The 3-Step Caries Risk Assessment Appointment

Historically, the dental “checkup” or hygiene appointment consisted of examining patients for signs/symptoms of oral diseases. Cavities caused by the caries infection, periodontal disease caused by a periodontal infection, accelerated wear of the teeth caused by a variety of oral environmental conditions such as bruxism (clenching), etc. Signs of disease are identified through a variety of methods, including x-rays, oral examination with an explorer or probe, and your dental practitioner’s education and experience, while symptoms are generally reported by the patient. The historical dental appointment identified issues that presented after the damage has already been done. Caries risk assessment is a diagnostic method used to identify issues on the other “side of the equation” or before irreversible damage has occurred. This allows dental professionals and patients the opportunity to intervene with behavior modification and prescription/professional therapies.


Step 1: Risk Factors

In most dental practices performing caries risk assessment, a patient’s risk factors are identified in one of two ways. Either the patient is handed a risk assessment form prior to the appointment while in the reception area and asked to fill out the risk factor survey questions, or the dental hygienist/assistant interviews the patient regarding any risk factors they may have. However the information is gathered, the goal is simply to identify factors that may be placing the patient at risk for dental decay. Based on the present risk factors, the dental professional will use this information to help guide them when recommending prescription/professional product therapies targeted for specific risk issues or making restorative or cosmetic recommendations.


Step 2: Bacterial Biofilm Imbalance/Biofilm Challenge

In order to assess if a patient has a current bacterial imbalance on their teeth, any bacterial testing will be done prior to any x-rays, cleaning, or oral examination. The most common biofilm challenge test is the CariScreen Caries Susceptibility Test, which is a simple and painless swab sample test from the biofilm on the teeth (See “The Science of ATP Testing”). The CariScreen test provides a numerical result between 0 and 9999. A reading of 1500 or higher is indicative of a patient with a bacterial biofilm imbalance or more specifically a biofilm challenge.

Many patients assume that if they get a high reading, it means they have cavities, while others believe that if they have cavities, they are guaranteed a high CariScreen result. But this is not always the case. A high CariScreen test result simply means there is an abundance of bacteria and/or cavity-causing bacteria on the teeth. A low CariScreen test result means there is a low quantity of bacteria and/or cavity-causing bacteria on the teeth.

Just as a patient with low cholesterol can have a heart attack, or a patient who quit smoking 5 years ago can be diagnosed with lung cancer, the signs/symptoms of a disease, in this case cavitation in the teeth, do not always occur immediately after a risk factor or imbalance is detected. Like many diseases, there are multiple factors that contribute to the development of signs/symptoms .A patient who suffers a heart attack may not have high cholesterol, but they may have high blood pressure or inflammation in their arteries. Similarly, a patient with cavities may have a saliva issue, making them more susceptible to tooth decay even though their biofilm challenge is low. Or a patient with a high biofilm challenge and no current decay may simply not have any detectible cavities yet. The dental professional will use other caries risk assessment information to decide if the CariScreen test results or any other bacterial test results are of concern. If a biofilm challenge is found, the practitioner will make recommendations for antibacterial therapy. If a biofilm challenge is not currently present, the practitioner will make recommendations based on other factors, and antibacterial therapy is not likely to provide a benefit for the patient.


Step 3: Disease Indicators

Disease indicators are signs of caries imbalance. Disease indicators include signs like new or progressing visible cavitations, new or progressing cavities detected by x-ray, new/active white spot lesions on the teeth, and a history (last 3 years) of decay. Having signs/symptoms of the disease, cavities present, or a history of decay is the best predictor of cavities in the future. Patients with a disease indicator found during their risk assessment have a 63.9–88% chance of new decay in the next 12 months without intervention.1

Because of the high likelihood of new decay if a disease indicator is found, practitioners make appropriate recommendations for reducing risk based on the patient’s risk factors, biofilm challenge, and disease indicators. Patients with disease indicators should take their practitioners’ therapy recommendations seriously. Not only do these patients have a very high likelihood of new decay in the next 12 months, but the current home care and therapy program they are using is obviously not providing enough protective factors to keep them in balance. Based on the patient’s decay history and severity, long-term therapy may be necessary to get the patient back into balance and stop the decay process. Most patients respond fairly quickly, showing progress within 1–2 follow-up appointments if they adhere to daily recommendations. Some patients may require multiple follow-up visits and therapy modification to reduce their risk.


  1.  Sophie Domejean, Joel M White, and John D. B. Featherstone, “Validation of the CDA CAMBRA Caries Risk Assessment —A Six-Year Retrospective Study,” J Calif Dent Assoc 39, no. 10 (2011): 709–15.

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