Cariogram E Book

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/326539271
Cariogram - A Multifactorial Risk Assessment Model for Dental Caries
Book · May 2018
CITATIONS READS
0 39
3 authors, including:
Ricky Pal Singh

I.T.S Centre for Dental Studies & Research
19 PUBLICATIONS 10 CITATIONS
SEE PROFILE
All content following this page was uploaded by Ricky Pal Singh on 21 July 2018.
The user has requested enhancement of the downloaded file.

!

"

"

"

#

" $

$ %& '$ ( ) % *&'(+

,

-. ' /

0" 12

#$ - /)
) $

3'

!
"
##$%
&!

!"#$

%
" !
&

' &
(
)*!
&
"
"*)+,-!

./
!0$'1% 213453%6#$&%7"$#% 75$
$4#&1
8&$&

8 9,): %
" !
&

' & (

"
"9,):

A deep sense of satisfaction filled me with the completion of my library
dissertation; more so, I feel a sense of gratitude towards all my mentors and well-
wishers whom I wish to thank.
It is with deep gratitude and humbleness that I wish to express my
indebtedness to my reverted teacher and guide Dr. B.K. Srivastava, Professor and
Head, Department of Preventive and Community Dentistry, Kothiwal Dental
College and Research Centre, Moradabad, for his sagacious guidance and
encouragement and also inculcating in me a quest for excellence, humility, honesty
and a high sense of professionalism. Above all his inspirational support has
provided just the right impetus for carrying out my library dissertation.
I also wish to express my indebtedness to my teacher and co-guide Dr.
Ramesh N. Professor, Department of Preventive and Community Dentistry,
Kothiwal Dental College and Research Centre, Moradabad, from whom I have
obtained guidance and help and have imbedded the importance of detail at work.
I express my deep sense of gratitude to Dr. Pradeep Tangade, Professor and
Dr. Ravishankar .T.L, Reader, Department of Preventive and Community Dentistry,
Kothiwal Dental College and Research Centre, Moradabad, from whom I have
obtained guidance and constant encouragement in my study.
I extend my thanks to the Principal Dr. Sanjay Singh, Mr. K.K. Misra,
Director, and Mr. Sanjay Sinha, Administrative Officer, Kothiwal Dental College
and Research Center for helping and giving valuable support to utilize the library
and information centers to complete out my work.
I am indebted to my parents and my friends for their encouragement and
support. Dr. AVNISH SINGH

CONTENTS
Page No.
Introduction 1
Objective 4
Concept of The Cariogram 5
Review of Literature 6
Discussion 24
The Cariogram 26
Cariogram Aims 29
Cariogram- the five sectors 30
Use of Cariogram model 39
Measures to reduce caries activity and caries risk 71
Conclusion 73
Bibliography 75
Introduction
During the period of primitive medicine and dentistry, literature was meagre;
so history fails to record with certainty that when and by whom dentistry was
practiced first. In 17th Century, dentistry originated in United States when several
³barber-dentists´ were sent from England. The practice of early dentists consisted
mainly of tooth extraction as dental caries at that time was considered a ³gangrene-
like´ disease.1 The practice of dentistry during the founding years was not based on
scientific knowledge. So dentists began to be educated in the basic sciences and
clinical dentistry, resulting in practioners who posed and showed intellectual and
scientific curiosity.
Though dental caries has affected human since pre-historic times, the
prevalence of this disease has increased greatly in modern times world-wide, an
increase which is strongly associated with dietary changes. It has been considered an
infectious, transmissible and probably the most common chronic disease in the world.
It is an important public health problem. Pain, disability, and handicap from dental
caries are common and the costs of treatment are a major burden to health care
systems. The aetiological factors of dental caries are largely known and although it is
preventable, it continues to exist in significant proportions. This scenario is partly
attributed to existing inequalities in oral health promotion with respect to different
populations; hence there is a need to adopt a more progressive approach to prevention.
It is a widespread problem along with periodontitis with considerable biological,
physiological, economical, social and psychological consequences.
Oral health being an important aspect of human well-being and quality of life,
treatment must be based on the most current scientific and clinical knowledge
available. There is scientific proof that dental caries can be managed and to a large
degree completely prevented. Nevertheless, the burden of oral disease is still
1
Introduction
excessive for many individuals: therefore, increased preventive efforts remain
necessary.
As we know, every disease is associated with agent or agents. The disease
agent may be unidentified for certain diseases. Where the disease agent is not firmly
established, the aetiology is generally discussed in terms of risk factors. Risk factors
are often suggestive, but absolute proof of cause and effect between a risk factor and
disease is usually lacking. Risk factors may be truly causative, they may be merely
contributory to the undesired outcome, or they may be predictive only in a statistical
sense. Dental caries is one such disease which is very complex in its nature; several
risk factors for dental caries have been identified and studied. Certain risk factors can
be modified, others cannot be modified. The modifiable risk factors are amenable to
intervention and are useful in the care of the individual. The unmodified or immutable
risk factors are quite challenging to health care professionals. The risk factors should
be comprehensively studied, tackled, modified so that the occurrence of dental caries
can be prevented.2
The risk for caries development varies significantly for different age groups,
individuals, teeth and tooth surfaces. Therefore, caries ± preventive measures be
integrated and must be based on predicted risk. The process of caries risk assessment
enables to identify those persons who will most likely develop caries; hence proper
preventive and curative measures can be implemented to prevent or at least slow
down the occurrence or progression of disease.
As we enter the new millennium, we must continue to concentrate our efforts
on preventing, controlling and arresting dental caries. However, needs-related
preventive and maintenance programs must be introduced and must be cost effective.
More emphasis have to be placed on skills such as diagnosis, pathophysiology,
2
Introduction
disease risk assessment and risk predictions at group, individual and tooth surface
levels.
Now, the question arises, what exactly the caries risk is and how caries risk
assessment may be performed for a patient. It is based on the view that the main
etiological factors for the dental caries are known and that these factors can be
identified and often modified to the benefit of the patient. To illustrate and assess
caries risk profile of an individual, a new concept is introduced, known as ³The
Cariogram´.
The Cariogram
This new model, the Cariogram, was presented in 1996 by Bratthall D, for
illustration of the interactions of caries-related factors. The model makes it possible
to single out individual risk or resistance factor. The original Cariogram was a circle
divided into three sectors, each representing factors strongly influencing carious
activity ± Diet, Bacteria and Susceptibility.3 Cariogram illustrates caries related
factors and suggests action to be taken. It can be a tool for motivating the patient, and
the model can also serve as a support for clinical decision making while selecting
preventive strategies for the patient.
3
Objective
To illustrate the use of the caries risk assessment computer-software
program ± The Cariogram.
4
Concept of The Cariogram
The Cariogram is an interactive computer program, first developed by
Bratthall D in 1996 and was further refined in the year 1997. It is a new approach to
caries risk assessment. It has similarities with Keyes¶ circles but differs in that it is
possible to single out the impact of individual risk factor.
The Cariogram presents a graphical picture that illustrates a possible overall
caries risk scenario. The program contains an algorithm that presents a µweighted¶
analysis of the input data, mainly biological factors. Furthermore, it expresses the
extent to which different etiological factors of caries affect the caries risk for a
particular individual and provides targeted strategies for those individuals.
For the Cariogram, the patient is examined and the data is collected for some
factors of direct relevance for caries, including bacteria-, diet-, and susceptibility-
related factors. The various factors/variables are given a score according to a
predetermined scale and entered in the computer program. According to its built-in
formula, the program presents a pie diagram where µbacteria¶ appears as a red sector,
µdiet¶ as a dark blue sector and µsusceptibility¶-related factors as a light blue sector. In
addition, some µcircumstances¶ are presented as a yellow sector. The four sectors take
their shares, and what is left appears as a green sector and represents the chance of
avoiding caries.
5
Review of Literature
Bratthall (1996)4 comprised a summarizing discussion for a set of 13 papers on the
theme caries decline. The complexity of the issue was highlighted, and it was
concluded that there was not one single factor explaining the changes observed.
Actually, in one and the same population, different explanations may be relevant for
different individuals, for different age groups, for different teeth and for different
periods of time. A new model for understanding the interaction of various caries
etiological factors was proposed. The model illustrated how in one situation caries
activity can increase (or decrease) due to one such factor, while in another situation
different factors were more important. As it, in a graphic way, maps the interactions
of relevant factors, the author has chosen to call it a cariogram, and the process of
preparing such graphs, cariography.
Petersson and Bratthall (2000)5 conducted a study to use the Cariogram program on
a set of patients, and compared the outcome of its risk evaluation with those made by
dental hygienists and dentists. A questionnaire, containing the descriptions of five
patients with detailed information on nine factors generally associated with caries
under the headings of: caries experience, related diseases, diet-contents, diet-
frequency, mutans streptococci and lactobacilli counts in saliva, fluoride program,
saliva secretion and saliva buffer capacity, were given to the participants. They were
asked to rank the patients according to their ³chance to avoid dental caries´ during the
coming year. The results were compared with the assessments obtained from the
Cariogram. 73.5% of the dental hygienists and 78.5% of the dentists ranked the
patients for caries risk either identically or with only one deviation when compared to
the Cariogram. It was concluded that the 'opinion' of the Cariogram on caries risk was
in agreement with that of the majority of the participants. In addition, the Cariogram
6
program induced discussions about the relative impact of etiological factors of caries.
It is envisaged that the Cariogram can serve as a tool in the teaching of caries risk.
Petersson et al (2002)6 conducted a study to assess the caries risk in schoolchildren
using the Cariogram and evaluated the program by comparing the caries risk
assessments with the actual caries increment in children over a 2 year period. They
took a study population of 438 individuals of age 10 ± 11 years who lived in and
around the city of Halmstad, situated on the west coast of Sweden. At the baseline the
study consisted of a questionnaire on diet, consumption of sweets, oral hygiene and
fluoride exposure. Saliva sampling was done to measure the secretion rate, buffering
capacity and mutans streptococci and lactobacilli counts. DMFT and DMFS were
calculated from records and bite-wing radiographs. These all informations were given
the Cariogram scores on predetermined criteria. These scores were entered in the
Cariogram and caries risk was assessed. Re±examination was done for actual caries
increment for each child after 2 years. The children were divided into 5 groups
according to the assessed caries risk at baseline. The Cariogram predicted a 0 ± 20%
(high risk), 21 ± 40%, 41 ± 60%, 61 ± 80%, 81 ± 100% (low risk) chance of avoiding
new lesions, 8, 35, 42, 73 and 83% respectively, had no new lesions 2 yrs later.
Logistic regression analyses were carried out using DMFS increment (caries/no
caries) during 2 years as the response variable. When the cariogram was included,
only two factors, the Cariogram (p<0.001) and the DMFS at baseline, i.e. past caries
experience (p=0.001), turned out to be significantly associated with caries increment.
When the Cariogram was excluded, lactobacillus count, mutans streptococci, diet
intake frequency and DMFS at baseline were significantly associated with caries
7
increment. The cariogram predicted caries increment more accurately than any
included single-factor model.
Petersson et al (2003)7 evaluated caries risk assessment computer program, the
Cariogram, by comparing the risk assessment of the program with the actual caries
increment in a group of elderly individuals over a period of 5 years. The study
population consisted of 148 individuals of Sweden on whom the incidence study was
performed on coronal and root caries. The participants were examined and
interviewed at baseline about their general health and dietary habits. Data on oral
hygiene and use of fluoride were obtained and saliva analysis included mutans
streptococci and lactobacilli counts, buffering capacity and secretion rate. DMFT and
DMFS were calculated, both at the baseline and 5 years later by clinical and
radiographic examinations. The information described above were given a score on a
predetermined criteria and entered into the Cariogram program to calculate the caries
risk for each individual and to assess the risk for further caries activity and express the
result ³as the chance of avoid caries´. Based on the baseline recordings, the
individuals were divide into 4 risk groups 0 - 20% (high risk), 21 - 40%, 41 ± 60%
and 61 - 100% (low/rather low risk) ³chance of avoiding caries´, according to the
Cariogram. The program predicted 13, 32, 23 and 48% respective to each group, had
no new DFS over 5 years and 18, 40, 72 and 84% respectively had no new lesions at
the 5th year. The mean DMFS increment over 5 years was 12.8 in the high/rather high
risk group (0 - 40% ³chance of avoiding caries´) which included 43% of the
individuals. In the low/rather low risk group (61 ± 100% ³chance of avoiding caries´),
the corresponding value was 5.2 where the group had 21% of the participants. The
mean DMFS increment for the whole group of the elderly individuals was 9.5. In this
8
study the Cariogram was able to sort the elderly individuals into risk groups that
reflected the actual caries outcome.
Abu-Alenain (2003)8 compared the out come of caries risk evaluation made by the
Cariogram program on a set of patients with those made by some clinicians in Jeddah.
A questionnaire-contained description of five patients was given to 70 dentists
working in the public health sector in Jeddah city. Detailed information of nine factors
generally associated with dental caries, under the headings of: caries experience,
related diseases, diet-contents, diet-frequency, mutans streptococci in saliva, fluoride
program, saliva secretion and saliva buffer capacity were provided for each patient.
The participants were asked to rank the patients according to caries risk starting with
the patient that has the highest chance to avoid cavities. The scores for the different
factors for the five patients were entered into the Cariogram and their "chance to
avoid caries" was calculated. According to the cariogram, case IV showed 94%, case
II 55%, case III 24%, case V l3%, case I 12% chance to avoid new cavities. This
means that the ranking order according to the cariogram was IV, II, III, V, I. The
results showed that 65.7% of the dentists ranked the patients for caries risk identically
as the cariogram with only one deviation to the program. About 25.7% and 8.6% of
dentists ranked only two and one cases, respectively, identical to the cariogram. There
was a significant correlation between the ranking order of the 65.7% of dentists and
the ranking order of the cariogram. While, there was no correlation between the
ranking order of the 25.7% and 8.6% groups of dentists and the ranking order of the
Cariogram. It was concluded that the Cariogram could be a reliable tool in risk
assessment that will give standardized results between different cases.
9
Peterson (2003)9 conducted studies to evaluate the Cariogram model and to
investigate if the program was in line with how colleagues, dental students and dental
hygienists would evaluate a set of cases. The first two studies (Paper I and II)
confirmed that the 'opinion' on the risk profile of the risk assessment program was in
line with the opinions of the majority of the responders in these groups. In the third
study (Paper III), the Cariogram assessments were tested against the "reality" for the
first time. The model was used to assess risk for caries among children and to evaluate
the program by comparing the caries risk assessments of the risk model with the
actual caries increment of the children over a two-year period. The hypothesis was
that the Cariogram should be able to sort the children into caries risk groups according
to the actual caries increment and the results confirmed the theory. It was also
demonstrated that the Cariogram assessed caries increment more accurately than any
included single factor model. Following the evaluation of the program on the children,
the aim of the fourth study (Paper IV) was to evaluate the model for risk assessment
in a group of elderly individuals. Comparing the caries risk assessment of the program
with the actual caries increment over a five-year period showed that the program was
able to arrange this group of elderly individuals into risk groups that reflected the
actual caries incidence. The aim of the fifth study was to compare the risk profiles of
the children with the risk profiles of the elderly. The evaluation of caries risk among
the children showed that 3% was considered having very high caries risk, while 50%
appeared in the low risk group. The corresponding values for the group of elderly
individuals were 26% and 2%. Overall, the risk for caries, as assessed by the
Cariogram, was twice as high for the elderly as for the children (V). The present study
also tries to explore the concept of risk, the terminology and definitions related to risk,
risk management and risk assessment in dentistry.
10
Petersson et al (2004)10 compared the caries risk profiles of children and elderly, in
relation to the actual annual caries increment and the impact of some selected caries
related factors. The risk profiles were created by a computerized risk assessment
program, the Cariogram, which evaluates data and presents the weighted and
summarized result as one figure, illustrating the ³percent chance of avoiding caries´
in the future. The data was originated from two separate longitudinal studies
illustrating the Cariogram's capacity to assess caries risk. One study comprised about
400 children and the other included about 150 elderly patients. At the baseline,
information on past caries experience, diet, oral hygiene and use of fluoride was
obtained. Saliva analysis included mutans streptococci and lactobacilli counts,
buffering capacity and secretion rate. The above information was interpreted into the
Cariogram scores on a predetermined criteria and the caries risk was assessed. After 2
and 5 years respectively, caries was re-evaluated and the incidence was compared
with the predictions. 50% of the children and only 2% of the elderly appeared in the
lowest caries risk group. Of the elderly, 26% belonged to the highest caries risk group
versus 3% of the children. The mean DFS increment per year for the total group of
children was 0.4 ± 0.8 (SD) and 1.2 ± 1.9 for the elderly. Individual factors
contributing significantly to the higher risk profiles for the adults were higher plaque
scores, higher counts of mutans streptococci and lower buffering capacity. Over all,
the risk for caries, as assessed by the Cariogram, was twice as high for the elderly.
Bratthall and Petersson (2005)11 conducted a study on multifactorial risk assessment
model for a multifactorial disease [dental caries] using the Cariogram. The cariogram
was evaluated in two large longitudinal studies in young children and in elderly, by
comparing the risk model with the actual caries increment over a 2 year period for
11
young children and 5 year period for elderly individuals. The study population
consisted of 438 young children of 10 ± 11 years of age and 208 elderly individuals in
the age groups of 55, 65 and 75 years. The risk assessment consisted of a
questionnaire on dietary habits and fluoride exposure, and saliva samples to measure
saliva secretion rate, buffer capacity, lactobacilli and mutans streptococci counts, and
estimation of oral hygiene and caries experience. Values were entered into the
cariogram - a computer program in order to calculate caries risk profile. Re-
examination for caries was performed after 2 years for young Children and 5 years for
elderly groups. The mean DMFT value of 438 children at baseline was 0.87 ± 1.35
(SD) and mean DMFT after 2 years follow-up was 1.38 ± 1.97 (SD). Cariogram
prediction showed that individuals in highest risk group showed a mean DMFT
increment of 1.67, while the lowest risk group had 0.23. Cariogram also predicted that
83% of the children in low-risk group had not developed any new caries lesions
whereas in the high risk group, 92% of the children developed new caries lesions. The
mean DMFT at baseline for the elderly group was 23.45 ± 4.19 and the
correspondence value for DMFS was 89.53 ± 25.07. Cariogram prediction showed
that individuals in highest risk group showed a mean DFS increment of 9.54, while
the lowest risk group had 1.74. Cariogram also predicted that 84% of the elders in
low-risk group had no new caries lesions whereas in the high risk group, it was 18%.
In conclusion, in both the studies, the Cariogram was able to sort the individuals into
risk groups that reflected the actual caries outcome.
Twetman et al (2005)12 investigated the relationship between caries risk and
glycosylated haemoglobin and evaluated the use of a computerized caries risk
assessment program as a predictor of metabolic control in schoolchildren with Type-I
12
diabetes mellitus. The study population consisted of 64 patients aged 8 - 16 years,
who were referred for treatment of acute Type-I diabetes to the Pediatric Clinic at the
Country Hospital in Halmstad, Sweden. After diagnosis, the disease was brought
under control according to a standard protocol with short-acting daytime insulin
(Actrapid) administered by Novapen in individual doses combined with medium-
acting insulin for night-time use (Insulatard). Within 2 weeks after the onset of
diabetes, a caries risk assessment was carried out for each individual, with the aid of a
computer program (the Cariogram). Nine biological and behavioural variables of
relevance for caries development were given scores according to predetermined scales
and entered into the program, which were compromised general health, past caries
experience, oral hygiene level, fluoride use, unfavorable dietary intake, saliva
secretion rate, salivary mutans streptococci, salivary lactobacilli and salivary buffer
capacity. According to a weighted formula, a pie diagram is presented in which the
chance of avoiding new caries is expressed as a percent. The patients were grouped
into 4 different Cariogram scores: 1 = low risk (100 ± 76% chance of avoiding caries),
2 = moderate risk (75 ± 51%); 3 = increased risk (26 ± 50%) and 4 = high risk (0 ±
25% chance of avoid caries). The data on the level of metabolic control were
collected from the medical records at the 3-year check-up. Caries increment was
registered at recall clinical examinations.
A statistically significant positive relationship between caries risk and metabolic
control was found (r = 0.51; p < 0.01), with a sevenfold increased risk of impaired
metabolic control after 3 years in those assessed with high caries risk at onset (OR =
7.3; P < 0.01). When the cariogram was used as a predictor for the metabolic state of
the disease, the sensitivity and specificity was 75% and 71%, respectively. The
negative predicted value was 91%. A statistically significant relationship between
13
caries risk and glycosylated haemoglobin was demonstrated in a group of young
people with type-I diabetes. The caries risk assessment at the diagnosis of diabetes
mellitus in children may be a good indicator of overall health care that can provide
useful prognostic information on the level of metabolic control after 3-years.
Tayanin et al (2005)13 conducted a study to analyze caries risk factors and illustrate
the caries risk profiles of 12 ± 13 year old children living in Laos, using the computer
program, the Cariogram. In their study they took 100 Laotian and 392 Swedish
children, and obtained information regarding diet intake and fluoride use through
questionnaire and they analyzed saliva for mutans streptococci and lactobacilli counts,
secretion rate and buffering capacity. Oral hygiene was assessed using the Silness and
Loe criteria and caries prevalence was recorded according to WHO criteria. The data
were entered into the cariogram to determine each child¶s caries risk, expressed as
³the chance of avoiding carries´. The children were divided in five risk groups. The
mean DMFT level of the Laotian children was 4.61±2.95 and 1.38±1.97 in the
Swedish group. For the risk factors, plaque amount, frequency of food intake, saliva
secretion rate, buffering capacity and fluoride, the Laotian children had significantly
less favorable values compared to the Swedish group. The mean DMFT for the five
cariogram groups was (from low to high risk) 0.00, 3.00, 3.56, 5.66, 6.11 for the Lao
children and 0.31, 1.39, 2.56, 3.03, 2.91 for the Swedish ones. The mean chance of
avoiding caries was 37.3% for the Laotians and 69.2% for the Swedish children (p <
0.001). According to the 'opinion' of the Cariogram, the Laotian children
demonstrated significantly higher caries risk than Swedish children.
14
Galaviz et al (2005)14 carried out a study to determine risk level for caries
development using the Cariogram. A total of 150 school children from 10-13 years of
age were selected randomly, from an elementary school in the urban zone of
Zacatecas, Mexico. Saliva samples were collected and tested using the
microbiological test to determine mutans streptococci and Lactobacilli counts, saliva
flow rate buffer capacity and clinical evaluation for dental health (DMFT). The
average DMFT was 1.55 ± 1.8. 45% of the population evaluated was caries free.
According to the Cariogram, the caries risk groups, high and moderate were higher in
males than females. For the whole sample, 50% are in low risk for caries development
and 8.66% is located in a high risk, according to the Cariogram. The study concluded
that the Cariogram can be used for prevention in healthy patients and for monitoring
in the case of patients with caries or with predisposition.
Giorghe et al (2005)15 reviewed the Cariogram model as a new concept, conceived
initially as an educational model, aiming at illustrating the multifactorial background
of dental caries in a simple way. This educational interactive program has been
developed for better understanding of the multifactorial aspects of dental caries and to
act as a guide in the attempts to estimate the caries risk. Caries risk is the probability
that an individual will develop carious lesions, reaching a given stage of the disease in
progression during a specified period of time, conditional that the exposure status for
risk factors remains stable during the period in question. For patients with high caries
risk, efforts should be made to increase the "chance" sector and reduce each sector
responsible for caries risk and particularly the unfavorable one.
15
Alain et al (2006)16 demonstrated the application of the Cariogram software in the
management of dental care for 3 elderly patients in Sweden. They collected patients
relevant information (on the caries experience, related general diseases, diet content,
diet frequency, amount of plaque, streptococcus mutans count in saliva, fluoride
program, saliva secretion rate and saliva buffering capacity) and then scored
according to a standardized protocol and entered into a computerized program called
the Cariogram. Based on the cariogram scores for each patient, the program predicted
12%, 22% and 27% ³chance to avoid caries´ in 1st, 2nd and 3rd patient respectively.
The Cariogram software program highlighted both the relevant caries-related factors
and the practical therapeutic interventions for all the 3 elderly patients.
Leous and Tikhonova (2006)17 evaluated the changes of the caries risk and the
weighted impact of different etiological factors on the risk after dental health
instruction in young people using the Cariogram. The study population consisted of
223 dental students aged 18 - 25 years, who were randomly selected and allocated to
experimental and control groups. All subjects were examined for caries risk
assessment at the baseline and after three months, by using the Cariogram. Data
collection included a clinical examination and a self-administered questionnaire. The
clinical examination comprised the DMFT level and oral hygiene status. The
questionnaire comprised the data on general health, caries incidence, diet and prior
fluoride exposure. The Method of Clinical Caries Rate Prediction (P. Leous 1990)
was used to determine the clinical findings indicating increased caries risk. Each
person of the experimental group was given visual presentation and detailed
information about caries risk factors according to the Cariogram. They were
motivated for the regular and careful oral hygiene, trained for tooth brushing and had
16
a diet counselling. The control group had the same oral hygiene instructions without
visual presentation of the Cariogram. After 3 months the re-examination was done.
The average caries risk at the baseline in experimental and control group was high
(75% and 73% respectively). After three months it decreased to moderate (49%)
among people of experimental group and stayed high (66%) in control group
(p<0.05). The ³Susceptibility´ and ³Diet´ factors (23% and 20% accordingly) ranked
first among weighted impacts on the caries risk at the baseline, ³Bacteria´ factor
(19%) ranked second and ³Circumstances´ factor (12%) ranked third. After 3 months
the Susceptibility factor (14%) among weighted impacts ranked first, "Bacteria" and
"Diet" factors (13% and 12% accordingly) ranked second and "Circumstances" factor
(9%) ranked third. This interactive predictive computer program the Cariogram
showed good results as a tool for revealing and removing caries risk factors.
Amila et al (2007)18 conducted a study to examine caries risk using the Cariogram
model, an interactive PC program for caries risk evaluation in 12-year-old children
and to correlate caries risk in children of different socioeconomic backgrounds. The
study population consists of 109, 12-year-old children from Sarajevo, the capital of
Bosnia and Herzegovina. They were divided in three groups, based on their
socioeconomic background (children with a high, middle and low socioeconomic
background). Baseline data on general health condition, diet frequency and use of
fluoride were obtained. DMFT and plaque scores (Silness and Loe plaque index) were
calculated. Saliva analyses included lactobacilli and mutans streptococci levels in
saliva, saliva secretion and buffer capacity. Scores were entered into the Cariogram
model and risk was calculated for each child. Most of the 12-year-old children had a
medium risk of caries, with a 59.4% chance of avoiding future caries. In the study
17
population the dominant sector, in the average caries risk profile of children was diet,
with 12.5% of risk; the bacteria sector (plaque and mutans streptococci level) was
10.8%; the susceptibility sector (fluoride programme, saliva secretion and buffering
capacity) was 9.7%; and the circumstances sector (caries experience and medical
history) was 7.4%. Caries risk profiles showed that there were differences in the
socioeconomic status of children with significantly greater risk in children with poor
living conditions who also had the most unfavorable caries risk profiles. The study
concluded that the Cariogram model can successfully determine caries risk profiles
for 12-year-old children of different socioeconomic status and can be used in
developing preventive strategies for reducing caries risk in children.
Miravet et al (2007)19 conducted a study to determine the caries risk of a population
by means of the Cariogram software, and examined the relationships between the
different variables used by the Cariogram and risk of caries determined by this
program. A cross-sectional study was conducted on a sample of 48 undergraduate 1st
year dental students at the University of Valencia. The data was collected by a
questionnaire on general health and oral hygiene habits like frequency of tooth
brushing and the use of fluoridated toothpaste and mouth washes. Clinical and
radiological examinations were done for calculating DMFT and DMFS. Plaque index
and saliva sampling for saliva buffer capacity, saliva secretion rate, mutans
streptococci and lactobacilli counts were done. The caries risk of each individual was
then obtained by drawing up the Cariogram. The caries risk obtained in each sector
was 6.0% for Diet, 5.75% for Bacteria, 6.65% for Susceptibility and 4.29% for
Circumstances. Overall, the caries risk was 22.81% and the chance to avoid caries
was 77.19%. Past caries experience, streptococcus mutans counts, fluoridation
18
programme and buffer capacity of the saliva were the factors included in the
Cariogram that showed significant correlation with the caries risk determined by the
program. Other factors that the Cariogram does not include directly, such as DMFT,
DMFS and the plaque index, also showed high correlation with risk. Linear regression
analysis makes it possible to draw up more simplified models from the predictive
variables with the highest correlation to caries risk. The predictive variable which
makes the greatest contribution to the model is streptococcus mutans counts, followed
by the DMFT index and the buffer capacity of the saliva. The Cariogram has shown
itself to be a complete method for determining caries risk and identifying the different
factors involved.
Stecksen-Blicks et al (2007)20 investigated the existing caries risk factors in
preschool children and illustrated their caries risk profiles graphically with an aid of a
computer-based program. All the children aged 2-year-old from a small town in
northern Sweden were invited and 87% (n = 125) accepted to participate. The data
was collected along with a questionnaire concerning the child's normal diet and sugar
consumption. Special care was taken to note the intake of sweet drinks and sugary
between-meal products. Questions on general health and medication, toothbrushing
frequency with parental help and use of fluorides were also included. The caries
prevalence was recorded with mouth mirror and probe and the level of oral mutans
streptococci was enumerated with a chair-side technique. The obtained data were
computerized in a risk assessment program (Cariogram) and a graphical profile of
each child was constructed. The caries prevalence was 6%, and 18% had detectable
levels of oral mutans streptococci. The sugar consumption was strikingly high with
82% and 97% having ice cream and sweets once a week or more often. In 22% of the
19
families, toothbrushing with parental help was not a daily routine. Of the children,
51% displayed a low chance (0-20%) of avoiding caries in the future. The frequency
of sugar consumption was the most pertinent factor in the children's caries risk
profiles. Half of the subjects exhibited a low chance of avoiding caries in the near
future and the strongest single factor was frequent sugar consumption. Therefore
efforts to limit and reduce the sugar intake in young children are important measures
for primary caries prevention.
Sonbul et al (2008)21 evaluated the caries profile in a group of Saudi adults with
several dental restorations by assessing various caries-related factors using the
Cariogram model. They correlated the Cariogram data expressed as ³the chance of
avoiding caries´, with initial caries lesions (DiS), total initial and manifest caries
lesions (Di+mS), and filled surfaces (FS). The study population consisted of 175
individuals in Saudi Arabia, aged between18 ± 56 years. All of them were interviewed
about their oral health, dietary habits and use of fluorides, and were examined for
dental caries, both clinically and radiographically. Salivary and microbiological
factor, including the number of mutans streptococci and lactobacillus, buffer capacity
and secretion rate were obtained using chair side tests. The individuals were divided
according to Cariogram data ³the chance of avoiding caries´ into four risk groups: 0-
20% ³high risk´, 21-40% ³medium risk´, 41-60% ³low risk´ and 61-100% ³very low
risk´. The mean number of teeth, total Di+mMFS, Di+mS and FS were 26.0, 53.8,
19.3 and 22.6 respectively. The mean ³chance of avoiding caries´ was 31%. ANOVA
revealed the statistically significant difference between the high risk group and the
other three risk groups with respect to Di+mS (p < 0.01) and FS (p < 0.05). The
mean DiS of the high risk group differed significantly from that of the low risk group
20
(p < 0.05). The Cariogram model can identify the caries-related factors that could be
the reasons for the estimated future caries risk, and therefore help the dentist or dental
hygienist to plan appropriate preventive and treatment measure in daily clinical
practice. In addition, there is a direct association between the categorized outcomes of
the Cariogram and DiS and Di+mS indices.
Hanganu and Murariu (2008)22 assessed the dental students caries risk by means of
the Cariogram software and examined the relationships between the caries related
factors and the risk of caries determined by this program. The study population
comprised of 112 dental students from five academic years, from the Faculty of
Dental Medicine in Iasi, Romania. The data was collected by questionnaire
(consisting questions on general health, dietary content, frequency of diet, oral
hygiene habits and fluoride program), saliva sample (consisting of saliva secretion
rate, saliva buffering capacity and mutans streptococci and lactobacilli counts) and by
clinical examination (DMFT, DMFS and Plaque index). These all informations were
assigned a Cariogram score on predetermined criteria which were entered into the
program. For each individual a Cariogram diagram was obtained which showed a pie
chart with five sectors that represented the different groups of factors linked to dental
caries. The caries risk of each individual was expressed as percentage of chance to
avoid caries in the Cariogram model. The caries risk obtained in each sector was 8.0%
for Diet, 7.65% for Bacteria, 9.35% for Susceptibility and 5.22% for Circumstances.
Overall, the caries risk was 28.88% and the chance to avoid caries 71.12%. Past caries
experience, Streptococcus mutans counts, fluoridation programme and buffer capacity
of the saliva were the main factors that showed significant correlation with the caries
risk determined by this software. Other variables that the Cariogram does not include
21
directly, such as DMFT, DMFS and the plaque index, also showed high correlation
with caries risk. Cariogram is a useful pedagogic tool for dentists, dental hygienists
and dental assistants in discussions with patients about their caries risk.
Holgerson et al (2009)23 validated caries risk profiles assessed by a computer
program against actual caries development in preschool children, by studying the
possible impact of a preventive program on the risk profiles and comparing the
individual risk profiles longitudinally. Caries risk was assessed in 125 two-year-old
children invited to participate in a 2-year caries-preventive trial with xylitol tablets. At
7 years of age, 103 were available for follow-up, 48 from the former intervention
group and 55 from the control group. At baseline and after 5 years, 7 variables
associated with caries were collected through clinical examinations and
questionnaires, and scored and computed with a risk assessment program
(Cariogram). Children assessed as having a "low chance (0-20%) of avoiding caries"
had significantly higher caries at 7 years of age compared to children with a lower
risk in the control group (p<0.05) but not in the intervention group. Overall predictive
accuracy and precision, however, were moderate in both groups. Less than half of the
children remained in the same risk category at both ages, despite a largely unchanged
consumption pattern of sugar. The majority of the children who changed category
displayed a lowered risk at 7 years. The intervention program seemed to impair the
predictive abilities of Cariogram. A modified Cariogram applied on preschool
children was not particularly useful in identifying high caries risk patients in a low-
caries community.
22
Al-Mulla et al (2009)24 conducted a study to analyze caries-related factors after
orthodontic treatment and to use the Cariogram computer program to describe caries
risk profiles at follow-up in these patients. The study population consisted of 100
orthodontic patients aged 12±29 years, with a mean age of 17.5 years from Riyadh,
Kingdom of Saudi Arabia. They were divided into two groups (50 in each) based on
their decayed, filled surfaces index (DFS). High (5 ')6DQGORZ DFS) groups
were created. All patients were examined after debonding in the following order:
plaque score, caries examination, saliva samples, bitewing radiographs, panoramic
radiographs, and intra-oral digital photos. All types of carious lesions in both the
enamel and dentine were diagnosed clinically and radiographically and included in
the DFS index. A paraffin-stimulated whole saliva sample was collected for
estimations of secretion rate, buffer capacity, and number of mutans streptococci and
lactobacilli. The DFS in the high caries group was more than 4 times higher than that
in the low caries group. The low caries group (2 DFS) displayed a statistically
significant difference and low values for the following factors, DFS (P < 0.001),
lactobacilli (P < 0.001), mutans streptococci (P < 0.001), and high Cariogram percent
(P < 0.001). The plaque index displayed very close significance (P = 0.051).
Regarding the Cariogram values, the ³chance of avoiding new cavities´ was 75% in
the low caries group and 42% in the high caries group (P < 0.001). Patients with high
DFS) numbers before orthodontic treatment had a higher risk of developing
caries. They had significantly higher numbers of mutans streptococci and lactobacilli
and had less chance of avoiding new cavities according to the Cariogram.
23
Discussion
Dental caries is a multifactorial disease in nature. The multifactorial model for
etiology of dental caries proposed by Keyes incorporates the role of Host, Agent,
Environment and Time factors, in causing dental caries. The development of dental
caries is a dynamic process of demineralization of the dental hard tissues by the
products of bacterial metabolism, alternating with periods of remineralization. This
pathologic process occurs on continuous basis, in which any lesion may range from
changes at the molecular level to gross tissue destruction and cavity formation.
Figure-1 The Process of Demineralization and Remineralization
A detail of a tooth (to the right = enamel).

It is covered by plaque, which consists
mainly of bacteria. Plaque is often found
close to the gum, in between teeth, in
fissures and at other "hidden" sites.
Demineralization:
When sugar and other fermentable
carbohydrates reaches the bacteria, they
form acids which start to dissolve the
enamel - an early caries lesion occurs due
to loss of Calcium and Phosphates
Remineralization:
When sugar consumption has ceased,
saliva can wash away sugars and buffer
the acids. Calcium and Phosphates can
again enter the tooth. The process is
strongly facilitated by fluorides.
A CAVITY occurs if the Demineralization "wins" over the Remineralization

over time
24
Discussion
Even though facts and figures on the several etiological and resistance factors
of caries have continuously been recorded during the past century, efforts to predict
the disease accurately have been only partly successful.25 During the last few decades,
numerous reports have dealt with the subject of caries risk assessment.26,27,28 Clearly,
to be able to predict which individual would develop cavities in the near future,
thereby enabling targeted preventive measures to be taken, would save precious
resources on costly treatment procedures.
Caries risk assessment studies have so far taken either of two major forms:
cross- sectional studies, where various caries related factors are identified, measured
and correlated to the actual caries status of the individual, i.e. to the past caries
experience; or longitudinal studies, where factors are related to the caries increment
over a period of time, usually 1-3 years.29
Data obtained from these cross-sectional and longitudinal studies are then
analyzed using a variety of statistical methods. In the early studies, researchers often
used simple correlation, while in more recent years, sensitivity/specificity and
predictive powers have been applied.30 Regarding sensitivity/specificity, the principle
is to use a specific cut-off value for the factor under investigation and to define a
special outcome of the test, such as a defined number of cavities that should be
present or appear after the selected period of time. However, this kind of approach has
generally not been very successful in presenting the required values for sensitivity and
specificity.
A more promising approach was observed in the famous University of North
Carolina Caries Risk Assessment Study, where advanced multiple regression analyses
were adopted. In spite of that, the success was only moderate.31 The multi-factorial
etiology of dental caries points to a risk assessment model that would include the
25
Discussion
different factors or parameters that accompany the development of new carious
lesions. Based on this concept, the Cariogram as a risk assessment model has been
proposed.
Many previous studies using the Cariogram have compared the µopinion¶ of
the program with those of dentists, dental instructors, dental hygienists and dental
students on a set of clinical cases. The results showed that the risk assessment
according to the Cariogram was in line with the opinions of the majority of these
groups.5
The idea of using several risk factors together is of course not new.32 The
unique property of the Cariogram is that each factor, in each group, is µweighted¶ for
its cumulative input and not just added. The program contains about 5 million
combinations of factors. Thus, the Cariogram considers the total pattern of risk
factors. For example, if a patient has one unfavorable factor, such as high sucrose
consumption, high mutans counts or poor oral hygiene, the individual is not
considered to have a particularly high caries risk. On the other hand, if all these
factors were unfavorable, the risk would be much higher, and obviously higher than if
the three individual risk values were added. If, then, in addition, saliva problems were
present and/or fluoride was not used, the risk would increase considerably.
Several studies have shown that social factors such as economic status and
education levels are related to caries experience and increment.33,34 These parameters,
however, are not directly included in the Cariogram model.
The Cariogram
The Cariogram is an interactive computer program, first developed by
Bratthall D in 1996 and was further refined in the year 1997. It is a new approach to
26
Discussion
caries risk assessment. It was originally developed as an educational model, in the
first place for discussions within the profession. Later on, the interactive version has
found a place in education of dental staff and for education and discussions with
patients concerning preventive strategies. The Cariogram has similarities with Keyes¶
circles but differs in that it is possible to single out the impact of individual risk
factors. In recent years, Hansel Petersson et al.6,7 has performed a series of studies to
evaluate the program.
The computer version of the Cariogram presents a graphical picture that
illustrates a possible overall caries risk scenario. The program contains an algorithm
that presents a µweighted¶ analysis of the input data, mainly biological factors (Table
1). Furthermore, it expresses the extent to which different etiological factors of caries
affect the caries risk for a particular individual and provides targeted strategies for
those individuals. The Cariogram does not specify the particular number of cavities
that will or will not occur in the future. It expresses caries risk only. It does not take
into account problems such as fractures of teeth or fillings, discolorations, etc. that
may make new fillings necessary.
This program cannot replace the personal and professional judgement of caries
risk made by the examiner. However, it may give valuable hints and may even serve
as a basis for discussions with the patient regarding various risk factors and
preventive strategies. In other words, it does not take over the judgement or the
responsibilities of the examiner, but may serve as a valuable tool in the clinical
decision-making.
27
Discussion
Table-1.Caries related factors according to the program
Variable Data used Score
Caries DMFT, DMFS and new 0: DMFT=0

Experience caries lesions in the last 1: good oral health status
year 2: normal oral health status
3: new caries in the past year
Related disease Questionnaire on general 0: No disease
Health 1: Disease/conditions, mild degree
(moderate influence on caries)
2: Severe degree, long-lasting (strong
influence on caries)
Diet, content Sugar content of diet (diet 0: Very low fermentable carbohydrate,
questionnaire) and /%ñ colony-forming units
Lactobacillus count (CFU)/ml
1: Low fermentable carbohydrate,
non-cariogenic diet, LB = 104
CFU/ml
2: Moderate fermentable carbohydrate
content, LB = 105 CFU/ml
3: High fermentable carbohydrate,
Intake of inappropriate diet,
/%6 CFU/ml
Diet, frequency Number of intakes/day 0: Maximum three meals/day (including
snacks)
1: Maximum five meals/day
2: Maximum seven meals/day
3: More than seven meals/day
Plaque amount Silness-Loe Plaque Index 0: Extremely good oral hygiene, PI <0.4
( PI) 1: Good oral hygiene, PI = 0.4 - 1.0
2: Less than good oral hygiene,
PI=1.1 - 2.0
3: Poor oral hygiene, PI > 2.0
Streptococcus CRT Bacteria (Caries Risk 0: Strep. mutans class 0

Mutans count Test) culture 1: Strep. mutans class 1
2: Strep. mutans class 2
3: Strep. mutans class 3
Fluoridation Oral health questionnaire 0: Fluoride toothpaste plus constant
Program use of additional measures
1: Fluoride toothpaste plus infrequently
additional Fluoride measures
2: Fluoride toothpaste only
3: Avoiding fluorides, no fluoride
28
Discussion
Saliva secretion Stimulated saliva 0: Normal saliva secretion, >1.1ml/min.

- amount 1: Low, 0.9 - 1.1 ml stimulated
saliva/min.
2: Low, 0.5- 0.9 ml saliva/min.
3: Very low, Xerostomia, <0.5 ml
Saliva/min.
Saliva buffer CRT Buffer (Caries Risk 0: Adequate, Dentobuff blue;

Capacity Test Buffer) Normal or good buffer capacity,
Saliva - pH > 6.0
1: Reduced, Dentobuff green; Less
than good buffer capacity,
Saliva - pH = 4.5-5.5
2: Low, Dentobuff yellow; Low
Buffer capacity, Saliva ± pH <4.0
Cariogram ± aims
,OOXVWUDWHVWKHLQWHUDFWLRQRIFDULHVUHODWHGIDFWRUV.
,OOXVWUDWHVWKHFKDQFHWRDYRLGFDULHV
([SUHVVHVFDULHVULVNJUDSKLFDOO\
5HFRPPHQGVWDUJHWHGSUHYHQWLYHDFWLRQV
&DQEHXVHGLQWKHFOLQLF
&DQEHXVHGDVDQHGXFDWLRQDOSURJUDPPH
How is a Cariogram created?
The patient is examined and data collected for some factors of direct relevance
for caries, including bacteria-, diet-, and susceptibility-related factors. The various
factors/variables are given a score according to a predetermined scale and entered in
the computer program. According to its built-in formula, the program presents a pie
diagram where µbacteria¶ appears as a red sector, µdiet¶ as a dark blue sector and
µsusceptibility¶-related factors as a light blue sector. In addition, some µcircumstances¶
are presented as a yellow sector. The four sectors take their shares, and what is left
appears as a green sector and represents the chance of avoiding caries.
29
Discussion
Cariogram - the five sectors
The Cariogram, a pie circle-diagram, is divided into five sectors, in the
following colours: green, dark blue, red, light blue and yellow indicating the different
groups of factors related to dental caries.
Figure-2 The five sectors of the Cariogram
The green sector shows an estimation of the µActual chance to avoid new cavities¶.
The green sector is µwhat is left¶ when the other factors have taken their share.
The dark blue sector µDiet¶ is based on a combination of diet contents and diet
frequency.
The red sector µBacteria¶ is based on a combination of amount of plaque and mutans
streptococci.
The light blue sector µSusceptibility¶ is based on a combination of fluoride program,
saliva secretion and saliva buffer capacity.
The yellow sector µCircumstances¶ is based on a combination of past caries
experience and related diseases.
30
Discussion
Figure-3. What makes Sectors Small or Large?
The Red sector increases if there is a lot of

plaque, if there is a high proportion of extra
cariogenic bacteria in the plaque (such as mutans
streptococci and lactobacilli).
The Red sector decreases if there is a good oral

hygiene and if there is a low proportion of
cariogenic bacteria in the plaque.
The Blue sector increases if there is a high and

frequent intake of sugar and other easily
fermentable carbohydrates.
The Blue sector decreases if there is a low and

infrequent intake of sugar and other easily
fermentable carbohydrates.
The Light blue sector increases if susceptibility

is high, for example due to low exposure to
fluorides, low saliva secretion, low buffering
capacity of saliva.
The Light blue sector decreases if susceptibility

is low, for example due to proper exposure to
fluorides, normal saliva secretion, good buffering
capacity of saliva.
The bigger the green sector, the better it is from a dental health point of view.
Small green sector means low chance of avoiding caries = high caries risk. For
the other sectors, the smaller the sector, the better from a dental health point of
view.
In summary, the Cariogram shows whether the patient over all is at high,
intermediate or at low risk for caries. It also shows for every individual examined,
which etiological factors are considered responsible for the caries risk.
31
Discussion
Caries risk
Generally speaking, µrisk¶ is the probability that some harmful event will
occur. Risk is often defined as the probability of an µunwanted¶ event occurring within
a specified period of time. Caries risk is the probability that an individual will develop
carious lesions, reaching a given stage of the disease in progression during a specified
period of time, conditional that the exposure status for risk factors remains stable
during the period in question. Thus, Caries risk relates to the likelihood of a person
developing caries lesions or not.
Figure-4. Interactions - Risk for caries
All sectors have been reduced indicating sugar

discipline, plaque control and increased
resistance to disease.
Result: Reduced risk for cavities.
Same as above, but the three "gaps" have been

placed together.
Picture illustrates a large "gap", meaning a low

risk for caries.
With all factors under good control, the risk

can be very low. In a situation as illustrated,
there is no problem, for example, to increase
sugar consumption. There is a clear "safety
sector" before cavities occur.
32
Discussion
A small gap illustrates high risk. A slight

change will result in cavities. For example, a
decrease in saliva secretion, an increase in
sugar consumption, a less good oral hygiene
will close the gap.
An extreme situation. The figure illustrates that

some factors can be so prominent that they in
fact would have formed a larger sector. In this
case, a slight improvement is not enough,
radical improvements are needed. The case
illustrated has a high caries activity with
several new cavities per year. Diet factor is
strongly negative, and plaque contains high
proportions of mutans streptococci and
lactobacilli.
Therefore, the need for predicting the caries risk accurately is obvious, as
targeted preventive actions can be directed to those having a high caries risk, before
cavities could develop. Naturally, if the main etiological factors could be identified,
suitable treatment for that particular individual can be carried out with good results.
Which factors are to be considered in the estimation of caries risk?
These factors can be divided into two groups:
)DFWRUV LPPHGLDWHO\ LQYROYHG LQ WKH FDULHV SURFHVV HLWKHU DV µattack¶ or µdefence¶
mechanisms, at the site of the development of the lesion. To this group, on the attack
side, the dental plaque, the presence of various specific micro-organisms in the plaque
(including mutans streptococci) and the diet can be included. On the defence side for
example, the salivary protective systems and the fluoride exposure can be
incorporated. These are key factors determining if a caries lesion will occur or not, at
the specific tooth surface they are interacting.
33
Discussion
)DFWRUV UHODWHG WR WKH RFFXUUHQFH RI FDULHV ZLWKRXW DFWXDOO\ SDUWLFLSDWLQJ LQ WKH
development of the lesion. To this group for example various socio-economic factors
and past caries experience can be added. Such factors can be designated as indicators
of caries risk, but do not participate actually in the µmaking¶ of a cavity.
The Cariogram is basically built on the first group of factors. This does not
mean that the second group is ignored as these factors indirectly contribute to changes
in the factors in the first group. For example, poor socio-economic factors can affect
both oral hygiene and the diet of an individual negatively.
Factors, to which the tooth surface is directly exposed and which contribute to
the development of the caries lesion, are dependent on µdose¶, µfrequency¶ and
µduration¶. Each factor therefore has to be considered from this point of view. For
example, a large amount of plaque (high dose) only indicates high risk if present often
(high frequency) and for a longer period of time (long duration).
µWeights¶ - the relative impact of factors
The factors included in the Cariogram have been given different µweights¶.
This means that the key factors, which support the development of caries, or resist
caries, have a stronger impact than the less important factors when the program
calculates the µChance to avoid new cavities¶. The factors are also weighted in
relation to each other. Thus, different factors have different µweights¶ in different
situations and the number of combinations of factors is enormous. The given weights
are based on thorough search in the literature and evaluation of results in a large
number of scientific publications. In addition, clinical experience gained from decades
of use of saliva tests has been incorporated. However, it should be understood that
there are no actual scientific studies available that have evaluated all the factors at the
34
Discussion
same time, for different age groups and for different areas. Caries risk evaluations
cannot be made with mathematical exactness. For example, it is impossible to say
with 100 per cent certainty that ³this patient will definitely develop five cavities
during the coming year´. On the other hand, it is possible to say that ³based on
available information it seems very likely that this patient will develop several
cavities during the coming year ± with this combination of caries related factors,
cavities usually develop´. The Cariogram concept is an attempt to illustrate how a
large set of data can be evaluated - based on both science and art.
What does µChance to avoid caries¶ really imply?
The µChance to avoid caries¶ (green sector) and caries risk are explanations for
the same process but expressed inversely. When the chance is high, the risk is small
and vice versa.
CARIES RISK CHANCE TO AVOID CARIOGRAM

CARIES
High risk = Low chance = Small green sector
Low risk = High chance = Large green sector
If the Cariogram shows for example, that there was an 80 % chance to avoid caries,
taking into account all the factors, it means an over all 80 % chance in avoiding new
caries in the future. The caries activity will be low provided the patient does not
change his/her behaviour and biological factors on which the judgement was based
on.
The size of the "Chance" sector is determined by the four other factors - it is
³what is left´ when the others have taken their shares, for examples:
35
Discussion
Example 1. High caries risk - only a 5% chance to avoid cavities
The "Chance" is similar in the three Cariograms above, but the reasons are different.
Left: All factors add to the high risk.

Middle: Bacteria (Red) in particular unfavourable.
Right: Susceptibility (Light-blue) in particular unfavourable.
Example 2. Caries risk ± a 25% chance to avoid cavities
Again, the "Chance" is similar in the three Cariograms above, but the reasons are
different.
Left: Diet factor in particular favourable.

Middle: Bacteria in particular favourable
Right: Susceptibility in particular favourable.
Example 3. Low caries risk - 60% chance to avoid cavities
The "Chance" is similar in the three Cariograms, but the reasons are different.
Left: All factors reduced, resulting in reduced caries risk.

Middle: Although Diet is unfavourable, the other factors compensate for that.
36
Discussion
Right: Circumstances in particular unfavourable - for example, there has been a very
high past caries experience, but due to improvements in the other factors, the situation
has been brought under control.
From the given examples we can understand that different factors have different
"weights".
The program, in a normal case, never shows 0 % or 100 % chance to avoid
caries (should the figures appear, it is because of decimal rounding up). Needless to
say, the caries risk assessment is complex and one has to be cautious when
interpreting.
Is the Cariogram a risk model or a prediction model?
Actually, it is both because it acts as a prediction model that predicts who is at
high risk, and it is a risk model identifying the risk factors to facilitate planning of
interventions. A risk model is used when it is important to identify one or more risk
factors for the disease so that likely points for intervention can be planned. A risk
model, therefore, should exclude risk predictors such as past disease, number of teeth,
etc., as such factors do not cause further disease. A prediction model, on the contrary,
is used when one is mainly interested in identifying who is at high risk.
Is the algorithm of the Cariogram based solely on µevidence-based¶ studies?
No, there are too few studies of that kind to make it possible. Therefore, data
from many other studies and even case reports have affected the final formula. In
addition, the method of using metaanalyses for a multifactorial disease can give
misleading results. For example, the impact (weight) for caries incidence of sugar
consumption is much higher in a country with limited use of fluoride toothpastes
when compared with those countries where fluoride toothpaste, plus other fluoride
37
Discussion
exposures, are widely used. The Cariogram algorithm is built on FF&C, in other
words, taking into account µfull facts and circumstances¶. In doing so, one tries to
define the circumstances under which a particular factor should be given high-,
medium- or low-risk input. The algorithm is based on considerations such as, for
example, µa cariogenic diet is more µµdangerous¶¶ if there is abundant plaque
containing cariogenic bacteria¶ or µlow saliva secretion rate is particularly dangerous
if several other factors are unfavourable¶. Thus, the idea is to combine factors that are
related to caries incidence.
What is the sensitivity and specificity of the Cariogram?
Calculating such values demands µcut-off¶ points and the Cariogram does not
have such a point. As risk is defined as the probability that some harmful event will
occur, therefore, risk is expressed as a fraction, without units. It takes values from 0
(absolute certainty that there is no risk, which can never be shown) to 1.0, where there
is absolute certainty that a risk will occur. Values between 0 and 1 represent the
probability that a risk will occur. In other words, the Cariogram expresses a
probability. For example, µ90% chance of avoiding caries¶ means that most people
with that particular combination of risk factors would stay without new cavities. If a
person, anyway developed caries with that probability, the program is not µwrong¶ as
it has not said µ100%¶.
Why use the Cariogram model?
The answer depends on who is asking. For a practicing dentist in an
industrialized country, an answer could be: it is a prediction/risk assessment model
that can be used in the daily routine of the clinic. It illustrates caries-related factors
and suggests actions to take. The tests needed can easily be performed and evaluated
38
Discussion
by the dental personnel. The model is affordable, user-friendly, and easy to
understand by anyone. It can be a tool for motivating the patient and the model can
also serve as a support for clinical decision making when selecting preventive
strategies for the patient.
How to use the Cariogram model?
Start program
The Cariogram program runs on PC Windows only. The computer should
have a colour screen. The Internet Version can be downloaded from this address:
http://www.db.od.mah.se/car/cariogram/cariograminfo.html35
Following the instructions given on that page we can start by clicking the µCariogram¶
symbol.
Hints - informative text
There are several µhints¶, informative texts, in the program. Point at the related
texts, figures or icons and if there are informative texts behind, they appear after a few
seconds.
Figure-5
39
Discussion
We do not have to click for the hint but just point. These hints are very useful, for
example, in giving scores for the different factors when building a Cariogram.
Functions
By clicking at the icons in the upper left corner of the screen we get
information about the following functions:
1. 2. 3. 4. 5. 6. 7.
Figure-6
1. Exit - if we want to close the program.
2. New - if we want to get a new empty screen (for a new patient).
3. About - to get facts about the program.
4. Help - to get more information on how to run the program.
5. Notes - to register and write comments on our patient.
6. Preliminary interpretation and proposed measures - targeted preventive and clinical
actions we can take, based on the scores we enter.
7. Print - to print the Cariogram or the recommendations.
The last two functions do not get activated until a Cariogram appears on the screen.
Identifying (registering) our patient
Also shown in the upper left of the program, just below the icons, are the data
needed (name, identification number, date of examination and name of the examiner)
to register and identify our patient.
40
Discussion
Figure-7
Click open the µnotes¶ icon above and enter the information for every patient we
examine. We can also add our own observations in the space given under µcomments¶.
This is only necessary if we would like to maintain records of our patients and to
avoid mix-up of patient records. Close notes by clicking µOK¶.
Figure-8
The details we just entered on the patient will appear on the upper left corner of the
screen as shown below. This information cannot be saved in the program. It is
suggested to print the patient information and maintain together with patient's records.
41
Discussion
Figure-9
New screen
To get a fresh new screen after entering data for every patient, we need to
click the µNew¶ icon, which is second in the upper left corner of the screen.
Colours of the different sectors
To the left, at the bottom of the screen, we can find the different sectors of the
Cariogram. Each sector, as mentioned already, has its own colour and represents a
group of factors.
Figure-10
Hints appear if we move the cursor to the coloured squares or to the accompanying
text and will give us an explanation as to which factor represents which sector.
42
Discussion
Settings for µCountry/Area¶
The impact of different caries related factors may differ between different
countries/areas depending on several background informations. µStandard set¶ is most
suitable for an industrialised country without water fluoridation.
Figure-11
The examiner may want the Cariogram to continuously express somewhat higher or
lower µChances to avoid cavities¶ than the standard set and could choose for
Country/Area µLow risk¶ or µHigh risk¶ accordingly. Thus, the µChance to avoid
cavities' becomes bigger or smaller respectively, but the relationship between the
factors Diet/Bacteria/Susceptibility/Circumstances is not affected.
Settings for µGroup¶
A patient may belong to a µgroup¶ with higher or lower caries risk compared to
the general population in the area. For example: Elderly patients with exposed root
surfaces have higher risk and the setting µHigh risk¶ is appropriate.
43
Discussion
Figure-12
If we use the Cariogram to investigate a special group or a population, pre-set µGroup¶
to Standard set, Low risk or High risk according to the group we have in mind.
Giving scores for the different factors
To build a Cariogram, scores for the caries related factors are entered in the
boxes on the right side of the screen. Again, hints appear when the cursor points at the
text or the scores. We can move the cursor to the respective ranges 0-3 or 0-2 and
choose our score (0, 1, 2, or 3) most suitable for our patient. We need to click on the
µarrow¶ to choose the right score (start with upward pointing arrow).
Figure-13
44
Discussion
Estimation of the caries risk. How to build the Cariogram?
In order to see a Cariogram develop in the screen, the examiner must give a
score for the different factors, shown in the right hand side of the screen. The
examiner has to gather information accurately by interview and by examining the
patient. In certain components of the sectors, like saliva and bacteria, further standard
diagnostic test results are needed to give the correct score to build the Cariogram in
the screen. The examiner should have all the relevant information when using this
program so as to get an accurate Cariogram reflecting the particular patient¶s caries
profile.
Figure-14
45
Discussion
Figures-15
We can enter the relevant scores in the boxes to the right by using µup¶ or
µdown¶ arrows (if no scores in the box, that is if the box is blank, start with µup¶
arrow). If we wish to check as to what exactly the scores mean for the appropriate
factor, a quick reference is shown when we move the cursor to the respective ranges
of 0-3 or 0-2. For all factors, µ0¶ is the best value and µ3¶ (or µ2¶ where 2 is the
maximum) is the most unfavorable score. A Cariogram will appear in the middle of
the screen when at least 7 scores have been entered in the boxes. There are 10 caries
related factors and it is therefore possible to enter 10 scores in this program, but the
Cariogram would already appear when only 7 scores have been entered.
The score for the µClinical Feeling¶ will automatically come up as µ1¶, which
is the standard. This means that the program estimates the caries risk on basis of the
other entered values. Only if the operator finds special reasons to abandon the
program's point of view, another score can be entered here.
46
Discussion
If any score is missing in the boxes, a pre-set value will be used (for the
remaining boxes when seven boxes have been filled). Any unfilled box thus makes
the program less specific. To obtain reliable and accurate results it is therefore best to
enter as many scores as possible instead of depending on pre-set values in the
program.
The µChance to avoid cavities¶- green sector- will appear as a value between 0
and 100 %. It cannot be negative or more than 100%. It is a favourable situation for
the patient if the green sector (chance to avoid caries) is large. A green sector of 75%
or more would indicate a very good chance to avoid new cavities in the coming year,
if conditions are unchanged. A green sector of 25% or less indicates a very high caries
risk.
Preliminary interpretation and proposed measures
A set of suggestions for targeted actions in the form of proposed measures can
be found if we click on the icon µPreliminary interpretation' in the upper left corner. It
should be understood that these are some suggestions only and do not give a full
picture of all possibilities. The responsible examiner must decide if suggested actions,
or other actions, are to be carried out or not. Note that the order of the points is not
related to their order of importance.
The Cariogram also helps us to illustrate and explain the situation to the
patient. For µhigh risk¶ patients we can discuss which of the factors the patient is
willing to change and what measures the dental team could consider. We can use the
Cariogram as an inspiration for the patient to make his/her own efforts and
demonstrate the patient how the caries risk can be reduced, that is to make the green
sector bigger, by just changing scores (to the right) for the different factors.
47
Discussion
Figure-16
Print out
The program has a print-out function in black and white and colour. We can
choose to print:
7KH&DULRJUDPLQcluding our own notes
3UHOLPLQDU\LQWHUSUHWDWLRQDQGSURSRVHGPHDVXUHV
Figure-17
When printing, we should choose if both or only one of the two alternatives
can be printed out.
48
Discussion
The patient's registration data (if we have entered it) will also be printed on the
preliminary interpretations to avoid mix-up with other patients. Therefore, we suggest
adding the patient's name, identification number and date of examination for every
patient before printing.
To print in colour, the colour printer must in advance be set as the standard
printer.
Although tested in many settings, it cannot be guaranteed that the print-out
function will work on all combinations of computers/printers. It is also dependent on
the settings of the printer and its graphical capacity. If the PC has a limited memory
capacity, it may be necessary to do separate print outs, that is do not mark print out
for both Cariogram and Preliminary interpretation at the same time.
Save
The Cariogram software has no particular µSave function¶. If we want to save
any of our comments under µNotes¶ in the Cariogram, we need to copy them to our
normal word processor (we need to use the following commands: Mark the text, use
Ctrl+c, open page in word processor, insert by Ctrl+v). If we need to hand over the
print out to the patient, it is a good idea to keep a second print out together with our
records of the patient. If we do so, we must remember to enter the patient¶s name,
identification number and date.
There is a way to save a picture of a completed Cariogram in a word
processor: When the Cariogram is filling up the screen, press µPrint screen¶, then
press µCtrl + c¶, then open a page in the Word program and paste it into a page with
µCtrl + v¶. Of course, the Cariogram is not interactive in this form. (Recommended
commands in this section may not apply to all computers).
49
Discussion
Explanation for the scores to be entered
Caries experience (caries prevalence)
Score Explanation
0 = Caries free and no Completely caries-free, no previous fillings,
fillings no cavities or M-missing teeth due to caries.
1 = Better than normal Better than normal - better status than
normal, for that age group in that area.
2 = Normal for age group Normal status for that age group.
3 = Worse than normal Worse status than normal for age group, or
several new caries-lesions the last year.
The examiner must have an opinion about the caries prevalence in the
country/area where the patient lives to choose the right score. If there is no adequate
actual epidemiological data, we must use the information in the figure-18 for
comparison.
At the clinical examination, number of cavities, fillings and missing teeth
should be recorded. The presence of cavities and fillings, the µcaries prevalence¶ is an
important factor as it illustrates how the balance between resistance factors and caries
inducing factors has been in the past, or may be at present. If the caries prevalence is
high, it means that the patient has been susceptible to the disease during a past period
of time.
DMFT and DMFS are means to numerically express the caries prevalence and
are obtained by calculating the number of Decayed (D), Missing (M) and Filled (F)
teeth (T) or surfaces (S).
It is thus used to get an estimation illustrating how much the dentition so far
has become affected by dental caries. Usually, it is calculated on 28 teeth, excluding
18, 28, 38 and 48 from the index.
50
Discussion
The older the patient is, the more unsafe is the DMF-T as a picture of the
patients caries situation, as several teeth could have been extracted because of reasons
other than caries, for example periodontal disease.
A more detailed index is DMF calculated per tooth surface, DMFS. Molars
and premolars are considered having 5 surfaces, front teeth 4 surfaces. A surface with
both caries and filling is scored as D. Maximum value for DMFS comes to 128 (third
molars are excluded).
Reference values
There is actually no "normal" level of caries, as different populations have
different caries prevalence. In using the Cariogram, local epidemiological surveys can
be used. In the next page there is an example from Sweden and from the UK.
Figure-18 DMFT values for different age groups based on the so called Jonkoping¶s
epidemiological survey in 1993.
51
Discussion
The blue curve in the middle represents values from the Jonkoping, Sweden,
survey and represents a mean value for different age groups in that area.
,IWKHSDWLHQWKDVD'0)7YDOXHDERYHWKHXSSHUUHGFXUYHLWZLOOEHFODVVLILHGDV
µworse¶ than µnormal¶.
,I WKH SDWLHQW KDV D '0)7 EHORZ WKH ORZHU JUHHQ FXUYH LW ZLOO EH FODVVLILHG DV
µbetter than normal¶.
'0)7EHWZHHQWKHJUHHQDQGWKHUHGcurves will be classified as µnormal¶. Observe
though, that with the ongoing dental health improvement the area µnormal¶ will
continuously change for the better.
Example: A 30-year-old man with a DMFT = 11 will be as normal for his age group.
A 45-year-old with a DMFT = 13 is µbetter than normal¶. A 55-year-old with a
DMFT = 25 is µworse than normal¶.
The values given in the diagram represent figures for a country surrounding
and including a medium size city in the middle of South Sweden. This data is
compatible for several Western European countries. However, the DMFT value for
the younger age groups such as 20 and 30 maybe less by about 2 DMFT due to the
improving caries situation seen in the young.
Related general diseases
Score Explanation
0 = No disease There are no signs of general diseases of importance
related to dental caries. The patient is µhealthy¶.
1 = Disease/conditions, A general disease, which can indirectly influence the

mild degree caries process, or other conditions which can
contribute to higher caries risk, e.g. poor eye-sight,
inability to move.
52
Discussion
2 = Severe degree, Patient could be bed-ridden or may need continuous

long-lasting medication which could affect the saliva secretion.
Several general diseases or conditions can directly or indirectly influence the
caries process, either through affecting saliva formation and composition, through a
caries-inducing dietary pattern or through medicines. Diseases or conditions in early
childhood may have influenced the formation of the enamel.
For example:
Autoimmune diseases, like Sjogren's syndrome.
Intake of medicines.
Radiation towards the head-neck region.
Other problems and handicaps should be taken into consideration. For
example, poor eye-sight may affect correct oral hygiene measures. Handicapped
patients could have difficulties in cleaning their teeth properly.
Diet, contents
Score Explanation
0 = Very low fermentable Very low fermentable carbohydrate,
Carbohydrate extremely µgood¶ diet from the caries point
of view. Sugars or other caries-inducing
carbohydrates on a very low level. Lowest
lactobacillus class needed to support a zero.
1 = Low fermentable carbohydrate, Low fermentable carbohydrate, µnon-

µnon-cariogenic¶ diet cariogenic¶ diet, appropriate diet from a
caries perspective. Sugars or other caries
inducing carbohydrates on a low level. Diet,
as for an µinformed¶ group.
53
Discussion
2 = Moderate fermentable Moderate fermentable carbohydrate content.

Carbohydrate content Diet with relatively high content of sugars
or other caries inducing carbohydrates.
3 = High fermentable carbohydrate Inappropriate diet from a caries perspective.

intake inappropriate diet High intake of sugar or other caries
inducing carbohydrates.
Diet plays a key role in the development of dental caries, and a correlation
between consumption of fermentable carbohydrates and caries has been demonstrated
in several studies, especially where an effective preventive fluoride program is absent.
Fermentable carbohydrates include dietary sugars (mainly sucrose, glucose, fructose)
and cooked starches, which can be broken down rapidly by salivary amylase to
fermentable sugars (glucose, maltose and maltotriose). Thus most eating occasions are
potentially cariogenic. However, there are different types of artificial sweeteners and
sugar substitutes such as cyclamate, asparatame, saccharin and sugar alcohols like
sorbitol, xylitol and isomalt that are non-cariogenic.
A good support for diet counselling is the use of saliva tests, like the
lactobacillus test. A high lactobacillus count may indicate high carbohydrate
consumption. Retention areas, open cavities or bad fillings could contribute to a high
lactobacillus count. One way of measuring lactobacilli is using the µDentocult® LB¶
method. {See section "Estimation of lactobacilli in saliva" for more detailed
information about the test in the clinic.}
Diet, frequency
Score Explanation
0 = Maximum three meals per Very low diet intake frequency, a maximum of
day (including snacks) three times per 24 hour as a mean under a
longer time period.
54
Discussion
1 = Maximum five meals per day Low diet intake frequency, a maximum of five
times per 24 hour, as a mean.
2 = Maximum seven meals per High diet intake frequency, a maximum of
day seven times per 24 hour, as a mean.
3 = More than seven meals per Very high diet intake frequency, a mean of
day more than seven times per 24 hour.
Frequency of intake of fermentable carbohydrates is one of the key factors in
the estimation of caries risk. Even a small snack - a biscuit or a sweet - contributes to
acid production. There are several methods available by which a patient can be
evaluated. For example: intake frequency questionnaire, the interview method (24-h
recall) where we can search for a typical dietary pattern in an ordinary day's intake
and the dietary record method (usually three days record) where the patient writes
down the amount and type of diet for three ordinary days including a weekend day
(avoiding birthdays and festival days).
Plaque, amount
Score Explanation
0 = Extremely good oral hygiene, No plaque, all teeth surfaces are very clean.
Plaque Index, PI < 0.4 Very µoral hygiene conscious¶ patient, uses
both tooth brush and inter- dental cleaning
aids.
1 = Good oral hygiene, A film of plaque adhering to the free gingival

PI = 0.4-1.0 margin and adjacent area of the tooth. The
plaque may be seen in situ only after
application of disclosing solution or by using
the probe on the tooth surface.
2 = Less than good oral hygiene, Moderate accumulation of soft deposits,

PI = 1.1- 2.0 which can be seen with the naked eye.
55
Discussion
3 = Poor oral hygiene, Abundance of soft matter within the gingival

PI > 2.0 pocket and/or on the tooth and gingival
margin. The patient is not interested in
cleaning the teeth or has difficulties in
cleaning. You feel like cleaning his/her teeth
thoroughly, professionally and immediately!
Plaque is the direct and important etiological factor for caries (and
periodontitis). Different indices could be used to estimate the amount of plaque, for
example, to express in per cent how many surfaces are affected. If we use another
criteria other than the Plaque Index used in the table above, then we need to convert
our scores to a scale of four with µ0¶ for the best score and µ3¶ for the most
unfavourable situation.
Mutans streptococci
Score Explanation
0 = Strip mutans class 0 Very low or zero amount of mutans streptococci in
saliva. Only about 5% of the tooth surface
colonised by the bacteria.
1 = Strip mutans class 1 Low levels of mutans streptococci in saliva. About

20% of the tooth surfaces colonised by the bacteria.
2 = Strip mutans class 2 High amount of mutans streptococci in saliva.

About 60% of the tooth surfaces colonised by the
bacteria.
3= Strip mutans class 3 Very high amounts of mutans streptococci in the
saliva. More than 80% of the tooth surfaces
colonised by the bacteria.
Mutans streptococci refer to a group of bacteria, mainly Streptococcus mutans
and Streptococcus sobrinus, considered to play a particular active role in the
development of caries, especially in the early stages of the lesion formation. They
grow on solid surfaces in the mouth, that is teeth or on crowns, bridges or dentures.
56
Discussion
Strip mutans class 0 does not mean exactly that the patient is completely free from
this bacterial species.
Mutans streptococci are acidogenic and aciduric, meaning that they can produce acids
which can dissolve the tooth substance and that they can survive and even produce
acids in a low pH environment. They can also produce extracellular glucans, which
helps them to adhere to the tooth surfaces.
Fluoride programme
Score Explanation
0 = Receives µmaximum¶ fluoride Fluoride toothpaste plus constant use of
programme additional measures - tablets or rinsings and
varnishes. A µmaximum¶ fluoride program.
1 = Additional F measures, Fluoride toothpaste plus some additional

infrequently measures - tablets or rinsings and varnishes
infrequently.
2 = Fluoride toothpaste only Fluoride toothpaste only, no supplements.
3 = Avoiding fluorides, no fluoride Avoiding fluorides, not using fluoride

toothpastes or other fluoride measures.
Fluoride is a very strong factor inducing resistance to caries and of importance
for remineralization of early caries lesions. Unfortunately there is no simple test
available to estimate the fluorides in the mouth which means that the relevant
information on fluorides has to be obtained by patient interviews only.
Saliva secretion - amount
Score Explanation
0 = Normal saliva secretion Normal saliva secretion, more than 1.1 ml
stimulated saliva per minute.
1 = Low, 0.9 - 1.1 ml stimulated Low, from 0.9 to less than 1.1 ml stimulated
saliva/min saliva per minute.
57
Discussion
2 = Low, 0.5- 0.9 ml saliva/min Low, from 0.5 to less than 0.9 ml stimulated
saliva per minute.
3= Very low, Xerostomia, <0.5 ml Very low saliva secretion, dry mouth, less
saliva/min than 0.5 ml saliva per minute; problem judged
to be long-standing
Estimation of the saliva flow rate (amount of saliva) can be done in the clinic
using simple methods. The patient¶s subjective symptoms of a dry mouth, lack of
saliva, and saliva volumes are not always correct, and an objective test method is
recommended.
If a reduced flow is recorded, one can normally expect that not only the amount but
also the quality of the saliva is changed to the worse. Medication, radiation therapy to
head and neck that affect the salivary glands, salivary stones, anorexia nervosa,
autoimmune diseases and diabetes mellitus are examples of reasons for the low
secretion rate. We must try to judge if the low secretion rate is of a temporary cause or
if it is long-lasting. We must choose the values from the table above so that they can
represent the saliva secretion rate over a long period of time.
In measuring saliva flow rate, one can either choose µunstimulated¶ or µstimulated¶
saliva secretion. They are often but not always co-related. If one is uncertain, both
types of saliva should be measured.
Saliva buffer capacity
Score Explanation
0 = Adequate, Dentobuff blue Normal or good buffer capacity, Saliva end -
pH > 6.0
1 = Reduced, Dentobuff green Less than good buffer capacity, Saliva end- pH
4.5-5.5
2= Low, Dentobuff yellow Low buffer capacity, Saliva end - pH <4.0
58
Discussion
The saliva has several important protective functions, both for teeth and for
oral mucosal surfaces. In particular, its clearance of food debris, sugars and acids
from the oral cavity is important for caries protection. Several buffer systems try to
keep pH close to neutral. Buffer capacity is one saliva factor that can be measured.
A simple chairside method called Dentobuff ® Strip can be used to measure the saliva
buffering capacity.
Clinical judgement
It is the opinion of the dental examiner, i.e. µThe clinical feeling¶.
Score Explanation
0 = More positive than what the The total impression of the caries situation,
Cariogram shows based on including social factors, gives a positive view,
the scores entered more positive than what the Cariogram seems
to indicate. The examiner would like to make
the green sector bigger, i.e. improve the
µChance to avoid caries¶ for the patient.
1= Normal setting! Risk The total impression of the caries situation,

according to the other values including social factors, gives a view, in line
entered with what the tests and the other factors seem to
indicate and points to the same caries risk as in
the Cariogram. The examiner does not have any
reason to change the program's inbuilt
evaluation.
2= Worse than what the The total impression of the caries situation,
Cariogram shows based on including social factors, points in the direction
the scores entered of increased caries risk. Less than good
compared to what the tests and the other factors
seem to indicate. The examiner would like to
make the green sector smaller, which is to
reduce the µChance to avoid caries¶.
59
Discussion
3 = Very high caries risk, The total impression of the caries situation,
examiner is convinced that including social factors, is very bad. The
caries will develop, examiner is very sure that caries will occur the
irrespective of what the coming year and would want the green sector to
Cariogram shows based on be minimal, irrespective of the Cariogram
the scores entered results. The examiner overrules the program's
inbuilt estimation.
This factor is on a principle that is different from the other factors. It gives an
opportunity for the examiner to express his/her µClinical feeling¶, if the opinion
differs from the program's inbuilt estimation.
µClinical judgement¶ is automatically pre-set to score 1. That value will let the
other factors express the µchance to avoid new cavities¶ according to the program. If
we have a reason to believe that the µChances¶ are better or worse, we can change to
lower or higher values respectively.
If one wishes to change the µclinical feeling¶ (not agree to the normal setting)
it should be done last. In other words, let the Cariogram build-up from the other
factors and then include the score for judgement. Naturally, if there is a valid reason
pointing to disagree (better or worse) with the Cariogram result, scoring accurately for
the clinical judgement is very relevant.
Reasons that could affect the clinical feeling and motivate for other score than
µ1¶ could be the examiners opinion of the patient¶s interest for preventive actions,
her/his capacity to understand given advice, the examiner¶s opinion of the rightness
of, for example, the diet situation, judgement of clinical examination or if the test
results actually reflect the condition over a long period of time.
The score µ0¶could be taken into consideration if other preventive actions have
been installed which are not expressed in the factors of the program. The score µ3¶ has
60
Discussion
the greatest input (weight) of all the factors of the program, it means that we actually
do not need the Cariogram, because we overrule the judgement of the program.
At the same time, the possibility to use the score µ3¶ shows that the examiner
has the final responsibility of the total judgement. The score µ0¶ does not have the
corresponding great positive input (weight) because it is not reasonable to believe that
the caries risk could be non-existent if several bad factors are present.
Saliva and bacteriological test methods
The tests should be done in the beginning of a treatment session or at a
separate occasion and at least an hour after a meal, toothbrushing or smoking. It is
important that the patient is relaxed and calm. The patient should not be sick or unfit.
The tests should not be done in the middle of a treatment procedure for example after
an injection with local anaesthesia or after cavity preparation. The patient should not
be on any antibiotics during the past one month.
Estimation of the rate of flow of µstimulated¶ saliva
Materials needed for the test: Paraffin and measuring cup or glass.
1. The patient should neither eat nor smoke for one hour prior to sampling.
2. The patient should be seated in an upright, relaxed position.
3. A paraffin pellet is given to the patient to chew for 30 seconds, then to spit out the
accumulated saliva or swallow it.
4. The patient then continues to chew for five minutes, with the accumulated saliva
collected continuously into a measuring glass. Time could be reduced if secretion rate
is high, prolonged if rate is low.
61
Discussion
5. After 5 minutes, the amount of saliva is measured and the secretion rate calculated.
Example: 3.5 ml in 5 min = 0.7 ml/min
Normal saliva secretion is more than approximately 1 ml/min.
If all the tests are performed at the same occasion, the practical order should be:
Measure secretion rate
Use some of the collected saliva for buffer capacity
6WULSPXWDQVWHVW
Use remaining saliva for lactobacillus test.
Evaluation of the saliva buffer capacity
Dentobuff Strip is a quick and easy way to determine salivary buffering
capacity. An indicator system incorporated in the test strip changes colour, clearly
showing the buffer capacity of the saliva. The test is done as following:
1. Place a Dentobuff test strip, test pad facing up, on an absorbent surface like a paper
towel, without touching the test pad.
2. Use the enclosed pipette to apply a drop of stimulated saliva to the test pad, enough
to cover the entire pad.
3. After exactly 5-minute reaction time, compare the colour that has developed on the
test pad with the Dentobuff Strip Colour Chart.
Low Medium High
Figure-19
62
Discussion
When a drop of collected saliva is added to the test pad of the strip, the saliva
starts to dissolve acids which have been dried into the test pad, which also contains
pH sensitive dyes. This test system discriminates between low (yellow), medium
(green) and high (blue) buffer capacity.
The colour reaction can be uneven or mixed. In that case, evaluate buffer
capacity according to the colour indicating the lowest value. If reaction is difficult to
interpret, repeat the test.
Estimation of Mutans streptococci in saliva
Dentocult SM is used to estimate the Streptococcus mutans count in saliva.
The method is based on the use of a selective culture broth and the adherence of
mutans streptococci to the test strip.
Method:
1. Take a bacitracin disc from the vial using a forceps or a needle. Do not forget to
close the cap tightly back.
2. Put the bacitracin disc into the culture broth vial and let it stand for at least 15
minutes.
3. Give the patient a paraffin pellet to chew for at least one minute. Chewing results in
mutans bacteria moving from the tooth surfaces to the saliva.
4. Take one strip mutans test from the container, touching only the square end. Insert
2/3 of the strip into the patient¶s mouth and rotate it on the surface of the tongue for
about 10 times. The strip should not be rubbed on the tongue, only wetted well.
5. Remove the Strip mutans from the tongue, pulling it between closed lips in order to
remove any excess saliva.
63
Discussion
6. Place the Strip mutans in the culture medium. The cap should remain 1/4 open.
Hold the vial upright.
7. Fill in the data on the patient label and attach it to the vial.
8. Place the culture vial in an incubator at 35-37 ºC (95-99 ºF) and incubate for 48
hours.
After incubation allow the test strip to dry and evaluate the strip now or later.
The strip can be conserved for several years.
The number of mutans streptococci per ml saliva is obtained by comparing the
test strip with evaluation chart and then classified as ±
0 1 2 3
Figure-20
The so-called Strip Mutans test is based on the ability of mutans streptococci to
grow on solid surface in combination with a selective broth (high sucrose concentration in
combination with bacitracin). As the bacitracin can be added to the broth just before use,
the shelf-life of the test can be prolonged considerably. Colony density, CFU/ml, is then
counted. Four classes are used for this bacterial test.
Estimation of lactobacilli in saliva
Dentocult LB is a dip-slide method for estimating the salivary lactobacillus
count. It consists of a slide with a selective substrate for Lactobacillus.
64
Discussion
Method:
1. Let the patient chew on the enclosed paraffin pellet for at least one minute (if saliva
is not already collected for secretion rate assessment).
2. Collect the stimulated saliva in the test tube.
3. Remove the nutrient medium from the culture vial without touching the agar
surfaces.
4. Pour saliva from the test tube over both agar surfaces, making sure that they are
totally wetted.
5. Allow the excess saliva to drip off, then screw the slide tightly back into the culture
vial.
6. Write the patient's name and date of sampling on the enclosed label and stick it on
the culture vial.
7. Place the culture vial in an upright position in an incubator for four days at 35
ºC/95 ºF.
After incubation - remove the nutrient agar slide from the culture vial after
four days. Compare the colony density on the agar surfaces with the densities of the
model chart.
3 4 5 6
10 10 10 10
Figure-21
Other microorganism can grow on Dentocult. Often that is not a big problem if
the slide is incubated in an incubator. If incubated in room temperature, the risk for
growing of yeast-fungus increases.
65
Discussion
Plaque Index (PI) according to Silness-Loe
As a suitable index to estimate the amount of plaque, we have chosen Plaque
Index, PI, according to Silness and Loe. PI assesses the amount of plaque in the
cervical part of the tooth. Four sites on each tooth are recorded, buccal, lingual and
proximal surfaces.
PI 0= No plaque
PI 1= A film of plaque adhering to the free gingival margin and adjacent area of the
tooth. The plaque may be seen in situ only after application of disclosing
solution or by using the probe on the tooth surface.
PI 2= Moderate accumulation of soft deposits within the gingival pocket or on the
tooth and gingival margin which can be seen with the naked eye.
PI 3= Abundance of soft matter within the gingival pocket and/or on the tooth and
gingival margin.
The Index for the four surfaces is summarized and split by 4, which gives an
index for the tooth. If the index for all teeth are summarized and split by the number
of included teeth, we get the index for the patient. In the original article Silness and
Loe used six teeth: 16, 12, 24 and 36, 32, 44.36
The measurement could of course include all teeth to give a more
representative value. The use of a disclosing solution is recommended to visualise
plaque bacteria to the patient, and it also makes it easier to record.
If we use a % index, for example expressing the % (percentage) of how many
tooth surfaces are covered with plaque, we should try to express the values to a scale
of four grades. An example:
PI =0 Less than 5% plaque adhering

surfaces.
PI =1 5-20 % plaque adhering surfaces.
66
Discussion
PI =2 More than 20-50% plaque adhering

surfaces.
PI =3 More than 50% plaque adhering
surfaces.
Caries risk assessment ± examples of 4-case reports
Example 1. Very High caries risk - only a 2% chance to avoid cavities
The case illustrated above has a normal caries experience (given score 2) for his age
group and a disease (handicap) which is considered being of some relevance (score 1)
for the caries activity.
Diet content of sugars is fairly high (score 2) with a frequency of 7 intakes per day,
including between meal snacks (score 2).
Oral hygiene (plaque amount) is fairly good (score 1) but the level of mutans
streptococci is very high (Strip mutans score 3).
Fluoride exposure consists of fluoride from toothpaste only (score 2), no extra
supplements. Saliva secretion is very low (Xerostomia, score 3) and saliva buffer
capacity is somewhat reduced (Dentobuff Green, score 1).
The combination of factors is evaluated as that the risk for new cavities in the coming
year is very high. The low saliva secretion rate in combination with the cariogenic
diet and the high level of mutans streptococci makes it urgent to introduce preventive
measures. The low saliva secretion has a heavy impact - that's why the light-blue
sector in this case is so large.
67
Discussion
Example 2. Very High caries risk - a 18% chance to avoid cavities
Example-2 is a case which illustrates a normal caries experience (2) for his age group
and no disease (handicap) which is considered being of relevance (0) for the caries
activity.
Diet content of sugars is fairly high (2) with more than 7 intakes per day, including
between meal snacks (3).
Oral hygiene (plaque amount) is less good (score 2) and the level of mutans
streptococci is fairly high (Strip mutans score 2).
Fluoride exposure consists of fluoride from toothpaste only (2), no extra supplements.
Saliva secretion is normal (0) and saliva buffer also normal (Dentobuff Blue, score 0).
year is very high, although not as high as in Example 1. The cariogenic diet and the
high level of mutans streptococci in combination with less good oral hygiene makes it
urgent to introduce preventive measures.
68
Discussion
Example 3. A rather low caries risk - a 62% chance to avoid cavities
The case illustrated above has a normal caries experience (2) for his age group and no
disease (handicap) which is considered being of relevance (0) for the caries activity.
Diet content of sugars is fairly high (2) but frequency of intakes rather low, max 5
intakes per day, including between meal snacks (1).
Oral hygiene (plaque amount) is less good (score 2) and but the level of mutans
streptococci is rather low (Strip mutans score 1).
Fluoride exposure consists of fluoride from toothpaste only (2), no extra supplements.
year is rather low. The fairly low diet frequency is important in combination with low
mutans streptococci levels. Some actions to further decrease the caries risk are
recommended.
69
Discussion
Example 4. Very low caries risk - 94% chance to avoid cavities
The case illustrated above has less caries experience (1) than what is normal for his
age group and no disease (handicap) which is considered being of relevance (0) for
the caries activity.
Diet content of sugars is fairly low (1) and frequency of intakes also rather low, max 5
intakes per day, including between meal snacks (1).
Oral hygiene (plaque amount) is good (1) and the level of mutans streptococci is low
(Strip mutans score 1).
Fluoride exposure consists of fluoride from toothpaste, plus extra supplements (1).
year is very low. The diet is fine from a cariological point of view, oral hygiene is
good in combination with low mutans streptococci levels and there is a supplementary
fluoride program. Actions to decrease the caries risk further are not necessary.
70
Discussion
Measures to Reduce Caries Activity and Caries Risk
Sector Patient measures Dental personnel measures
To reduce the Red sector - the Dental personnel can analyze the
plaque factor - a proper oral situation by identifying sites often
hygiene is needed. covered with dental plaque, and
instruct how to improve the situation
Toothbrushing twice a day there.
can be seen as a minimum
and where indicated, further Further on, it is possible to analyze
measures should be installed the microbial flora to estimate the
after instructions from oral proportions of extra cariogenic
health personnel. microorganisms such as mutans
streptococci and lactobacilli. Advice
Parents can be observant so can be given how to avoid high
their children will have a proportions of such microorganisms.
chance to adopt a low-
cariogenic plaque covering as Dental plaque situation can be
little as possible of the teeth improved by repeated professional
mechanical tooth-cleaning. Where
indicated, various antimicrobial
solutions or varnishes, for example
containing chlorhexidine, can be
applied professionally to reduce
numbers of cariogenic
microorganisms. Patients can be
instructed to follow up the treatment
by proper home care.
To reduce the Blue sector - Dental personnel can analyze the

the diet/sugar factor - a "sugar situation by discussing the dietary
discipline" is needed. That patterns and by identifying products
means to avoid "un- that should be avoided or reduced.
necessary" frequent intakes of
sugar containing snacks. Use Further on, it is possible, by
of sugar substitutes in sweets analyzing the microbial flora for
can be recommended. lactobacilli, to get an idea about the
cariogenicity of the food with respect
Parents can be observant so to sugar content. Advice can be given
their children will have a how to reduce the blue sector by
chance to adopt a proper diet proper diet. Information regarding
both from a general health as sugar-free substitutes can be given.
well as a dental aspect.
To reduce the susceptibility Dental personnel can analyze the

and increase the resistance to situation by checking saliva
caries disease, the patient properties, in particular to control if
should have a proper fluoride saliva secretion rate is normal and if
exposure, for example from buffering capacity is functioning. If
71
Discussion
tooth pastes. In addition, any of these properties are failing,

various fluoride supplements dental personnel can help in
can be used after advice from identifying reasons (for example
dental personnel. drugs) and if possible try to improve
the situation. Saliva substitutes can
Diet which promotes normal be recommended in extreme
saliva secretion rate by proper situations.
chewing is to recommend.
For fluoride, dental personnel can
prescribe or recommend proper
supplements. The fluoride
concentration at tooth surfaces can be
strongly increased by applications
from professionally administered
products such as fluoride varnishes,
gels or solutions. Patients can be
instructed to follow up these
treatments by proper home care.
In many cases, the measures performed by the patient should be enough to
keep the caries disease under control after having received proper instructions. In
more severe cases, professional measures are needed and the degree of risk factors
and disease outcome will decide the intensity of the actions.
When the disease comes under control, the professional measures can step by
step be reduced. Saliva samples can often help in deciding when the situation is
significantly improved.
For elderly patients, patients with handicaps or patients with special problems
repeated professional support for prolonged period of times may be needed,
sometimes life-long.
72
Conclusion
As people are living longer and retaining more natural teeth than was the case
for previous generations, oral health care providers must remain attentive to caries
risk factors and the effective management of caries throughout the lifespan.
Numerous caries risk prediction and evaluation models have been developed
which are all designed to evaluate the caries risk in a patient or a population as
accurately as possible, but none has predominated over the others. The Cariogram, is
considered one of the most reliable model for predicting caries risk in an individual
because it is an objective, quantitative method that uses a computer program to
calculate the data, with results that can be printed out and saved. Another advantage is
that it makes a series of recommendations for preventive action according to the
caries risk. The pie chart presentation with its different sectors makes it easier for
patients to understand, so increases their motivation and their comprehension of the
factors that are having or could have a negative effect on their oral health.
The Cariogram software program highlights both relevant caries-related
factors and practical therapeutic interventions for the patients. Past caries experience,
Streptococcus mutans counts, fluoridation programme and buffer capacity of the
saliva are the main factors included in the Cariogram that shows significant
correlation with the caries risk determined by this software. Other variables that the
Cariogram does not include directly, such as DMFT, DMFS and the plaque index,
also shows high correlation with caries risk. The Cariogram show if the patient over
all is at high, intermediate or at low risk for caries. It also shows for every individual
examined, which etiological factors are considered responsible for the caries risk. The
results also indicate where targeted actions to improve the situation will have the best
effect.
73
Conclusion
The Cariogram model has been evaluated in scientific studies of both children
and adults, including elderly persons. It is a useful pedagogic tool for dentists, dental
hygienists and dental assistants in discussions with patients about their caries risk.
Today, the Cariogram program is used in several dental schools in Sweden. Given the
oral health challenges facing people who live in institutions, expansion to the long-
term care setting seems particularly promising. The Cariogram program complements
the current trend toward computerized record-keeping and management of clinical
data, which is especially helpful in the management of a multifactorial disease such as
caries.
The importance of properly predicting the occurrence of lesions is obvious as
targeted preventive actions can be directed to those persons having a high risk for
caries, and scarce resources can be properly utilized. In addition, as dentistry moves
toward earlier detection of lesions and a more preventive, rather than restorative,
orientation, good risk assessment will be essential for improving the predictive values
of new screening and diagnostic methods by pre-selecting at risk subpopulations. The
use of cariogram can be a reliable tool in risk assessment that will give standardized
results between different cases. The use of the program can also serve as a basis for
discussion with colleagues about the relative impact of different caries etiological
factors and preventive strategies. In addition to that, it can give valuable hints and
may serve as a basis for treatment planning of particular patient and preventive
strategies needed for each patient.
74
Bibliography
1. Roberson TM, Heymann HO and Swift EJ. Sturdevant¶s Art and Science of
Operative Dentistry. Elsevier publication. 5th edition 2006; Pg.5.
2. K.Park. Preventive and Social Medicine. M/S Banarsidas Bhanot publication.19th
edition 2005; Pg.34-35.
3. Peterson A. Diagnosis and Risk Prediction of dental caries. Quintessence
publishing Co, Inc. 2000; Pg172.
4. Bratthall D. Dental caries: intervened--interrupted--interpreted. Concluding
remarks and cariography. Eur J Oral Sci 1996;104(4):486-491.
5. Petersson GH and Bratthall D. Caries risk assessment: a comparison between the
computer program 'Cariogram', dental hygienists and dentists. Swed Dent J.
2000;24(4):129-137.
6. Petersson GH, Twetman S and Bratthall D. Evaluation of a computer program
for caries risk assessment in schoolchildren. Caries Res 2002;36:327-340.
7. Petersson GH, Fure S and Bratthall D. Evaluation of a computer-based caries
risk assessment program in an elderly group of individuals. Acta Odontol Scand
2003;61:164-171.
8. Abu-Alenain DA. Reliability of a Cariogram model as caries risk assessment tool.
Cairo Dental Journal 2003;19(2):165-169.
9. Petersson GH. Assessing caries risk--using the Cariogram model. Swed Dent J
2003;27(Suppl.158):1-65.
10. Petersson GH, Fure S, Twetman S and Bratthall D. Comparing caries risk
factors and risk profiles between children and elderly. Swed Dent J. 2004;28(3):119-
128.
75
Bibliography
11. Bratthall D and Petersson GH. Cariogram ± a multifactorial risk assessment
model for a multifactorial disease. Community Dent Oral Epidemiol 2005;33:256-
264.
12. Twetman S, Petersson GH and Bratthall D. Caries risk assessment as a
predictor of metabolic control in young Type 1 diabetics. Diabet Med 2005;22:312-
315.
13. Tayanin GL, Petersson GH and Bratthall D. Caries risk profiles of 12-13-year-
old children in Laos and Sweden. Oral Health Prev Dent 2005;3(1):15-23.
14. Galaviz LAA, Padilla MP, Esparza SF, Medina MCA, Escobedo JM, and
Flores AA. The use of Cariogram in caries risk level determination in schoolchildren
in Zacatecas, Mexico. Odontologica 2005;2(1):42-51.
15. Giorghe A, Vataman R and Pancu G. The cariogram principle applied to the
patients with high caries risk. Rev Med Chir Soc Med Nat Iasi 2005;109(3):660-663.
16. 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±463.
17. Leous P and Tikhonova S. Caries risk assessment in young people based on the
³Cariogram´. OHDMBSC 2006;5(1):7-11.
18. Amila Z, Sedin K and Maida G. Caries risk assessment in Bosnian children
using Cariogram computer model. Int Dent J 2007;57:177-183.
19. Miravet AR, Company JMM and Silla JMA. Evaluation of caries risk in a
young adult population. Med Oral Patol Oral Cir Bucal 2007;12:E412-418.
20. Stecksen-Blicks C, Holgerson PL and Twetman S. Caries risk profiles in two-
year-old children from northern Sweden. Oral Health Prev Dent. 2007;5(3):215-221.
21. Sonbul H, Al-Otaibi M and Birkhed D. Risk profile of adults with several
dental restorations using the Cariogram model. Acta Odont Scand 2008;66:351-357.
76
Bibliography
22. Hanganu C and Murariu A. Caries risk assessment in dental students from Iasi,
Romania. OHDMBSC 2008;7(3):42-47.
23. Holgerson PL, Twetman S and Stecksen-Blicks C. Validation of an age-
modified caries risk assessment program (Cariogram) in preschool children. Acta
Odontol Scand. 2009;16:1-7.
24. Al Mulla AH, Al Kharsa S, Kjellberg H and Birkhed D. Caries risk profiles in
orthodontic patients at follow-up using Cariogram. Angle Orthodontist
2009;79(2):323-330.
25. Stewart PW and Stamm JW. Classification tree prediction models for dental
caries from clinical, microbiological and interview data. J Dent Res1991;70(9):1239-
1251.
26. Tinanoff N. Dental caries risk assessment and prevention. Dent Clin North Am
1995;39(4):709-719.
27. Moss ME and Zero DT. An overview of caries risk assessment, and its potential
utility. J Dent Educ1995;59:932-940.
28. Abernathy JR, Graves RC, Bohannan HM, Stamm JW, Greenberg BG and
Disney JA. Development and application of a prediction model for dental caries.
Community Dental Oral Epidemiol 1987;15:24-28.
29. Hausen H. Caries prediction ± state of the art. Community Dent Oral Epidemiol
1997;25:87-96.
30. Douglass CW. Risk assessment in dentistry. J Dent Educ 1998;62(10):756-761.
31. Beck JD, Weintraub JA, Disney JA, Graves RC, Stamm JW, Kaste LM et al.
University of North Carolina Caries Risk Assessment Study: Comparisons of high
risk prediction, any risk prediction, and any risk etiological models. Community Dent
Oral Epidemiol 1992;20:313-321.
77
Bibliography
32. Rundegren J and Ericson T. Actual caries development compared with expected
caries activity. Community Dent Oral Epidemiol 1978;6:97-102.
33. Slade GD, Spencer AJ, Davies MJ and Steward JF. Influence of exposure to
fluoridated water on socioeconomic inequalities in children¶s caries experience.
Community Dent Oral Epidemiol 1996;24:89-100.
34. Truin GJ, Konig KG, Bronkhorst EM, Frankenmolen F, Mulder J and van't
Hof MA. Time trends in caries experience of 6- and 12-year-old children of different
socioeconomic status in The Hague. Caries Res 1998;32(1):1-4.
35. http://www.db.od.mah.se/car/cariogram/cariograminfo.html
36. Silness J and Loe H. Periodontal disease in pregnancy. Acta Odont Scand
1964;22:121-135.
78
View publication stats

Cariogram E Book

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Cariogram E Book

Hochgeladen von

Copyright:

Verfügbare Formate

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

Cariogram - A Multifactorial Risk Assessment Model for Dental Caries

Book · May 2018

Ricky Pal Singh

The user has requested enhancement of the downloaded file.

                

    

 8 &$& 

A deep sense of satisfaction filled me with the completion of my library

wishers whom I wish to thank.

It is with deep gratitude and humbleness that I wish to express my

Head, Department of Preventive and Community Dentistry, Kothiwal Dental

encouragement and also inculcating in me a quest for excellence, humility, honesty

I also wish to express my indebtedness to my teacher and co-guide Dr.

Ramesh N. Professor, Department of Preventive and Community Dentistry,

I express my deep sense of gratitude to Dr. Pradeep Tangade, Professor and

Dr. Ravishankar .T.L, Reader, Department of Preventive and Community Dentistry,

obtained guidance and constant encouragement in my study.

and information centers to complete out my work.

I am indebted to my parents and my friends for their encouragement and

support. Dr. AVNISH SINGH

Concept of The Cariogram 5

Cariogram- the five sectors 30

Use of Cariogram model 39

Measures to reduce caries activity and caries risk 71

scientific knowledge. So dentists began to be educated in the basic sciences and

prevalence of this disease has increased greatly in modern times world-wide, an

preventable, it continues to exist in significant proportions. This scenario is partly

attributed to existing inequalities in oral health promotion with respect to different

populations; hence there is a need to adopt a more progressive approach to prevention.

It is a widespread problem along with periodontitis with considerable biological,

physiological, economical, social and psychological consequences.

degree completely prevented. Nevertheless, the burden of oral disease is still

excessive for many individuals: therefore, increased preventive efforts remain

As we know, every disease is associated with agent or agents. The disease

contributory to the undesired outcome, or they may be predictive only in a statistical

be comprehensively studied, tackled, modified so that the occurrence of dental caries

individuals, teeth and tooth surfaces. Therefore, caries ± preventive measures be

preventive and curative measures can be implemented to prevent or at least slow

down the occurrence or progression of disease.

As we enter the new millennium, we must continue to concentrate our efforts

on preventing, controlling and arresting dental caries. However, needs-related

More emphasis have to be placed on skills such as diagnosis, pathophysiology,

caries risk profile of an individual, a new concept is introduced, known as ³The

illustration of the interactions of caries-related factors. The model makes it possible

activity ± Diet, Bacteria and Susceptibility.3 Cariogram illustrates caries related

preventive strategies for the patient.

To illustrate the use of the caries risk assessment computer-software

program ± The Cariogram.

The Cariogram is an interactive computer program, first developed by

possible to single out the impact of individual risk factor.

The Cariogram presents a graphical picture that illustrates a possible overall

particular individual and provides targeted strategies for those individuals.

related factors. The various factors/variables are given a score according to a

Bratthall (1996)4 comprised a summarizing discussion for a set of 13 papers on the

preparing such graphs, cariography.

dental hygienists and dentists. A questionnaire, containing the descriptions of five

frequency, mutans streptococci and lactobacilli counts in saliva, fluoride program,

Petersson et al (2002)6 conducted a study to assess the caries risk in schoolchildren

study consisted of a questionnaire on diet, consumption of sweets, oral hygiene and

experience (p=0.001), turned out to be significantly associated with caries increment.

included single-factor model.

Petersson et al (2003)7 evaluated caries risk assessment computer program, the

8&$&

DFS) numbers before orthodontic treatment had a higher risk of developing