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Year : 2016  |  Volume : 14  |  Issue : 2  |  Page : 188-196

Knowledge, attitude and practice regarding caries risk assessment and management in Delhi - National Capital Region: A cross-sectional survey

Department of Pedodontics and Preventive Dentistry, I. T. S. Dental College, Hospital and Research Centre, Greater Noida, Uttar Pradesh, India

Date of Web Publication10-Jun-2016

Correspondence Address:
Mousumi Goswami
Department of Pedodontics and Preventive Dentistry, I. T. S. Dental College, Hospital and Research Centre, Greater Noida - 201 306, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2319-5932.181894

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Introduction: Evaluating a patients' risk is an essential primary step in the prevention of dental caries. Based on its results, different preventive strategies catering to patients' specific needs should be advised. Aim: To assess and compare the knowledge, attitude, and practice among dentists who are either attached with an institute or running a private practice or both in Delhi-National Capital Region regarding caries risk assessment (CRA) and management. Materials and Methods: Knowledge, attitude, and practices of dentists' regarding CRA and management were assessed through a 30-item questionnaire. Data were analyzed using SPSS software 21.5. Frequencies were used to assess the demographic information, knowledge, attitude, and risk assessment practices. Results: Dental professionals with institutional attachment were better aware of the importance of CRA and practised it more frequently as compared to the dentists who were solely attached with a private practice. This attitude could be due to lack of time and inclination to treat more number of patients in a working day. Pedodontists were more aware than other specialists. Conclusions: There is a need to update knowledge regarding CRA and incorporate preventive practices in daily work schedule among dentists of all specialties.

Keywords: Caries management, caries management by risk assessment, dentist's awareness, preventive practices, risk assessment

How to cite this article:
Goswami M, Sachdeva P, Paul S, Walia V, Chawla S. Knowledge, attitude and practice regarding caries risk assessment and management in Delhi - National Capital Region: A cross-sectional survey. J Indian Assoc Public Health Dent 2016;14:188-96

How to cite this URL:
Goswami M, Sachdeva P, Paul S, Walia V, Chawla S. Knowledge, attitude and practice regarding caries risk assessment and management in Delhi - National Capital Region: A cross-sectional survey. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2020 Jul 3];14:188-96. Available from: http://www.jiaphd.org/text.asp?2016/14/2/188/181894

  Introduction Top

There is a booming interest toward evidence-based dental treatment. The intention of this approach is to formulate patient treatment decisions on a combined use of current best evidence and individual clinical expertise.[1] In comparison to the conventional management of dental caries based on the surgical rehabilitation of the affected tooth portion alone, current management strategies employ treating dental caries based on a customized risk assessment tailored toward each patient.[2] Evaluating a patients' risk is an essential primary step in the prevention of dental caries. Based on its results, different preventive strategies catering to patients' specific needs should be devised.

In spite of the identification of dental caries as a preventable disease from many years, the acceptance of preventive and corrective control strategies based on a medical model of disease management by the dental profession has been limited.[3] Caries management by risk assessment (CAMBRA) is an evidence-based caries management protocol that gives the clinician different management strategies allowing them to make appropriate restorative, therapeutic, and preventive recommendations.[4],[5],[6] The value of prevention is widely recognized by the dental profession, and teaching this topic has become a foundational principle and integral part of predoctoral dental curricula.[7] However, the current evidence suggests that the paradigm shift to prevention has not been universally implemented.[8],[9] While the basic scientific principles that lead to understanding oral disease development have been identified, translation of these principles into practice may pose significant challenges during students' training and in practice.[7]

Although the actual incitement to carry out caries risk assessment (CRA) may vary from country to country and from clinician to clinician, the rational for conducting CRA remains undisputed.[10] Few studies have examined dentists' subjective ratings of the importance of specific caries risk factors or tested whether dentists use this information in treatment planning.[7],[11],[12],[13]

Given, the importance of prevention and early treatment of dental caries, we sought to assess and compare the knowledge, attitudes, and practices of dentists who are either attached with an institute or running a private practice or both in Delhi-National Capital Region (NCR) regarding CRA, management and caries prevention counseling with children and adults. The frequency of utilization of the CAMBRA protocols was also assessed and compared.

  Materials and Methods Top

This descriptive study utilized a cross-sectional survey design assessing knowledge, attitude, and practices of dentists' regarding CRA and management through a 30-item questionnaire.

Knowledge was computed through a series of 10 questions (true/false items). The attitude was assessed through a total of 10 questions including 2 pictorial questions. The pictorial questions were added to further strengthen the data and inquire the practical viewpoint of dentists toward the various levels of clinical and radiographic interventions. Permission to reproduce the clinical and radiographic images was duly obtained from the author.[14] A 4-point Likert-type scale (1 = never, 2 = sometimes, 3 = frequently, and 4 = always) was used to gauge occurrence of caries management recommendations used by the dentists.[15]

Approval for the survey was duly obtained from the institutional ethical committee. The questionnaire used in this study is a modified form of the survey instrument used in a study conducted by Francisco et al.[4] and permission to utilize the same was obtained. In addition, the survey instrument was pilot tested among 30 dental professionals. It was found to be reliable with Cronbach's alpha value above 0.75. Based on the 70% prevalence (using pilot study estimations), 95% confidence level and 5% precision of knowledge related to CRA among dental professionals of Delhi NCR, the sample size was estimated at 320.

  Results Top

Frequencies were used to assess the demographic information, knowledge, attitude, and risk assessment practices. Statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS) version 21.5 IBM Corp, Released 2012, IBM SPSS, Statistics for windows, Version 21.5., Armonk, NY: IBM Corp. Of the 320 survey forms filled, only 275 were valid for analysis. Surveys with incomplete data were excluded. [Figure 1] illustrates the final sample size and clinical practice settings noted by the respondents. [Figure 2] shows the percentage distribution of pedodontists.
Figure 1: Distribution of sample

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Figure 2: Percentage distribution of pedodontists and non pedodontists

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Knowledge scores

[Table 1] reveals that majority of the participants correctly identified caries as a transmissible disease (87%). History of caries lesions in the last 1 year, low-socioeconomic status, and reduced saliva flow were correctly identified as increasing risk for caries disease by 89%, 65% and 97.5% of the respondents, respectively. Surprisingly, only half of the dentists questioned identified white spot lesions as carious lesions. 65% recognized chlorhexidine as not being bacteriostatic or bactericidal to all caries pathogens. Dentists attached with an institute fared much better than dentists who were solely attached with a private practice. Likewise, pedodontists were better aware than their counterparts.
Table 1: Dentists' knowledge of caries risk assessment

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Attitude scores

The vast majority of the participants (94%) noted performing CRA as an integral part of dental practice with complete agreement (100%) seen among dentists attached with an institute and pedodontists. Respondents strongly felt confident in detecting incipient caries in their early reversible stages (80%) and comfortable explaining CRA management protocols (74%) to patients as indicated by [Table 2]. However, only a mere 37% of the dentists questioned felt that they had enough time to practice CRA on each patient. [Table 3] and [Table 4] displays that none of the dentists running a private practice strongly agreed to be able to perform CRA in a child <5 years of age which was in stark contrast to the pedodontists (31.5%). The figures were slightly better for patients aged between 5 and 11 years (65%). Overall, the dentists felt more competent to assess the caries risk in patients above 12 years of age. The timing of clinical and radiographic intervention was computed through two pictorial questions. The majority of the dentists chose to restore at subsequently greater lesion severity and deeper lesion depth [Table 5] and [Table 6].
Table 2: Factors influencing utilization of caries risk assessment

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Table 3: Self-perceived competency in assessing caries risk for patients of different age groups according to specialty

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Table 4: Self-perceived competency in providing preventive counseling to patients of different age groups according to specialty

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Table 5: Clinical intervention

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Table 6: Radiological intervention

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Practice behaviors

[Table 7] highlights the dentists' CRA management recommendations. Only 32% of private practitioners frequently prescribed fluoridated toothpaste compared to the 53% of dentists who were attached with an institute. Low-dose over-the-counter (OTC) fluoride rinses (67%) and topical fluoride applications (58%) are only sometimes prescribed by the dentists. Amorphous calcium phosphate (ACP) products, xylitol gums, and probiotics were either never (25%, 65%, and 60.7%, respectively) or only sometimes (57%, 31%, and 36.7%, respectively) proposed. Diet counseling was always practiced by 65% of the pedodontists which was in sharp contrast to the 32% of other specialists who always practiced it. Individualized oral hygiene instruction (68%) and an individualized recall interval (68%) were the most-used caries management recommendations.
Table 7: Dentists' caries risk assessment management recommendations

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  Discussion Top

Dental caries is the most common oral disease that affects a significant number of Indian population.[16] National Health Survey conducted in 2004 throughout India has shown dental caries in: 51.9% in 5-year-old children, 53.8% in 12-year-old children, and 63.1% in 15-year-old teenagers.[17] An understanding of the development of dental caries enables us to prevent and treat this disease.

According to the current standard of care, an individualized prevention and treatment program should be developed for each patient.[18] CAMBRA is an evidence-based methodology where the clinician assesses risk factors for each individual patient, followed by diagnosis and prognosis of caries disease. Based on the evidence presented, the clinician then corrects the problems (by managing the risk factors) using specific treatment recommendations including behavioral, chemical, and minimally invasive procedures.[19] This study provides information regarding the current level of knowledge, attitudes, and practice behaviors concerning CRA, and management by dentists.

Slightly more than half of the private practitioners recognize patients with history of restorations within the past 3 years to be at a high risk for future dental caries. Dentists, particularly private practitioners, were of the opinion that if a patient has had a lesion restored, he belongs to a low-risk category. Nearly half of the private practitioners questioned thought that patients' socioeconomic status had nothing to do with his caries index. This may be explained because that a private practitioner runs his practice in a localized area and deals with a particular stratum of society. On the other hand, a dentist attached with an institute experiences patients from all backgrounds and as a result may be more cognizant of the paramount role played by the patient's socioeconomic situation in his risk of developing caries.

Surprisingly, half of the dentists questioned do not recognize white spot lesions as incipient carious lesions. White spot lesions represent an early stage of tooth decay formation. Most of the current prevention strategies focus on remineralization at the earliest stage of caries detection. However, the inability of the dentist to recognize this stage may prevent him from offering minimally invasive services which aim at remineralization. Consequent to this finding, a mere 7% of dentists questioned chose to restore a lesion at an early stage of clinical and radiographic evidence of caries. Nearly all the respondents recognized that patients at a high risk of dental caries need to be counseled about the role of sugary and starchy foods; however, less than half of the dentists always practiced diet counseling as a regular caries preventive measure. These figures were slightly better for pedodontists, majority of whom always practiced diet counseling, which may be a result of its inclusion in core clinical training during the postgraduate program.

In this study, a vast majority of the respondents considered performing CRA as an integral part of dental practice; however, the lack of time prevented them from practicing it on each patient. In a study conducted by Riley et al., 69% percent of dentists perform CRA on their patients. Recently graduated dentists, dentists with busier practices, and those who believe a dentist can predict future caries were the most likely to use CRA. Furthermore, dentists who perform CRA were more likely to provide individualized caries prevention to their patients.[11] A survey of dentists practicing in the city of Indianapolis, Indiana found that 72% of respondents used some type of risk assessment.[12] A postal survey of members of the Texas Academy of Pediatric Dentists reported that 36% of the respondents provided CRA on more than 76% of their patients, and only 9% of dentists did not assess caries risk.[13] Teich et al. examined the implementation of CAMBRA-based risk assessment program in a predoctoral clinic at one dental school and assessed the accuracy of caries risk evaluation by the students. Their results showed that students were not rigorous enough in documenting the factors and determining the patient's risk. The study concluded that to increase the sensitivity of risk assessment, training, and recalibration for students and faculty members should be an ongoing process.[7]

This study also aimed to assess the competency of dentists to perform CRA in patients of different age groups. Interestingly, none of the private practitioners felt strongly competent to assess caries risk for a child younger than 5 years of age. Although these figures were better for pedodontists, they still fail to cross the half way mark. Overall, the dentists were more comfortable in assessing risk for patients aged above 12 years of age. Lack of patient cooperation and specialist centered approach may be responsible for these results.

In this study, the most frequently used preventive approaches in caries management were recommending OTC fluoride dentifrices, antimicrobial rinses, individualized oral hygiene instructions, and setting an individualized recall interval. The majority of the dentists, only sometimes, prescribed a low-dose fluoride mouth rinse, amorphous calcium products, and topical fluoride applications. Fluoride therapy has been the cornerstone of caries management therapy; however, the lack of its advocacy by a greater number of the practicing dentists requires a strong reinforcement and update of the caries-preventive benefits by fluorides.

Newer arenas in caries management include the use of products containing xylitol and probiotics. Short-term consumption of xylitol is associated with decreased Streptococcus mutans levels in saliva and plaque.[20] The main goal for the use of probiotics in caries prevention is to replace and displace cariogenic bacteria, mainly mutans streptococci, with noncariogenic bacteria.[21] These preventive strategies however remain unexplored among Indian dentists. The majority of the dentists questioned in this study have never prescribed xylitol or probiotic products to their patients.

The shortcomings of this study include the limited sample size which may have failed to represent the entire population of the practicing dentists. That is, dentists who chose to respond to the survey may have been different than those who did not respond, thus biasing the results. Furthermore, surveys are subject to a social desirability bias. A dentist may have chosen to respond in a manner which is expected of him and not what he routinely practices.


CRA forms the main-stay of minimally invasive dentistry. All dentists irrespective of their specialties need to practice it to deliver a high standard of care to their patients. Fluoride mouthwashes and varnishes along with products containing ACP-casein phosphopeptide, xylitol, and probiotics need to be actively prescribed owing to their established anti-cariogenic action as well as their ease of availability.

  Conclusions Top

CAMBRA has emerged as the new paradigm in patient care and provides an evidence-based approach with the potential for significant advantages over traditional methods. There is a need to update knowledge regarding CRA among dentists of all specialties. A positive attitude toward CRA and management needs to be encouraged. Caries preventive practices need to be consciously incorporated in daily work schedule to harness maximum benefits in the treatment of patients and hence reduce future invasive treatment needs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Zero D, Fontana M, Lennon AM. Clinical applications and outcomes of using indicators of risk in caries management. J Dent Educ 2001;65:1126-32.  Back to cited text no. 1
Fontana M, Young DA, Wolff MS. Evidence-based caries, risk assessment, and treatment. Dent Clin North Am 2009;53:149-61.  Back to cited text no. 2
Hallett KB. The application of caries risk assessment in minimum intervention dentistry. Aust Dent J 2013;58 Suppl 1:26-34.  Back to cited text no. 3
Francisco EM, Johnson TL, Freudenthal JJ, Louis G. Dental hygienists' knowledge, attitudes and practice behaviors regarding caries risk assessment and management. J Dent Hyg 2013;87:353-61.  Back to cited text no. 4
Young DA, Featherstone JD. Implementing caries risk assessment and clinical interventions. Dent Clin North Am 2010;54:495-505.  Back to cited text no. 5
Young DA, Featherstone JD. Caries management by risk assessment. Community Dent Oral Epidemiol 2013;41:e53-63.  Back to cited text no. 6
Teich ST, Demko C, Al-Rawi W, Gutberg T. Assessment of implementation of a CAMBRA-based program in a dental school environment. J Dent Educ 2013;77:438-47.  Back to cited text no. 7
Garcia RI, Sohn W. The paradigm shift to prevention and its relationship to dental education. J Dent Educ 2012;76:36-45.  Back to cited text no. 8
Doméjean-Orliaguet S, Gansky SA, Featherstone JD. Caries risk assessment in an educational environment. J Dent Educ 2006;70:1346-54.  Back to cited text no. 9
Twetman S, Fontana M, Featherstone JD. Risk assessment – Can we achieve consensus? Community Dent Oral Epidemiol 2013;41:e64-70.  Back to cited text no. 10
Riley JL 3rd, Qvist V, Fellows JL, Rindal DB, Richman JS, Gilbert GH, et al. Dentists' use of caries risk assessment in children: Findings from the Dental Practice-Based Research Network. Gen Dent 2010;58:230-4.  Back to cited text no. 11
Bahleda L, Fontana M. Evaluating the use of caries risk assessment procedures by Indianapolis area dentists (abstract P8). Indiana University School of Dentistry Proceedings. Indianapolis: Printing Partners of Indianapolis; 2003. p. 25.  Back to cited text no. 12
Evans RW, Pakdaman A, Dennison PJ, Howe EL. The caries management system: An evidence-based preventive strategy for dental practitioners. Application for adults. Aust Dent J 2008;53:83-92.  Back to cited text no. 13
Espelid I, Tveit AB, Mejàre I, Sundberg H, Hallonsten AL. Restorative treatment decisions on occlusal caries in Scandinavia. Acta Odontol Scand 2001;59:21-7.  Back to cited text no. 14
Likert R. A technique for the measurement of attitudes. Arch Psychol 1932;22:1-55.  Back to cited text no. 15
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National Oral Health Survey and Fluoride Mapping. An epidemiological study of oral health problems and estimation of fluoride levels in drinking water. Dental Council of India, New Delhi, 2004;32:67-78.  Back to cited text no. 17
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Twetman S, Keller MK. Probiotics for caries prevention and control. Adv Dent Res 2012;24:98-102.  Back to cited text no. 21


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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