Caries risk assessment: Limited evidence for current models


Caries is very common and assessing an individual patients’ risk of developing caries is considered important to provide a basis for planning and organising prevention and treatment strategies to enhance patient care. While past caries experience is recognised as an important predictor of future disease a range of other factors have been included in multi-risk studies and models.

The aim of this review was to evaluate whether standardised caries risk assessment (CRA) models are able to evaluate the risk according to the actual caries status and/or the future caries increment.


 Searches were conducted in the PubMed, Scopus and Embase databases.  Randomised controlled trial (RCT), cross-sectional studies, cohort studies, comparative studies, validation studies and evaluation studies, reporting CRA using standardized models in patients of any age related to caries data recorded by Decayed, Missing, Filled Tooth/ Surface (DMFT/S) or the International Caries Detection and Assessment System (ICDAS) indices published from 2000 onwards were considered.

Two reviewers independently selected studies extracted data and assessed risk of bias.  A customised quality assessment tool from the National Heart, Lung, and Blood Institute and Research Triangle Institute International was used. Sensitivity and specificity values and 95% confidence intervals (CIs) were calculated where possible. A narrative summary of the findings was presented.


  • 32 studies (No RCTs) were included.
  • 16 studies involved children; 4 children and adults and 12 adults.
  • 31 studies used the Cariogram alone or in comparison with other models.
  • 19 studies were considered to be of good quality, 9 fair quality and 4 Low quality.
  • All the studies conducted in children suggested a statistically significant association between the risk level measured by the CRA model and the actual caries status or the caries increment in a follow-up examination
  • Studies in adults also showed a positive association between the CRA model and caries data.
  • Sensitivity and Specificity was evaluated in 7 papers, 6 involving children and one involving adults
Study Population Sensitivity Specificity Positive likelihood ratio Negative likelihood ratio
Children 66.4 78.5 3.088 0.428
Children 52.0 79.5 2.537 0.604
Children 70.5 65.8 2.061 0.448
Children 46.0 88.0 3.833 0.614
Children 75.0 71.0 2.586 0.352
Children 41.0 79.8 2.030 0.739
Adults 47.0 72.5 1.709 0.731


The authors concluded: –

The evidence relating to the quality of existing CRA models in assessing and predicting caries lesions is limited; even if Cariogram was used in few studies of good quality carried out in children and adults, no sufficient evidence is available to affirm that the method is effective in caries assessment and prediction. The full Cariogram and reduced versions, eight or seven factors, appear to produce similar results. Although other CRA models, such as CAT, CAMBRA, NUS-CRA and PreViser, might be effective in clinical settings, the scientific evidence to date is limited


This review is the latest in a number of reviews and studies that have considered the effectiveness of CRA and CRA models (Caries Risk Assessment: Dental Elf Blogs) The last review we looked at back in 2015 (Dental Elf 16th Nov 2015) included a similar number of studies finding that the quality of the available studies on CRA models was limited. As with the previous review the heterogeneity of the study designs and the data presentation mean that meta-analysis is challenging. While the Cariogram was used in almost all the papers different versions using a different number of factors were used.  More high quality studies are needed to assess the effectiveness of CRA and the number of factors needed to deliver the most clinically useful risk assessment.


Primary Paper

Cagetti MG, Bontà G, Cocco F, Lingstrom P, Strohmenger L, Campus G. Are standardized caries risk assessment models effective in assessing actual caries status and future caries increment? A systematic review. BMC Oral Health. 2018 Jul 16;18(1):123. doi: 10.1186/s12903-018-0585-4. PubMed PMID: 30012136; PubMed Central PMCID: PMC6048716.

Original review protocol on PROSPERO

Other references

Caries Risk Assessment: Dental Elf Blogs

Dental Elf 16th Nov 2015

Caries risk assessment – limited evidence to support current methods




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