BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT
Caries-Risk Assessment and Management for
Infants, Children, and Adolescents
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Caries-risk
2022 assessment and management for infants, children, and adolescents.
The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2023:301-7.
Abstract
This best practice reviews caries-risk assessment and patient care pathways for pediatric patients. Presented caries-related topics include
caries-risk assessment, active surveillance, caries prevention, sealants, fluoride, diet, radiology, and nonrestorative treatment. Caries-risk
assessment forms are organized by age: 0-5 years and ≥6 years old, incorporating three factor categories (social/behavioral/medical, clin-
ical, and protective factors) and disease indicators appropriate for the patient age. Each factor category lists specific conditions to be graded
“Yes” if applicable, with the answers tallied to render a caries-risk assessment score of high, moderate, or low. The care management
pathway presents clinical care options beyond surgical or restorative choices and promotes individualized treatment regimens dependent
on patient age, compliance with preventive strategies, and other appropriate strategies. Caries management forms also are organized by
age: 0-5 years and ≥ 6 years old, addressing risk categories of high, moderate, and low, based on treatment categories of diagnostics, pre-
ventive interventions (fluoride, diet counseling, sealants), and restorative care. Caries-risk assessment and clinical management pathways
allow for customized periodicity, diagnostic, preventive, and restorative care for infants, children, adolescents, and individuals with special needs.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and
Scientific Affairs to offer updated information and recommendations regarding assessment of caries-risk and risk-based management protocols.
KEYWORDS: CARIES-RISK ASSESSMENT; CARIES PREVENTION; CLINICAL MANAGEMENT PATHWAYS; DENTAL SEALANTS; FLUORIDE
Purpose Background
The American Academy of Pediatric Dentistry (AAPD) Caries-risk assessment
recognizes that caries-risk assessment and management proto- Risk assessment procedures used in medical practice generally
cols, also called care pathways, can assist clinicians with have sufficient data to accurately quantitate a person’s disease
decisions regarding treatment based upon a child’s age, caries susceptibility and allow for preventive measures. However, in
risk, and patient compliance and are essential elements of con- dentistry, sufficiently-validated multivariate screening tools to
temporary clinical care for infants, children, and adolescents. determine which children are at higher risk for dental caries
These recommendations are intended to educate healthcare are limited.3,4 Two caries risk assessment tools, namely the
providers and other interested parties on the assessment of Cariogram5 and CAMBRA tools6, have been validated in clinical
caries risk in contemporary pediatric dentistry and aid in trials and clinical outcomes studies. Several other published
clinical decision making regarding evidence- and risk-based caries-risk assessment tools utilize similar components but
diagnostic, fluoride, dietary, and restorative protocols. have not been clinically validated.5,7 Nevertheless, caries-risk
assessment:
Methods 1. fosters the treatment of the disease process instead of
This document was developed by the Council on Clinical treating the outcome of the disease.
Affairs, adopted in 20021, and last revised in 20192. To update 2. allows an understanding of the disease factors for a
this document, an electronic search was conducted of publi- specific patient and aids in individualizing preventive
cations from 2012 to 2021 that included systematic reviews/ discussions.
meta-analyses or reports from expert panels, clinical guidelines, 3. individualizes, selects, and determines frequency of
and other relevant reviews using the terms: caries risk assess- preventive and restorative treatment for a patient.
ment AND diet, sealants, fluoride, radiology, nonrestorative 4. anticipates caries progression or stabilization.
treatment, active surveillance, caries prevention. Five hundred
ninety-two articles met these criteria. Papers for review were
chosen from this list and from references within selected
articles. When data did not appear sufficient or were incon- ABBREVIATION
clusive, recommendations were based upon expert and/or AAPD: American Academy of Pediatric Dentistry.
consensus opinion by experienced researchers and clinicians.
THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 301
, BEST PRACTICES: CARIES-RISK ASSESSMENT AND MANAGEMENT
Caries-risk assessment is part of a comprehensive treatment in predicting it (e.g., life-time poverty, low health literacy)
plan approach based on age of the child, starting with the age and include those variables that may be considered protective
one visit. Caries-risk assessment models currently involve a factors. The most-used caries-risk factors include low salivary
combination of factors including diet, fluoride exposure, a flow, visible plaque on teeth, high frequency sugar consump-
susceptible host, and microflora that interplay with a variety of tion, presence of appliance in the mouth, health challenges,
social, cultural, and behavioral factors.8 Caries-risk assessment sociodemographic factors, access to care, and cariogenic
is the determination of the likelihood of the increased inci- microflora.11 The presence of caries lesions, either noncavitated
dence of caries (i.e., new cavitated or incipient lesions) during or cavitated, also has been shown in numerous studies to be
a certain time period9,10 or the likelihood that there will be a a strong indicator of caries risk. Clinical observation of caries
change in the size or activity of lesions already present. With lesions, or restorations recently placed because of such lesions,
the ability to detect caries in its earliest stages (i.e., noncavitated are best thought of as disease indicators rather than risk
or white spot lesions), health care providers can help prevent factors since these lesions do not cause the disease directly or
cavitation.11 indirectly but, very importantly, indicate the presence of the
Caries risk factors are variables that are thought to cause factors that cause the disease. Protective factors in caries risk
the disease directly (e.g., microflora) or have been shown useful include a child’s receiving optimally-fluoridated water, having
Table 1. Caries-risk Assessment Form for 0-5 Years Old
Use of this tool will help the health care provider assess the child’s risk for developing caries lesions. In addition, reviewing specific
factors will help the practitioner and parent understand the variable influences that contribute to or protect from dental caries.
Factors High risk Moderate risk Low risk
Risk factors, social/behavioral/medical
Mother/primary caregiver has active dental caries Yes
Parent/caregiver has life-time of poverty, low health literacy Yes
Child has frequent exposure (>3 times/day) between-meal sugar-containing
Yes
snacks or beverages per day
Child uses bottle or nonspill cup containing natural or added sugar frequently,
Yes
between meals and/or at bedtime
Child is a recent immigrant Yes
Child has special health care needs α Yes
Risk factors, clinical
Child has visible plaque on teeth Yes
Child presents with dental enamel defects Yes
Protective factors
Child receives optimally-fluoridated drinking water or fluoride supplements Yes
Child has teeth brushed daily with fluoridated toothpaste Yes
Child receives topical fluoride from health professional Yes
Child has dental home/regular dental care Yes
Disease indicators ß
Child has noncavitated (incipient/white spot) caries lesions Yes
Child has visible caries lesions Yes
Child has recent restorations or missing teeth due to caries Yes
α Practitioners may choose a different risk level based on specific medical diagnosis and unique circumstances, especially conditions that affect
motor coordination or cooperation.
ß
While these do not cause caries directly or indirectly, they indicate presence of factors that do.
Instructions: Circle “Yes” that corresponds with those conditions applying to a specific patient. Use the circled responses to visualize the balance
among risk factors, protective factors, and disease indicators. Use this balance or imbalance, together with clinical judgment, to assign a caries
risk level of low, moderate, or high based on the preponderance of factors for the individual. Clinical judgment may justify the weighting of one
factor (e.g., heavy plaque on the teeth) more than others.
Overall assessment of the child’s dental caries risk: High Moderate Low
Adapted with permission from the California Dental Association, (Ramos-Gomez et al. ) 33 Copyright © October 2007.
302 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
