Two Protocols for Assessing the Risk of Dental Caries in Adolescents: A Comparative Study

ABSTRACT

Objective:  To evaluate the caries risk in adolescents, according to different protocols.

Material and Methods:  This is an observational, cross-sectional, quantitative, and analytical study, performed in 2024, in Araçatuba city, São Paulo, Brazil, with 15-year-old adolescents enrolled in an educational foundation that helps them find work. Sample size calculation was performed considering the prevalence of high risk of dental caries as the main outcome. Caries risk was evaluated according two protocols: 1) Technical Area of Oral Health of the State Department of Health of São Paulo, Brazil (TAOH); 2) American Dental Association (ADA). Data were collected by a single researcher through clinical examinations and interviews. Data were analyzed using descriptive statistics techniques and the binomial test was used to compare the proportions according to the caries risk.

Results:  103 adolescents participated in the study. The proportion of low caries risk was higher (p=0.0113) in TAOH protocol compared to ADA protocol. Dental caries index (DMFT) was 3.56+3.39. The classification according to TAOH protocol was: 59.23% high risk; 25.24% moderate risk; and 15.53% low risk. The classification according to ADA protocol was: 62.14% high risk; 33.01% moderate risk; and 4.85% low risk.

Conclusion:  In both protocols, the caries risk of most adolescents was classified as high. The proportion of low caries risk was higher according to the TAOH protocol compared to ADA protocol.

Keywords:
Dental Caries; Dental Caries Susceptibility; Risk Factors; Adolescent

Introduction

Dental caries represents an important public health problem in several countries around the world, where the disease affects, unequally, individuals from different populations, age groups, and socioeconomic levels [¹,²,³,⁴]. Dental caries has a multifactorial etiology, so that the onset of the disease can be influenced by several factors, such as socioeconomic conditions, demographic characteristics, behavioral factors, quality of dental biofilm control, access to dental care, and biological factors [⁵,⁶,⁷,⁸,⁹].

For a long time, the focus for the management of tooth decay was the curative approach, prioritizing the identification of the disease, removal of the decayed tissue and restoration of the cavity, however, as a result of the recurrence of tooth decay in already restored teeth or failure of restorations, this approach can lead to a repetitive cycle of removing decayed tissue or deficient restorations, which can promote the progressive loss of healthy tooth tissue, weakening the tooth structure and subsequent loss of the tooth element [¹⁰,¹¹]. In this context, in recent years, a paradigm shift has been observed in the management of dental caries, with the current trend that emphasizes the use of strategies based on the management of risk factors and early preventive interventions, instead of focusing only on restorative treatment [¹²,¹³].

Dental caries risk assessment consists of an approach that aims to establish the risk or probability of developing a future carious lesion. The main objective of this assessment is to identify individuals who are at increased risk for the occurrence or progression of dental caries lesions during a specific period of follow-up [¹⁴,¹⁵].

Dental caries risk assessment can help professionals make decisions about the educational, preventive, and treatment procedures used, so that different dental caries risk assessment models have been developed and continuously validated over time and present differences in their content and approach used to assess the risk of dental caries [¹⁵]. Thus, it is understood that the predictive performance of each model, that is, the correspondence between the predicted risk or probability of developing dental caries and that observed in the temporal follow-up, can be influenced by such differences [¹⁶].

Therefore, carrying out studies that compare dental caries risk assessment models in different populations is essential, as poor predictive performance can result in inadequate or inappropriate decisions in managing the risk of dental caries and, thus, not achieving the desired results regarding the maintenance or improvement of individuals’ oral health [¹⁵].

Different dental caries risk assessment models have been proposed, however, for use in public health services, it is important to consider the time spent, ease of application, reproducibility, way of interpreting results, and data validity. Thus, the objective of this study was to evaluate and compare the risk of dental caries in adolescents, according to different classification protocols. The two protocols selected for this study differ in terms of the aspects analyzed. The protocol proposed by the Technical Area of Oral Health of the State Department of Health of São Paulo, Brazil, exclusively evaluates clinical aspects and is quicker to apply. In contrast, the protocol proposed by the American Dental Association analyzes clinical conditions, general health conditions, and other behavioral conditions, requiring more time to apply [¹⁷,¹⁸]. Considering the possibility of applying these protocols in population studies, it is important to understand whether there are significant differences in comparing the results of the two protocols.

Material and Methods

Study Design and Ethical Clearance

This is an observational, cross-sectional, quantitative, and analytical study, carried out with adolescents, regularly enrolled in a public educational foundation, located in the Araçatuba city, São Paulo, Brazil, which helps adolescents to find work in 2024.

The study was submitted and approved by the Research Ethics Committee (CAAE process number: 63645422.0.0000.5420). To recruit the adolescents, the Informed Consent Form was provided to obtain authorization from the legal guardian.

Sample

Adolescents aged 15 years old were included in the study. Adolescents who were away for health reasons; presented any condition that made it impossible to perform the oral clinical examination, or were absent from the data collection stage after five attempts, were excluded from the research.

The sample size calculation was carried out using the Epi InfoTM software version 7.2, based on data obtained from a pilot study conducted on a group of 20 adolescents not included in the final research sample. The determination of the sample size was carried out considering the prevalence of adolescents at high risk of dental caries as the main outcome, applying the two protocols evaluated in the present research. Between the results of the two protocols, the one that presented the largest size minimum sample was adopted. Thus, considering a population of 132 15-year-old adolescents enrolled in the educational foundation and adopting a confidence level of 95%, an acceptable margin of error of 5% and an expected proportion of adolescents at high risk of tooth decay of 60%, a minimum sample size of 98 adolescents was determined to compose the study sample. All regularly enrolled adolescents who met the criteria established for the study were invited to participate (N=132), resulting in a sample of 103 adolescents (Figure 1).

Figure 1
Flowchart of the process of obtaining the sample study.

Meetings were held with the educational institution's coordinators to obtain authorization to carry out the research. The clinical examinations to assess oral conditions and the application of collection instruments to evaluate the risk of dental caries were conducted by a single researcher, who had been previously calibrated. The kappa coefficient was calculated to verify intra-examiner agreement, obtaining a value of 0.92. Exams to assess dental condition and application of collection instruments to assess the risk of dental caries were carried out by a single, previously calibrated researcher. The Kappa coefficient was calculated to verify intra-examiner agreement, obtaining a value of 0.92. The dental condition examination adopted the codes and criteria of the World Health Organization (WHO) [¹⁹].

The clinical examinations to assess dental condition were performed individually in a dental office installed in the educational institution, using the WHO millimeter-sized periodontal probe and a flat mouthc mirror. The interviews to apply the questionnaires were carried out individually in a reserved room, located within the educational institution.

In the present study, the protocols for assessing the risk of dental caries proposed by the Technical Area of Oral Health of the State Department of Health of São Paulo (TAOH), Brazil, and by the American Dental Association (ADA) were used. The protocol proposed by the Technical Area of Oral Health of the State Department of Health of São Paulo, Brazil, evaluates clinical aspects, considering the dental caries factor in combination with the analysis of the dental biofilm factor (absence of gingivitis; presence of gingivitis in at least three dental elements) [¹⁷]. Patients patients without history of dental caries are classified as having low risk of dental caries; patients with presence of restored teeth and/or presence of chronic caries lesion and/or tooth with temporary restoration are classified as having moderate risk of dental caries; patients with teeth with demineralization of the enamel that appears as a white spot on the surfaces of the tooth and/or presence of teeth with caries lesion in grooves, pits and scars without evident pulp involvement and/or presence of a tooth with caries lesion on the proximal surface, angles of the incisal edge and cervical third without evident pulp involvement and/or presence of a tooth with suspected pulpal or periapical involvement with clinical condition in the form of pulpitis, fistula, exposed pulp, abscess or pain are classified as having high risk of dental caries. Patients with the presence of gingivitis in at least 3 teeth are classified as having a high risk of dental caries [¹⁷].

The data collection instrument for dental caries risk assessment proposed by the American Dental Association is divided into three sections: Contributing conditions, General health conditions, and Clinical conditions. The protocol presents eighteen fields of information to be evaluated, which include the variables: exposure to fluoride; consumption of sugary foods or drinks; regular access to dental care; experience of tooth decay in the mother/caregiver/similar (assessed only in patients aged between 6 and 14 years); special health care needs; chemotherapy or radiotherapy; eating disorders; medicines that reduce salivary flow; abusive use of alcohol or drugs; cavitated or non-cavitated caries lesions and restorations in the last 36 months; teeth lost due to tooth decay in the last 36 months; visible dental biofilm; unusual dental morphology that compromises hygiene; interproximal restorations; exposed root surfaces; restorations with excess or deficient margins or open contact points with food impaction; use of orthodontic appliance; xerostomia. Responses to each item are classified to indicate low, moderate, or high risk for developing dental caries [¹⁸]. Absence of exposure to fluoride; lack of regular access to dental care; presence of eating disorders; use of medications that reduce salivary flow; alcohol or drug abuse; presence of 1 or 2 cavitated or non-cavitated caries lesions and restorations in the last 36 months; presence of visible dental biofilm; presence of unusual dental morphology that compromises hygiene; presence of interproximal restorations; presence of exposed root surfaces; presence of restorations with excess or deficient margins or open contact points with food impaction; and use of orthodontic appliances are conditions equivalent to a moderate risk of dental caries [¹⁸]. Presence of frequent or prolonged consumption of sugary foods or drinks between meals; chemotherapy or radiotherapy; 3 or more cavitated or non-cavitated caries lesions and restorations in the last 36 months; teeth lost due to tooth decay in the last 36 months; and xerostomia are conditions equivalent to a high risk of dental caries. The patient is classified as low risk of dental caries if he/she only presents responses in the conditions equivalent to low risk of caries; the patient is classified as moderate risk of dental caries if he/she only presents responses in the conditions equivalent to low and moderate risk of caries; and the patient is classified as high risk of dental caries if he/she presents one or more responses in the conditions equivalent to high risk of caries [¹⁸].

Data Analysis

The data were analyzed using descriptive statistics techniques and the results are presented in tables. Data collection was performed and the distribution of absolute frequency and percentage frequency of adolescents according to the dental caries risk classification was obtained. The binomial test for two proportions was used to compare the proportions of cases classified as high risk of dental caries between the protocols used. The correlation between the dental caries risk classifications of the two protocols was analyzed using Spearman’s rank correlation test. Data processing was carried out using the Epi Info software version 7.2 (Centers for Disease Control and Prevention, Atlanta, GA, USA), adopting a significance level of 5%.

Results

All enrolled adolescents who met the established study criteria were invited to participate (N = 132), resulting in a sample of 103 adolescents (response rate, 78.03%). As shown in Table 1, it was observed that the majority of participants were male (57.28%) and declared themselves as having brown skin color (54.37%).

Table 1
Sample characterization of the adolescents.

Variables	N	%
Sex
Male	59	57.28
Female	44	42.72
Skin color
Brown	56	54.37
White	38	36.89
Black	8	7.77
Yellow	1	0.97

As shown in Table 2, the proportion of adolescents classified as low risk of developing dental caries was significantly higher (p<0.05) according to the protocol of the TAOH (15.53%), compared to the protocol of the ADA (4.85%). There was no statistically significant difference between the two protocols in relation to the proportion of adolescents classified as being at high risk of dental caries and those at moderate risk of dental caries. There was a significant positive correlation (p<0.0001) between the dental caries risk classifications of the two protocols (r = 0.5085).

Table 2
Comparison of the proportion of adolescents according to their risk of dental caries, using different assessment protocols.

Caries Risk	Protocols				p-value
	TAOH		ADA
	N	%	N	%
Low	16	15.53	5	4.85	0.0113
Moderate	26	25.24	34	33.01	0.2199
High	61	59.23	64	62.14	0.6687
Total	103	100.00	103	100.00

• TAOH: Technical Area of Oral Health of the State Department of Health of São Paulo, Brazil; ADA: American Dental Association.

It was observed that 78.64% of adolescents had at least one tooth affected by tooth decay. The average DMFT index was 3.39+3.04, comprising 41.43% decayed teeth, 1.90% missing teeth and 56.67% filled teeth. The highest and lowest DMFT index values verified were 12 and 0, respectively (Figure 2).

Figure 2
Minimum value, first quartile, median, third quartile, and maximum value of the DMFT index of adolescents.

The classification of adolescents, according to the protocol of Technical Area of Oral Health of the State Department of Health of São Paulo, Brazil, was: 59.23% high risk; 25.24% moderate risk; and 15.53% low risk, highlighting the dental biofilm factor in 32.04% of patients, and presence of caries lesion with cavitation in 46.61% of patients (Table 3).

Table 3
Distribution of absolute and percentage frequencies of adolescents, according to the dental caries risk classification of the protocol of the Technical Area of Oral Health of the State Department of Health of São Paulo.

Dental Caries Factor	Dental Biofilm Factor	Caries Risk	N	%
Without history of dental caries	Absence	Low	16	15.53
	Presence	High	4	3.88
Presence of restored teeth	Absence	Moderate	26	25.24
	Presence	High	7	6.80
Demineralization of the enamel that appears as a white spot on the surfaces of the tooth	Presence	High	2	1.94
Caries lesion in grooves, pits, and scars without evident pulp involvement	Absence	High	22	21.37
	Presence	High	12	11.65
Caries lesion on the proximal surface, angles of the incisal edge, and cervical third without evident pulp involvement	Absence	High	4	3.88
Tooth with suspected pulpal or periapical involvement with clinical condition in the form of pulpitis, fistula, exposed pulp, abscess, or pain	Absence	High	3	2.91
	Presence	High	7	6.80
Total			103	100.00

The classification of adolescents, according to the American Dental Association protocol, was: 62.14% high risk; 33.01% moderate risk; and 4.85% low risk. Among the assessed risk factors for dental caries analyzed in this protocol, the most notable were the frequent or prolonged consumption of sugary foods and drinks between meals in 44.66% of patients, the presence of at least 3 carious lesions or restorations in the last 36 months in 32.04% of patients, and lack of regular dental care in 63.11% (Table 4).

Table 4
Distribution of adolescents, according to contributing, general health, and clinical conditions analyzed in the American Dental Association's dental caries risk assessment protocol.

Variables	Low Risk		Moderate Risk		High Risk
	Yes		No		No
	N	%	N	%	N	%
Contributing Conditions
Exposure to fluoride (through drinking water, supplements, professional applications, toothpaste)	103	100.00	0	0.00	0	0.00
Consumption of sugary foods or drinks (including juices, carbonated or non-carbonated soft drinks, energy drinks, medicinal syrups)	Especially at mealtimes				Frequent or prolonged between meals
	57	55.34	0	0.00	46	44.66
Patient receives regular dental care at a dental office	38	36.89	65	63.11	0	0.00
General Health Conditions
Special health care needs (developmental, physical, medical, or mental disabilities that prevent or limit the performance of adequate oral health care by you or your caregivers)	103	100.00	0	0.00	0	0.00
Chemotherapy/Radiotherapy	103	100.00	0	0.00	0	0.00
Eating disorders	100	97.09	3	2.91	0	0.00
Medications that reduce salivary flow	100	97.09	3	2.91	0	0.00
Drug/alcohol abuse	100	97.09	3	2.91	0	0.00
Clinical Conditions
Cavitated or non-cavitated (incipient) carious lesions or restorations	No new carious lesions or restorations in the last 36 months		1 or 2 new carious lesions or restorations in the last 36 months		3 or more carious lesions or restorations in the last 36 months
	41	39.81	29	28.16	33	32.04
Teeth lost due to decay in the last 36 months	102	99.03	0	0.0	1	0.97
Visible dental biofilm	65	63.11	38	36.89	0	0.00
Unusual dental morphology that compromises oral hygiene	93	90.29	10	9.71	0	0.00
Interproximal restorations - 1 or more	81	78.64	22	21.36	0	0.00
Exposed tooth root surfaces present	103	100.00	0	0.00	0	0.00
Restorations with excesses and/or deficient margins; open contact points with food impaction	89	86.41	14	13.59	0	0.00
Orthodontic appliances (fixed or removable)	94	91.26	9	8.74	0	0.00
Xerostomia	98	95.15	5	4.85	0	0.00

Discussion

In the present study, it was found that, in both protocols used, the caries risk of most adolescents was classified as high, however, there was a significant difference in the proportion of patients classified as having a low risk of developing dental caries.

From the analysis of the prevalence of tooth decay, it was possible to verify that the vast majority of adolescents examined had at least one tooth affected by tooth decay. This result is in agreement with findings from a systematic review study, which found a high prevalence of untreated caries and neglect of oral health care in children and adolescents from different regions of the world [²⁰]. In this sense, there is a need to plan and execute strategies and actions for promotion, prevention, and education in oral health aimed at this population.

A systematic review study evaluated the effectiveness of health promotion interventions on the knowledge, behavior, and oral health status of adolescents and verified that oral health promotion programs aimed at this population have the ability to improve clinical results in the short and long term [²¹]. It should be noted that programs must use interactive and strategic methods, considering the behavioral characteristics of adolescents, including self-awareness and assistance from the community and peers, to carry out activities to promote oral health during longer interventions [²¹,²²].

The evaluation of the components of the DMFT index demonstrated that, although the majority of dental elements affected by caries were restored, a considerable number still had untreated carious lesions. The findings of this research are in according to other studies that indicate that there is still a specific portion of adolescents without access to dental care, highlighting the need to implement strategies that aim to improve and facilitate access to dental services for this population [²³,²⁴].

The considerable proportion of dental elements with untreated caries lesions is one of the factors related to the fact that the majority of adolescents were classified as patients at high risk of dental caries in both assessment protocols used. In this context, it should be noted that adolescence is characterized as an important period in an individual's development, and that health decisions made at this stage can reflect on health and lifestyle in adult life. Thus, the effects of inadequate oral conditions in this age group go beyond functional limitations and negatively impact social and psychological relationships [²⁵,²⁶].

Another important factor contributing to the classification of adolescents as patients at high risk of dental caries in both protocols used was the accumulation of dental biofilm. Studies indicate that gingivitis is the most prevalent form of change in periodontal condition in adolescents and is associated with socioeconomic factors and oral hygiene habits and practices, promoting a negative impact on the quality of life related to oral health in this population [²⁷,²⁸]. A study carried out on high school students, aged between fourteen and fifteen years old, verified the effect of motivational actions and practical training as an oral hygiene education strategy for adolescents. As a result, a significant improvement was observed in the level of oral hygiene of adolescents, highlighting the need to maintain educational programs aimed at adolescents [²⁹]. Therefore, considering that gingivitis is a reversible inflammatory condition, there is a need to implement health education strategies, aiming to develop actions that promote positive changes in the oral hygiene habits of adolescents, making them aware of the importance of their own actions in maintaining their oral health.

In the present study, the comparison between the two protocols demonstrated that there was a significant difference in the proportion of adolescents classified as patients at low risk of dental caries, with a higher proportion in the protocol that exclusively evaluated oral clinical aspects. The findings of this research demonstrate that this difference in proportion may be due to the analysis of different oral clinical factors between the protocols and, mainly, to the fact that one of the protocols also investigates the presence of contributing factors, behavioral and general health conditions.

Among these factors, it was noted that frequent or prolonged consumption of sugary foods and drinks between meals was identified as one of the main factors that contributed to the classification of adolescents as patients at high risk of dental caries. This finding highlights the need for educational and preventive measures aimed at controlling the consumption of sugary foods and drinks, reducing adolescents' exposure to highly cariogenic foods.

Reinforcing the results of the present study, a survey carried out to investigate the experience of dental caries in the permanent dentition of 4950 adolescents aged between 12 and 15 years of age in England, Wales, and Northern Ireland demonstrated that the high frequency of consumption of foods and drinks with added sugar was associated with the development of dental caries [³⁰].

In the general health context, it should also be noted that high intake of sugary foods and drinks can promote not only an increase in dental caries, but also obesity and other health risks for adolescents. Studies have shown that cultural and family factors, especially parents' eating habits, represent one of the main factors that influence sugar intake by adolescents [³¹]. Considering the importance of parental influence on sugar intake among adolescents, the development of educational actions and strategies that promote parental control and awareness about the consequences of high intake from sugary foods and drinks can play an important role in future interventions to reduce its intake by adolescents.

The presence of interproximal restorations was also a factor related to the increased risk of dental caries in the adolescents analyzed in the present study, which may be related to poor oral hygiene practices, especially in relation to the use of dental floss. Reinforcing the findings of this research, other studies also report that flossing is not part of the daily habits of most adolescents [³²,³³]. In this context, it is noteworthy that the presence of dental biofilm retention factors, such as orthodontic appliances and dental restorations with excess or deficient margins, was also identified among the adolescents participating in this research. These facts highlight the importance of health education measures and the active and persistent participation of dental professionals, with the aim of promoting adolescents' awareness of the importance of maintaining oral hygiene habits.

In the group of adolescents analyzed in the present study, it was observed that the majority of participants had experienced tooth decay, so that different results can be found in research conducted in populations with a lower prevalence of tooth decay. This can be considered a limitation of the study.

Conclusion

In both protocols used, the risk of dental caries for the majority of adolescents was classified as high. The proportion of adolescents classified as low risk of developing dental caries was higher according to the protocol of the Technical Area of Oral Health of the State Department of Health of São Paulo, Brazil, compared to the protocol of the American Dental Association. It is possible to suggest that the analysis of contributing factors, behavioral aspects and general health conditions can lead to changes in the classification of adolescents at low risk of developing dental caries.

• Financial Support
  This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

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Edited by

• Academic Editor:
  Fátima Regina Nunes de Sousa

Publication Dates

• Publication in this collection
  28 Nov 2025
• Date of issue
  2026

History

• Received
  12 July 2024
• Reviewed
  09 Nov 2024
• Accepted
  05 Mar 2025