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Available online at ajdhs.com 

Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2023 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided 

the original author and source are credited  

 

 

Risk Factors for Caries in Elementary School Children Based on 
Caries Management by Risk Assessment (CAMBRA) 
Quroti A’yun*, Herastuti Sulistyani, Dewi Risnawati, Ika Fitri Dilianti D 

Department of Dental Health, Health Polytechnic Yogyakarta, Indonesia 

Article Info: 
_____________________________________________ 
Article History: 

Received   03 October 2023     
Reviewed  09 November 2023 
Accepted   28 November 2023 
Published 15 December 2023 

_____________________________________________ 
Cite this article as:  

A’yun Q, Sulistyani H, Risnawati D, Dilianti D IF, Risk 
Factors for Caries in Elementary School Children 
Based on Caries Management by Risk Assessment 
(CAMBRA), Asian Journal of Dental and Health 
Sciences. 2023; 3(4):11-14 

DOI: http://dx.doi.org/10.22270/ajdhs.v3i4.57          

_____________________________________________ 
*Address for Correspondence:   

Quroti A’yun, Department of Dental Health, Health 
Polytechnic Yogyakarta, Indonesia  

Abstract 
_________________________________________________________________________________________________________________ 
Background: the prevalence of dental caries in children aged 10 to 14 years is almost 41.4%. The 
CAMBRA method helps doctors identify the cause of dental caries by identifying risk factors in each 
patient. Based on research, the etiology of dental caries was found by identifying risk factors in each 
participant. This study aims to describe what factors influence dental caries in children based on 
CAMBRA. Method: This research uses observational analysis with. The respondents were students 
at SDN Kadipiro I, Bantul, Special Region of Yogyakarta, Indonesia. Purposive sampling was used to 
create the sample, which included 82 children between the ages of 10 and 12 years. The research 
was carried out by finding dental caries risk factors using the CAMBRA method: 1. cavity or new 
dentin lesion, 2. white spot, 3. restoration in the last three years, 4. saliva volume, 5. plaque 
index/PHPM, 6. water pH saliva, and 7. Frequency of consumption of sweet foods. Data were 
analyzed using the SPSS version 25.0 program which included frequency analysis. Results: The 
results of the analysis showed five risk factors for caries, namely the condition of the teeth, cavities 
or new dentin lesions were found in 58 respondents (70.7%), predisposing factors, the number of 
plaque was obtained in 44 respondents (53.7%), the frequency of protective factors was obtained 
and the frequency of caries was obtained. 63 respondents experienced dental caries. Conclusion: 
The risk factors for dental caries based on CAMBRA that influence children's dental caries are the 
criteria for lesion depth of dentin, saliva pH, and amount of plaque. 

Keywords: CAMBRA, risk factors, caries, children 

 

INTRODUCTION  

Dental caries together with periodontal disease are the most 
common dental and oral diseases in society, including children. 
Dental caries is an infectious disease that has become a global 
health problem. Dental caries has a prevalence five times higher 
than asthma and seven times higher than allergic rhinitis. It is 
estimated that 89% of Indonesian children under the age of 12 
suffer from dental caries.1–3 

Basic Health Research in 2018 recorded that 45.3% of the 
Indonesian population had dental and oral health problems and 
in the Special Region of Yogyakarta the figure was 47.7%. The 
prevalence of dental caries in children aged 10-14 is 41.4%.4 
Dental caries that is not treated in children will cause many 
unfavorable things, for example the emergence of pain, the 
possibility of infection, and the occurrence of foci of infection in 
the body, disruption of daily activities, psychomotor problems, 
and growth disorders.5,6 Dental caries is one of the problems 
that often arises during a child's growth and development, in 
addition to other problems, namely malnutrition, obesity and 
allergies.7 

Dental caries is a multifactorial disease, one of which involves 
substrate etiological factors, in this case carbohydrates, as the 
most essential medium for cariogenic bacteria. Caries is an 
irreversible microbiological disease of calcified tooth tissue 
which is characterized by demineralization of inorganic 
material and destruction of organic tooth material and will 
cause cavities. Caries is a disease of hard tooth tissue which is 
characterized by decalcification of inorganic dental material 

and loss of mineral content and is followed by damage to the 
organic tooth matrix. Caries is a multifactorial disease, which is 
the interaction of several factors. Newburn developed the 
concept of caries tetralogy, which concluded that there are 4 
main factors that interact in the process of caries occurrence. 
The four factors are: (1) teeth (2) bacteria, (3) carbohydrate 
substrate/diet, (4) time as an additional factor.8,9 

Caries Management by Risk Assessment (CAMBRA) builds an 
understanding of dental caries, which is a disease initiated by a 
complex biofilm (not just one pathogen), which dynamically 
changes with the environment and local chemical factors on the 
tooth surface, pellicle and saliva. The CAMBRA philosophy was 
first introduced nearly a decade ago when an informal group 
called the Western CAMBRA Coaliton was formed that included 
stakeholders from education, research, industry, government 
agencies and private practitioners in the western region of the 
United States. This research is focused on obtaining caries risk 
factors based on the Caries Risk Assessment Form. Caries risk 
prediction equation, and the contribution of caries risk factors.10 

METHOD AND MATERIAL  

The research design used is quantitative research, namely 
observational. This research did not manipulate variables but 
looked at the reality directly from respondents, namely the risk 
factors for child caries based on CAMBRA. This research was 
carried out at SDN Kadipiro I, Bantul Regency, Special Region of 
Yogyakarta. The total sample was 82 children, with a sampling 
technique using side purposive with research sample inclusion 

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A’yun et al                                                                                                                         Asian Journal of Dental and Health Sciences. 2023; 3(4):11-14 

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criteria: male/female aged 9-12 years and willing to be 
research samples. 

Data collection was carried out quantitatively using the 
following measuring instruments: Decay Index, Check-list of 

tooth condition variables, Check-list of biological predisposing 
factor variables, Check-list of protection factor variables. The 
analysis used is descriptive analysis presented in a frequency 
distribution.

  

RESULT 

Table 1. Distribution of respondent characteristics 

Respondent characteristics Frequency Percentage 

Gender   

Male 44 53.7 

Female  38 46.3 

Mother's education   

Elementary School 13 15.9 

Junior High School 23 28.0 

Senior High School 36 43.9 

Bachelor 10 12.2 

Based on table 1, it was found that 44 (53.7%) of the respondents were male with 36 (43.9%) of their mothers' education being high 
school. 

 

Table 2. Frequency distribution Condition of teeth 

Variable Yes  No 

n % n % 

Cavities/dentin depth lesions 58 70,7 24 29,3 

Proximal enamel lesions 10 12,2 72 87,8 

White spots on the surface 30 36,6 52 63,4 

Restoration in the last 3 years 7 8.5 75 91.5 

Based on table 2, it was found that 58 (70.7%) respondents had cavities/dentin depth lesions, 72 (87.8%) respondents had proximal 
enamel lesions, 52 (63.4%) respondents had white spots on the surface, and 75 respondents did not have any damaged teeth. 

 

Table 3. Frequency distribution of biological predisposing factors 

Variable Yes  No 

n % n % 

Biofilm maturation 34 41,5 48 58,5 

There is high plaque >27 38 46,3 44 53.7 

Consuming sweet foods more than 3 times a day 55 67.0 27 33.0 

Factors that reduce the rate of saliva flow 0 0 82 100 

Saliva volume <1ml/minute 47 57.3 35 42.7 

There are deep pits and fissures 37 45,1 45 54,9 

Take medication 0 0 82 100 

There are open roots 11 13,4 71 86,6 

Using orthodontic appliances 0 0 82 100 

The results of the analysis of the frequency distribution of predisposing factors in table 3 show that 48 respondents (58.5%) had no 
mature biofilm, 44 respondents (53.7%) had a low number of plaques, and 55 respondents (67.0%) consumed sweet foods more than 
3 times/day. A total of 82 respondents (100%) had no factors that influence saliva flow rate, 47 respondents (57.3%) had a volume of 
less than 1 ml/minute, and 45 respondents (54.9%) had no deep pits and fissures. Table 5 also shows that 82 (100%) did not consume 
drugs that affect saliva flow, 71 respondents (86.6%) did not have open roots, and 82 respondents (100%) did not use orthodontic 
devices. 

 



A’yun et al                                                                                                                         Asian Journal of Dental and Health Sciences. 2023; 3(4):11-14 

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Table 4. Frequency distribution of Protection Factors 

Variable Yes  No 

n % n % 

Fluoridation of drinking water 26 31,7 56 68,7 

Fluoride toothpaste at least once a day 80 97,6 2 2,4 

Fluoride toothpaste at least twice a day 73 89 9 11 

Mouthwash (0.05% Na F) every day 1 1,2 81 98,8 

Fluorine varnish (last 6 months) 8 9,8 74 90,2 

Topical fluoride (last 6 months) 4 4,9 78 95,1 

Chlorhexidine mouthwash (every 1 x / week in the last 6 months) 2 2.4 80 97.6 

Xylitol gum/lozenge 4 times a day for the last 6 months 2 2.4 80 97.6 

Calcium phosphate for the last 6 months 6 7,3 76 92,7 

The frequency distribution of protective factors in table 4 shows that 56 respondents (68.7%) have no fluoridation of drinking water, 
80 respondents (97.6%) brush their teeth at least once a day, and 73 respondents (89%) brush their teeth at least once a day. 2 times 
a day. A total of 81 respondents (98.8%) did not use mouthwash (0.05% NaF) every day, 74 respondents (90.2) did not get fluor 
varnish (last 6 months), and 78 respondents (95.11) did not get topical fluoride treatment (last 6 months). The results of measuring 
gargling with Chlorhexidine (every 1 x / week in the last 6 months) showed that 80 respondents (98.8%) did not do it, 80 respondents 
(98.8%) did not have the habit of chewing xylitol gum/lozenge 4 x a day for 6 months last time, and 76 respondents (92.7%) did not 
receive calcium phosphate during the last 6 months. 

 

Table 5. Description of the frequency of dental caries 

Variable Yes  No 

n % n % 

Dental caries 19 23,2 63 75,8 

Table 5 shows that the frequency distribution of caries is that 63 respondents experienced dental caries. 

 

DISCUSSION 

Based on the research results, before chewing the apple, the 
average value was 2.113 in the apple group, after chewing the 
apple, the average value was 0.431, based on the Wilcoxon test, 
the significance value was 0.001 < 0.05. This means that there 
is a difference between the pre-test and post-test in the apple 
group. 

Based on the results of statistical tests, it was found that the 
lowest debris index value before chewing an apple 

Children are at varying degrees of risk for caries throughout 
their lives. Increasingly, recent findings suggest that for success 
in caries prevention, dental health professionals must initiate 
preventive interventions from the first year of life. The 
consequences of childhood dental caries include a higher risk 
of new carious lesion cavities in both primary and permanent 
teeth, increased risk of hospitalization and emergency 
department visits, increased costs and time of treatment, 
inadequate physical development (especially height and 
weight). body), loss of time at school and reduced ability to 
receive lessons, and reduced quality of life related to dental and 
oral health.11 

The concept of caries balance/imbalance is a visual depiction of 
the multifactorial nature of caries. This illustrates the 
determinants of caries, and the dynamic interaction of the 
biofilm with the oral environment. It is this oral environment 
that will determine the nature of the biofilm on each tooth 
surface and if the condition is severe enough to cause 
demineralization and visible changes on the tooth surface. 
Demineralization occurs due to an imbalance between existing 
risk factors and protective factors. This entire process is called 

a caries risk assessment. Caries balance/imbalance is a balance 
between caries indicators, risk factors and protective factors 
that will determine whether the caries process continues, stops 
or remineralization occurs.11 

CAMBRA is an evidence-based approach to prevent or treat the 
causes of dental caries at an early stage rather than waiting for 
permanent damage to the teeth. This philosophy requires an 
understanding that dental caries is a disease of infectious 
biofilm bacteria that arises in an oral cavity environment 
dominated by pathological factors. Researchers suggest this 
disease is a consequence of a shift in the homeostatic balance of 
normal microflora due to changes in local environmental 
conditions, for example pH, which favor the growth of 
cariogenic pathogens.12 

The essence of the CAMBRA philosophy of care is the assessment 
of each individual patient's disease indicators, risk factors and 
protective factors to determine current and future dental caries 
disease.13 

Caries risk assessment (CRA) is an important 
component of caries management and should be considered 
the standard of care and included as part of the dental 
examination. This is important in decision making to guide the 
dentist in determining the diagnosis, prognosis and treatment 
plan for each patient. 

Implementation of caries risk assessment in clinical practice is 
best done using the CRA form, to ensure that each patient is 
systematically assessed in the same way, based on the best 
available research.11 

Several versions of the CRA form exist, 
and with clinical outcomes use multiple indicators and risk 
factors.10 The American Dental Association (ADA) developed 
two forms that determine low, moderate or high risk: one for 



A’yun et al                                                                                                                         Asian Journal of Dental and Health Sciences. 2023; 3(4):11-14 

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patients aged 0-6 years, and another for patients aged over 6 
years. The American Academy of Pediatric Dentistry (AAPD) 
has developed two forms that determine low, moderate or high 
risk: one for pediatric patients aged 0-5 years, and one for 
children aged over 5 years. There are also two forms published 
by the California Dental Association (CDA), validated risk 
assessment tools using large cohorts of patients and found 
significant comparisons regarding the number of cavities in the 
future.14 

While all these forms differ in terms of risk factors, disease 
indicators and protective factors, they all agree that the 
strongest predictor of future dental caries is the patient's 
experience with caries, such as carious lesions or new 
restorations within the last three years,  although each form 
uses different variables to describe the caries experience.14,11 

CONCLUSION 

Based on the results of the research and discussion, it can be 
concluded that the risk factors for dental caries based on 
CAMBRA that influence children's dental caries are the criteria 
for dentin depth lesions, saliva pH and plaque amount. 

ACKNOWLEDGEMENTS 

The authors thank to all participants and research assistants. 

CONFLICT OF INTEREST 

The authors declare that they have no conflict interests. 

ETHICAL CLEARANCE 

This research has received a certificate of appropriate research 
ethics from the Yogyakarta Health Research Ethics Commission 
No. DP.04.03/e-KEPK.1/130/2023. 

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https://doi.org/10.1186/s12903-020-1010-3
https://doi.org/10.1186/s12903-020-1010-3
https://doi.org/10.3390/dj7010022
https://doi.org/10.35790/eg.2.1.2014.4013
https://doi.org/10.1038/nrdp.2017.30
https://doi.org/10.1111/cdoe.12031
https://doi.org/10.1007/s40368-020-00547-5
https://doi.org/10.1007/s40368-020-00547-5

