should be used for children younger than 3 years of age, starting when teeth begin to erupt.31American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young children. J Am Dent Assoc 2013;145(2):190-1. doi.org/10.14219/jada.2013.47 From age 3 to 6, no more than a pea-sized amount should be used. Children should also be supervised once old enough to brush their teeth.

Table 2. Topical fluorides for caries prevention
Under age 6 at increased risk for caries In-office:
5% NaF varnish at least every 3 to 6 months
Home use:
Twice-daily use of regular fluoride toothpaste (amount based on age - see above)
Age 6 + at increased risk for caries In-office:
5% NaF varnish or 4-minute 1.23% APF gel at least every 3 to 6 months
Home use: Twice-daily use of 5,000 ppm fluoride paste/gel or weekly rinsing with 0.2% NaF
Patients at low risk for caries Twice-daily use of fluoride toothpaste may be sufficient

Sealants
Current recommendations support the use of pit-and-fissure sealants in the primary and permanent dentition, on sound occlusal surfaces and noncavitated (incipient) occlusal carious lesions.32Wright JT, Crall JJ, Fontana M, Gillette EJ, Nový BB, Dhar V 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. doi.org/10.1016/j.adaj.2016.06.001 This includes use of resin-based sealants, compomers and glass ionomers.

Figure 4. Priority and alternative recommendations for non-cavitated coronal lesions, primary and permanent teeth

Interventions for non-cavitated and cavitated caries lesions
Recommendations for the arrestment or reversal of non-cavitated and cavitated lesions have been developed and ranked based on efficacy, resource use, feasibility and patient values and preferences.33Slayton RL, Urquhart O, Araujo MWB, Fontana M, Guzmán-Armstrong S, Nascimento MM 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):P837-49.E10. doi.org/10.1016/j.adaj.2018.07.002 The primary recommendation for non-cavitated lesions in primary and permanent teeth is use of sealants plus 5% NaF varnish (application every 3-6 months) on occlusal surfaces, 5% NaF varnish on approximal surfaces, and 5% NaF varnish or 1.23% APF gel on lingual and facial surfaces. Priority recommendations and lower-priority alternatives for non-cavitated coronal lesions can be found in Figure 4.

For arrestment or reversal of root caries, 5,000 ppm fluoride toothpaste/gel is the priority recommendation for non-cavitated and cavitated lesions. Lower-priority alternatives include 5% NaF varnish (every 3-6 months), 38% SDF + potassium iodide annually, 38% SDF annually, and 1% chlorhexidine+1% thymol varnish (every 3-6 months). For coronal cavitated lesions in primary and permanent teeth, 6-monthly applications of 38% silver diamine fluoride (SDF) is prioritized over 5% sodium fluoride applied weekly for 3 weeks. When using SDF, dark staining occurs. Patients must be informed of this drawback and provide consent before treatment is provided. Use of a two-step product with application of 38% SDF followed by potassium iodide minimizes discoloration, leading to it being more acceptable to some patients.

Patient Education

Patient education is essential. While some modifiable risk factors, e.g., tooth morphology, can be addressed in-office, others are not and require patient compliance such as improving oral hygiene or dietary improvement. Patients should be instructed on twice-daily oral hygiene and advised on reducing fermentable carbohydrates. Additionally, poor oral health literacy is linked to poor oral health, and understanding risk is a difficult concept that requires more than basic health literacy skills.34Baskaradoss JK. Relationship between oral health literacy and oral health status. BMC Oral Health 2018;18:172. Available at: https://doi.org/10.1186/s12903-018-0640-1. While performing a CRA, jointly walking through the process and deriving a score may help patients understand their risk factors and risk level. Information presented visually and using digital technology can help patients develop a better understanding.35Collins FM. Oral health literacy. Available at: https://www.colgateoralhealthnetwork.com/article/oral-health-literacy/

Patient education is essential for individuals to understand disease risk and potential interventions.

Figure 5. Traffic-light presentation of risk level in patient report

For digital tools where the patient fills in the initial information, a visual image can already convey to the patient that they are at risk before they see their dentist. The example shown is the ‘traffic light’ system in OHIS, showing risk level. (Figure 5) Another example is to show patients a before and after Cariogram charts, for instance, by increasing the fluoride exposure score to show a patient that the chance of having a cavity decreases if they receive in-office fluoride treatments and use prescription-level home fluorides.36Alian AY, McNally ME, Fure S, Birkhed D. Assessment of Caries Risk in Elderly Patients Using the Cariogram Model. J Can Dent Assoc 2006;72(5):459–63.

Conclusions

Validated risk assessment tools can increase the accuracy and repeatability of risk assessment, and reports generated can help educate patients. While clinician barriers including time constraints exist, the clinical examination part of CRA is already performed. Dental team members can also assist with inputting risk factors and protective factors. Increased patient understanding and compliance may reduce future time needed to reinforce home care and to obtain patient acceptance for care. In knowing a patient’s risk level, evidence-based recommendations can be implemented to improve oral health. There is emerging evidence for improved patient compliance with CRA-based interventions and oral health outcomes following CRA and implementation of recommended interventions.24Twetman S, Banerjee A. (2020) Caries Risk Assessment. In: Chapple I, Papapanou P. (eds) Risk Assessment in Oral Health. Springer, Cham.,37Edwards AGK, Hood, K, Matthews EJ et al. The effectiveness of one to one risk communication interventions in health care: a systematic review. Med Decis Making 2000;20:290-7.

References

  • 1.U.S. Department of Health and Human Services. Oral health in America: A report of the Surgeon General, Executive summary. Rockville, MD: National Institutes of Health, National Institute of Dental and Craniofacial Research. 2000.
  • 2.Chen KJ, Gao SS, Duangthip D, Lo ECM, Chu CH. Prevalence of early childhood caries among 5-year-old children: A systematic review. J Investig Clin Dent 2019;10(1):e12376. doi:10.1111/jicd.12376
  • 3.Fleming E, Afful J. Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016. NCHS Data Brief 2018;307. Available at: https://www.cdc.gov/nchs/data/databriefs/db307.pdf.
  • 4.Dye B, Thornton-Evans G, Li X, Iafolla T. Dental caries and tooth loss in adults in the United States, 2011-2012. NCHS Data Brief. 2015;197.
  • 5.Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al. Dental caries. Nat Rev Dis Primers 2017;25(3):17030.
  • 6.World Health Organization. Risk factors. Available at: https://www.who.int/topics/risk_factors/en/
  • 7.Tagliaferro E, Pardi E, Ambrosano V, Meneghim G, Pereira, MAC. An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007). Braz J Oral Sci 2008;7(27):7.
  • 8.Bibby BG, Krobicka A. An in vitro method for making repeated pH measurements on human dental plaque. J Dent Res 1984;63:906-9.
  • 9.American Dental Association. Caries Risk Assessment Form (Age 0-6). Available at: https://www.ada.org/~/media/ADA/Member%20Center/FIles/topics_caries_under6.pdf.
  • 10.American Dental Association. Caries Risk Assessment Form (Age >6). Available at: http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6.ashx.
  • 11.AAPD. Caries-risk Assessment and Management for Infants, Children, and Adolescents. Latest revision, 2019. Available at: https://www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf
  • 12.AAPD. Best Practices. Perinatal and Infant Oral Health Care. 2016.. Available at: https://www.aapd.org/globalassets/media/policies_guidelines/bp_perinataloralhealthcare.pdf.
  • 13.Dasanayake AP, Warnakulasuriya S, Harris CK, Cooper DJ, Peters TJ, Gelbier S. Tooth decay in alcohol abusers compared to alcohol and drug abusers. Int J Dent 2010;2010:786503.
  • 14.Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B. Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res 2005;39(1):41-7.
  • 15.Opal S, Garg S, Jain J, Walia I. Genetic factors affecting dental caries risk. Aust Dent J 2015;60:2-11.
  • 16.Gomez A, Espinoza JL, Harkins DM, Leong P, Saffery R, Bockmann M et al. Host genetic control of the oral microbiome in health and disease. Cell Host Microbe 2017;22:269-78 e263.
  • 17.Featherstone JDB, Alston P, Chaffee BW, Rechmann P. Caries Management by Risk Assessment (CAMBRA)*: An Update for Use in Clinical Practice for Patients Aged Through Adult. In: CAMBRA® Caries Management by Risk Assessment A Comprehensive Caries Management Guide for Dental Professionals. (2019) Available at: https://www.cdafoundation.org/Portals/0/pdfs/cambra_handbook.pdf.
  • 18.Cagetti MG, Bontà G, Cocco F, Lingstrom P, Strohmenger L, Campus G. Are standardized caries risk assessment models effective in assessing actual caries status and future caries increment? A systematic review. BMC Oral Health 2018;18(1):123. doi: 10.1186/s12903-018-0585-4.
  • 19.Malmö University. Cariogram – Download. Available at: https://www.mah.se/fakulteter-och-omraden/Odontologiska-fakulteten/Avdelning-och-kansli/Cariologi/Cariogram/.
  • 20.Petsi G , Gizani S, Twetman S, Kavvadia K. Cariogram caries risk profiles in adolescent orthodontic patients with and without some salivary variables. Angle Orthod 2014;84(5):891-5. doi:10.2319/080113-573.1.
  • 21.Martin J, Mills S, Foley ME. Innovative models of dental care delivery and coverage. Patient-centric dental benefits based on digital oral health risk assessment. Dent Clin N Am 2018;62:319-25.
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  • 23.American Dental Association. Electronic oral health risk assessment tools. SCDI White Paper No. 1074, 2013. Available at: http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/ADAWhitePaperNo1074.pdf?la=en.
  • 24.Twetman S, Banerjee A. (2020) Caries Risk Assessment. In: Chapple I, Papapanou P. (eds) Risk Assessment in Oral Health. Springer, Cham.
  • 25.Rechmann P, Chaffee BW, Rechmann BMT, Featherstone JDB. Caries Management by Risk Assessment: Results From a Practice-Based Research Network Study. J Calif Dent Assoc 2019;47(1):15-24.
  • 26.Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Based Dent Pract 2017;17(1):1-12.
  • 27.Dou L, Luo J, Fu X, Tang Y, Gao J, Yang D. The validity of caries risk assessment in young adults with past caries experience using a screening Cariogram model without saliva tests. Int Dent J 2018;68(4):221-6. doi: 10.1111/idj.12378
  • 28.Thyvalikakath T, Song M, Schleyer T. Perceptions and attitudes toward performing risk assessment for periodontal disease: a focus group exploration. BMC Oral Health 2018;18(1):90.
  • 29.Riley JL 3rd, Gordan VV, Ajmo CT, Bockman H, Jackson MB, Gilbert GH. Dentists’ use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network. Community Dent Oral Epidemiol 2011;39(6):564-73.
  • 30.Weyant RJ, Tracy SL, Anselmo T, Frantsve-Hawley J, Meyer DM, Beltrán-Aguilar ED et al. Topical fluoride for caries prevention. J Am Dent Assoc 2013;144(11):1279-91. doi.org/10.14219/jada.archive.2013.0057
  • 31.American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young children. J Am Dent Assoc 2013;145(2):190-1. doi.org/10.14219/jada.2013.47
  • 32.Wright JT, Crall JJ, Fontana M, Gillette EJ, Nový BB, Dhar V 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. doi.org/10.1016/j.adaj.2016.06.001
  • 33.Slayton RL, Urquhart O, Araujo MWB, Fontana M, Guzmán-Armstrong S, Nascimento MM 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):P837-49.E10. doi.org/10.1016/j.adaj.2018.07.002
  • 34.Baskaradoss JK. Relationship between oral health literacy and oral health status. BMC Oral Health 2018;18:172. Available at: https://doi.org/10.1186/s12903-018-0640-1.
  • 35.Collins FM. Oral health literacy. Available at: https://www.colgateoralhealthnetwork.com/article/oral-health-literacy/
  • 36.Alian AY, McNally ME, Fure S, Birkhed D. Assessment of Caries Risk in Elderly Patients Using the Cariogram Model. J Can Dent Assoc 2006;72(5):459–63.
  • 37.Edwards AGK, Hood, K, Matthews EJ et al. The effectiveness of one to one risk communication interventions in health care: a systematic review. Med Decis Making 2000;20:290-7.