CARIES RISK ASSESMENT

AND CARIES VACCINE

K.SANTOSHI
K.SANTOSHI
MDS
MDS II
II
 CONTENTS
 CARIES RISK ASSESMENT
 Introduction
 Caries imbalance
 Objectives
 Caries risk models
 Caries assesment tool
 Caries management by risk assesment
 Cariogram
 Traffic light matrix
 Caries risk factors
 Caries risk indicator
 Test in caries risk assesment
 Caries activity test
 Use of Caries risk assesment
CARIES VACCINE
Introduction
Immunity
Types of immune response
Requirements of caries vaccine
Streptococcus mutans
Antigenic components of streptococcus mutans
Mechanism of action of caries vaccine
Routes of immunization
Adjuvants and delivery systems
Recent advances
Risks
Limitation
Conclusion
refferences
INTRODUCTION

Dental caries is a multifactorial, transmissible, infectious oral disease

caused primarily by the complex interaction of cariogenic oral flora
(biofilm) with fermentable dietary carbohydrates on the tooth surface over
time.
IS THE OCCURRENCE AND PROGRESSION OF DENTAL
CARIES SIMILAR IN ALL INDIVIDUALS
Caries risk assesment

Procedure to predict
future caries
development before
the clinical onset of
the disease

Guideline on Caries-risk Assessment and Management for Infants, Children, and

Adolescents Reference manual 2011; 37( 6): 15 -16
 What
What is
is Risk??
Risk??
Is
Is the
the probability
probability of
of an
an event
event occurring
occurring following
following an
an exposure
exposure

Risk Factor
Is an environmental, behavioral, biologic or lifestyle exposure or characteristic
that increases the probability of a disease occurring
(Beck 1998)

Risk
Risk Indicator/Predictor/
Indicator/Predictor/ Marker
Marker
Biologic
Biologic marker
marker that
that is
is indicative
indicative of
of the
the disease
disease process,
process, but
but itit is
is not
not thought
thought to
to be
be
etiological
etiological for
for that
that disease.(
disease.( Beck
Beck et
et al
al .,., 1992)
1992)
Caries balance and imbalance concept Protective
Protective factors:
factors:
•Saliva
•Saliva &
& sealants
sealants
Risk
Risk Factors
Factors •Antibacterial
•Antibacterial
•Bad
•Bad bacteria
bacteria •Fluorides
Disease
Disease indicators:
indicators: •Fluorides
•Absence
•Absence of
of saliva
saliva •Effective
•White
•White spots
spots •Effective diet
diet
•Dietary
•Dietary
•Restorations
•Restorations >3
>3 yy habits(poor)
habits(poor)
•Enamel
•Enamel lesions
lesions
•Cavities/
•Cavities/ dentin
dentin

Caries progression No caries

 Caries risk assessment
Process of collecting data regarding various factors and indicators to
predict caries activity in the immediate future( Petersson et al 2003)

Four step process:

1.Identification of measurable risk factors

2.Development of multifactorial tool

3.Risk assessment to determine a patient risk profile

4.Application of preventive measures to patients risk

profile
Objectives

To improve the oral health in children,adolescents and

adults

Introduce casual measures before irreversible lesions have

become established

Utilize resources in a cost effective way

Norman O Harris et al. primary preventive Dentistry;2004.p285-316

AAPD Guidelines

Treatment of the
disease process Anticipates caries
instead of treating the progression or
outcome of the stabilization
disease.

Individualizes,
selects, and Gives an
determines frequency understanding of the
of preventive and disease factors for a
restorative treatment specific patient.
for a patient.

AAPD 2002, revised in the year 2014

Caries risk factors
Plaque

ML&DL sufaces of mandbular

molars
MB&DB surfaces of maxillary
and mandibular molars
Palatal of maxillary anteriors
2)- SPECIFIC MICROBES
•.
3)-DIET
4)- EATING PATTERN
• Infants and toddlers - regularly bottle fed with sweet drinks at
night or breast fed for > twelve months- risk factors for caries.

•Teenagers and young adults- excessive consumption of soft drinks

risk factors for caries
Fall in plaque pH after consumption of sugary foods may be
modified by the consumption of less fermentable foods before,
concurrently or afterward egs: cheese.
5) SALIVA
• important role.
• salivary flow rate
• Main factors governing stability of enamel are the pH and
concentration of Ca, PO3 4-, and F in solution which are all
derived from saliva.
 Caries indicators
pp
pathological protective
1.Dietary factors- 1.Dietary factors-
High sugar consumption Preference for non cariogenic diet
:
Frequent meals snacking Sugar exposures are limited to meal
Prolonged bottle feeding time
2.Socioeconomic status 2.Socioeconomic status
High risk in siblings and parents Good oral hygeine and knowlegde
incre maternal MS levels about prevention-parents
No access to clinics Regular access to clinics
3.Fluoride exposure 3.Fluoride exposure
No exposure to fluoridated exposure to fluoridated drinking
drinking water water
4.Medical factors Fluoride dentrifrice
Special children,salivary 4.Medical factors
dysfunction Special children-preventive
5.Salivary factors regimen, salivary subtitutes
Poor flow 5.Salivary factors
High MS levels Normal salivary flow
• A number of CRA methods have been proposed for use in
clinical practice as follows:

• Caries Questionnaire in combination with Clinical

Observations 
• AAPD's Caries-risk Assessment Form.
• Caries Assessment and Risk Evaluation (CARE) test 
• Caries management by risk assessment (CAMBRA)
• The Cariogram Model 
• Traffic Light Matrix (TLM).
 Caries risk model
Caries assessment tool

This tool was developed by the American Academy of Paediatric

Dentistry (AAPD) in 2006. Depending on the age of children CAT
incorporates three factors in assessing caries risk, namely, biological as
well as protective factors and clinical findings
 American Academy of Pediatric Dentistry Caries Risk Assessment Tool
(CAT*)
Low risk Moderate risk High risk
Clinical  No caries  Carious teeth in past 24 months  Carious teeth in the past 12
Conditions  No enamel demineralization  1 area of enamel demineralization months
 No visible plaque (enamel  More than 1 area of enamel
 No gingivitis  Caries “white spots lesions”) demineralization
 Gingivitis  (enamel caries, “white spot
lesions”
 Visible plaque on anterior front
teeth
 Radiographic enamel caries
 High titers of mutans
streptococci
 Wearing dental or orthodontic
appliances
 Enamel hypoplasia

Environmental  Optimal systemic topical fluoride  Suboptimal systemic fluoride  Suboptimal topical fluoride
Characteristics exposure exposure with optimal topical exposure
 Consumption of simple sugars or exposure  Frequent (i.e. 3 or more) between-
foods strongly associated with  Occasional (1-2) between-meal meal exposures to simple sugars or
caries initiation primarily at exposures to simple sugars or foods strongly associated with
mealtimes foods strongly associated with caries
 High caregiver socioeconomic caries  Low-level caregiver socioeconomic
status  Mid-level caregiver socioeconomic status (i.e. Eligible for Medicaid)
 Regular use of dental care in an status (i.e., eligible for school lunch  No usual source of dental care
established dental home program or SCHIP)  Active caries present in the mother
 Irregular use of dental services

General Health  Children with special health care

Conditions needs
 Conditions impairing saliva
*AAPD, Council on Clinical Affairs, www.aapd.org composition/flow
Caries questionnaire in combination with clinical observation

Featherstone et al. evolved a consensus statement to assess individual

caries risk from a questionnaire that address issues such as maternal
dental history, family dynamics, socioeconomic status, oral hygiene
measures, fluoride exposure and frequency of sugar exposure.

Clinical observations were made by visual, tactile and radiographic

examination of teeth.
CARE TEST
Division of Diagnostic Sciences of the University of Southern California School of Dentistry
developed a novel salivary test for genetic CRA called the CARETEST
Caries management by risk assessment (CAMBRA)

The CAMBRA philosophy was first introduced nearly a decade ago

when an unofficial group called the Western CAMBRA Coalition was
formed that included stakeholders from education, research, industry,
governmental agencies and private practitioners based in the western
region of the United States.
 This involves an evaluation of the etiologic and protective factors
and the establishment of the risk for future disease, followed by the
development of a patient-centered evidence-based caries
management plan.

 Essentially based on the same factors as CAT to assess caries risk

Cariogram (Brathall et al., 1997)

Cariogram is a new way in which to illustrate the interaction between

caries related factors.

Chance - The Chance to avoid

new cavities in the near future
Diet - frequency of eating as
well as contents of diet
Bacteria - Plaque amount as
well as types of bacteria
Susceptibility - tooth resistance
(fluorides) and saliva
characteristics
Circumstances - Past caries
experience and general diseases
and conditions
Example . High caries risk - only a 5% chance to avoid
cavities

The "Chance“- similar -- 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 - Low caries risk - 60% chance to
avoid cavities

 The "Chance" - similar -- three Cariograms, but the

reasons are different.
 Left: All – reduced---- reduced caries risk.
Middle: - Diet is unfavourable, the other factors compensate
for that.
Right: Circumstances - particular unfavourable - for
example, -- very high past caries experience, but due to
improvements in the other factors, the situation has been
brought under control.
 Peterson G et al in 2003 gave the opinion that the Cariogram
predicted caries increment more accurately than any included single-
factor model.
• Petersson GH. Assessing caries risk-using the Cariogram model. Swed
Dent J Suppl. 2003;(158):1-65

Meiravet AR et al in 2007 said that the past caries experience,

Streptococcus mutans count, fluoridation programme and buffer
capacity of the saliva are 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.
. • Mieravet AR, Letra A, Rose EK, Brandon CA, Resick JM, Marazita ML, Vieira
AR. Inherited risks for susceptibility to dental caries. Caries Res. 2007;42:8–13.
Traffic Light Matrix (TLM):
• This is a commonly used CRA tool.

• TLM is based on 19 criteria in 5 different categories including

saliva (6 criteria),
plaque (3 criteria),
diet (2 criteria),
fluoride exposure (3 criteria) and
modifying factors (5 criteria).

• The objective is to alert the clinician regarding the current risk status.

• This color code model keeps the visual interpretation simple and
communicable to the patient as well.
 a) Resting: hydration, viscosity and pH
 Saliva: b) Stimulated: quantity/rate, pH and buffering
capacity

 Plaque pH, maturity and bacteria – Mutans count

number of sugar and acid exposures in between

Diet:
meals/ day

 : Fluoride water,Toothpaste, professional treatment

:
Modifying factors

drugs that reduce salivary flow, diseases resulting in dry mouth, fixed/removable
appliances, recent active caries and poor compliance
The system scores Red, yellow & green light for each risk factors
depending on predetermined criteria.

• Tests are carried for each risk factors independently and scores
are generated.

•The scores are compared with predetermined criteria. based on

theis criteria
Red for- high risk
yellow for- moderate risk
green for- low risk
 TESTS IN CRA
 Bacterial challenge- determination of Mutans streptococcus as an
indicator of relative risk.
 Diet- determination of lactobacilli as an indicator of sugar
content in diet.
 Remineralization potential- salivary flow rate and buffer capacity
as an indicator of potential biologic repair. 
 Host susceptibility- caries experience as an indicator of past
activity.
 Microbial tests for mutans streptococci detection
 • Several methods are available to measure the levels of mutans
streptococci in saliva and plaque and on individual tooth
surfaces .
 LABORATORY METHOD
 CHAIR SIDE METHOD
 SURVEY METHOD
 SELECTIVE METHOD
 ADHERENCE METHOD
LABORATORY TEST

Saliva is collected from the individual

to be sampled
Mixed with proper transport medium

After incubation using a selective

medium, mutans colonies on the plates
are counted
The results are expressed as no. of
colony forming per units per ml saliva.
 Microbial tests for Lactobacilli count
LABORATORY METHOD:
• Saliva is obtained by chewing a piece of paraffin

• Shaken with glass beads to break up aggregates of bacteria

• Saliva is then mixed with a buffer solution and 1 ml of the dilutions 10-2 and
10-3

• 10 ml is poured into the Petri dish

• Plates are incubated at 37◦ c for 4 days.

Lactobacilli appear as whitish dots

CARIES ACTIVITY TESTS
SNYDER TEST
 Principle: It measures the ability of salivary
microorganisms to form organic acids from a
carbohydrate medium.
 Medium contains an indicator dye, Bromocresol green.
 This dye changes color from Green to Yellow in the
range of pH 5.4 to 3.8
 EQUIPMENT: Saliva collecting bottles
 Paraffin
 Tube contains Snyder glucose agar and bromocresol
green adjusted to a pH 4.7-5
 Pipettes
51
 Incubator
PROCEDURE
Saliva is collected before breakfast by chewing paraffin

A tube of snyder glucose agar is melted and then cooled to 50

degrees

Saliva specimen is shaken vigorously for three minutes

0.2 ml of saliva is pipetted into the tube and mixed by rotating

tube

Agar is allowed to solidify in the tube and incubated at 37 degree c

Color change of indicator observed in 24,48,72 hours

 RESULTS
24 hours 48 hours 72 hours
COLOR Yellow Yellow Yellow
CARIES Marked Definite Limited
ACTIVITY
COLOR Green Green Green
CARIES Continue to Continue to Caries inactive
ACTIVITY incubate incubate

53
SWAB TEST

 PRINCIPLE: It measures the ability of salivary

microorganisms to form organic acids from a carbohydrate
medium
 PROCEDURE:
 Swab the buccal surface of the teeth with cotton applicator,
 And it is subsequently incubated in the medium for 48
hours.
 ADVANTAGES :

No collection of saliva.

54
 RESULTS
pH Caries activity
4.1 Marked caries activity
4.2-4.4 Active
4.5-4.6 Slightly active
Over 4.6 Caries in active

55
Dentobuff test /salivary buffer capacity
test
 Principle : the test measures the number of milliliters of
acid required to lower the pH of saliva, from pH 7.0to 6.0
 Equipment:
 Ph meter
 Titration equipment
 0.05N lactic acid
 0.05 N base
 Paraffin
 Sterile glass jars

56
5 ml of stimulated saliva collected

pH meter corrected to room temperature

pH of saliva adjusted to 7.0 by addition of lactic acid and base

Lactic acid added to sample till pH og 6.0 is reached

Number of millimeters of lactic acid required to reduce pH from 7.0

to 6.0 is measured the buffer capacity.
57
 Use of CRA

• Evaluate the degree of patient’s risk of developing caries to

determine the intensity of treatment.
• Help identify main etiologic agents to determine the type of
treatment
• Improve the reliability of the prognosis of the planned
treatments
• Assess the efficacy of proposed management and preventive
treatment plan at recall visits.
CARIES VACCINE
INTRODUCTION

What are Vaccines

Immunobiological
substance designed to
produce specific
protection against a
given disease.

They maybe . prepared

from live modified
organisms, inactivated or
killed organisms,
cellular fractions,
toxoids or combinations
of these.
Types of Immunity
 Primary Immune Response

Reaches its peak &

IgG appears in few
Antigen Administered
days if antigenic
declines quickly stimulus is adequate

IgG reaches its peak

Latent period of Antibody titer in7-8 days & declines
induction 3-10 days gradually raises in
next 2-3 days over weeks/months

Antibodies appear in First antibody Outcome:B&T

blood elicited IgM
type lymphocytesnproduce
memory cells
 Secondary/Booster response

Involves production of IgM & IgG

antibodies too

IgM production brief & longer,IgG

antibody shows prolonged
production.

Accelerated response attributed to

immunological memory
CARIES VACCINE

Dental Caries Vaccine: It can be

developed by identifying specific
bacterial cause of dental caries and the
function of salivary glands as an effector
site of the mucosal immune system
Requirements of a caries vaccine

Identify
target

Should not
harm
host

it shoul be able
toIdentify
component of
immune system
that should be
stimulated/induced
 Streptococcus Mutans

S. mutans
WHAT?
Gram +ve S.Sobrinus
Facultative S.Ratti
Anaerobe S.Criceti
8 serotypes S.Downei
Type h most S.Ferus
prevalent S.macacae
Acquisition of S.mutans

DNA probe technology have

suggested that low levels of
mutans streptococci may be
found in the oral cavity
during the first year of life.
 Thus, data suggests that
‘window of vaccine
opportunity’ could exist
between 12 and 18 months
for most populations.
Molecular pathogenesis of dental caries

Acquired pellicle forms on tooth surface

Antigen II/III
or Pac

Interaction of bacterial proteins(adhesins) with

pellicle Glucosyltranf
erases
GTF- B/C

Further accumulation of acidogenic

streptococci
Antigenic components of
S. mutans

ADHESINES
identifi ed as antigens I/
II, Pac, or P1 and Streptococcus sobrinus, Spa-A or Pag)

GLUCOSYL
TRANSFERASE

GLUCAN BINDING
PROTEIN

DEXTRAN
Mechanism of action of caries vaccine

sIg

Inactivate GTF
Reduce glucans, plaque

Bacterial surface
receptors
Routes of immunisation

Oral/mucosal

Systemic(subcutaneous)

Active Gingivo salivary

Passive dental immunisation

 Oral

 Antigen was applied by oral feeding, gastric intubation,

or in vaccine containing capsules or liposome
 Disadvantages
 Detrimental effects of stomach acidity on antigen
 Inductive sites were relatively distant
 Short duration
 Intranasal

 Targets the nasal associated lymphoid tissue

( NALT )
 Action - Induces immunity to bacterial antigens to
avoid colonization and accumulation of
microorganisms
Minor salivary glands
 Minor salivary glands of lips, cheeks,
and soft palate can be
the potential routes for mucosal induction
of salivary immune responses.
 Their short, broad secretory ducts
facilitate retrograde access of bacteria
and their products
 Tonsillar route

Has both IgA and IgG response: IgG is

more dominant.(Van Kempen ,Boyoka et
al 2000)

Palatine tonsils and nasopharyngeal

tonsils contribute precursor cells to
mucosal effector sites: such as salivary
gland.
Positive results in rabbits.
 Rectal

Colorectal region as an
inductive location for
mucosal immune responses
in humans
it has the highest
concentration of lymphoid
follicles in the lower
intestinal tract
Systemic / subcutaneous

IgG,IgM IgA

Active gingivo‑salivary route

IgG, IgA

Passive Immunization
Monoclonal antibodies
Egg- yolk antibodies

Transgenic plants:
 Adjuvants & Delivery Systems

Heat labile
enterotoxins Microcapsules & Liposomes
(Cholera & E.coli) microparticles
Katz 1993

Fusing with
Synthetic peptides
salmonella
RECENT ADVANCES:
 Recently, a vaccine has been discovered; a protein called
p1025.
 This protein tricks S.mutans; into a belief that there are no
vacant sites on the tooth for it to attack.
 The bacteria consists of a surface protein that adheres to
the enamel.
 Researchers have found that p1025 mimics the protein of
the bacterium, occupying all docking sites.
 Risk of using caries vaccine

 All vaccines have risks.

.
Due to potential of S.mutans whole cells to induce
heart – reactive Antibody, the development of subunit
vaccine (AgI/II) for caries has been focused of intense
research interest.
Limitations
 In order to make immunization against caries further
clinical trials should be aimed at establishing whether
the findings from animal experiments can be transferred
to humans. 
 Efficacy of caries vaccine is limited and is of short
duration and further studies are required to evaluate the
efficacy
  Limited research has been done in humans and most of
these studies were conducted in the early years and
showed only short‐term protection. 
 Conclusion

CARIES RISK ASSESMENT

The paradigm change in our understanding of dental caries and its
prevention and treatment makes it mandatory for all dentists treating
infants, children, adolescents, and adults to incorporate CRA into their
clinical practice and utilize risk-based caries management protocols to
make diagnostic, preventive, and restorative recommendations for their
patients.

CARIES VACCINE
Caries vaccine definitely has a role to do in the future as it interferes
with the metabolism of the major etiological agent.
Integrating the caries vaccine after its development into public health
programs could be beneficial in bring dental caries to a minimal level.
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 Arora B, Setia V, Kaur A, Mahajan M, Sekhon HK,
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