By: Lee Ann Brady, DMD
This article originally appeared on Pankey.org. Dr. Brady granted permission for igniteDDS to share with our readers.
For most of us, caries risk assessment feels second nature; we’ve been trained to do it from the start. Diagnosing caries and periodontal disease are among the first skills we develop in dental school.
Early on, it’s a conscious, methodical process, but over time, it becomes second nature. You likely have a caries risk assessment protocol that runs through your mind in a split second, without even consciously considering all the factors involved.
Does Your Team Truly Understand Caries Risk Assessment?
Although caries risk assessment has become so ingrained in our thinking, that’s not always true for the rest of the dental team. Spending time with hygienists, assistants, and other team members often reveals that while they play a crucial role in the process, they may not have the same depth of understanding. They might not be able to explain why we monitor some lesions and treat others.
That’s why I take issue with the phrase “watching” a cavity. If I were a patient, my immediate question would be: What are you watching it do? The reality is, we’re watching it worsen until intervention is necessary. That terminology has never sat well with me, and while I don’t claim to have the perfect alternative, I believe we need better language to communicate this to patients.
The Surprising Truth About Caries Trends
When I returned to private practice after nearly a decade of teaching at Pankey, I expected to see fewer cases of caries. I assumed that with advancements in preventive dental care, our efforts would have significantly reduced tooth decay rates.
Instead, I saw more.
This was surprising, especially considering a 1986 epidemiological study by the CDC that predicted the near eradication of tooth decay within 30 years. At the time, fluoride was in public water supplies, preventive programs were in schools, sealants were widely used, and more people were visiting the dentist. The data suggested that if those trends continued, caries would decline significantly.
But things changed.
Our life expectancy has increased, meaning more people are managing their oral health over longer periods. Dietary habits evolved; think about how much more sugar and acid patients consume today, whether from frequent snacking or drinks like Starbucks lattes. Medications that cause dry mouth have become more prevalent. And some of the preventive measures that once helped, like fluoride in public water, have been scaled back or challenged by public skepticism.
A New Approach: CAMBRA
Recognizing that I needed to reassess my own approach, I came across CAMBRA—Caries Management by Risk Assessment. Developed by Dr. Doug Young at the University of the Pacific, CAMBRA was first adopted by the California Dental Association as the standard for caries risk assessment and later endorsed by the ADA.
If you haven’t reviewed an actual CAMBRA form, I highly recommend it. The ADA provides both pediatric (ages 0-7) and adult (ages 8 and up) versions, which are available to members. When I first looked at the form, I assumed I already knew everything on it. But going through it—especially in a team meeting with my assistants and hygienists—proved to be one of the most valuable exercises we’ve done.
What the CAMBRA Form Taught Me
The form includes caries risk factors that may be easy to overlook in daily practice. For example, it specifies that if a patient has had a caries lesion in the past 36 months, they cannot be classified as low risk. They automatically move to moderate or high risk. That’s not just intuition; it’s a structured, evidence-based assessment.
Another key factor on the form is whether the patient wears fixed or removable dental appliances. Initially, my mind went straight to orthodontic brackets and wires—of course, they increase caries risk due to hygiene challenges. But the form made me think more broadly. Research shows that clear aligners, such as Invisalign, also elevate caries risk. Unlike traditional braces, they don’t impede home care, but they do create an acidic oral environment between the aligner and the teeth, accelerating demineralization.
The Biggest Takeaway: Acidic Oral Environment and Caries Risk
One of the most critical insights we’ve gained over the past few decades is the role of oral pH in caries formation. The biggest physiological risk factor for caries isn’t just sugar—it’s an acidic oral environment. Understanding this and integrating structured risk assessment tools like CAMBRA can help us refine our approach to prevention and treatment in ways that benefit both our practices and our patients.
Caries risk assessment isn’t just about intuition. It’s about evolving with the science. The more we educate ourselves and our teams, the better we can serve our patients and truly work toward the prevention that was once predicted but has yet to be realized.
Watch this Pankey Webinar by Dr. Brady for more in-depth information about Caries Risk Assessment and Prevention, and learn more about preventive products, like remineralizing toothpastes, fluoride varnishes, and silver diamine fluoride in preventing and treating caries disease in your patients.
