dental caries is a multifactorial disease caused by interactions between acidogenic 
 bacteria , biofilm and individual caries risk factors ( e.g. , saliva composition , fluoride 
 exposure and dietary components ) . in 
 a global context ,
its prevalence is still high , particularly in children . because dental caries is preventable , 
 caries risk assessment ( cra ) is an important tool assisting the dentist to better understand the cariogenic profile 
 of a patient .
the process includes 
 collecting relevant historical data of the patient , such as the medical and dental 
 history .
the complex nature of caries risk has led to the development of different 
 protocols that are not all validated .
cariogram , a software program from 
 sweden , stands out as it has been clinically proven to be effective in evaluating caries 
 risk .
the outcomes are 
 presented graphically to the patient , indicating the probability of avoiding new carious 
 lesions .
cariogram is based on a set of pathological and protective factors 
 - caries experience , systemic diseases , diet contents and frequency , amount of plaque , 
 mutans streptococci , fluoride sources , saliva secretion and buffer capacity - in 
 addition to the professional clinical judgment . as some factors are considered more 
 relevant than others regarding caries development ,
most information is easily collected at the dental practice , but saliva and bacteria 
 assessment require specific tests which are not frequently performed by a 
 dentist .
the use of 
 cariogram is limited to places where a computer system is available and 
 where those tests can be performed .
for that reason , alternatives ways of performing cra 
 have been proposed ; it is suggested that the best way of implementing cra in clinical 
 practice would be by the use a form , ensuring that all patients could be assessed 
 systematically in the same manner .
the main differences between the 
 cariogram software and the new form include the following : filling in the 
 form does not require a computer ; the variables " mutans streptococci " , " salivary buffer 
 capacity " and " clinical judgement " are excluded and the form assesses risk based on the 
 sum of values attributed to each etiological factor . finally , it classifes the patient 
 as having a low , moderate or high caries risk and provides treatment guidelines for each 
 category .
this study aimed to determine whether the newly developed cra form could 
 classify schoolchildren according to their caries risk and to evaluate relationships 
 between caries risk and the variables in the form .
this study is part of a clinical trial that aims to compare the performance of 
 different sealant materials in the prevention of dental caries .
therefore , children 
 considered at moderate and high caries risk needed to be identified . with that 
 purpose , a survey was carried out in an elementary school located in parano , which 
 is a deprived area of brazil 's federal district .
all 298 children aged 5 to 7 years 
 old and enrolled at school were invited to participate .
children whose parents did 
 not sign the informed consent form and those who needed special care were excluded 
 ( figure 1 ) .
the study was approved by the 
 ethics committee of the school of medicine of the university of braslia ( reference 
 no .
information about the prevalence of dental caries was obtained according to 
 international caries detection and assessment system ( icdas ) ii .
the dentist was trained in using icdas , having 
 completed its e - learning program .
additionally , a pilot study was also conducted at 
 the braslia university hospital for the examiner calibration covering other oral 
 conditions that were assessed : toothache , gingival bleeding and visible plaque .
the oral examinations took place in a dental office located inside the school , with 
 the children sitting on a conventional dental chair under optimal lighting .
a plane 
 buccal mirror , who - cpi probe and air syringe were used in the clinical examination . 

then , the examiner cleaned 
 all tooth surfaces with only a toothbrush , after which dental caries was recorded in 
 primary and permanent teeth .
caries risk was assessed according to a form based on cariogram , in which seven variables were 
 included , as shown in figure 2 .
the form is 
 able to convert into scores the information that was collected about each patient . 

according to the cariogram built - in algorithm , each variable in the form was weighted 
 at a relevant ratio and the scores were assigned .
variables assessed , their description , the instrument used and the scores of 
 each variable according to severity dmft = decayed , missing , filled teeth the variables " caries experience " , " oral hygiene " and " salivary flow " were obtained 
 clinically . for all other variables ,
the information was retrieved from 
 questionnaires previously sent to parents . for calculating caries experience ,
data 
 were converted into dmft / dmft scores according to amorim , et al .
all children were classified as having a normal salivary flow during 
 the clinical examination .
after completion of the forms and summing up the scores for 
 all variables , each child was classified as belonging to a low ( 033 ) , moderate 
 ( 3466 ) or high caries risk ( > 67 ) group .
first , linear regressions were performed , considering caries risk as a dependent 
 variable and the variables presented in figure 
 2 as the independent ones .
this study is part of a clinical trial that aims to compare the performance of 
 different sealant materials in the prevention of dental caries .
therefore , children 
 considered at moderate and high caries risk needed to be identified . with that 
 purpose , a survey was carried out in an elementary school located in parano , which 
 is a deprived area of brazil 's federal district .
all 298 children aged 5 to 7 years 
 old and enrolled at school were invited to participate .
children whose parents did 
 not sign the informed consent form and those who needed special care were excluded 
 ( figure 1 ) .
the study was approved by the 
 ethics committee of the school of medicine of the university of braslia ( reference 
 no .
information about the prevalence of dental caries was obtained according to 
 international caries detection and assessment system ( icdas ) ii .
the dentist was trained in using icdas , having 
 completed its e - learning program .
additionally , a pilot study was also conducted at 
 the braslia university hospital for the examiner calibration covering other oral 
 conditions that were assessed : toothache , gingival bleeding and visible plaque .
the oral examinations took place in a dental office located inside the school , with 
 the children sitting on a conventional dental chair under optimal lighting . a plane 
 buccal mirror , who - cpi probe and air syringe were used in the clinical examination . 

then , the examiner cleaned 
 all tooth surfaces with only a toothbrush , after which dental caries was recorded in 
 primary and permanent teeth .
caries risk was assessed according to a form based on cariogram , in which seven variables were 
 included , as shown in figure 2 .
the form is 
 able to convert into scores the information that was collected about each patient . 

according to the cariogram built - in algorithm , each variable in the form was weighted 
 at a relevant ratio and the scores were assigned .
variables assessed , their description , the instrument used and the scores of 
 each variable according to severity dmft = decayed , missing , filled teeth the variables " caries experience " , " oral hygiene " and " salivary flow " were obtained 
 clinically . for all other variables ,
the information was retrieved from 
 questionnaires previously sent to parents . for calculating caries experience ,
data 
 were converted into dmft / dmft scores according to amorim , et al .
all children were classified as having a normal salivary flow during 
 the clinical examination .
after completion of the forms and summing up the scores for 
 all variables , each child was classified as belonging to a low ( 033 ) , moderate 
 ( 3466 ) or high caries risk ( > 67 ) group .
first , linear regressions were performed , considering caries risk as a dependent 
 variable and the variables presented in figure 
 2 as the independent ones .
the sample population comprised 150 children ( 81 girls and 69 boys ) with a mean age 
 and standard deviation of 6.80.62 .
the majority of them were from low - income 
 families ( less than one brazilian minimum wage ) .
caries 
 prevalence in primary dentition , including enamel and dentine carious lesions , was 
 98.6% , and 77.3% when only dentine lesions were considered .
the mean dmft score was predominantly 
 influenced by the d - component , as only 18.6% children presented fillings or extracted 
 teeth .
the permanent dentition caries prevalence , including enamel and dentine 
 lesions , was 34% and when only dentine lesions were considered , 12.6% .
intra - examiner reliability in diagnosing carious lesions was determined by 
 re - examining 9.3% of the children .
the kappa - coefficient value was o.924 , showing a 
 high level of reliability .
the mean dmft scores of the children classified as being at low , moderate or high 
 risk , according to the form based on cariogram , are presented in table 1 .
distribution of variables scores 
 according to assessed caries risk is presented in table 2 .
children distribution and mean dmft according to caries risk dmft = decayed , missing , filled teeth .
sd= standard deviation distribution of variables scores occurrence according to caries risk 
 assessed in order to establish the variables that influenced caries risk the most , a 
 univariate model was applied , including all variables presented in figure 2 .
results are presented in table 3 and show that the variable " related 
 diseases " was the only one that did not have a statistically significant effect on 
 the caries risk profile .
variables included in the univariated model the significant factors were then included in a multivariate forward model , showing 
 that the most relevant variable in caries risk prediction was caries experience 
 ( table 4 ) .
the sample population comprised 150 children ( 81 girls and 69 boys ) with a mean age 
 and standard deviation of 6.80.62 .
the majority of them were from low - income 
 families ( less than one brazilian minimum wage ) .
caries 
 prevalence in primary dentition , including enamel and dentine carious lesions , was 
 98.6% , and 77.3% when only dentine lesions were considered .
the mean dmft score was predominantly 
 influenced by the d - component , as only 18.6% children presented fillings or extracted 
 teeth .
the permanent dentition caries prevalence , including enamel and dentine 
 lesions , was 34% and when only dentine lesions were considered , 12.6% .
intra - examiner reliability in diagnosing carious lesions was determined by 
 re - examining 9.3% of the children .
the kappa - coefficient value was o.924 , showing a 
 high level of reliability .
the mean dmft scores of the children classified as being at low , moderate or high 
 risk , according to the form based on cariogram , are presented in table 1 .
distribution of variables scores 
 according to assessed caries risk is presented in table 2 .
children distribution and mean dmft according to caries risk dmft = decayed , missing , filled teeth .
sd= standard deviation distribution of variables scores occurrence according to caries risk 
 assessed in order to establish the variables that influenced caries risk the most , a 
 univariate model was applied , including all variables presented in figure 2 .
results are presented in table 3 and show that the variable " related 
 diseases " was the only one that did not have a statistically significant effect on 
 the caries risk profile .
variables included in the univariated model the significant factors were then included in a multivariate forward model , showing 
 that the most relevant variable in caries risk prediction was caries experience 
 ( table 4 ) .
caries risk assessment is an important tool that contributes to identification of risk 
 factors and guides the dental professional in the decision - making process involved in 
 effective prevention and management of dental caries .
the common practice is to assess these factors individually but , 
 as dental caries is a multifactorial disease , more than one factor can predict future 
 caries .
therefore , the use of 
 validated instruments for guiding the professional in establishing the risk profile of a 
 patient is essential .
for that reason , the form based on the cariogram 
 software , which has been validated in schoolchildren , was chosen for use in 
 this investigation .
it includes factors involved in the caries process which can be 
 easily assessed , clinically or with questionnaires , without requiring a computer system , 
 thus allowing , in our case , its application in a school located in a low - income 
 community .
the fact that neither salivary buffer capacity nor microbial tests were 
 included in the form can be justified by the low predictive values of both tests in 
 relation to dental caries .
it is known that in the presence of fluoride , a high number 
 of mutans streptococci and/or lactobacilli may be tolerated in the oral fora without 
 causing any harm to the teeth . for the univariate model used in the present study ,
all variables that are included in 
 the form based on cariogram were analyzed , except " salivary flow " , as none 
 of the children presented clinical aspects of hyposalivation .
for the forward stepwise 
 multiple regression model , five variables were included in the analysis and , together , 
 could explain 90.4% of the caries risk observed in the sample .
these results are 
 corroborated by previous studies using the cariogram software , which showed 
 high correlation between caries experience and caries risk profiles .
furthermore , caries experience is considered the strongest predictor 
 for future caries , even when other forms of cra are used .
results show that the form based on cariogramwas able to classify the 
 schoolchildren according to the three caries risk categories : low , moderate and high . 
 however , few children were allocated to the low and high categories . regarding the low 
 risk group ,
this finding can be ascribed to the high caries prevalence among the 
 children included in the sample .
this outcome is in line with a previous study conducted 
 in the same area , where caries prevalence was 67% for children in the same age 
 group .
however , how sure are we 
 that children with a mean dmft of 3.38 ( 86% of whom were classified as belonging to the 
 moderate risk group ) do not belong to the high caries group ?
these children had a low 
 proportion of missing and filled teeth and a high proportion of decayed teeth . the variable " caries experience " ,
even though it was the most relevant for caries 
 prediction in the analyzed form , might still not show enough influence on the overall 
 results , since children with an average high dmf score were mostly considered as being 
 at only moderate risk of developing caries , particularly those living in areas with 
 fluoridated water and access to fluoridated toothpaste .
it is important to discuss the weighting given to the " fluoride sources " variable in the 
 form . among all factors included in the form ,
the complete absence of a fluoride source 
 is the one that counts the most for the fnal outcome ( 50 points ) .
this makes sense as 
 the effectiveness of fluoride in preventing and controlling caries progression has been 
 highly documented .
however , in the 
 present study , all children received the lowest score ( zero ) for the variable " fluoride 
 source " , as they live in an area which has fluoridated water ( 0.07 ppm ) , and brush their 
 teeth with fluoridated toothpaste .
another variable that may be responsible for the low differentiation of the children 
 between caries risk groups was " salivary flow " , since the absolute majority of the 
 examined children presented normal salivary flow .
firstly , it is common to observe an 
 increase in salivary flow rate with an increase in childhood age .
furthermore , children who suffer from 
 dental caries generally do not present clinical aspects of decreased salivary secretion 
 and , if present , these are often related to systemic diseases .
the long - term use of sugary medications , as well as the 
 presence of systemic diseases , is related to an increment in caries risk .
however , the form was effective in classifying the children with the highest dmft scores 
 ( > 4 ) as having a high risk of developing carious lesions .
it was observed that , 
 although these children received the lowest scores for " fluoride sources " and " salivary 
 flow " , they got maximum scores for all other factors related to diet and hygiene 
 included on the form , showing the multifactorial etiology of dental caries .
these 
 patients would normally score 68 points , just 1 point above the borderline between 
 moderate and high caries risk .
any minimal control of diet or hygiene would already lead 
 them into the moderate risk group .
further discussion of the proper weighting of the 
 variables in the simplified form is encouraged . also , it is important to note that the 
 outcome of the cariogram software is the chance ( % ) of avoiding new carious 
 lesions , while the simplified form classifes children according to three risk groups 
 categories .
transformation of cariogram results into risk groups has already 
 been performed , using five subgroups according to the chance of avoiding new lesions 
 [ very low ( 0 - 20% ) , low ( 21 - 40% ) , medium ( 41 - 60% ) , high ( 61 - 80% ) and very high 
 ( 81 - 100% ) ] .
the school in which the survey was carried out is located in an unprivileged community 
 with difficulties in access to health care .
this can explain , in part , the high number 
 of children presenting dental treatment needs .
also , this fact reinforces the " feeling " 
 of the authors that the number of children identified as high - risk should be higher . in 
 the cariogram software
a professional clinical judgement variable allows the 
 examiner to increase the risk for patients that are believed to have a higher chance to 
 develop compared to the data results only .
maybe , in the simplified form , in which this 
 variable is absent , a modification in the caries risk group threshold values could act 
 as the clinical judgment variable of the original software .
the fact that a substantial number of parents did not sign the informed consent form 
 might suggest that their children were caries - free and the parents did not feel that 
 exposing them to a dental examination was a necessity .
if this assumption is correct , 
 the absence of these children could help to explain the very high prevalence of caries 
 in the studied population and , therefore , some of the results found in the analysis of 
 the form usage .
it is suggested that the form based on cariogramshould be 
 applied in a population with different oral health needs , in order to confirm the 
 ability of the instrument to properly identify subjects who are at low risk .
the form based on the cariogram software was able to classify the 
 schoolchildren according to low , moderate and high caries risk , with a large 
 concentration in the moderate risk group , despite the high average dmft .
caries 
 experience , oral hygiene , frequency of food consumption , sugar consumption and fluoride 
 sources are the variables that were shown to be highly correlated with caries risk .
 identifying caries risk factors is an important measure which contributes to best 
 understanding of the cariogenic profile of the patient . 
 the cariogram software 
 provides this analysis , and protocols simplifying the method were suggested.objectivesthe aim of this study was to determine whether a newly developed caries risk 
 assessment ( cra ) form based on the cariogram software could classify 
 schoolchildren according to their caries risk and to evaluate relationships 
 between caries risk and the variables in the form.material and methods150 schoolchildren aged 5 to 7 years old were included in this survey . 
 caries 
 prevalence was obtained according to international caries detection and assessment 
 system ( icdas ) ii . 
 information for filling in the form based on cariogram was 
 collected clinically and from questionnaires sent to parents . 
 linear regression 
 and a forward stepwise multiple regression model were applied to correlate the 
 variables included in the form with the caries risk.resultscaries prevalence , in primary dentition , including enamel and dentine carious 
 lesions was 98.6% , and 77.3% when only dentine lesions were considered . 
 eighty - six 
 percent of the children were classified as at moderate caries risk . 
 the forward 
 stepwise multiple regression model result was significant ( r2=0.904 ; 
 p<0.00001 ) , showing that the most significant factors influencing caries risk 
 were caries experience , oral hygiene , frequency of food consumption , sugar 
 consumption and fluoride sources.conclusionthe use of the form based on the cariogram software enabled classification of the 
 schoolchildren at low , moderate and high caries risk . 
 caries experience , oral 
 hygiene , frequency of food consumption , sugar consumption and fluoride sources are 
 the variables that were shown to be highly correlated with caries risk . 
INTRODUCTION
MATERIAL AND METHODS
Study population
Clinical examination
Caries risk assessment
Statistical analysis
RESULTS
Subjects
Dental caries
Reliability of data collection
Caries risk
DISCUSSION
CONCLUSION