Abstract
Purpose: This study aimed to evaluate the caries risk of patients before orthodontic treatment using Caries Management by Risk Assessment (CAMBRA).
Methods: A dental hygienist conducted interviews and intraoral examinations of patients attending the Orthodontic Department at Asahi University Medical and Dental Center for initial orthodontic consultation. Items related to disease indicators (D), risk factors (R), and protective factors (P) were checked using CAMBRA. Caries risk levels of patients were classified into four categories: low, middle, high, and extreme. Total scores of D, R, and P between the low/middle and high caries risk patients were compared using the Wilcoxon rank sum test. The association between each factor and caries risk in patients classified as low/middle and high was statistically analyzed with Fisher’s exact test (significance level 5%).
Results: The distribution of caries risk levels was 11.8% (low), 1.4% (middle), and 86.8% (high). Factors D and P significantly influenced the results (P < 0.05), while factor R had no impact (P > 0.05). The presence of white spot lesions (D3) and restorative treatment within the past three years (D4) frequently correlated with high caries risk. Conversely, the use of fluoride toothpaste daily (P1, P2) was associated with a lower frequency of high caries risk.
Conclusion: A large percentage of patients were classified as high caries risk. It is necessary to reduce disease indicators (D3, D4) and to improve protective factors (P1, P2).
Introduction
Orthodontic treatment is performed to resolve patient’s dental and skeletal problems. During orthodontic treatment, the ability to maintain a high level of oral hygiene tends to be reduced as it is much harder to clean around bonded orthodontic appliances; hence deterioration of the oral environment can easily occur. It has been reported that patients with high caries risk at the initial visit have a higher incidence of caries during the period of orthodontic treatment [1]. Therefore, it is essential to evaluate the caries risk of patients prior to the commencement of orthodontic treatment and to establish good plaque control for those patients with high caries risk to improve the oral environment as well as control any other risk factors that have been identified.
To properly assess the oral condition of patients before orthodontic treatment, quantitative caries risk assessment is necessary, but it is not currently being implemented [2]. The International Caries Classification and Management System (ICCMS) was developed to standardize caries diagnosis, risk assessment and treatment decisions based on overall evidence [3].
Caries Management by Risk Assessment (CAMBRA) is a caries risk assessment method [4,5] and has reached its current evaluation methodology through several clinical studies [6,7,8,9]. CAMBRA classifies the caries risk level into low, middle, high, and extreme based on the balance of three factors: disease indicators (D), risk factors (R), and protective factors (P), through interviews and intraoral examinations and/or tests. It especially points out the importance of fluoride therapy and antimicrobial therapy for patients classified as high or extreme [9].
Caries risk assessment had not been routinely performed for patients before orthodontic treatment in the Orthodontic Department at Asahi University Medical and Dental Center. Therefore, the CAMBRA method was introduced as a caries risk assessment tool, and caries risk assessment commenced for all new patients. The purpose of this study was to evaluate the caries risk of patients before orthodontic treatment using CAMBRA, to understand the caries risk, and to examine the influence of each factor and item on caries risk. The hypothesis of this study was to determine whether specific items of the three factors (D, R, and P) of CAMBRA influenced the caries risk level.
Materials and Methods
Subjects
The study included 68 patients (20 males and 48 females, average age of 15.1 years) who visited the Orthodontic Department at the Asahi University Medical and Dental Center for initial orthodontic consultation between April 1, 2022 and March 31, 2023. Patients with systemic diseases or congenital syndromes were excluded from the study.
After explaining the study to the patients prior to orthodontic treatment, it was conducted with the consent of those who agreed to participate and their parent/guardian.
Methods
A dental hygienist affiliated with the orthodontic department conducted interviews and intraoral examinations of patients by using the CAMBRA form available in Japan (Fig. 1) [9] to check the items related to disease indicators, risk factors, and protective factors. One item under risk factors was determined using the CariScreen (Yoshida, Tokyo, Japan) test values, with a value (1,501-9,999) indicating a high caries risk (R1). Since the study subjects were under 40 years of age and no patients were found to have issues with salivary secretion during the oral examination, items related to saliva tests (R5, R6, and P8) were omitted in this study. The caries risk levels of patients were classified into four categories: low, middle, high, and extreme, according to CAMBRA's evaluation method [9].
Table 1 Information of the study subjects
| Gender |
Age* |
Average age |
| male |
female |
total |
6-12 |
13-21 |
22-39 |
40-65 |
65- |
15.1 |
| 20 |
48 |
68 |
24 |
37 |
7 |
0 |
0 |
|
| 29.4 |
70.6 |
100 |
35.3 |
54.4 |
10.3 |
0 |
0 |
Upper columns: number of the subjects, lower columns: percentage (%). *Age distribution of the subjects was classified according to Erikson's stages [10,11].
Table 2 Distribution of caries risk levels in this study
| Caries risk level |
Low |
Middle |
High |
Extreme |
Total |
| Number of the subjects |
8 |
1 |
59 |
0 |
68 |
| Percentage (%) |
11.8 |
1.4 |
86.8 |
0 |
100 |
Statistical analysis
The total scores were not normally distributed according to the Shapiro-Wilk normality test (P < 0.05). After this, to compare the total scores of disease indicators, risk factors, and protective factors between the patients classified as low and middle (low/middle) and high caries risk, statistical analysis was conducted using the Wilcoxon rank sum test. Fisher’s exact test was then used to examine the association between each factor and caries risk in patients classified as low/middle and high. Statistical processing was performed using the analysis software (SPSS ver. 27.0, IBM Corp., Chicago, IL, USA) with a significance level of 5%.
Results
Patient information
Table 1 presents the information of the study subjects, with 29.4% being male and 70.6% female. When classified according to Erikson's stages [10,11], the age distribution was 35.3% for 6-12 years, 54.4% for 13-21 years, and 10.3% for 22-39 years, respectively.
Caries risk assessment results
Table 2 shows the distribution of caries risk levels in this study. The distribution of caries risk levels was 11.8% low, 1.4% middle, and 86.8% high. No patients were classified as extreme in this study. Table 3 shows the distribution of the checked items in disease indicators, risk factors and protective factors of the patients. Full checked boxes were not seen for each factor.
Table 4 shows the number and the proportions of checked items for disease indicators, risk factors, and protective factors in patients classified as low/middle (left) and high (right) caries risk. The low and middle caries risk groups were combined as low/middle due to the only one middle caries risk patient identified in this study. Statistical analysis of the impact of the three factors on caries risk classification revealed that disease indicators and protective factors significantly influenced the results (P < 0.05), while risk factors did not have a significant impact (P > 0.05).
In terms of the association between each item of disease indicators, risk factors, and protective factors with the caries risk classification, the items; D3, D4, P1, and P2 showed statistically significant associations (P < 0.05), while other items did not. This indicated that the presence of white spots on tooth surfaces (D3) and restorative treatment within the past three years (D4) frequently correlates with a high caries risk (P < 0.05). Conversely, the use of fluoride toothpaste once or twice daily (P1, P2) is associated with a lower frequency of high caries risk (P < 0.05).
Table 3 Distribution of the checked items for disease indicators, risk factors and protective factors in patients
| Factors |
Number of checked items |
Number of subjects |
Proportion (%) |
| Disease indicators |
0 |
20 |
29.4 |
| 1 |
37 |
54.4 |
| 2 |
10 |
14.7 |
| 3 |
1 |
1.5 |
| 4 |
0 |
0 |
| Risk factors |
0 |
1 |
1.5 |
| 1 |
6 |
8.8 |
| 2 |
27 |
39.7 |
| 3 |
32 |
47.1 |
| 4 |
2 |
2.9 |
| 5 |
0 |
0 |
| 6 |
0 |
0 |
| Protective factors |
0 |
12 |
17.6 |
| 1 |
10 |
14.7 |
| 2 |
22 |
32.4 |
| 3 |
24 |
35.3 |
| 4 |
0 |
0 |
| 5 |
0 |
0 |
| 6 |
0 |
0 |
| 7 |
0 |
0 |
Table 4 Proportions of checked items for disease indicators, risk factors and protective factors in patients classified as low/middle and high caries risk
| Factors |
Items |
Caries risk level* |
Statistics |
| low/middle |
high |
P value |
S/NS** |
| Disease indicators |
D1 |
0 (0) |
2 (3.4) |
>0.05 |
NS |
| D2 |
0 (0) |
1 (1.7) |
>0.05 |
NS |
| D3 |
0 (0) |
28 (47.5) |
0.008 |
S |
| D4 |
0 (0) |
29 (49.2) |
0.008 |
S |
| Risk factors |
R1 |
9 (100) |
55 (93.2) |
>0.05 |
NS |
| R2 |
3 (33.3) |
34 (57.6) |
>0.05 |
NS |
| R3 |
2 (22.2) |
11 (18.6) |
>0.05 |
NS |
| R4 |
5 (55.6) |
45 (76.3) |
>0.05 |
NS |
| R5** |
- |
- |
- |
- |
| R6** |
- |
- |
- |
- |
| R7 |
0 (0) |
0 (0) |
>0.05 |
NS |
| R8 |
0 (0) |
0 (0) |
>0.05 |
NS |
| Protective factors |
P1 |
9 (100) |
37 (100) |
0.026 |
S |
| P2 |
9 (100) |
37 (100) |
0.026 |
S |
| P3 |
0 (0) |
0 (0) |
>0.05 |
NS |
| P4 |
5 (62.5) |
29 (49.2) |
>0.05 |
NS |
| P5 |
0 (0) |
1 (1.7) |
>0.05 |
NS |
| P6 |
0 (0) |
0 (0) |
>0.05 |
NS |
| P7 |
0 (0) |
0 (0) |
>0.05 |
NS |
| P8*** |
- |
- |
- |
- |
*% in parentheses, **S: significant (P < 0.05), **NS: not significant in each item between the low and high caries levels (P > 0.05), ***The items related to saliva tests (R5, R6, and P8) were omitted in this study.
Discussion
The subjects of this study were patients who visited for orthodontic treatment, predominantly younger individuals. It has been reported that plaque accumulation due to fixed orthodontic appliances can increase the incidence of caries during orthodontic treatment [12] and assuming other factors are present. Particularly with the use of multi-bracket appliances, white spot lesions tend to form around the brackets [13]. Given that young orthodontic patients often have inadequate oral hygiene, it is crucial to objectively and quantitatively assess the caries risk of each patient before commencing orthodontic treatment, considering the characteristics of the appliances and the patient’s age. Proper brushing instruction and the use of fluoride are essential to aid caries prevention during orthodontic treatment.
When the principles of CAMBRA were introduced in 2003, a major transformation in how to conceptualize and treat the caries disease was established [14]. With CAMBRA, scientific, evidence-based solutions for prevention and treatment of caries as a manageable medical condition, not a mechanical problem, were translated into clinically relevant guidelines for oral health practitioners [15].
The caries risk was evaluated in this study using CAMBRA at the initial visit of patients seeking orthodontic treatment. The CAMBRA form used in this study is available in Japan, which was modified from the original form [8] because of the different products and treatment methods between Japan and the USA (Fig. 1). CAMBRA classifies caries risk levels into low, middle, high, and extreme. Featherstone et al. [8] provided specific examples for extreme, including disease indicators such as obvious cavitations, multiple proximal caries on radiographs, and numerous restorations within the past three years; risk factors such as heavy plaque accumulation, frequent snacking, reduced salivary flow, and medication-induced dry mouth; and protective factors such as using fluoride toothpaste only once a day.
They emphasized the importance of topical fluoride therapy and antimicrobial therapy for patients classified as high or extreme. The recommended fluoride therapy involves using high-concentration fluoride toothpaste (5,000 ppm F) twice daily and combining it with antimicrobial therapy (0.12% chlorhexidine gluconate mouthrinse). The effectiveness of 5,000 ppm fluoride toothpaste has been documented in the guidelines for caries treatment by the Japanese Society for Conservative Dentistry [16,17]. However, only 1,500 ppm or less fluoride containing toothpastes are approved under Japanese pharmaceutical regulations. The Japanese commercial mouthrinses contain only 0.05% chlorhexidine gluconate, since patient compliance is likely to be low due to the side effects of chlorhexidine [18]. Featherstone et al. [8] recommend the daily use of xylitol gum or mints for patients classified as high or extreme, though such home care is not commonly adopted by patients in Japan.
The minimally invasive dentistry (MID) concept [19] has been widely accepted by Japanese clinicians. On the other hand, the current dental treatments covered by the Japanese national health insurance system are still mainly focusing on drill and fill treatments, not focusing more on preventative care and no treatment. That means there are less financial incentives for dentists to maintain patients with a caries-free oral cavity.
The caries risk assessment in this study revealed that 89.6% of patients were classified as high risk. Statistical analysis of the influence of the three factors, disease indicator, risk factor, and protective factor, on caries risk classification showed that disease indicator and protective factor significantly influenced the results, while risk factor did not.
CariScreen is a commercial adenosine triphosphate (ATP) meter. ATP readings have the possibility to indicate bacteria or oral streptococci activity in microbial plaque [20]. This finding suggests the need for caution, as the proportion of patients classified as high risk (≥1,501) by CariScreen (R1) was significantly higher in both low/middle and high caries risk groups (Table 4). Therefore, reducing the CariScreen value below 1,500, i.e., ensuring thorough plaque control, is extremely important for patients before starting orthodontic treatment.
Additionally, the association between each item of disease indicator, risk factor, and protective factor with caries risk classification showed significant correlations for the items; D3, D4, P1, and P2, while other items did not. This indicates that the presence of white spots on tooth surfaces (D3) and restorative treatment within the past three years (D4) frequently correlates with a high caries risk classification, while the use of fluoride toothpaste once or twice daily (P1, P2) is associated with a lower frequency of high caries risk classification. The action of brushing twice daily without fluoride toothpaste will prevent biofilm build-up as it disrupts its formation and is likely to aid or prevent the biofilm from becoming dysbiotic in nature [8,21]. The result is the biofilm is less likely to initiate caries as the acidogenic species remain in lower numbers [22,23]. Therefore, the hypothesis that some specific items influenced the caries risk level was accepted in the current study. However, a limitation exists in the caries risk levels in this study. The low and middle caries risk groups were combined as low/middle due to only one middle caries risk patient being identified. Also, no patients were classified as extreme. To improve the accuracy of the information, more subject data should be collected in the future.
At the center, patients classified as high risk receive a caries prevention plan, created with reference to the CAMBRA treatment menus in the USA. However, due to differences in the healthcare systems, materials used, home care products, and patient dietary habits between the USA and Japan, caries prevention management methods corresponding to CAMBRA risk levels need to be adapted to the current state of the caries prevention in Japan. Moreover, as the problematic factors and items differ for each patient, it is necessary to extract problematic factors from the evaluation items and create a tailor-made caries prevention plan for each patient.
From the current study, it is strongly suggested that the caries risk assessment of patients before orthodontic treatment should be an essential item of care, and the caries risk management according to the caries risk level should be performed during orthodontic treatment. Furthermore, it is necessary to implement thorough caries prevention management by dental hygienists before starting orthodontic treatment, assess the effect of interventions on caries risk levels, and continuously evaluate caries risk throughout orthodontic treatment until its completion.
From the limited results of this study, the following conclusions were achieved. A large percentage of the patients were classified as high caries risk. It is necessary to reduce disease indicators (D3, D4) and to improve protective factors (P1, P2). It is essential to establish a caries prevention program tailor-made to the individual risks of each patient.
Abbreviations
ATP: adenosine triphosphate; CAMBRA: Caries Management by Risk Assessment; D: disease indicators; ICCMS: International Caries Classification and Management System; MID: minimally invasive dentistry; NS: not significant; P: protective factors; R: risk factors; S: significant
Ethical Statements
This study was approved by the Ethics Committee of Asahi University, School of Dentistry (Approval No. 35008).
Conflicts of Interest
The authors declare no conflict of interest related to this paper. Toru Nikaido is the Associate Editor of Asian Pacific Journal Dentistry and the Director of Japanese Dental Science Federation. He was not involved in the editorial evaluation or decision to accept this article for publication at all.
Funding
This work was supported by Grant-in-Aid for Scientific Research (C) No. 21K09924 from the Japan Society for the Promotion of Science.
Author Contributions
RM: conceptualization, investigation, methodology, data curation, formal analysis, visualization, and writing; YT: conceptualization, investigation, methodology, data curation, formal analysis, visualization, and review; HT: conceptualization, methodology, formal analysis, writing, review, and editing; KU: data curation, formal analysis, visualization, and review; WT: conceptualization, investigation, methodology, data curation, formal analysis, and review; NK: conceptualization, methodology, formal analysis, review, and supervision; MI: methodology, formal analysis and review; MB: formal analysis, review and editing; TN: conceptualization, methodology, formal analysis, review, editing, and supervision. All authors read and approved the final version of the manuscript.
ORCID iD
-
1) RM: rena@alice.asahi-u.ac.jp, https://orcid.org/0009-0001-0833-3147
1) YT: morishi@alice.asahi-u.ac.jp, https://orcid.org/0009-0000-3847-4760
2) TN: nikaido-ope@dent.asahi-u.ac.jp, https://orcid.org/0000-0002-7346-1831
2) HT*: hanemi@dent.asahi-u.ac.jp, https://orcid.org/0009-0000-4263-3621
3) KU: ueno@dent.asahi-u.ac.jp, https://orcid.org/0000-0002-0786-6208
4) WT: wakakot@dent.asahi-u.ac.jp, https://orcid.org/0000-0003-3377-3520
4) NK: nkitai@dent.asahi-u.ac.jp, https://orcid.org/0000-0002-5746-9155
5) MI: ikeda.csoe@tmd.ac.jp, https://orcid.org/0000-0003-2214-4980
6) MB: mfburr58@hku.hk, https://orcid.org/0000-0001-9735-1904
Data Availability Statements
All data generated or analyzed during the current study are available from the corresponding author on reasonable request.
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