International Dental Journal (1999) 49 , 1526

Caries-risk assessment*
E. Reich, A. Lussi and E. Newbrun
FDI Commission

Summary Dental caries has a multifactorial aetiology in which there is an interplay of three principal factors: the host (saliva and teeth), the microflora (plaque), and the substrate (diet), and a fourth factor: time. There is no single test that takes into consideration all these factors and can accurately predict an individuals susceptibility to caries. The risk of dental caries can be evaluated by analysing and integrating several causative factors. These include caries experience (initial caries lesions and established caries defects, secondary caries and present caries activity), fluoride use, extent of plaque present, diet, bacterial and salivary activity and social and behavioural factors.

In many countries the prevalence of dental caries in children and adolescents has markedly regressed over the past years. Epidemiological studies show an uneven distribution of dental caries. Approximately 25 per cent of the population exhibits significantly more caries than the rest of the population, a phenomenon that has been termed polarisation1. Dental caries has a multifactorial aetiology in which there is an interplay of three principal factors: the host (saliva and teeth), the microflora (plaque), and the substrate (diet), and a fourth factor: time2. There is no single test that takes into consideration all these factors and can accurately predict an individual s susceptibility to caries. The risk of dental caries can be evaluated by analysing and integrating several causative factors. In daily practice the caries-risk is determined in order to assess the individual patients risk, to identify the main causative factors and to recommend specific preventive measures for that individuals needs. Caries-risk assessments during treatment can serve as a monitoring aid for the success of the treatment. They may also be very useful for screening populations in community preventive programmes by identifying caries prone children who need more intensive preventive care. Since caries is preventible, the diagnosis of caries as a lesion in a tooth is not sufficient for a treatment plan. In order to devise a needs-related treatment plan for a patient, a proper medical diagnosis is needed, based

*Project initiated and report approved by the FDI Commission

1999 FDI/World Dental Press 0020-6539/99/01015-12

on certain components. Firstly, the caries must be recorded where present on each surface as either initial lesions (reversible) or cavities (irreversible). Secondly the activity of these lesions should be assessed to estimate the severity of the caries in the patient. Thirdly the caries-risk should be assessed because it provides an estimate of future caries activity. With this information the amount of preventive intervention required to arrest existing initial caries can be estimated. In addition this information will aid the dentist in choosing the appropriate restorative treatment. Much progress has been achieved in the prevention of dental decay over the past decades310. Epidemiological studies have demonstrated high caries active individuals in the same population as moderate or low caries active individuals11,12 (Figure 1). Caries prevalence indicators can be used for assessing either caries activity or the risk of future caries. However, caries-risk does not remain constant throughout life and may be modified by preventive intervention both by the patient and by the dentist 1315. Determination of caries-risk is important for: Assessment of the individual aetiological factors of existing carious lesions and of the caries risk situation. Repeated determination of the caries-risk allows an evaluation of the success of, or the need for, modification of preventive measures. Indications of an increased caries-risk in specific children in community preventive programmes will allow selection of an individual preventive

16 International Dental Journal (1999) Vol. 49/No.1

Figure 1 Relative size of high caries-risk populations as a percentage of the total populations of Germany in age groups 8/9 years old, 13/14 years old, 3544 years old and their share of percentage of total DMFT scores. Limportance relative des populations risque lev de carie comme pourcentage dune population totale en Allemagne pour les groupes dge de 8/9 ans, 13/14 ans, 3544 ans et leur part du pourcentage de la totalit des indices CAO. Relativer Umfang der stark kariesgefhrdeten Bevlkerungsgruppen als prozentualer Anteil an der Gesamteinwohnerzahl Deutschlands bezogen auf 8/9jhrige, 13/14jhrige sowie 35 44jhrige und ihr prozentualer Anteil an den DMF-Gesamtwerten. Relativo tamao de poblaciones de alto riesgo de caries como porcentaje de la poblacin total de Alemania en grupos de edades de 8 a 9aos, de 13 a 14 aos, de 35 a 44 aos y su parte del porcentaje del ndice total CPO.

Figure 2 Distribution pattern of carious tooth surfaces of deciduous and permanent teeth in Bavarian children in 1992. Deciduous teeth in 6 year old children, permanent teeth in 9 year old children. Les schmas de rpartition des surfaces dentaires caries des dents temporaires et permanentes chez des enfants bavarois en 1992. Les dents temporaires chez des enfants de 6 ans, des dents permanentes chez des enfants de 9 ans. Verteilung kari ser Zahnoberfl chen bei Milch- und bleibenden Zhnen bayrischer Kinder im Jahre 1992. Milchzhne bei 6jhrigen und bleibende Zhne bei 9jhrigen Kindern. Patrn de distribucin de superficies cariadas de dientes deciduos y permanentes en nios de Bavaria, 1992. Dientes deciduos en nios de 6 aos de edad, dientes permanentes en nios de 9 aos de edad.

programme in order to minimise the development of carious lesions.

Diagnosis of dental caries

Dental caries involves demineralisation of dental hard tissues by organic acids leading to the formation of cavities. Caries ranges from initial lesions confined to enamel to dentinal lesions which may ultimately expose the pulp. For epidemiological studies various criteria for the diagnosis of caries are used. Besides a simple yes/no decision, there are several more refined concepts for further differentiation. Initial lesions may be subdivided into two classes: D1 and D2, both without dentinal involvement. More advanced lesions may be characterised by size16 and/or involvement of dentine and the pulp (D3/D4)17. There are no universallly accepted standards for caries diagnosis. Therefore, indications of sensitivity and specificity may vary18. This in turn will influence the interpretation of epidemiological data with respect to prevalence or incidence values as well as the validity of caries risk determinations. With respect to the treatment of patients, the detection of initial lesions is a necessary diagnostic threshold. Some initial caries can be detected by a more careful

clinical diagnosis and the evaluation of radiographs. In addition, new technical tools have become available that can improve the precision of diagnosis, such as electrical conductivity measurements, laser fluorescence, fibre optic transillumination and digital radiography1928.

Caries susceptibility
This is the susceptibility (or resistance) of a tooth to a caries-producing environment. The risk of developing a lesion, however, is individual and varies, depending on the tooth, its localization, surfaces, previous fluoride exposure etc. (Figure 2).

Caries activity
Caries activity is a measure of the speed of progression of a carious lesion. Retrospectively it can be determined as caries incidence, that is, new carious lesions over time of an individual or population.

Caries-risk
Generally speaking, risk is defined as the probability of incidence of an event within a certain period of time.

Reich et al.: Caries-risk assessment 17

Figure 3 Schematic representation of caries incidence and caries activity. La reprsentation schmatique de la frquence des caries et de lactivit des caries. Schematische Darstellung des Kariesvorkommens und der Kariesaktivitt. Representacin esquemtica de incidencia y de actividad de caries.

almost 60 per cent3941. Initial caries lesions are supposed to give a better predictability than the number of filled (FS) or carious surfaces (DS)42,43. Conversely, the inclusion of initial lesions in DMFS- or DS-values does not increase the accuracy43. In adults, existing DMF-values are less sensitive for predicting future coronal caries than in children. However, there is a close connection between existing caries and the risk of developing root caries4448. Caries prevalence in primary teeth can correctly predict future caries in permanent teeth49,50. The sensitivity of prediction was increased by including primary teeth and first permanent molars into the assessment51.

Fluorides
There are various concepts as to the mechanisms of action of fluorides52 especially regarding the extent of the pre-eruptive versus post-eruptive effects 53,54. The demineralisation process in the mouth is not a continuous acid attack: periods of demineralisation are followed by phases of remineralisation55. The local action of fluoride on the tooth surface appears to be at least as important as the incorporation of fluorides into dental hard tissues during tooth formation5658. The posteruptive effect of fluoride depends on the fluoride concentrations in the mouth, therefore regular fluoride exposure is of decisive importance in reducing caries54,5961. The salivary fluoride content has some association with caries susceptibility but its diagnostic or predictive value is questionable62.

The caries-risk, therefore, is the risk of an individual developing a carious lesion. Increased risk may be the result of several caries-producing factors coinciding or of insufficient defence mechanisms leading to different caries prevalence ( Figure 3). By definition, risk is aimed at assessing developments in the future. It can, however, be assessed only on the basis of symptoms present at, or having manifested themselves by, the time of assessment.

Risk factors for the development of caries

Caries is not the consequence of a singular event (as is a classical infectious disease for example) but it is rather a sequel of a series of processes happening over a longer period of time. The aetiological factors which can be diagnosed today, that is, the risk of caries, do not necessarily have to be identical with the causative factors which led to the development of a carious lesion29. In scientific studies various so-called predictors for the risk of caries have been investigated3036. These could be clinical signs of caries or risk indicators, such as factors associated with the development of caries. Their effects on the development of caries can be either causative or modifying. Causative relationships are often identified as risk factors. An individual with an increased risk of caries may, therefore, be a person with a higher than average exposure to the causative risk factors mentioned below.

Oral hygiene
A further prerequisite for caries development is the existence of bacterial plaque on the teeth. Caries can be reduced by mechanical removal of plaque from tooth surfaces, however, most patients do not remove it effectively44,6366. Frequent (biweekly) para-professional tooth cleaning with a fluoride-containing paste substantially prevents caries and reduces gingivitis but the practicability and cost of such programmes is questionable6768. The effectiveness of mechanical cleaning alone is hard to evaluate, since tooth brushing is usually done using fluoridated toothpaste. Furthermore most plaque indices are based on smooth tooth surface scores whereas most caries occurs in fissures and interproximally.

Bacteria
Shortly after birth an oral ecosystem is established consisting of different kinds of bacteria. The colonisation of the mouth by odontopathic bacteria is by human transmission, mostly from mothers, fathers or caregivers to infants, and depends upon the quantity of these bacteria the parents harbour. Toddlers who carry a large

Caries
Epidemiological studies have shown a positive correlation between past caries experience and future caries development30,37,38. The sensitivity of that parameter is

18 International Dental Journal (1999) Vol. 49/No.1

amount of mutans streptococci already at 2 and 3 years of age show a noticeably higher risk of developing caries on primary teeth6973. A correlation between the number of carious lesions and numbers of mutans streptococci has been established in the saliva of children and adults 7476 . The accuracy of salivary tests for mutans streptococci in predicting caries in the whole population is less than 50 per cent39,40,77,78. Microbiological tests show close associations between odontopathogens and caries in subjects with high caries experience and conversely, low numbers of odontopathogens in low or non-caries subjects79. They identify the two extremes in a disease susceptible population but are less effective in predicting caries in the moderate risk subjects. Even though lactobacilli are not primarily responsible for caries development, they are found in increased numbers when large amounts of carbohydrates are eaten. Other microbiological tests are even less sensitive in predicting caries than the mutans tests 39 41,77,80. In countries with low caries prevalence, the caries-predictability of microbiological tests is further decreased78,81.

which is attributed to their slower clearance rate104106. The root surface is extremely susceptible to demineralisation by starchy foods101. In addition to the intrinsic cariogenicity of a food, the manner of its consumption is of great importance as demonstrated in the Vipeholm-study 107 and other investigations108. It is known that the amount of carbohydrate, particularly sugars 109111 alone is not the only factor, but that the frequency of the intake is important. Patients statements about their eating habits have to be critically evaluated, therefore, self reporting of diet has low predictability. The amount of sugar intake has a noticeable effect on fissure caries 112. Today, per capita sugar disappearance (utilisation) in industrial nations with low caries incidence, has only a slight effect on caries prevalence 113. Thus, little caries increase was found in young children with good oral hygiene irrespective of dietary habits 114. At the same time high sugar intake showed an increased caries prevalence only when the oral hygiene was poor115.

Modifying factors for the development of caries

Saliva
Saliva has a buffering effect on acids which are produced by plaque micro-organisms and can also clear food particles from the mouth. The production of saliva and salivary clearance is stimulated by chewing. The salivary flow rate increases in small children up to the age of approximately 10 years and continues to increase slightly thereafter to adulthood. The number of patients who show a reduced salivary flow rate is increasing especially in seniors. This is due not so much to age per se, but rather the side effects of certain medications that reduce salivary flow. In individuals with markedly reduced salivary function, caries activity is significantly increased77,8284. A high buffer capacity of the saliva reduces the risk of coronal and root caries77,82,85. However buffer capacity paralleles salivary flow rate. Other salivary factors such as concentration of proteins, different ions or enzyme activities are of very slight value for prognosis of caries-risk8688.

Age
Epidemiological surveys of caries show an increase in caries prevalence with age. Newly erupted teeth are more susceptible to caries, particularly at pit and fissure sites. The susceptibility seems to be increased also by the difficulty of cleaning the teeth until they have reached the occlusal plane and opposing teeth are occluding. As the enamel matures it is less likely to decay. Accordingly children are at greatest caries risk at those ages when teeth have just erupted.

Gender
During childhood and adulthood women show higher DMF-values than men. But in general their oral hygiene is better and they have fewer missing teeth than men. It is unlikely that women have a higher caries susceptibility, rather they seek more dental care, which is reflected in a higher F-component of the DMF-Index.

Eating habits
The role of diet in the caries process is primarily local rather than systemic. The cariogenicity of food depends on its components 8993 and is influenced by various factors 9498. Carbohydrates are metabolised by plaque bacteria into acids at different rates. Although the ranking of specific foods by the decrease in plaque pH approximates to their cariogenicity in animals99100 the same does not follow in humans who are omniverous101103. Combinations of starch and sucrose as found in cakes are highly cariogenic in animal studies,

Behaviour
The patients attitude towards his or her health has a distinct effect on the resulting caries susceptibility. A health-conscious behaviour, which is reflected in sensible eating habits and regular oral hygiene using a fluoridated dentifrice, reduces caries incidence. Behavioural patterns, especially eating habits, influence caries susceptibility and caries-risk. In industrialised countries a significantly higher DMFvalue is found in patients in all age groups that regularly seek dental care116. As is the case with many

Reich et al.: Caries-risk assessment 19

other diseases, dental services are mostly sought when symptoms are already present. In other words dental treatment is related to a high risk for illness. When the demand changes towards more preventive services, these numbers should shift.

services influences its acceptance. Based on current knowledge about the aetiology of caries, this disease cannot be cured by restorative measures, but only by preventive ones137.

Assessment of caries-risk
Social, genetic and occupational factors
Socio-economic status is highly relevant to caries prevalence117. Caries is more prevalent in lower than in higher social classes 116,118. This is not due to more expensive treatment, but to a greater health interest in upper social classes. Important social factors are education 119 and occupation120. The parents care is reflected in the dental health of their children. Immigrants, too, can develop a higher caries risk in their new surroundings due to changes in eating habits, especially an increase in more sugary snacks. Under these circumstances an entire group may show increased caries-risk 121,122. Studies of identical twins who have been raised separately, have shown that other aetiological factors are more important than genetic factors such as tooth morphology, position and occlusion 103. Workers in industries such as bakeries, candy and chocolate factories and sugar cane cutters, have higher caries prevalence than workers in other industries 124127. In order for dentists to practice preventive dental medicine they need information about the caries-risk status of their patients. The validity of a caries-risk assessment can be evaluated as regards specificity, sensitivity, positive and negative predictive values. Thus the riskassessment can be tested for how well it correlates with future disease138. In diagnosing caries risk, no single test can simultaneously measure host resistance, microbial pathogens, and cariogenicity of the diet. Multiple predictor models (including mutans scores, baseline caries prevalence, fissure retentiveness score, dietary habit index, salivary buffering and flow rate) are necessary to classify a person according to caries risk. The use of multivariate analysis combining several factors offers the potential for making relatively good predictions, with reasonable sensitivity/specificity expectations 139 . Scheinin has developed a computer program that combines eight diagnostic tests for analysis by a logistic regression model that provides assessment of interrelations and produces odds ratios 140,141. This program can be run on a personal computer of the type already being used in many private dental offices and provides a graphic representation of the observations. By combining past caries experience and values of mutans streptococci a more predictive model is obtained than with either individual test alone. Sensitivity was calculated as 71 per cent, specificity 81 per cent. In other studies using as many as fifteen cariesrisk factors a sensitivity of only 59 per cent and specificity of 83 per cent was achieved. The best accuracy of prognosis was given by clinical caries diagnosis, with microbiological factors contributing only slightly more to the accuracy of prediction142. The evaluation of various clinical indices by experienced clinicians provides an adequate assessment of cariesrisk 29,143,144. Other methods that are being tested for cariesrisk assessment include the Plaque Formation Rate Index (PFRI) which measures daily plaque formation. There is a correlation between the amount of streptococci in the saliva, tooth surfaces covered by plaque and caries-risk 145,146. Comprehensive clinical tests of this method are not yet available 147. Using a value based on a complete clinical examination (Dentoprog)51 caries-risk can be assessed. The value is calculated on discoloured pits and fissures of the first permanent molars, and on initial lesions on smooth surfaces in school children aged 7 to 10 years. This method allows for a fast clinical assessment of caries-risk in school children.

General medical factors

General medical factors, like the long-term use of sugary liquid medications by children, increase caries prevalence 128,129. Many other medications, especially psycho-pharmaceutical products, reduce the flow of saliva and, thus, increase caries-risk 130. Cytotoxic chemotherapy disrupts the mineralisation of teeth and thereby raises the caries prevalence of these teeth131. Data concerning caries prevalence in mentally or physically retarded populations compared to nonretarded are mixed, some have higher prevalence, others not132134.

Dental therapy
The type of treatment delivered by dentists depends in part on the costs to the patient 135. On the other hand the dentist s academic education, continuing education, knowledge of preventive measures, and the use of modern techniques are additional factors influencing treatment 136.

Health system
The therapy proposed by the dentist is influenced by that society s health system. The coverage of dental

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Discussion
Significance of caries-risk assessment
The prevalence and incidence of caries influences the predictability of the caries-risk assessment148. The identification of subjects with high caries-risk is relatively accurate where children and adolescents are concerned and when sufficient base-line data are available. The situation is different where adults are concerned because they receive more dental treatment but lack preventive programmes83. Since secondary caries is the most frequent cause of replacement of restorations149 and root caries becomes a problem for adults, caries-risk assessment and, when needed, preventive intervention is also necessary for adults. Today, decreasing caries prevalence with a skewed distribution requires a different approach to prevention and treatment. The rate of caries progression is slower for those using fluoride on a regular basis as compared to others who do not use fluoride or use it inappropriately150152. Caries prevention using fluoride applications, anti-bacterial therapeutic agents, and sealants has been shown to be effective 153. However, these treatments should be selectively applied, according to the needs of the individual patient otherwise caries prevention is not cost effective154,155.

appropriate methods are available to prevent and treat caries in an efficient way. The question still is whether we can identify high-risk, susceptible subjects with sufficient accuracy. For the prediction of caries none of the risk markers investigated156 reached the predictive power for the proposed combined sensitivity and specificity of 160 per cent. Hausen 138 concluded that none of the measures available today for assessing the caries risk could be relied on mechanically. In the clinical situation the accurate prediction of caries is not as important as the assessment of the individual caries risk and risk factors. Even with routinely available clinical and sociodemographic information at clinical examination a dentist can identify high caries risk subjects with good accuracy143.

Consequences for preventive group medicine

In order to arrest the development of caries as early as possible it is important that caries-risk status be assessed 148. For children in kindergarten a simple assessment of previously acquired lesions will suffice 51.

Consequences for individual prophylactic treatment

The assessment of the caries-risk is a measure which is tailored for the individual patient: To evaluate the degree of the caries-risk. To identify the main aetiological factors and in the case of high caries-risk to tailor a preventive treatment plan suitable for that patient. To assess the efficacy of the treatment and plan future treatments.

Classification and consequences

A high caries-risk group is defined as a sub-group of the population which is at greater risk of acquiring caries than the average population. The borderline between low, moderate or high risk is not precise, but depends on the prevalence within the population and on additional factors. When there are only a few caries-risk factors present, then the evaluation is of a low cariesrisk , when there are many risk-factors present the classification is of a high caries-risk, and the moderate caries-risk group falls in between (see Table 4 in Newbrun18). Prevention is directed towards the reduction of the risk-factors. The percentage of children with a high caries-risk is approximately 20 to 25 per cent of the population. This group requires intensive preventive intervention (Figure 1 ). This does not mean that preventive dental care is not required for everyone else, only that the intensity of preventive treatment varies according to need. For the successful application of this high-risk strategy three basic prerequisites are necessary138. First, the occurrence of caries must be low enough to justify the effort and time of identifying patients with a high risk for developing caries. Second, there must be methods available that are accurate, acceptable and feasible. Third, the preventive measures must be effective. While the first point is dependent on a public health point of view of the situation in the respective country, the situation might be different in the setting of the individual dental practice. With respect to the preventive measures,

Clinical approach
The general assessment of the patient includes a caries history, that is, past caries experience and the number of teeth lost due to caries. Other factors to be considered at the initial examination and at recall are ( Figure 4): Caries (initial caries lesions and established caries defects, secondary caries and present caries activity). Fluoride (type and frequency of use). Extent of plaque present (performance of oral hygiene). Diet (eating habits with regard to the number of main meals and snacks as well as the amount of sugar intake). Bacterial and salivary tests (where appropriate for example, if a high caries-risk is suspected29. These may include the SM-test, the LB-test, and salivary flow rate and buffer capacity. They are used in practice because of motivational aspects 157). Social and behavioural factors (to evaluate the patient for compliance).

Reich et al.: Caries-risk assessment 21

Name

Age

Risk factors for caries at the initial examination History: Caries prevalence (in relation to age) 0 General factors: Caries 0 Plaque 0 Sum Current risk factors for caries Date Caries activity/incidence 0 Caries activity/incidence 0 Caries activity/incidence 0 Caries activity/incidence 0 Caries activity/incidence 0 Caries activity/incidence 0 Caries activity/incidence 0
Plaque 0 Plaque 0 Plaque 0 Plaque 0 Plaque 0 Plaque 0 Plaque 0 Fluorides 0 Fluorides 0 Fluorides 0 Fluorides 0 Fluorides 0 Fluorides 0 Fluorides 0 Diet 0 Diet 0 Diet 0 Diet 0 Diet 0 Diet 0 Diet 0 MS 0 MS 0 MS 0 MS 0 MS 0 MS 0 MS 0 Control appointments 0 Control appointments 0 Control appointments 0 Control appointments 0 Control appointments 0 Control appointments 0 Control appointments 0 Fluorides 0 Tooth loss due to caries 0 Diet 0 MS 0 Control appointments 0 ........ ........ ........

Current risk
........ ........ ........ ........ ........ ........ ........

Figure 4 Caries risk assessment chart for use at initial and follow examinations. Tableau de lvaluation du risque de carie pour utilisation lors des examens initial et suivant. Tabelle zur Kariesrisikoeinschtzung fr die Erst- und Nachuntersuchungen. Grfico de evaluacin de riesgo de caries para uso en los exmenes iniciales y de seguimiento.

Interpretation of chart (Figure 4)

The caries-risk can be categorised for clinical practice into three categories: low, moderate and high. If there has been new caries since the last examination the caries-risk is moderate or high depending on the time

interval, number and severity of the lesions. If there has been no caries development since the last check-up, the caries-risk is moderate or low depending on the amount of plaque, frequency of sugar intake, MS (mutans streptococci) score and history of fluoride use by the patient.

Lvaluation des risques de caries R sum

La carie dentaire a une tiologie multifactorielle avec un effet rciproque des trois facteurs principaux : lhte (la salive et les dents), la microflore (la plaque) et le substrat (le rgime alimentaire), ainsi quun quatrime facteur, le temps. Il nexiste aucun test qui tienne compte de tous ces facteurs et puisse prvoir correctement le degr de susceptibilit aux caries dun individu. Le risque de carie dentaire peut tre valu par lanalyse et lintgration de plusieurs facteurs causatifs. Ceux-ci incluent le bilan de la carie (les lsions carieuses initiales et les dfauts carieux tablis, lactivit des caries secondaires et actuelles, lutilisation du fluorure, limportance de la plaque, le rgime alimentaire, lactivit salivaire et bactrienne et les facteurs de comportement et sociaux.

Kariesrisikoeinsch tzung Zusammenfassung

Zahnkaries liegt eine multifaktorielle tiologie zugrunde, wobei drei Hauptfaktoren zusammenwirken: Wirtsmedium (Speichel und Z hne), Mikroflora (Plaque) und Substrate (Nahrung). Erg nzt wird dieses Zusammenspiel durch den Zeitfaktor. Es existiert keine Testmethode, die alle vier Faktoren gleichermaen bercksichtigt und die in der Lage wre, die individuelle Kariesanflligkeit przise vorherzubestimmen. Das Zahnkariesrisiko kann durch Analyse bzw. Einbeziehung verschiedener tiologischer Faktoren ermittelt werden. Hierzu zhlen u.a. bereits existierende Kariesschden (Initialkariesl sionen und bestehende Kariesdefekte, Sekund rkaries und fortschreitende Kariesaktivit t), Anwendung von Fluorid, Ausma vorhandener Plaque, Ernhrung, Bakterien- und Speichelaktivitt sowie sozial- bzw. verhaltensbedingte Faktoren.

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Evaluacin del riesgo de caries Resumen

La caries dental tiene una etiologa multifactorial en la que interactan tres factores principales: el factor husped (saliva y dientes), la microflora (placa) y el sustrato (dieta), y un cuarto factor: el tiempo. No existe una prueba nica que tome en consideracin todos estos factores y que pueda predecir exactamente la propensin individual a la caries. El riesgo de la caries dental puede ser evaluado por medio del anlisis y combinacin de varios factores causativos.. Estos factores incluyen: la experiencia de caries (lesiones cariosas iniciales y defectos establecidos de caries, caries secundaria y la actividad presente de caries), uso del flor, grado de la placa presente, dieta, actividad bacteriana y salival y factores sociales y de comportamiento.

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Correspondence to: Professor E. Reich, University of Saarland, Department of Periodontology and Conservative Dentistry, D-66421 Homburg, Germany. E-mail: zmkerei@med-rz.uni-sb.de