Caries Risk Assessment: IHS Oral Health Program Guide
Sound clinical judgment is necessary to establish dental caries risk and prescribe appropriate interventions.
Gathering information from and about patients is critical in determining this risk. In this model, the key
decision which drives caries risk assessment is the presence of active cavitated lesions at the time of the
examination. Many studies indicate that previous caries experience is one of the best predictors of future
caries experience (1,2,4-7,30-34).
Risk Factors
Other factors that may predispose an individual to dental decay include the following:
Tooth morphology, age, fluoride exposure (both too much and not enough), oral hygiene,
frequency of dental visits, medical conditions and medications being taken, root exposure,
salivary flow, mutans streptococci levels, family’s dental experience, orthodontics, removable
appliances, and diet.
The type and nature of modifiers applicable to an individual may indicate that he/she should be moved
into a different risk category. No attempt was made to regulate the number of modifiers which would move
a person into a different risk category; this decision has been left up to the clinician’s judgment. However,
patients should be reassessed and reclassified at subsequent recall visits for the appropriate risk category. A
patient initially classified as “high-risk” or “moderate-risk” may fall into a “low-risk” category at recall if no
new lesions are found and modifying factors such as fluoride exposure and oral hygiene have changed.
“Low-risk” patients may also move into other categories if oral conditions change. Risk categories and
classification are fluid.
The following risk categories are defined and provide guidelines for preventive regimens as well as recall
intervals for assessing caries risk status:
Modifiers
Risk
Categories
Low-Risk Patients
A patient is considered to be at low risk if he/she has no active cavitated lesions at the examination
appointment and few risk modifiers are present. For the patient at low risk, the preventive regimen includes
reinforcing his/her use of fluoridated toothpaste, a review of oral hygiene procedures, and discussion of the
patient’s diet. If there are incipient lesions or deep pits and fissures and/or the patient has a previous
history of caries, apply sealants on all appropriate teeth. The application of sealants has been proven to be
one of the best caries preventive regimens available (35-38).
Low-risk patients can be advised to return to the dental clinic in 24-36 months. This time should be
shortened if a patient is in a mixed dentition stage or other modifiers are present.
Preventive
Regimen
Moderate-Risk Patients
Patients with one active cavitated smooth-surface lesion at the time of the exam are considered to be at
moderate risk. Again modifiers could place a patient in a higher or lower risk category.
Moderate-risk patients should receive appropriate education including diet, use of fluoride, and oral
hygiene at the exam appointment. Sealants should be applied to all appropriate teeth before any restorative
services are provided.
Based on local resources, over-the-counter daily fluoride mouthrinses or a semi-annual professionallyapplied topical fluoride treatment (foam, gel, or varnish) may be recommended or provided as appropriate
(39-42).
A six-month to 24-month recall should be implemented for these moderate-risk patients, depending on the
number of modifiers present. For example, a patient with only one smooth-surface lesion, but deep pits and
fissures, mixed dentition, poor oral hygiene, and lack of any fluoride exposure, should be recalled at shorter
intervals.
High-Risk Patients
Patients with two to five active cavitated smooth surface lesions on permanent teeth at the time of the
exam are considered to be at high risk in this protocol. Patients who were former “very high-risk patients”
could also be placed in this group. Again modifiers could place a patient in a different risk category, either
lower or higher.
These high-risk patients should receive appropriate treatment which includes pit and fissure sealants and
the restoration of carious lesions. Additional preventive treatment measures at the exam and subsequent
appointments could include: professionally-applied topical fluoride treatments (foam, gel, and varnish),
antimicrobial rinses, and patient education (diet, use of fluoride toothpaste, and oral hygiene).
A six-month to 12-month recall should be implemented for high-risk patients, depending on the number of
modifiers present. For example, a patient with two smooth-surface lesions, deep pits and fissures, good oral
hygiene, and regular fluoride exposure should be recalled at the longer interval.
Very High-Risk Patients
Patients with six or more active cavitated smooth surface lesions on permanent teeth at the time
of the exam are considered to be at very high risk. Immediate action should be taken on these very
high-risk patients to reduce or eliminate their dental infection before providing definitive
restorative care in the permanent dentition. At the examination appointment oral hygiene
instructions should be given and patients should be instructed to brush their teeth at least twice a
day with an antimicrobial product such as a chlorhexidine mouthrinse. Cavitated lesions should
be eliminated as soon as possible: two or fewer appointments are recommended; definitive
Preventive
Regimen
and
Treatment
restorations need not be placed at this time. Sealants should be placed on all pits and fissures as
appropriate and fluoride varnish placed on decalcified areas of the teeth. An antimicrobial rinse
should also be prescribed or dispensed to these patients after the cavitated lesions have been
treated
IHS Caries Risk Assessment Summary
Risk Category
Criteria
No Active Cavitated Lesions
Low
Moderate
One Active Cavitated Smooth
Surface lesion
High
Two to Five Active Cavitated
Smooth Surface Lesions
Very High
Six or more Active Cavitated
Smooth Surface Lesions
Preventive Services
Review OHI
Sealants if needed
24-36 Month Recall
OHI
Sealants as needed
Fluoride (OTC and/or
professional)
6-24 month Recall
OHI
Sealants as needed
Fluoride (OTC and/or
professional)
6-12 month recall
OHI
Antimicrobials
Sealants
Fluoride varnish
Modifying factors:
Tooth morphology, age, fluoride exposure (both too much and not enough), oral hygiene,
frequency of dental visits, medical conditions and medications being taken, root exposure,
salivary flow, mutans streptococci levels, family’s dental experience, orthodontics, removable
appliances, and diet.
References
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37.
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38.
Kidd EAM, Ricketts DNJ, Pitts NB. Occlusal caries diagnosis: a changing challenge for clinicians
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39.
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40.
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41.
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42.
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43.
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44.
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