CARIES RISK

ASSESSMENT AND
ANALYSIS OF VARIOUS
CARIES ACTIVITY TESTS

Presented By:
Sunaina jodhka
PG Student
CDC, Ludhiana
Time: 9 A.M.
Date:

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OUTLINE:

 Definition of Risk, Caries Risk And High Risk

 Caries Risk Assessment

 Importance of Caries Risk Assessment and Goals of Caries Risk Assessment

 Caries Risk Indicators

 AAPD Risk Assessment Tools

 Preventive Therapy Based On Risk

 Cariogram

 Caries Activity Tests

 Clinical Correlation Of Caries Activity Tests

 Relationship Between Tests And Cariogenic Factors

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RISK is the probability of an individual to develop a given disease or to experience a
health status over a specified period (Kleinbaum et al. 1982).

CARIES RISK: According to Hausen et al. (1994) caries risk is the probability of an
individual to develop least a certain number of caries lesions and reaching a given stage
of disease progression during a specific period of time, conditional on his or her
exposure status remaining stable during the time in question.

High risk can be defined as a group of people with the greatest percentage of teeth,
surface or sites with evidence of disease. One could follow the clinical diagnosis model
of presence or absence of the disease or determine a clinically significant cut-point, such
as number of caries lesions being, for example, more than two. (Beck 1998)

CARIES RISK ASSESSMENT

Caries risk assessment determines the probability of caries incidence (that is, number of
new cavities or incipient lesions) in a certain period. It also involves the probability that
there will be a change in the size or activity of lesions in the mouth. In daily practice the
caries risk is determined in order to assess the individual patient’s risk, to identify the
main causative factors and to recommend specific preventive measures for that
individual’s needs.

IMPORTANCE OF CARIES RISK ASSESSMENT

Caries risk assessment may be useful in the clinical management of caries by helping
the dental professional in the following ways:
 Help to identify the main etiologic agents that contribute to the disease or that,
because of their recent onset, may contribute to future disease, to determine the type
of treatment (for example, plaque control, diet control, increased fluoride exposure,
antimicrobial agents)
 Determine if additional diagnostic procedures are required (for example, salivary
flow rate analysis, diet analysis)
 Aid in restorative treatment decisions
 Improve the reliability of the prognosis of the planned treatment.

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 Assess the efficacy of the proposed management and preventive treatment plan at
recall visits.

GOALS OF CARIES RISK ASSESSMENT

The goals of caries risk assessment can be summarized as follows:
 Screen out low risk patients (to allow safe recommendations of long recall intervals)
 Identify high risk patients before they become caries active
 Monitor changes in disease status in caries active patients.
CARIES RISK INDICATORS:

Past Caries Experience: According to Powell et al (1998) and Wandera et al (2000) one of
the best predictors of future cavities is the presence of current cavities or evidence of
past caries in the form of existing restorations. The specific location of current or
previous caries also helps to predict future caries incidence. Patients that exhibit only
pit and fissure caries and not smooth surface caries have less risk of future caries than
those who have extension of the disease onto smooth surfaces.
However, previous caries experience is not useful in case of young children since
it is important to determine caries risk before disease manifests itself. The goal of caries
risk assessment in young children is to prevent caries initiation before the first sign of
the disease.
Microbiological Testing: Caries is a microbial disease in which the etiologic agents are
normal constituents of the oral flora and cause problems when their pathogenicity and
proportions change in response to environmental conditions. Shortly after birth an oral
ecosystem is established consisting of different kinds of bacteria. The colonization of the
mouth by odontopathic bacteria is by human transmission, mostly from mothers or
caregivers to infants, and depends upon the quantity of these bacteria the parents
harbor.
A correlation between the number of carious lesions and number of mutans
streptococci has been established in the saliva of children and adults. Microbiological
tests show close associations between odontopathogens and caries in subjects with high
caries experience and conversely, low number of odontopathogens in low or non-caries
subjects. They identify the two extremes in a disease susceptible population but are less
effective in predicting caries in the moderate risk subjects.
The results of Lactobacillus studies indicate that these organisms do not
participate in the original colonization of the teeth and are associated with the
carbohydrate consumption (Holbrook et al. 1995) and the progression of the disease
process (Loesche et al. 1973). This type of test can be useful when monitoring dietary
changes because levels of lactobacilli can be related to the intake of carbohydrates and
sugars.

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Plaque: The presence of visible plaque on the teeth of preschool children can be used as
an indicator of caries risk. This indicates poor oral hygiene and is an indirect indicator
of high levels of bacteria. Several studies have shown that there is correlation between
visible plaque on the primary teeth and caries risk (Granath et al. 1979, Chesters et al.
1992, Bjertness E. 1993, andOgaard et al. 1994)
Conditions that compromise the long term maintenance of good oral hygiene are
associated positively with caries risk. These may include physical and mental
disabilities, the presence of existing defective restorations or oral appliances. Therefore,
a risk assessment should consider not only the presence of plaque, but also other factors
such as crowded teeth, deep fissures, restoration overhangs and appliances.
Saliva: It is well-established that saliva plays an important role in the health of soft and
hard tissues of the oral cavity. Fox and colleagues recommend that dentists ask their
patients the following questions:
 Does you mouth feel dry when eating a meal?
 Do you sip liquids to aid swallowing dry foods?
 Do you have difficulty swallowing any foods?
 Does the amount of saliva in your mouth seem to be too little, too much or you do
not notice it?
The dentist should consider the following factors when evaluating the patient’s
answers:
 Are there any clinical signs that the patient’s salivary flow rate is decreased (dry
lips)
 Does the mouth mirror stick to the oral mucosa?
 Is there a lack of pool of saliva in the floor of the patient’s mouth?
 Is there difficulty in expressing saliva from the patient’s major salivary ducts?
 Does the mucosa appear dry?
 Is there an increase in caries in an unusual location (for example, mandibular
incisors)
 Does the patient have any systemic condition that may cause decreased salivary
flow rate?
 Is the patient taking any medications that decrease flow rate?
If the patient is considered at risk and saliva is one of the influencing risk factors, an
objective assessment of unstimulated flow rate should be performed for diagnostic
purposes and be recorded for future comparisons. Navazesh and colleagues found that
unstimulated flow rates have the strongest predictive validity for estimating caries risk.
The normal unstimulated flow rate varies between 0.3 and 0.4 ml/min, and values of
less than 0.1ml/min should be considered abnormal. Dentist should also assess the
stimulated flow rates so as to determine if management strategies based on salivary
stimulation (for example, recommending chewing sugarless gums) would benefit
patients.

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Diet: The role of diet in the caries process is primarily local rather than systemic. Sugar
exposure is an important etiologic factor in caries development. Other dietary
considerations include the retentiveness of the food, the presence of specific factors in
the food, and the type of carbohydrate. Dietary assessment should be done in which
interview process should focus on eating behaviors in between meals, including late-
night snacking. Follow up questions should determine the consumption pattern. For
example, does the patient consume food or drink rapidly, or does he or she nibble or sip
over an extended period? Generally, diet alone is an inadequate indicator of caries risk.
For example, a patient may snack several times a day but then brush immediately,
which would minimize the impact of diet alone. Therefore, other risk factors also need
to be considered, such as assessing a patient’s pattern and frequency of carbohydrate
intake and its relationship with oral hygiene habits.

Other indicators are: Socioeconomic status, exposure to fluorides, general medical

factors.

AAPD RISK ASSESSMENT TOOL:

The AAPD has provided a caries-risk assessment tool (CAT) that represents a first step
towards incorporating available evidence into a concise, practical tool to assist
both dental and non-dental health care providers in assessing levels of risk for
caries development in infants, children, and adolescents.
Clinicians using this tool should:
1. Be able to visualize adequately a child’s teeth and mouth and have access to a reliable
historian for non-clinical data elements
2. Assess all 3 components of caries risk–clinical conditions, environmental
characteristics, and general health conditions
3. Be familiar with footnotes that clarify use of individual factors in this instrument
4. Understand that each child’s ultimate risk classification is determined by the highest
risk category where a risk indicator exists (i.e., the presence of a single risk indicator in
any area of the “high- risk” category is sufficient to classify a child as being at “high
risk;” the presence of at least 1 “moderate-” risk indicator and no “high-risk” indicators
results in a “moderate-risk ” classification; and a child designated as “low-risk” would
have no “moderate- risk” or “high-risk” indicators

Also, users of the AAPD caries-risk assessment tool (CAT) must understand the
following features:
1. CAT provides a means of classifying dental caries risk at a point in time and,
therefore, should be applied periodically to assess changes in an individual’s risk status.

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2. CAT is intended to be used when clinical guidelines call for caries risk assessment.
Decisions regarding clinical management of caries however, are left to qualified dentists
(ideally, the dentist responsible for the child’s “dental home”).
3. CAT can be used by both dental and non-dental personnel. It does not render a
diagnosis. However, clinicians using CAT must be familiar with the clinical
presentation of dental caries and factors related to caries initiation and progression.
4. Since clinicians with various levels of skill working in a variety of settings will use
this instrument, advanced technologies, such as radiographic assessment and
microbiologic testing, have been included but are not essential for using this tool.

Caries risk Low risk Moderate risk High risk

indicators
Clinical conditions  No carious teeth  Carious teeth in  Carious teeth in
in past 24 months the past 24 months the past 12 months
 No enamel  One area of  More than one
demineralization enamel area of enamel
demineralization demineralization
 Radiographic
enamel caries
 No visible plaque;  Gingivitis  Visible plaque on
no gingivitis anterior teeth
 High titers of
mutans
streptococci
 Wearing
orthodontic
appliances
 Enamel
hypoplasia
Environmental  Optimal systemic  Suboptimal  Suboptimal topical
characteristics and topical systemic and fluoride exposure
fluoride exposure optimal topical
fluoride exposure
 Consumption of  Occasional (e.g. 1  Frequent (e.g. 3 or
simple sugars or or 2) between- more) between
foods strongly meal exposures to meals exposures to
associated with simple sugars or simple sugars or
caries initiation foods strongly foods strongly
primarily at meal associated with associated with
times caries. caries.
 High caregiver  Midlevel  Low-level
SES. caregiver SES caregiver SES
 Regular use of  Irregular use of  No usual source of

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 dental care in an dental services. dental care.
established dental
home.
General health  Active caries
conditions present in the
mother
 Children with
special health care
needs.
 Conditions
impairing saliva
composition/flow.
PREVENTIVE THERAPY BASED ON RISK:

Low risk Moderate risk High risk

Fluoridated dentifrice
Fluoridated dentifrice
Systemic fluoride
supplements
Professional topical
fluoride treatment
Sealants
Fluoridated dentifrice
Systemic fluoride
supplements
Professional topical
fluoride treatment
Sealants
Antimicrobials
Dietary counseling

CARIOGRAM:
The Cariogram is a graphical picture illustrating in an interactive way the individual's
risk for developing new dental caries in the future. It also simultaneously expresses to
what extent different etiological factors of caries may affect the caries risk for that
particular patient. It illustrates a possible over-all risk scenario, a caries risk profile,
based on what can be expected depending on an automated and weighted
interpretation of available information. It does not specify a particular number of
cavities that may occur. The program contains an algorithm that presents a “weighted”
analysis of the input data, mainly biological factors. By determing the extent to which
different etiologic factors affect caries risk, it provides targeted strategies for those
individuals.

HOW IS CARIOGRAM CREATED?

The patient is examined and data is collected for some factors of direct relevance for
caries. The various factors are given a score according to a predetermined scale and
entered in a computer program. According to in built formula, the program presents a
pie diagram where:

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 Dark blue sector represents diet based on combination of diet contents and
frequency.
 Red sector for bacteria and is based on combination of amount plaque and mutans
streptococci.
 Light blue sector represents susceptibility and is based on combination of fluoride
program, saliva secretion and buffer capacity.
 Yellow sector for circumstances based on combination of caries experience and
related diseases.
 Green sector shows an estimation of the “chance of avoiding caries.”

FACTOR INFORMATION TO BE COLLECTED CARIOGRAM SCORE

Caries experience
Related general disease
Diet content
Diet frequency
Amount of plaque
Streptococcus mutans
Fluoride Program
DMFT, DMFS, new caries
experience
Medical history, medications
Diet history (or Lactobacillus
test): quality of diet
Questionnaire results: quality of
dietary intake
Silness-Loe plaque index
Dentocult SM Strip mutans test
Fluoride exposure
0: No caries, no fillings
1: Better than normal for the age
group
2: Normal for the age group
3: Worse than normal for the age
group
0: Healthy
1: Presence of a general disease
that can indirectly influence the
caries process
2: Continuous medication or
bedridden
0: Very low fermentable
carbohydrate
1: Low fermentable carbohydrate
2:High fermentable
carbohydrates
3: Very high fermentable
carbohydrate intake
0: Maximum 3 meals/day
1: Maximum 5 meals/day
2: Maximum 7 meals/day
3: More than 7 meals/day
0: < 5% plaque adhering surfaces
1: 5-20% plaque adhering
surfaces
2: 21-50% plaque adhering
surfaces
3:> 50% plaque adhering surfaces
0: S. mutans< 105 CFU/ml
1: S. mutans< 105-106 CFU/ml
2: S. mutans< 106-107 CFU/ml
3: S. mutans> 107 CFU/ml
0: Maximum fluoride exposure

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Saliva secretion rate
Saliva Buffering Capacity
Clinical judgement
1: Additional fluoride measures
(other than tooth paste), but
infrequent application
2: Flouride tooth paste only
3: Avoidance of fluorides
Secretion rate on stimulated 0: normal saliva secretion
saliva test 1: Low, 0.9-1.1 ml/min
2: Low, 0.5-0.9 ml/min
3: Very low, <0.5 ml/min
Dentobuff (or similar test) 0: Adequate, saliva pH> 6.0
1: Reduced, saliva pH 4.5-5.5
2: Low, saliva pH < 4.0
Opinion of dental examiner; the 0: More positive
examiner’s own clinical and 1: Normal setting
personal score for the individual 2: worse
patient 3: very high caries risk

Cariogram 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 be taken. The model
is affordable, user friendly, and easy to understand by anyone. It can be tool for
activating the patient.

CARIES ACTIVITY TESTS

Caries activity tests have been used in dental research for many years and some tests
have been adapted for routine use in the dental office. There is no single ideal test in
existence at present, although these tests are a valuable adjunct for patient motivation in
a plaque control program. Innumerable tests have been designed and described in the
literature. Some of the proposed uses of an accurate caries susceptibility test are as
follows:
For the Clinician
1. To determine the need for caries control measures
2. As an indicator of patient cooperation
3. To act as an aid in timing of recall appointments
4. As a guide to insertion of expensive restorations
5. To aid in the determination of prognosis
6. As a precautionary signal to the orthodontist in placing bands

For the research worker

1. As an aid in the selection of patients for caries study
2. To help in the screening of potential therapeutic agents
3. To serve as an indicator of periods of exacerbation and remission

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Snyder has suggested that a suitable caries activity test should:
1. Have a sound theoretical basis
2. Show maximal correlation with clinical status
3. Be accurate with respect to duplication of results
4. Be simple
5. Be inexpensive
6. Take little time
In addition, a good caries test should possess at least 3 characteristics:
Validity, Reliability and Feasibility

CARIES ACTIVITY TESTS

Current knowledge of the caries process is based on 3 variables: the bacterial flora, the
substrate and host susceptibility and it is these variables that form the basis of the caries
activity tests.

LACTOBACILLUS COLONY COUNT TEST (Hadley, 1933)

Action
This test estimates the number of acidogenic and aciduric bacteria in the patient’s saliva
by counting the number of colonies appearing on tomato peptone agar (pH= 5.0) or LBS
(Rogosa) agar.
Procedure
The subject is asked to chew paraffin before breakfast and then the saliva is collected in
a bottle. The specimen is shaken and a 1:10 dilution is prepared by pipetting 1mL saliva
into a 9mL sterile solution and a further 1:100 dilution is made. The 1:100 dilution is
mixed and 0.4mL of it is spread on the agar surface and incubated at 37 0C for 3-4 days
by using a Quebec counter.

Results
No of Lactobacilli/mL saliva Caries Activity
0-1000 Little or none
1000-5000 Slight
5000-10,000 Moderate
>10,000 Marked
Test Analysis
The Lactobacillus colony count test is one of the oldest caries activity tests. Aciduric
conditions associated with caries favor growth of Lactobacillus (Sims, 1970). Therefore,
Lactobacilli flourish where carious lesions are found and may even be considered
pathogonomic for the disease. The salivary count represents the number of Lactobacilli
spilling over from retentive and carious areas of teeth. Since Lactobacilli are not
essential for the initiation of a lesion, their levels in saliva reflect the number of existing

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lesions and acidic conditions in the mouth. The correlation of this test with clinical
caries activity has been demonstrated in numerous studies.
However, though it takes only a few minutes to do the test, the results are not
available for several days and the counting of colonies is a very tedious process. Also,
the test is not simple for it requires complex equipment and relatively trained personnel
with bacteriological training with costs, too, being relatively high for the test.
Despite its shortcomings, the Lactobacillus colony count test has generally been
accepted in the past and is still used as a reference test for new caries activity tests.

DENTOCULT (Dentocult, Orion Diagnostica)

A practical and simple method of estimating the Lactobacilli is available as an office
test. Here, undiluted paraffin stimulated saliva is poured over a plastic slide and
incubated at 35-370C for 4 days. The colony density is not counted, but compared to a
chart and classified as about 1000, 10000 or 1000,000 aciduric organisms per mL of
saliva.
This method gives a highly significant correlation with conventional Lactobacilli count
(Crosner, 1981). Moreover, since it is simple, cost-reasonable and easy to read, it offers a
practical office test.

SNYDER TEST (Snyder, 1951)

Action
This calorimetric test devised by Snyder is based on the rate of acid production when a
sample of stimulated saliva is inoculated into glucose agar adjusted to a pH of 4.7 to 5.0
with bromocresol green as color indicator. Indirectly, the test is also a measure of
acidogenic and aciduric bacteria.
Procedure
Saliva is collected before breakfast by having the subjects chew paraffin. The saliva
sample is then shaken vigorously. 0.2 mL of saliva is pipetted into the agar and
incubated at 370C. The color change of the indicator is observed after 24, 48 and 72
hours of incubation by comparison with an uninoculated tube against a white
background.

Results
Time (Hrs) 24 48 72
Color Yellow Yellow Yellow
Caries Activity Marked Definite Limited

Color Green Green Green

Caries Activity Continue test Continue Inactive

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 test
Test Analysis
The Snyder test is simple, takes 24-48 hours and requires only simple equipment and
moderate training and costs. This test meets some of the requirements of an ‘ideal’ test.
Snyder and others have found a high correlation between caries activity and a positive
Snyder test result. However, neither Snyder test nor the Lactobacillus colony count test
can predict the extent of caries expectancy with any reliability for one individual but are
more useful on a group basis.

REDUCTASE TEST
Action
This test measures the rate at which an indicator molecule, diazoresorcinol, changes
from blue to red to colorless on reduction by mixed salivary flora.
Procedure
Saliva is collected by chewing paraffin and expectorating directly into the collection
tube. When the saliva reaches the calibration mark (5mL) the cap is replaced. The
sample is mixed with a fixed amount of diazoresorcinol. The color change after 30
seconds and after 25 minutes is taken as a measure of caries activity.
Results
Color Time Score Caries Activity
Blue 15 min 1 Non conducive
Orchid 15 min 2 Slightly conducive
Red 15 min 3 Moderately conducive
Red Immediately 4 Highly conducive
Pink/White Immediately 5 Extremely conducive

Test Analysis
Rapp and colleagues have claimed a good correlation of this test with clinical caries
experience. They also say that this test measures the activity of a single enzyme,
reductase. This enzyme is involved in the formation of products dangerous to the tooth
surface. Other workers concluded that this test does not give results of diagnostic value
but does give a clinical correlation between the reductase activity and numbers of
salivary anaerobes.

BUFFER CAPACITY TEST

Action
This test measures the number of milliliters of acid required to lower the pH of saliva
through an arbitrary pH interval.

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Procedure
10 mL of stimulated saliva are collected under oil and 5mL of this are measured into a
beaker. After correcting the pH meter to room temperature, the pH of the saliva is
adjusted to 7.0 by the addition of lactic acid or base. The level of lactic acid in the
graduated cylinder is re-recorded. Lactic acid is then added to the sample until a pH of
6.0 is reached. The number of milliliters of acid required to reduce the pH from 7.0 to
6.0 is a measure of buffer capacity.

Test Analysis
There is generally an inverse relationship between buffering capacity of saliva and
caries activity. The saliva of individuals whose mouths contain considerable number of
carious lesions frequently has a lower acid-buffering capacity than the saliva of those
who are relatively caries-free. This test, however, does not correlate adequately with
caries activity.

MUTANS GROUP SCREENING TEST

Plaque/Toothpick Method
Principle
This test involves a screening of a diluted plaque sample streaked on a selective culture
medium.
Procedure
Plaque samples are collected from the gingival third of buccal tooth surfaces (one from
each quadrant) and placed in ringer’s solution. The sample is shaken and streaked
across mitis-salivarius agar plate. The cultures are examined under a low power
microscope and the total colonies in ten fields recorded.
Test Analysis
This test is an attempt to semi-quantitatively screen the dental plaque for a specific
group of caries inducing streptococci, Streptococcus mutans. The relationship between
the presence of Streptococcus mutans in plaque and subsequent dental caries
experience seems to hold up best for grade 3, i.e. with largest number of colonies.

Saliva/Tongue blade Method

Action
This test estimates the number of Streptococcus mutans in mixed paraffin stimulated
saliva when cultured on mitis-salivarius agar bacitracin (MSB) agar.
Procedure
The subjects chew saliva for about a minute following which; they are given a tongue
blade, which they rotate in their mouth 10 times, so that both sides of the tongue blade
are thoroughly inoculated by the subject’s flora. Both sides of a tongue blade are then

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pressed onto an MSB agar. Counts of more than 100 CFU of S. mutans per milliliter of
saliva by this method are proportional to >106 CFU by other methods.
Test Analysis
This test was developed for use with large numbers of school children and avoids the
necessity of collecting saliva. An updated and simpler version of this method, Strip
mutans (Orion Diagnostica), uses a liquid medium with a long shelf life. Colonies of S.
mutans grow directly on the spatula, which is later analyzed under a microscope.

FOSDICK CALCIUM DISSOLUTION TEST

Action
This test measures the milligrams of powdered enamel dissolved in 4 hours by acid
formed when the patient’s saliva is mixed with glucose and powdered enamel.
Procedure
Twenty-five milliliters of gum-stimulated saliva are collected. Part of this is analyzed for
calcium content. The rest is placed in an 8-inch sterile test tube with about 0.1g of
powdered human enamel. The tube is sealed and shaken for 4 hours at body
temperature after which it is again analyzed for calcium content.
Test Analysis
The chewing of gum to stimulate saliva produces sugar. If paraffin is used, a
concentration of about 5% glucose is added. The amount of enamel dissolution
increases as the caries activity increases. In limited studies, the correlation is good.
However, the test is not simple, the equipment is complex and the time is 4 hours. Also,
personnel must be trained and the cost is high.

DEWAR TEST
Action and Procedure
This test is similar to the Fosdick calcium dissolution test except that the final pH after 4
hours is measured instead of the amount of calcium dissolved.

STREPTOCOCCUS MUTANS DIP SLIDE METHODS

Action
These tests (Dentocult SM, Orion Diagnostica; Caries Screen SM, Apo Diagnostics)
classify salivary samples according to estimates of S. mutans colonies growing on
modified mitis-salivarius agar.
Procedure
Dentocult SM:
The subject chews paraffin and stimulated saliva is collected for 5 minutes. The saliva is
poured over an agar-coated slide and after the slide dries, bacitracin discs are placed in
the middle of the inoculated agar about 1cm from each other. A carbon dioxide tablet is

15
inserted in the tube containing the slide and incubated for 48 hours. A zone of inhibition
10-20 mm in diameter is formed around each bacitracin disc. If present, S. mutans
appears as small, blue colonies growing within the zone of inhibition. The colony
density is compared with a model chart and classified as:

0- Negligible
1-less than 100,000
2-100,000 to 1,000,000
3- More than 1,000,000 S. mutans CFU/mL saliva
Caries Screen SM:
A bacitracin tablet is placed in the buffered diluent and allowed to dissolve completely.
Meanwhile the subject chews paraffin for 15-20 seconds, swallowing the saliva. While
continuing to chew wax, the subject expectorates 1-2 mL into a diluent vial, which is
capped and gently mixed. The dip-slide coated on both sides with mitis-salivarius agar
is immersed for a few seconds in the diluent containing saliva and bacitracin. A carbon
dioxide tablet is placed in the empty dip slide vial and 2 drops of water are added. The
dip slide is replaced into its vial and tightly closed. The vial is placed upright for 48
hours at 370C in an incubator. The colony density on the agar plate is compared with a
reference colony density chart that shows equivalent of 10000, 50000, 100000, 250000,
500000, 0r 100, 0000 CFU/ mL of saliva.
Test Analysis
This simple quantitative method correlates strongly with actual laboratory methods of
quantifying S. mutans by standard culturing to an upper limit of 10 5-106 CFU/mL of
saliva.

PREDICTION OF FUTURE CARIES BASED ON PREVIOUS CARIES EXPERIENCE

Action
As an alternative to chemical or bacteriological tests for determining caries activity,
previous caries experience can be used as a reasonable indication of future trends.

Procedure
Koch (1970) grouped 9- and 10 year old children into a high caries group and a low
caries group on the basis of:
1. Proximal surfaces of incisors and first permanent molars
2. Buccal surfaces of maxillary first permanent molars
3. Lingual surfaces of mandibular first permanent molars

Addition of these restored surfaces in each child provided a type of caries index for that
individual. Those who had a score of 4 or more were considered high caries active while
those who had a 0 score were considered low caries active. After 1 year the high caries

16
active group developed 9.5 new carious tooth surfaces, compared with 5.3 in the low
caries active group, the difference being statistically significant.

Results
Caries activity No. of selected restored New carious surfaces
surfaces
Low 0 5.30
High >4 9.52
Test Analysis
This method is a practical means of identifying children with high and low caries
activity and can be useful in screening children to be used in clinical therapeutic trials
or in practice for those who require extensive preventive therapy.

CLINICAL CORRELATION OF CARIES TESTS

Test Basis Method Clinical correlation

Lactobacillus Aciduric (saliva) Quantitative Group correlation
count
Snyder Aciduric (saliva) Qualitative Group correlation
Swab Aciduric (plaque) Qualitative Unsatisfactory
Fosdick Total orgs (saliva) Quantitative Not established
Dewar Total orgs (saliva) Quantitative Unsatisfactory
Rickle’s Total orgs (saliva) Quantitative Unsatisfactory
Reductase Total orgs (saliva) Qualitative Group correlation
Amylase Ability to Qualitative Unsatisfactory
hydrolyze starch or
Quantitative
Buffer Buffer capacity Quantitative Unsatisfactory
capacity
S.mutans S.mutans (plaque) Quantitative Correlation with
screening high-caries group

RELATIONSHIP BETWEEN TESTS AND CARIOGENIC FACTORS

RELATIONSHIP TO FLORA
Most tests utilize saliva as the source of cariogenic flora whereas a plaque sample would
be more rational. The bacteria found in saliva represent the wash-off from plaque,
mucosa and tongue and most resemble the tongue flora. Streptococcus mutans will
form acid from a number of different sugars but is not aciduric. Yet the two most

17
frequently used caries activity tests, the Lactobacillus and the Snyder test employ a
medium of pH 5.5 or less which is not likely to foster the growth of these caries
inducing streptococci. In fact these tests were designed at the time when Lactobacillus
acidophilus, an aciduric organism was considered to be the cause of caries.
Nevertheless the relationship between Lactobacilli and initial caries can only be an
indirect one and it is more logical to develop more direct tests for cariogenic flora.

Another feature of the Snyder test is that they use an indicator bromocresol green which
is blue-green at pH Ê 5.4 and turns yellow at pH 3.8 or less. However the so called
critical pH at which a significant amount of enamel dissolves is pH 5.4 to 5.5 and
therefore it is more appropriate to use an indicator such as bromocresol purple, which is
purple at pH 6.8 and yellow at pH 5.2. This indicator has been used in the Rickle’s test.

RELATIONSHIP TO SUBSTRATE
There is overwhelming evidence implicating sucrose as the principal dietary component
involved. Several studies have shown that a strict reduction of the dietary intake of
carbohydrates results in the lowering of the salivary Lactobacillus count. Cariogenic
streptococci can establish themselves on smooth surfaces, given the necessary substrate
and that once a defect has occurred in the enamel, the Lactobacillus can multiply there.
A comprehensive dietary survey is a good way of testing the caries induciveness of the
substrate; there is a general agreement that the currently available caries activity tests
serve as a check for patient cooperation as regards both dietary regime and oral hygiene
procedures. They serve as a practical visual aid in persuading patients to undertake
preventive measures. Thus the evaluation of success of dietary counseling by bacterial
examination gives an objective indication of the co-operation of the patient. A change of
dietary habits is reflected in the microflora within several weeks, and the patient is
motivated to continue his efforts.

RELATIONSHIP TO HOST RESISTANCE- TOOTH AND SALIVA

None of the tests has attempted to use an individual’s enamel, although the Fosdick test
has used pooled enamel powder. Difference in fluoride content can significantly alter
the solubility of enamel and a test using pooled enamel other than the patient’s enamel
cannot be justified. Recently developed techniques of enamel biopsy permit sampling of
an individual’s tooth but these techniques have not yet been adapted for susceptibility
tests.

Salivary pH is notoriously variable, partly because of the loss of carbon dioxide during
storage. Thus there are no clear-cut differences between patients with high and low
caries prevalence. Salivary acid buffering capacity has shown some correlation with
caries prevalence. However, the correlation of buffering capacity with caries is not

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adequate for predicting individual caries incidence. Measurements of salivary amylase
content have been related to dental caries experience but animal feeding experiments
indicate that starch is not sufficiently cariogenic.

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