Journal of Conservative Dentistry

: 2021  |  Volume : 24  |  Issue : 2  |  Page : 163--168

Perspective and practice of root caries management: A multicountry study – Part II: A deeper dive into risk factors

Abdurahman Salem1, Rayhana Aouididi2, Juliana Delatorre Bronzato3, Haider Al-Waeli4, Mousa Abufadalah5, Saleem Shaikh5, Yassir Yassir6, Ahmed Mhanni7, Priyanka Vasantavada8, Hatem Amer9, Abubaker Qutieshat10,  
1 Primary Care, National Health Service, Lothian, UK
2 Oral Biology, Jordan University of Science and Technology, Irbid, Jordan
3 Restorative Dentistry, State University of Campinas, São Paolo, Brazil
4 Periodontics, Faculty of Dentistry, Dalhousie University, Halifax, Canada
5 Restorative Dentistry, College of Dentistry, Majmaah University, Al Majma'ah, Saudi Arabia
6 Orthodontics, College of Dentistry, University of Baghdad, Baghdad, Iraq
7 Prosthodontics, Faculty of Dentistry, University of Tripoli, Tripoli, Libya
8 Dental Public Health, Teesside University, Middlesbrough, UK
9 Oral Pathology, Cairo University, Cairo, Egypt
10 Restorative Dentistry, Dundee Dental School, University of Dundee, Dundee, UK

Correspondence Address:
Dr. Abubaker Qutieshat
Restorative Dentistry, Dundee Dental School, University of Dundee, Dundee


Background: The potential of an improved understanding to prevent and treat a complex oral condition such as root caries is important, given its correlation with multiple factors and the uncertainty surrounding the approach/material of choice. Deeper insights into risk factors may improve the quality of treatment and reduce the formation of root surface caries. Aim: The present work aims to gain knowledge about dentists' opinions and experiences on assessing the risk factor related to the development of root caries and to help identify any overlooked factors that may contribute to less efficacious clinical outcomes. Methodology: A questionnaire related to root surface caries was distributed among practicing dentists in nine different countries, namely the United Kingdom, Libya, Jordan, Saudi Arabia, Egypt, Brazil, India, Malaysia, and Iraq. Questionnaire responses were analyzed, and the results were compared among the groups. Results: Dentists around the world ranked the oral hygiene status of patients as the most important factor in the development of root surface caries. Patients with poor oral hygiene, active periodontal disease, reduced salivary flow, and gingival recession are perceived to have a higher risk of developing new root surface caries. There is a greater focus on prevention in the UK and greater levels of untreated dental disease in other countries, especially those recovering from civil wars. Conclusion: This work identified some overlooked factors that may have contributed to the less efficacious clinical outcomes reported in the literature. It is hoped that this deep dive into risk factors coupled with the findings presented in Part I of this study will be used as a basis for a more comprehensive investigation into the management of patients with root surface caries.

How to cite this article:
Salem A, Aouididi R, Delatorre Bronzato J, Al-Waeli H, Abufadalah M, Shaikh S, Yassir Y, Mhanni A, Vasantavada P, Amer H, Qutieshat A. Perspective and practice of root caries management: A multicountry study – Part II: A deeper dive into risk factors.J Conserv Dent 2021;24:163-168

How to cite this URL:
Salem A, Aouididi R, Delatorre Bronzato J, Al-Waeli H, Abufadalah M, Shaikh S, Yassir Y, Mhanni A, Vasantavada P, Amer H, Qutieshat A. Perspective and practice of root caries management: A multicountry study – Part II: A deeper dive into risk factors. J Conserv Dent [serial online] 2021 [cited 2023 Dec 2 ];24:163-168
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Root caries is a multifactorial disease that exhibits softened, brownish, and irregular tissue on the root surface in the proximity of the cementoenamel junction.[1] Various risk predictors of root caries have been identified in two recent systematic reviews of observational longitudinal[2] and cross-sectional[3] studies, namely age, socioeconomic status, gingival recession, oral hygiene status, and smoking.

The prevalence of caries has been decreasing in the general population, and therefore, the number of dental restorations and missing teeth has been reduced.[4] As a function of an increased number of retained teeth, and as shown by the UK Adult Dental Health Survey of 2009,[5] the percentage of people with loss of gingival attachment is on the increase in the UK. The percentage of people with exposed root surfaces is also on the increase indicating that, regardless of the etiology or pathogenesis, gingival recession is an increasing problem with age. Hence, more teeth are exposed to root surface caries lifelong, paired with an increasing lifespan of the individual.[6] As such, root caries is becoming an issue of dental public health concern among the elderly patient population, especially those with suboptimal oral hygiene, impaired dexterity, and reduced salivary flow.

An understanding of the risk factors is important for the diagnosis, prevention, and adequate treatment of root surface caries. Dentists should routinely document the caries risk status of their patients and track any changes over time.[7] Moreover, given the high rate of failure of root surface restorations, recognition of the risk factors can enhance the predictability of failure and its possible avoidance.

The root surface exposure is often associated with substandard esthetics, dentinal sensitivity, and carious and noncarious cervical lesions and an increase in the amount of exposed root surface would therefore increase the risk of root surface caries. Root surface exposure resulting from gingival recession is a complex phenomenon that may pose significant therapeutic problems to the dentist. Several studies reported age as a risk factor for the development of root surface caries based on the fact that the amount of gingival recession increases with age.

In the scientific literature, there was no conclusive evidence that could have indicated a direct association between root surface caries and the number of teeth present in the oral cavity. It has been well established that the most accurate indicator of developing carious lesions in the future is previous caries experience.[8] In case of root caries, previous caries experience remains to be a consistent and significant risk factor. Therefore, clinically, it is important to provide a thorough caries risk assessment for patients who have carious and/or restored root surfaces.

Recent systematic reviews have documented positive associations between smoking and new root caries.[2],[3],[9] This may be because smokers accumulate markedly more dental calculus than nonsmokers and are more prone to periodontal diseases. Although some negative effects have been reported, it is difficult to imagine reasons for causation in case patients choose to try to quit smoking.[10] Similar associations were found with sociodemographic factors and the level of oral health knowledge as individuals at a lower socioeconomic or education level are more likely to have suboptimal oral health knowledge and behavior.[11]

The variations among dentists on what is perceived as a risk factor in the development of root surface caries are mainly due to their training and expertise which reflect the choices they make in their practice in terms of preventive measures to be taken and the outline for the management of such cases to ensure the best clinical outcome for their patients. Thus, every effort needs to be made to enable the perception of the risk factors from the viewpoint of dentists from all around the world in such a manner as to assist with the development of novel prevention and treatment of root surface caries. This can only be ascertained by surveys, personal testimonies, and observation. Therefore, this paper presents a questionnaire survey of dentists' perception of the most important risk factors in the development of root caries. Responses were obtained from nine different countries to get a wider range of opinions and perspectives.


A multicountry cross-sectional survey was designed for distribution to qualified dentists from nine countries (UK, Libya, Jordan, Saudi Arabia, Egypt, Brazil, India, Malaysia, and Iraq). The questionnaire was distributed by e-mail using an online survey service platform (Google Forms) with tracking disabled. E-mails were sent out to 400 registered dentists in each of the 9 countries. Potential participants were selected at random from the official dental online registers database in each country. No tracking of nonresponders nor participants was possible and therefore responses were anonymous, and no follow-up was possible. Only registered dentists were included. Inclusion in the study was random with no reason to include or exclude any particular participant other than the desire to have representative data from all countries.

The questionnaires explored the experiences and views of root caries of qualified dentists in those countries. The questionnaire consisted of two sections: the first section explored the prevalence of the disease, diagnostic and detection methods, intraoral distribution, management, and follow-up (presented in Part I of this study as a separate article).[12] The second section explored the risk factors and lifestyle habits related to increased risk of developing root surface caries [Figure 1].{Figure 1}

A relational database was developed using Paradox (Paradox Version 3.5, Borland International) for input of data and interrogation. Statistical analyses were undertaken using GraphPad Prism (Graph Pad Software Inc., Version 9, San Diego, USA). Differences were tested using the Chi-squar test. P < 0.05 was considered significant.


In response to the invitation to participate in the study, a total of 1209 responses were received. The number of responses from each country was as follows: UK (134), Libya (120), Jordan (135), Saudi Arabia (118), Egypt (133), Brazil (155), India (138), Malaysia (168), and Iraq (108). The responses were gathered between December 14, 2019, and January 14, 2020.

Based on the data from dentists' responses, the factors influencing the selection of treatment modality for root caries included oral hygiene, diet, age, tooth type, and severity of the lesion. Chi-square testing revealed a significant difference in responses (χ2 = 144.2, P < 0.0001). Severity of the lesion and oral hygiene were the most influential factors for the selection of management methods in all countries. However, patients' diet influenced to a greater degree the management of the root surface lesions in the UK as compared to all other countries (23.86% UK cf. 3.3%–11.2% other countries).

Regarding the lifestyle-related factors that respondents reported to have the greatest impact on the development of root surface caries, there was no significant difference in responses (χ2 = 20.7, P = 0.0973). In all countries, retirement, bereavement, giving-up smoking, and deterioration of general health were the factors most thought to give rise to root caries. Surprisingly, diet as a risk factor was considered by dentists outwith the UK and Brazil to be relatively unimportant.

Respondents were asked to select the most important factors that play a role in the development of root caries. [Table 1] summarizes the relative ranking of importance of risk factors in the development of root caries according to country. The rankings did not statistically differ in the cases of oral hygiene state, physical disability, and mental disability/senility. However, there was a statistically significant difference between the rankings of all other factors.{Table 1}

In general, the respondents ranked highest in the oral hygiene status of patients followed by the presence of active periodontal disease, reduced salivary flow, and gingival recession. Interestingly, the total amount of sugar consumption and the frequency of sugar intake were only highly ranked among respondents from the UK and Brazil.


Before discussing the findings of this work, it is important to clarify why this multicountry survey was undertaken. Its first purpose was to contrast and compare the root caries management practices in nine different locations around the world (presented in Part I of this study as a separate article).[12] The second function of the survey was to shed some light on what can be learned from practicing dentists around the world that would advance the control of root surface caries and to help identify any overlooked factors that may contribute to less efficacious clinical outcomes.

In analyzing the findings, it is perhaps important to underscore a factor that seems to be overlooked by most respondents, and that is – diet. It has been well-documented in the literature that the consumption of sugars is associated with the development of root caries, especially in teeth with gingival recession.[2],[13],[14],[15] It is therefore surprising to note that respondents, except those from the UK and Brazil, perceived diet to be a relatively insignificant factor despite its association with dental caries. It is worth mentioning however that collagen degradation within the dentinal tubules can provide a source of nutrients for the cariogenic bacteria. Therefore, the invading microorganisms involved in root caries may be less dependent on carbohydrates than earlier thought.[1]

While the reported risk factors considered by dentists from around the world to be responsible for the development of root surface caries varied considerably, the “oral hygiene status” factor was predominantly and consistently chosen by respondents as the most important factor in all nine participating countries. To compare the responses from nine countries to each other and to other studies in the available literature, it is worthwhile to formulate a ranking system. One way of doing this, as we have attempted to demonstrate in this paper, is to multiply the rank of importance assigned to each criterion by the percentage, giving a weighting of 3 to the 'very important” rank, 2 to the “quite important” rank, and 1 to the “fairly important” rank.

This empirical comparison was undertaken for the findings of the present work and also for the UK-based questionnaire by McCombes[16] in an endeavor to standardize the comparison. A measure of the agreement between the rankings of risk factors provided by participating dentists is shown in [Table 2]. As a crude assessment of differences in responses, a numerical value from 0 to 18 was obtained by subtracting the weighted values of each risk factor group calculated using the proposed ranking method mentioned above. If the difference value is 0, it indicates that there is perfect agreement between the groups. Empirically, a difference of 3 or smaller can be considered as agreement.{Table 2}

From the values in [Table 2], it can be seen that there is general agreement between the present UK results and those generated 20 years ago[16] with the exceptions of poor crown margins, overhanging restorations, and poor general health. In case of poor general health, this was considered to be of lesser importance by UK dentists 20 years ago. Nowadays in the UK, several plans have been implemented to help assign routine preventive oral health care and dental domiciliary care to patients that are elderly or have significant, competing medical comorbidities which collectively have increased the access of the elderly to dental care.[17]

Poor crown margin and overhanging restorations were considered to be of greater importance by UK dentists 20 years ago. An explanation for this might be that the new state of the art of digital dentistry has improved dental restoration outcomes and might have played a role in lessening the likelihood of suboptimal margin finish of crowns.[18] In the past few years, the pace of research has accelerated further, and recently, chairside addition of bioactive molecules to conventional glass ionomer has been reported in the UK as an endeavor to improve mechanical properties, biocompatibility, and clinical durability of root surface glass ionomer restorations.[19]

It is worth mentioning that possible changes in the views of practicing dentists regarding root caries may have occurred since 1999, the year in which the first UK-based study was conducted.[16] This change can also be attributed to the significant influx of non-UK trained dentists into the UK over the past two decades.[20]

It is also interesting to note the general agreement between the responses from the UK and those from Brazil. In 2017, Brazil and the UK have begun a collaborative network in dental research and teaching that aimed to share the knowledge on minimally invasive restoration techniques and advance the partnership that has already existed between the dental academic institutions in both countries.[21] If one assumes that such collaborations prompted very similar responses in both the countries, then it is sensible to recommend that dental academic institutions around the world should adopt similar collaborative initiatives for a more comprehensive and up-to-date understanding of evidence-based practices and guidelines.

It is clear that there are several differences between the UK and non-UK responses, with non-UK dentists ranking the importance of active periodontal disease, higher than those in the UK. Conversely, the UK respondents assigned higher importance to the frequency and amount of sugar intake. In the opinion of the authors, these observations perhaps reflect the greater emphasis upon prevention in the UK and the greater levels of untreated dental disease in other countries.


This questionnaire survey revealed what dentists from 9 different countries regarded as the most important risk factors contributing to the development of root surface caries. Perceptions and beliefs between the UK and non-UK dentists exhibit some commonality although differ in the emphasis on diet. Patients with poor oral hygiene, active periodontal disease, reduced salivary flow, and gingival recession are perceived to have a higher risk of developing new root surface caries. Oral hygiene status was the most important risk factor in all countries. It is hoped that this deep dive into risk factors coupled with the findings presented in Part I of this study will be used as a basis for a more comprehensive investigation into the management of patients with root surface caries.


The authors would like to thank Drs. Fakrul Asif Rodzi, Wan Muhammad Fakhruddin, and Amirul Syafiq for their valuable contribution.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1AlQranei MS, Balhaddad AA, Melo MA. The burden of root caries: Updated perspectives and advances on management strategies. Gerodontology 2021;38:136-53.
2Zhang J, Leung KC, Sardana D, Wong MC, Lo EC. Risk predictors of dental root caries: A systematic review. J Dent 2019;89:103166.
3Zhang J, Sardana D, Wong MCM, Leung KCM, Lo ECM. Factors associated with dental root caries: A systematic review. JDR Clin Trans Res 2020;5:13-29.
4López R, Smith PC, Göstemeyer G, Schwendicke F. Ageing, dental caries and periodontal diseases. J Clin Periodontol 2017;44:S145-S52.
5Aminu AQ. Adult dental health survey 2009: Association between oral health outcomes and living arrangements of older adults in the UK. Br Dent J 2019;227:115-20.
6Heasman PA, Ritchie M, Asuni A, Gavillet E, Simonsen JL, Nyvad B. Gingival recession and root caries in the ageing population: A critical evaluation of treatments. J Clin Periodontol 2017;44 Suppl 18:S178-93.
7Doméjean S, Banerjee A, Featherstone JDB. Caries risk/susceptibility assessment: Its value in minimum intervention oral healthcare. Br Dent J 2017;223:191-7.
8Davies KJ, Drage NA. Adherence to NICE guidelines on recall intervals and the FGDP (UK) Selection Criteria for Dental Radiography. Prim Dent J 2013;2:50-6.
9Leite FR, Nascimento GG, Scheutz F, López R. Effect of smoking on periodontitis: A systematic review and meta-regression. Am J Prev Med 2018;54:831-41.
10ALHarthi SS, Al-Motlag SK, Wahi MM. Is trying to quit associated with tooth loss and delayed yearly dental visit among smokers? Results of the 2014 behavioral risk factor surveillance system. J Periodontol 2017;88:34-49.
11Costa SM, Martins CC, Bonfim Mde L, Zina LG, Paiva SM, Pordeus IA, et al. A systematic review of socioeconomic indicators and dental caries in adults. Int J Environ Res Public Health 2012;9:3540-74.
12Qutieshat A, Salem A, Aouididi R, Delatorre J, Al-Waeli H, Abufadalah M, et al. Perspective and practice of root caries management: A multi-country study – Part I. J Conserv Dent JCD 2021; 24:(In This Issue)
13Steele JG, Sheiham A, Marcenes W, Fay N, Walls AW. Clinical and behavioural risk indicators for root caries in older people. Gerodontology 2001;18:95-101.
14Suzuki S, Onose Y, Yoshino K, Takayanagi A, Kamijo H, Sugihara N. Factors associated with development of root caries in dentition without root caries experience in a 2-year cohort study in Japan. J Dent 2020;95:103304.
15Usha C, R S. Dental caries-A complete changeover (Part I). J Conserv Dent 2009;12:46-54.
16McCombes W. Root Caries in Middle Aged Patients: A Perspective from Scottish General Dental Practice. MSc Thesis, University of Dundee; 1999.
17Turner S, Symeonoglou P, Ross MK. The delivery of dental care to older adults in Scotland: A survey of dental hygienists and therapists. Br Dent J 2020;226:1-6.
18Rekow ED. Digital dentistry: The new state of the art–Is it disruptive or destructive? Dent Mater 2020;36:9-24.
19Qutieshat A, Salem A. Effects of bioactive additions on the physical properties of glass polyalkenoate cement. J Osseointegration 2019;11:497-503.
20Davda LS, Radford DR, Scambler S, Gallagher JE. Profiles of registrant dentists and policy directions from 2000 to 2020. BDJ Open 2020;6:26.
21Hosey MT. Conference report: Strategies for creating a collaborative network in research and teaching: CEDACORE. Br Dent J 2018;224:62-3.