The distribution of burden of dental caries in schoolchildren: a critique of the high-risk caries prevention strategy for populations

Data are from the National Preventive Dentistry Demonstration Programme (NPDDP) in the United States. The analyses identified the distribution of new carious lesions over a 4-year period in four groups of 7 year-old children who received differing preventive regimes.The majority of new lesions occurred in those children classified at lowest caries risk at baseline. Irrespective of the preventive regime adopted and the initial caries levels, children classified as 'highest risk' contributed less than 6% of the total number of new lesions developing over 4 years.These findings challenge the basis for the adoption of a high-risk strategy.A commonly adopted approach for the prevention of caries is the 'high-risk' strategy. For example, Messer [1] concluded that "... the need for, targeted prevention of dental caries for those at high risk has become apparent". The approach is based on three assumptions: first, those individuals with high future caries increments can be identified; second, measures taken to prevent the caries lesions are effective, and third, that those individuals belonging to sub-groups within a population who have previously experienced the highest levels of caries in the past will continue to do so in future. Indeed, any high-risk strategy aims to target those individuals at the greatest risk of future disease based on their current caries status or markers of disease.From a public health perspective, what is important when deciding upon a preventive approach is what impact the measure adopted would have on the total dental health and disease burdens of the population as a whole. Even if an approach was highly accurate in predicting future caries development and the intervention was relatively successful in reducing caries in that group, the distributive features of new disease may make the proposed approach inappropriate. Even if a high-risk group had a far higher annual increment than the remaining sub-groups of the population, due to the underlyin