AAPD caries-risk assessment and management for children (2022 revision): two risk forms, three risk levels, and a care pathway for each

What it says#

The document is an AAPD best practice from the Councils on Clinical Affairs and Scientific Affairs, adopted in 2002 as a caries-risk assessment tool and last revised in 2022 after a search of 2012 to 2021 publications (systematic reviews, expert panel reports and guidelines) that turned up 592 articles; where the data were insufficient, recommendations rest on expert and consensus opinion. Its purpose is to help clinicians decide treatment by a child's age, caries risk and compliance, with what it calls care pathways. It concedes at the outset that validated multivariate screening tools for children are limited: two tools, Cariogram and CAMBRA, have been validated in clinical trials and outcome studies, and other published forms use similar components without validation. Risk assessment is still worth doing, it says, because it treats the disease process rather than its outcome, individualizes the preventive discussion, sets the frequency of preventive and restorative care, and anticipates progression or stabilization.

The risk model combines diet, fluoride exposure, a susceptible host and microflora with social, cultural and behavioral factors, starting at the age-1 visit. The most-used risk factors are low salivary flow, visible plaque, frequent sugar consumption, an appliance in the mouth, health challenges, sociodemographic factors, access to care and cariogenic microflora. Existing lesions and recent restorations are called disease indicators rather than risk factors: they do not cause the disease but indicate that the causes are present. Protective factors are optimally fluoridated water, daily brushing with fluoridated toothpaste, professional topical fluoride and a dental home. The document lists the limits plainly: past caries experience is not particularly useful in young children and lesion activity may matter more than lesion count; salivary flow is hard to measure and may be irrelevant in the young; sugar frequency is hard to quantify; sociodemographic factors are proxies; how risk changes across the life span is undetermined; and genome-level factors may explain substantial variation.

Table 1 is the form for ages 0 to 5. Its social, behavioral and medical items are a mother or primary caregiver with active caries, a parent with lifetime poverty or low health literacy, more than 3 between-meal sugar exposures a day, a bottle or non-spill cup with natural or added sugar between meals or at bedtime, recent immigration and special health care needs; the clinical items are visible plaque and enamel defects; the protective items are fluoridated water or supplements, daily brushing with fluoridated toothpaste, professional topical fluoride and a dental home; the disease indicators are noncavitated (white spot) lesions, visible caries, and recent restorations or teeth lost to caries. Table 2, for 6 and older, adds hyposalivatory medication, low salivary flow, an intraoral appliance and defective restorations to the risk side, and on the indicator side lists interproximal lesions, new white spots, new cavitated lesions or lesions into dentin on a radiograph, and restorations placed in the last 3 years for a new patient or the last 12 months for a patient of record. The instructions on both forms are the same: circle yes where an item applies, visualize the balance among risk factors, protective factors and disease indicators, and assign low, moderate or high risk on the preponderance of factors with clinical judgment, which may weight one factor (heavy plaque, for instance) more than others.

Tables 3 and 4 are the care pathways, which the document traces to the 2011 pediatric CAMBRA protocols and justifies with the observation that surgical intervention alone does not stop the disease, that many lesions do not progress, and that restorations have finite longevity, so modern management means early detection of noncavitated lesions, an individual risk estimate and active surveillance. For a low-risk child: recall every 6 to 12 months, radiographs every 12 to 24 months, optimally fluoridated water, twice-daily brushing with fluoridated toothpaste, dietary counseling, sealants and surveillance. Moderate risk: recall every 6 months, radiographs every 6 to 12 months, fluoridated water or supplements where the supply is deficient, twice-daily fluoridated toothpaste, professional topical fluoride every 6 months, counseling, sealants, active surveillance of noncavitated lesions and restoration of cavitated or enlarging ones. High risk: recall every 3 months, radiographs every 6 months, water or supplements, twice-daily fluoridated toothpaste (for 6 and older, brushing with 0.5% fluoride gel or paste), professional topical fluoride every 3 months, 38% silver diamine fluoride on cavitated lesions, counseling, sealants, active surveillance, restoration of cavitated or enlarging lesions, and interim therapeutic restorations until permanent restorations can be placed. The table notes add the toothpaste amounts (a smear under 3, a pea from 3 through 5, a pea at 6), define surveillance and active surveillance, require informed consent for SDF that highlights the expected staining, and say the decision to seal primary and permanent molars should weigh both individual and tooth-level risk; for 6 and older they note that studies report an unfavorable cost-benefit ratio for sealants in low-risk children but expert opinion still favors sealing permanent teeth because risk changes over time.

The evidence base is itemized: four systematic reviews for fluoridated toothpaste, the CDC's fluoride guidelines for supplements, two systematic reviews for professional and prescription-strength fluoride, two for SDF, the FDA and ADA 2012 radiographic selection guidelines, two systematic reviews for sealants (only the ADA-AAPD review covering primary teeth), one for reducing sugar-sweetened beverages, and the AAPD's own ITR policy. Its three recommendations: risk assessment based on age, social, behavioral and medical factors, protective factors and clinical findings should be a routine part of new and periodic examinations by oral health and medical providers; while quantitative analysis is not yet possible, estimating low, moderate or high risk by preponderance enables evidence-based referral and sets the periodicity and intensity of care; and care pathways based on age and risk give providers criteria and protocols for the type and frequency of diagnostic, preventive and restorative interventions.

Who it applies to#

Every infant, child and adolescent, including those with special needs, at every new and periodic examination, whether the examiner is a dentist, a hygienist or a physician; the 0-to-5 form is deliberately written so a non-dental provider can use it. The document is a best practice, which in the AAPD's manual is a clinical recommendation, and the pathways are labeled examples. It produces a category, not a score, and it does not itself set restorative technique; the ITR policy, the pediatric restorative dentistry best practice and the fluoride therapy document carry those.

What changed#

The document has been revised repeatedly since its 2002 adoption as a caries-risk assessment tool, with care pathways added after the 2011 CAMBRA protocols, and the 2022 revision rests on 2012 to 2021 literature. The 2019 text was not read for this entry, so the line-by-line differences are not reported here. What the current version does that many offices do not: it ties recall and radiograph intervals to risk level rather than to a fixed six-month calendar, it puts 38% SDF and interim restorations inside the high-risk pathway, and it makes disease indicators the strongest signal of risk while refusing to turn the form into arithmetic.

Where the source is#

The document is the AAPD's Caries-risk Assessment and Management for Infants, Children, and Adolescents, 2022 revision, published in The Reference Manual of Pediatric Dentistry; the link under the title opens the AAPD's page for the best practice with the full text, and the PDF download carries Tables 1 to 4 as printed at pages 325 to 331 of the 2025 edition. Both are free. The 0-to-5 form is adapted with permission from the California Dental Association (Ramos-Gomez et al., 2007) and the 6-and-older form from Featherstone et al., 2007, and the pathways are labeled as examples.