Dental caries are common chronic conditions affecting people of all ages. Traditional dental caries detection methods included clinical examination and radiographs, diagnosing caries only after considerable tooth structure loss ^[1]. As a result, CRA systems were established to evaluate personal risk factors that will allow early intervention. The aim of these systems is to move the dental care system from a restorative approach to a preventive and patient-centered strategy ^[2].

This review is based on a thorough literature search from PubMed, Google Scholar, and recent findings from dental research journals. In this review, studies validating CRA systems such as CAMBRA, Cariogram, and CAT were reviewed. The inclusion criteria comprised studies published in peer-reviewed journals, systematic reviews, randomized controlled trials, and cohort studies. The data were analyzed based on effectiveness, predictive accuracy, and clinical applicability of different CRA tools.

Elements of Caries Risk Assessment

Caries risk assessment involves an identification and review of multiple etiological factors related to the pathogenesis of caries. Among these are:

• Biological factors: Type of bacterial composition, properties of saliva, and genetic predilection
• Behavioral factors: Oral hygiene habits, diet, and exposure to
• Socio-economic factors: Inequitable distribution of dental services, education levels, and prevailing cultural attitudes.

CRA tools integrate these factors to categorize individuals as low, moderate, or high risk for developing caries, guiding personalized preventive and therapeutic strategies ^[3].

Overview of Major Caries Risk Assessment Systems

1. Caries Risk Assessment Tool (CAT)

The American Academy of Pediatric Dentistry (AAPD) has developed the CAT, which is mainly for pediatric patients. This tool classifies caries risk according to age-specific criteria and contains risk indicators such as fluoride exposure, diet, and oral hygiene habits.

Advantages:

• Easy to apply in clinical
• Specific to pediatric
• Preventive

Limitations:

• Low applicability in adult
• Does not include microbiological or salivary diagnostic test

2.    Caries Management by Risk Assessment (CAMBRA)

CAMBRA, promoted by the California Dental Association, is an evidence-based approach that measures an individual's caries risk based on disease indicators, risk factors, and protective factors. It classifies patients into four categories: low, moderate, high, and extreme risk. This helps develop specific intervention plans.

Advantages:

• Provides a holistic evaluation that includes both protective and pathological
• Suitable for any age
• It offers concrete treatment

Limitations:

• Needs training to perform it
• Some subjective factors may affect risk categorizationb

3.      Cariogram

The Cariogram is a computer-based model devised to graphically illustrate caries risk. Developed by Bratthall and colleagues, it evaluates multiple weighted factors, including past caries experience, diet, bacteria, fluoride exposure, and saliva properties. The model is divided into five color-coded sectors (Figure 1), all representing key factors for risk as well as for protection:

• Green (Chance of not developing Caries): Probability of being caries-free; the higher the green area, the lower the risk.
• Red (Bacteria): Indicates the presence of cariogenic bacteria, as analyzed by microbial assessment and plaque scoring.
• Blue (Diet): Reflects the patient's diet, more specifically, their sugar intake patterns and amounts.
• Light Blue (Susceptibility): It encompasses the variables like salivary flow rate, fluoride exposure, and other host-related protective mechanisms.
• Yellow (Circumstances): Reflects the environmental factors, such as past caries history, social class, and availability of dental services.

Advantages:

• Graphic view of caries risk
• Integrates the data from all aspects including the microbiological factors
• It helps in patient education and

Limitations:

• Involves detailed data, especially bacterial counts, and salivary tests
• Not practical in all clinical conditions due to the complexity

Comparison of CRA Systems

The comparative analysis of various studies highlights key findings:

Studies confirm that CRA systems have much to offer in the way of predictive information for caries risk assessment, though each model has its limitations. Comparative analyses show that CRA models often classify the same patient differently and lead to different risk assessment outcomes.

A study by Zukanovic et al. (2007)^[10] revealed that the Cariogram model assigned 70% of the examinees to the middle risk, whereas CAT and Previser presented more dramatic risk assessment scores, frequently labeling patients as high risk. Another study involving 544 preschool children revealed that CAT was a highly sensitive tool (100%) but proved to be very poor in specificity (2.9%), overestimating the risk of caries most frequently. Exclusion of socioeconomic factors enhanced the specificity of such risk assessment. This overestimation could lead to unnecessary interventions in populations where caries prevalence is already low. CAMBRA’s predictive power was validated in multiple studies, with Doméjean et al. (2011)^[7] reporting that 88% of extreme-risk and 69.3% of high-risk patients developed new cavities

over six years. CAMBRA has also been reported to be more balanced in terms of sensitivity and specificity compared to CAT, though it requires a lot of input data, which may not be practical in resource-limited settings.

Cariogram, however has been successful in different studies. According to the research by Petersson et al. (2015)^[11], Cariogram high-risk patients were found to have a significantly higher DMFT scores than low-risk patients after three years. Leous et al. (2006)^[5] in another study reported that Cariogram-based patient education showed significant reduction in caries risk within three months.

Zero et al. (2001)^[12] compared several CRA models and concluded that predictive accuracy was dependent on population characteristics. For instance, CAT and Cariogram were designed for populations with low caries prevalence, and their efficiency was lower in high-prevalence communities. Gao et al. (2013)^[13] compared CAT, CAMBRA, Cariogram, and NUS-CRA in preschool children and found that algorithm-based tools like Cariogram and NUS-CRA had better predictive accuracy.

Another study showed that Cariogram was effective as a patient education tool, significantly reducing caries risk when combined with dietary and oral hygiene counseling. However, a randomized controlled trial assessing CAMBRA’s effectiveness in treatment planning found that it significantly reduced caries risk over two years (OR = 3.45, 95% CI: 1.67, 7.13)^[8].

The risk assessment for caries plays a vital role in preventive dentistry, where at-risk individuals are identified and interventions are guided. Each of the CRA tools has its strengths and weaknesses: CAT is simple but overestimates risk; CAMBRA integrates protective factors but requires a lot of data input; and Cariogram provides a graphical representation but depends. on microbiological data. Predictive accuracy of these models varies from one population to another, which makes it essential to have model-specific adjustments based on epidemiological and demographic factors.

In future research, such hybrid CRA models that integrate AI, machine learning, and greater epidemiological data can be created to improve predictability and implement efficient preventive measures in dentistry.

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