Evidence on existing caries risk assessment systems: are they predictive of future caries?

Validating Caries Risk Assessment Tools in High-Prevalence Filipino Toddlers

INTRODUCTION AND AIMS

Caries risk assessment is an essential part of the diagnostic process. Many studies have assessed these tools, proving their effectiveness in reducing future caries risk in developed countries with low caries prevalence. However, Filipino children have consistently registered high caries prevalence rates in successive official surveys. This prospective study aimed to compare the validity of available caries risk assessment tools in predicting future caries among a high-caries-prevalent population in the Philippines.

METHODS

From the vaccination registry of community health centres in Caloocan City, Philippines, children aged 4-24 months underwent oral examinations according to modified International Caries Detection and Assessment System (ICDAS) criteria, and their primary caregivers were interviewed using a structured questionnaire. Baseline caries risk categories were evaluated using 3 available tools, without biological tests. Caries incidence was recorded during the follow-up visit after 2 years.

RESULTS

Baseline oral examinations in 703 toddlers (mean age: 13.3 months, standard deviation (SD) 2.4) revealed a high caries prevalence of 29.2%. Of the 654 eligible children without cavitated caries at baseline, 323 (mean age: 35.6 months, SD 5.1) attended the 2-year follow-up visit, with a caries incidence (cavitated and non-cavitated) of 76.5%. Caries-risk Assessment Form (CrAF) demonstrated high sensitivity but low specificity scores (93.1% and 3.9%), while Caries Management by Risk Assessment (CAMBRA) showed similar patterns (71.7% and 34.2%). Conversely, Cariogram exhibited low sensitivity but high specificity (23.5% and 80.3%).

CONCLUSION

Among CrAF, CAMBRA or Cariogram, no assessment tool came close (sensitivity + specificity < 160) to effectively identify toddlers highly at risk of caries development.

CLINICAL RELEVANCE

Current CRA tools lack sufficient accuracy in predicting caries development in high-risk populations like Filipino children. Refinement or development of more valid tools is crucial for implementing effective caries prevention strategies at both individual and population levels.

Integrating oral and social factors in individual caries risk assessments in preschool children-a registry-based study

PURPOSE

To investigate the predictive ability of individual Caries Risk Assessments (CRA) regarding oral factors supplemented with social factors in relation to caries outcome in preschool children. Furthermore, to assess various models of CRA with oral and social factors included, aiming to identify the most suitable models for different age groups.

METHODS

The design is a retrospective registry-based cohort study. Children visiting the dentists at ages 3 and 6 years were included. Data on oral and social factors were obtained from dental records, the Swedish Quality register for caries and periodontitis (SKaPa), and Statistics Sweden (SCB). Various models of CRA were designed, combining oral and social factors. Models were analyzed with univariable associations using simple logistic regression, and the results were presented as odds ratios (ORs). In addition, models were analyzed with area under the receiver operating characteristic (ROC) curve (AUC). Pairwise comparisons were conducted by DeLong's test, with p < 0.05 considered significant.

RESULT

Oral factors were the most significant for caries outcome (OR 9.6), followed by social factors: foreign background (OR 4.6), low income (OR 2.83), low education of the mother (OR 2.77), single-parent family (OR 2.11), and having ≥ 3 siblings (OR 1.71), (p < 0.01). The predictive ability of CRA improved when models combining oral and social factors were used, compaired to CRA based solely on oral factors (p < 0.05). An increase of up to 15% was seen when CRA was conducted closer to the outcome.

CONCLUSION

Models for Caries Risk Assessment including oral and social factors increase the predictive ability. Caries Risk Assessment has limited durability.

Development and psychometric test of the myRisk mobile application for caries risk assessment

OBJECTIVES

To develop a caries-risk assessment application (myRisk app) and assess the psychometric properties based on content validity, construct validity, and how well it classifies the participants into different caries risk groups using caries increments at 10 months.

METHODS

The myRisk mobile application was developed using Android Studio 4.1.1. The content validity was assessed by three dental experts. To evaluate construct validity and the prediction of future dental caries, the participants (N = 88) were recruited from Rajvithi Home for Girls in Thailand by convenience sampling. The participants were completed a caries risk assessment (CRA) of myRisk app and ADA form. The oral examination was performed at the time of CRA and 10 months following the baseline.

RESULTS

Eighty-eight participants aged 12-29 used the myRisk app and completed the ADA form. The app content validity was acceptable (IOC = 0.67). According to myRisk, 7.9%, 71.6%, and 20.5% of the participants were classified into the low-, moderate-, and high-risk groups, respectively. The percent agreement of the caries-risk classification with the ADA form was 30.7%. Significant differences between the three risk groups were found in active caries (p < 0.001), type, and frequency of sugary snacks (p = 0.002). The app had a sensitivity of 68%, a specificity of 61%, and an area under the receiver operating characterisitic (ROC) curve of 0.61.

CONCLUSIONS

The myRisk app has acceptable content validity and sufficient diagnostic accuracy (sensitivity, specificity, and ROC curve). However, there is a different outcome in caries-risk classification compared with the ADA form.

Evaluation of Caries Risk Using Cariogram Among Orthodontic Patients Before and During Treatment: A Comparative Study

Objective The primary objective was to examine the Cariogram parameters among orthodontic patients with fixed appliances and evaluate the impact of preventive measures on mitigating the risk of dental caries during orthodontic therapy. Materials and methods Patients visiting the representative orthodontic clinics across 14 districts of Kerala participated in the comparative cross-sectional study from January 2023 to January 2024. The sampling method employed in this study was convenience quota sampling, where study subjects were allocated from each of the low, moderate, and high caries risk profiles until the sample size reached the minimal requirement within each group. The baseline Cariogram scores were used to divide the consented participants into two distinct groups. The intervention group was provided with preventive initiatives, including toothpaste comprising 1,450 ppm fluoride, 0.2% NaF mouthwash, pre-cut strands of SuperFloss, an orthodontic toothbrush designed for orthodontic braces, and an interdental flexible brush, as well as videos, pamphlets, and brochures that promoted oral health habits. In contrast, the control group received normal oral health education solely through the use of pamphlets and brochures. After six months, the Cariogram elements were re-evaluated for individuals in both groups. The independent sample t-test and paired t-test were applied to evaluate statistically significant differences between and within the two groups, respectively, using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, NY, US). The distribution of patients based on their caries risk profiles was compared between groups at the commencement of the study and six months later using the Chi-square test. Results While the intervention group had 20 males and 22 females, the control group consisted of 21 males and 21 females. The average age in the intervention and control groups was 20.7±3.56 years and 21.2±3.12 years, respectively. Between the two groups, age (t=-0.68; p=0.50) and gender differences (λ2=0.05; p=0.83) were statistically insignificant. The percentage mean of the "Chance to avoid caries" associated with the intervention group increased significantly from 46.15±0.96 to 57.88±1.91, (p<0.001). On the other hand, the chance to avoid caries in the control group at the commencement of the treatment and six months later was found to be statistically insignificant. A statistically highly significant differences for all the Cariogram parameters were found when contrasted between the groups after six months of orthodontic treatment. The distribution of caries risk categorization between the control and intervention groups after six months of orthodontic treatment was found to be statistically significant (λ2=20.16; p<0.0001). Further, a statistically significant difference was observed during the pre-treatment phase and six months later in the intervention group (λ2=13.02; p=0.001). Conclusion The study findings reveal that it would be prudent to utilize 0.2% sodium fluoride mouth rinse, SuperFloss, an orthodontic toothbrush designed for orthodontic braces, and an interdental flexible brush, along with toothpaste containing 1450 ppm fluoride daily, to mitigate the risk of dental cavities during orthodontic treatment, in comparison to the control group.

Comparison of two different caries risk assessment tools for infants and toddlers - A cross-sectional study

CONTEXT

One of the essential components for successful caries management is caries risk assessment (CRA). Among CRA tools (CRATs) published in the literature: Caries management by risk assessment (CAMBRA) 123 and American Academy of Pediatric Dentistry (AAPD) CRATs are specifically designed for infants and toddlers.

AIMS

The aim of this study is to compare readily available internationally accepted CRAT for infants and toddlers and check the usability of these tools in assigning caries risk among the Indian population.

SETTINGS AND DESIGN

The study was conducted at Baby Oral Health Promotion Clinic, Department of Pediatrics, Tertiary Care Hospital using a cross-sectional study design.

SUBJECTS AND METHODS

Data were collected using CAMBRA 123 and AAPD CRATs from 379 children aged 0-6 years. The caries risk of the children was recorded with each CRAT and a comparison was made between the two tools used.

STATISTICAL ANALYSIS USED

The percentage of agreement and Cohen's kappa coefficient were used to know the agreement between the CAMBRA 123 and AAPD CRATs using the SPSS statistical tool. The significance level was set at 5% (α = 0.05).

RESULTS

For children aged <2 years, the study showed slight agreement between the CAMBRA 123 and AAPD, whereas, for children more than 2 years, there was a fair agreement between the two methods which was statistically significant. This indicates that the agreement between the two methods is still not perfectly established, and AAPD CRA assigns a higher risk category than CAMBRA 123.

CONCLUSIONS

CAMBRA 123 is a promising user-friendly quantitative method for CRA in clinical practice. Since there is ambiguity in assessing the caries risk in children <2 years, there is a need to establish a CRAT that can be used exclusively for children below 2 years.

Multivariable prediction models of caries increment: a systematic review and critical appraisal

BACKGROUND

Multivariable prediction models are used in oral health care to identify individuals with an increased likelihood of caries increment. The outcomes of the models should help to manage individualized interventions and to determine the periodicity of service. The objective was to review and critically appraise studies of multivariable prediction models of caries increment.

METHODS

Longitudinal studies that developed or validated prediction models of caries and expressed caries increment as a function of at least three predictors were included. PubMed, Cochrane Library, and Web of Science supplemented with reference lists of included studies were searched. Two reviewers independently extracted data using CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) and assessed risk of bias and concern regarding applicability using PROBAST (Prediction model Risk Of Bias ASessment Tool). Predictors were analysed and model performance was recalculated as estimated positive (LR +) and negative likelihood ratios (LR -) based on sensitivity and specificity presented in the studies included.

RESULTS

Among the 765 reports identified, 21 studies providing 66 prediction models fulfilled the inclusion criteria. Over 150 candidate predictors were considered, and 31 predictors remained in studies of final developmental models: caries experience, mutans streptococci in saliva, fluoride supplements, and visible dental plaque being the most common predictors. Predictive performances varied, providing LR + and LR - ranges of 0.78-10.3 and 0.0-1.1, respectively. Only four models of coronal caries and one root caries model scored LR + values of at least 5. All studies were assessed as having high risk of bias, generally due to insufficient number of outcomes in relation to candidate predictors and considerable uncertainty regarding predictor thresholds and measurements. Concern regarding applicability was low overall.

CONCLUSIONS

The review calls attention to several methodological deficiencies and the significant heterogeneity observed across the studies ruled out meta-analyses. Flawed or distorted study estimates lead to uncertainty about the prediction, which limits the models' usefulness in clinical decision-making. The modest performance of most models implies that alternative predictors should be considered, such as bacteria with acid tolerant properties.

TRIAL REGISTRATION

PROSPERO CRD#152,467 April 28, 2020.

Predictive validity of the reduced Cariogram model for caries increment in non-cavitated and cavitated lesions: cohort study

BACKGROUND

The aim of this study is to assess the caries prediction of the reduced Cariogram by comparing baseline caries risk profiles with non-cavitated and cavitated lesions over periods of six, twelve, and 18 months.

METHODS

From May 2016 to October 2017, seven schools in Bhakkar, Pakistan, participated in a cohort study. First base line examination was conducted followed by examinations at 6, 12 and 18 months. Children intraoral examinations were performed on portable dental chair with in school premises by a trained examiner. A modified ICDAS index was used to measure caries at baseline and at follow-up examinations after 6, 12, and 18-months. A receiver operating curve (ROC) analysis was performed to evaluate its effectiveness for predicting dental caries increment.

RESULTS

About 40% of children had a low-risk status, 30.5% medium risk, and 29.7% high risk, at baseline risk assessment. At 18 months, 73% of high-risk children, 59% of medium-risk children, and 41% of low-risk children showed a caries increment. For the reduced Cariogram model, the area under the curve on the 6, 12 and 18 months follow-up was 0.63, 0.65 and 0.70 respectively.

CONCLUSIONS

Our findings indicates that a reduced Cariogram can predict the progression of caries in both cavitated and non-cavitated lesions and model exhibits a level of discriminatory ability. While it might not achieve a very high accuracy, it suggests that the model is able to predict caries increment effectively than random guessing.

Assessment of implementation of the caries management by risk assessment philosophy in a dental school

OBJECTIVE

This cross-sectional study assessed the implementation of documenting a baseline caries risk assessment (CRA) of patients seen by predoctoral dental students and its association with the presence of caries risk management (CRM) treatment.

METHODS

A convenience sample of 10,000 electronic axiUm patient records at Tufts University School of Dental Medicine was retrospectively assessed for the presence or absence of a completed CRA and CRM after IRB approval following predetermined inclusion and exclusion criteria. The CRM variables (nutrition counseling, sealant, fluoride) were identified by procedure codes that were completed by the student. Associations were assessed via the chi-square test, Kruskal-Wallis test (with Dunn's test and the Bonferroni correction used in post-hoc tests) and Mann-Whitney U test.

RESULTS

Most patients (70.5%) had a CRA completed. However, only 24.9% (out of the 7045 patients with a completed CRA) received CRM, while 22.9% of the 2,955 patients without a CRA received CRM. The difference between the groups with and without a completed CRA in terms of the percentage receiving CRM was not clinically significant. Significant associations were found between a completed CRA and in-house fluoride treatment (p = .034) and between a completed CRA and sealant treatment (p = .001). Patients with higher baseline CRA levels (i.e., greater risk) were more likely to have CRM (16.9% of the 785 patients at low risk, 21.1% of the 1282 patients at moderate risk, 26.3% of the 4347 patients at high risk, and 32.6% of the 631 patients at extreme risk). The association between these two variables was significant (p < .001).

CONCLUSION

There is evidence that students were mostly compliant with completing a CRA for most patients; however, there is a deficiency in implementation of CRM approach to help support dental caries management, and there is still much room for improvement.

The potential harm of not following clinical practice guideline recommendations

BACKGROUND

Clinical practice guidelines (CPGs) provide recommendations for clinicians on the basis of best evidence. CPGs are often not followed because of numerous barriers, including lack of awareness, inability to understand recommendations, and problems with implementation.

CASE DESCRIPTION

A case report is presented in which treatment of a patient's incipient caries lesions may not have followed a CPG available to practitioners, recommending conservative nonrestorative medical interventions. The resulting treatment led to pain and the need for endodontic therapy and full-coverage restoration.

PRACTICAL IMPLICATIONS

This case represents possible mismanagement leading to undue pain and additional costs that could have been avoided by being aware of, and following, the recommendations from CPGs.

Dental caries prediction and the indication of pit and fissure sealant in children first permanent molars: a prospective study

OBJECTIVES

To evaluate predictors for caries incidence on first permanent molars and to assess the accuracy and efficiency of these predictors for the indication of pit and fissure sealants.

METHODS

This 7-y cohort study started in 2010 with a sample of 639 children (1-5 years) from Southern Brazil. Dental caries was assessed using the ICDAS. Maternal education, family income, parental perception on child oral health and severe dental caries experience were collected at baseline and used to test the prediction of dental caries. Predictive values, accuracy and efficiency were estimated for each possible predictor.

RESULTS

About 449 children were re-assessed at follow-up (70.3% retention rate). The baseline characteristics showed similar risks for dental caries incidence in first permanent molars. Low family income and poor parental perception of child oral health were moderately accurate in correctly identifying sound children who would not need to receive pit and fissure sealant. However, all the adopted criteria have lower accuracy incorrectly identifying children who later developed dental caries in first permanent molars.

CONCLUSIONS

Distal and intermediate factors were relatively accurate in determining caries risk incidence on children's first permanent molars. The criteria adopted were more accurate in identifying sound children than those who need to receive pit and fissure sealant.

CLINICAL RELEVANCE

Our findings reinforce the idea that investing in strategies that take into account common risk factors still represents the best option for dental caries prevention. However, adopting only these parameters is not enough to indicate pit and fissure sealants.

How do dental practitioners, educators and students diagnose and manage caries risk and caries lesions? A COM-B analysis

OBJECTIVE

The International Caries Classification and Management System (ICCMS™), a comprehensive, evidence-informed, best clinical practice system, comprises a 4D cycle: 1D-Determine risk; 2D-Detect and assess lesions; 3D-Decide on a personalized care plan; and 4D-Do preventive and tooth-preserving care. The aim of this study was to establish how Colombian dental practitioners, educators and students diagnose and manage caries risk and caries lesions using the COM-B model and the ICCMS™ system.

METHODS

A total of 1094 participants (practitioners: n = 277; educators: n = 212; students: n = 605) completed a previously validated 79-item questionnaire which explores, based on the COM-B model, the practitioners' self-reported caries diagnosis and management behaviours. Descriptive statistics, Welch's ANOVAs and multiple linear regressions were computed.

RESULTS

All groups generally performed the behaviours within the 4-D categories 'Most of the time' to 'Always' (students: 4.06 ± 0.95; educators: 3.94 ± 0.98; practitioners: 3.86 ± 1.01). The most frequently performed diagnosis behaviours (1D/2D) were for practitioners assessing initial/moderate lesions (4.09 ± 1.01) and for educators and students cleaning teeth before lesion assessment (4.41 ± 0.80 and 4.38 ± 0.77 respectively). The least frequently performed decision/management (3D/4D) behaviour was non-operative care for moderate-caries lesions (when applicable) (practitioners: 2.64 ± 1.23; educators: 2.68 ± 1.17; students: 3.22 ± 1.41). Opportunity (Resources and Relevance) was the best COM-B predictor for diagnostic behaviours, whereas capability and opportunity (Relevance) were the strongest predictors for management behaviours.

CONCLUSION

Colombian practitioners, educators and students diagnose and manage caries risk and caries lesions implementing best practice with a high to very high frequency.

Caries risk assessment-related knowledge, attitude, and behaviors among Chinese dentists: a cross-sectional survey

OBJECTIVES

To investigate caries risk assessment (CRA)-related knowledge, attitudes, and practices among dentists in China, to describe their subjective ratings of the significance of specific caries risk factors and to identify factors associated with the level of knowledge, attitudes, and use of CRA in routine clinical practice.

MATERIALS AND METHODS

A cross-sectional anonymous online questionnaire survey was performed. The questionnaire was distributed via WeChat (Tencent, Shenzhen, China) to practicing dentists between November 25 and December 25, 2021. For participant recruitment, we employed purposive and snowball sampling techniques. Data were collected using a specialized web-based survey tool ( www.wjx.cn ) and analyzed with descriptive statistics and regression analyses.

RESULTS

A total of 826 valid questionnaires were collected. Only 292 (35.4%) respondents used CRA in routine practice, among whom a majority (243, 83.2%) did not use a specific CRA tool. The routine use of CRA was associated with the type of practicing office, attendance of caries-related lectures, the habit of reading caries-related literature, geographic location, and the total knowledge score. The mean total knowledge score was 3.13 (score range: 0 to 6). Knowledge levels were related to several sociodemographic characteristics, including geographic location, the type of practicing office, attendance of caries-related lectures and the habit of reading caries-related literature. The risk factor deemed most important was "current oral hygiene."

CONCLUSIONS

Caries risk assessment has not widely entered clinical practice in China. The level of CRA-related knowledge among dentists was generally suboptimal.

CLINICAL RELEVANCE

Strengthening CRA-related education may allow practitioners to develop a better understanding of caries risk assessment and hence promote its implementation.

Clinical practice guideline adaptation for risk-based caries management in 18-55 year-old Iranian adults

PURPOSE

To adapt an evidence-based clinical practice guideline (CPG) for risk-based management of caries in 18-55 year-old Iranian adults.

METHODS

A multidisciplinary adaptation team reviewed evidence-based guidelines such as the NICE, SIGN, and ADA according to the defined clinical questions. In addition, databases such as the PubMed and Google Scholar were searched and CPGs were screened and appraised using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) tool. Clinical scenarios were developed and their level of evidence, clinical advantage and adaptability were assessed. Following a two-round ranking by experts, the final recommendations were selected using the RAND-UCLA appropriateness method.

RESULTS

Of 17 CPGs, 5 were selected as the source guidelines for adaptation. To assess the risk of caries in the adult population, reduced Cariogram (without saliva tests) and CAMBRA were suggested as diagnostic tools. In addition, 53 risk-based recommendations on the preventive care (including the use of fluoride toothpaste, fluoride, and chlorhexidine mouthwash, at home and in-office fluoride gel, fluoride varnish, mouth buffering, and sealant), operative intervention threshold, and follow-up interval were adapted for Iranian adults.

CONCLUSIONS

A guideline was adapted for risk-based management of dental caries in Iranian adults. This helps local dentists in decision making and promoting oral health of adults. Further research is needed to assess the external validity and feasibility of the adapted guideline in the Iranian population.

Establishing risk-based recall interval for caries management among 11-12-year-old Pakistani children

Background

This study aims to investigate the rate of caries increment among 11-12-year-old Pakistani children over 18 months using modified International Caries Detection and Assessment Systems II (ICDAS) and subsequently establish an appropriate dental recall interval for our targeted population according to their caries risk intensity.

Methods

A prospective longitudinal study was conducted in Bhakkar, Punjab, Pakistan. The 226 children from seven schools of Bhakkar with the highest student enrolment were conveniently selected. Caries risk assessment was performed using a computer-based reduced Cariogram program. Caries increment among cavitated lesions was measured by modified Beck's method or adjusted caries increment. Two ICDAS II cutoffs were created for the analysis of cavitated lesion (ICDAS code 3–6) and cavitated plus non-cavitated lesion (ICDAS code A-6).

Results

At the risk assessment stage, 39.8% of the children were classified as low risk, 30.5% as medium risk, and 29.7% as high risk. Caries increment at both cutoff points increased with caries risk at all follow-ups. The highest caries increment was recorded at the third follow-up among high-risk children at cutoff 3–6 (1.95 ± 3.18) and A-6 (4.01 ± 4.31). However, the lowest caries increment was recorded at the third follow-up among low-risk children at cutoff 3–6 (0.18 ± 1.42) and A-6 (1.11 ± 3.33).

Conclusion

Based on the study findings for Pakistani children with cavitated lesions, the recommended risk-based recall interval for caries management is 18 months for those with low and medium caries risk and six months for those with high caries risk. On the other hand, recommendations for risk-based recall intervals for caries management in non-cavitated and cavitated lesions are six months for low-risk, moderate risk and high-risk for Pakistani 11-12-year-old children.

Caries risk assessment using different Cariogram models. A comparative study about concordance in different populations—Adults and children

This methodological survey aimed to verify whether there is concordance among several Cariogram different risk models at different thresholds, comparing both children and adult populations and how each risk/protective factor weight on the overall caries risk profile. Three groups’ data (two in children and one in adults) were obtained from previous studies, while a fourth, in young adults, was ad hoc enrolled. Different caries risk levels were assessed: a) three risk categories with two different thresholds as: “low risk”  =  61–100% or 81–100% chance to avoid caries, “moderate risk”  =  41–60% or 21–80% and “high risk”  =  0–40% or 0–20%, named model 1 and 2; b) four risk categories with two different thresholds as: “low risk”  =  61–100% or 76–100%, “moderate/low risk” = 41–60% or 51–75%; “moderate/high risk” = 21–40% or 26–50% and “high risk” = 0–20% or 0–25%, model 3 and 4; c) five risk categories as: “very low risk”  =  81–100%; “low risk”  =  61–80% “moderate risk” = 41–60%; “high risk” = 21–40% and “very high risk” = 0–20%, model 5. Concordance of the different Cariogram risk categories among the four groups was calculated using Cohen’s kappa. The weight of the association between all Cariogram models toward the Cariogram risk variables was evaluated by ordinal logistic regression models. Considering Cariogram model 1 and 2, Cohen’s Kappa values ranged from 0.40 (SE = 0.07) for the young adult group to 0.71 (SE = 0.05) for the adult one. Cohen’s Kappa values ranged from 0.14 (SE = 0.03 p<0.01) for the adult group to 0.62 (SE = 0.02) for the two groups of children in models 3 and 4. Statistically significant associations were found for all Cariogram risk variables excepting Fluoride program in models 4 and 5 and the overall risk on children’s samples. Caries experience showed a quite variable weight in the different models in both adult groups. In the regression analyses, adult groups’ convergence was not always achievable since variations in associations between caries risk and different risk variables were narrower compared to other samples. Significant differences in caries risk stratification using different thresholds stands out from data analysis; consequently, risk assessments need to be carefully considered due to the risk of misleadingly choosing preventive and research actions.

Diagnostic accuracy, available treatment, and diagnostic methods of dental caries in practice: a meta-analysis

Background

Diagnosis of dental caries and identification of patients with dental caries is the biggest challenge in dentistry. For this diagnostic accuracy, several methods are studied. The present study attempts to re-study the published data in the last 50 years, between 1960 and 2020.

Main body

Based on designed keywords, we made a thorough search of 4 different databases and found 3887 articles after removing the duplicate. The included database was PubMed, Ovid, Web of Science, and Cochrane library. On keen screening of the articles, we included 19 articles in the review. All the articles were analyzed based on the Cochrane risk assessment method. Maximum studies of up to 80% of caries management are based on children from 1 to 10 years of age. About 47% of articles were found based on reported use of drugs against dental caries, whereas 52.6% of articles were based on the behavioral and socio-demographic study of the mother and caretakers. We found that attentive parents and caretakers of the children can help in reducing the prevention of caries. Frese et al. (Sci Rep. 8(1):16991, 2018. 10.1038/s41598-018-34777-x), Liu et al. (PLoS ONE 8(11):e78723, 2013. 10.1371/journal.pone.0078723), and Innes et al. J Dent Res 99(1):36–43, 2020. 10.1177/0022034519888882) were the studied articles with high quality and low bias risk. These methods were based on the use of stannous fluoride for dental caries, the study of the effect of smoking on older adults, by checking the anxiety level of the participants.

Short conclusions

Tooth decay is a common condition in the general population and affects mostly children. The method with high accuracy and low risk can be recommended for routine treatment.

Expert consensus on dental caries management

Dental Caries is a kind of chronic oral disease that greatly threaten human being's health. Though dentists and researchers struggled for decades to combat this oral disease, the incidence and prevalence of dental caries remain quite high. Therefore, improving the disease management is a key issue for the whole population and life cycle management of dental caries. So clinical difficulty assessment system of caries prevention and management is established based on dental caries diagnosis and classification. Dentists should perform oral examination and establish dental records at each visit. When treatment plan is made on the base of caries risk assessment and carious lesion activity, we need to work out patient‑centered and personalized treatment planning to regain oral microecological balance, to control caries progression and to restore the structure and function of the carious teeth. And the follow-up visits are made based on personalized caries management. This expert consensus mainly discusses caries risk assessment, caries treatment difficulty assessment and dental caries treatment plan, which are the most important parts of caries management in the whole life cycle.

Effect of Probiotic Streptococcus salivarius K12 and M18 Lozenges on the Cariogram Parameters of Patients With High Caries Risk: A Randomised Control Trial

Purpose: To evaluate the effect of Probiotic Streptococcus Salivarius K12 and M18 Lozenges on the Cariogram (Cariogram Mobile application Version 1.3 developed by Wong Jung Ming, Faculty of Dentistry, National University of Singapore) parameters of patients with high caries risk.

Materials and Methods: Fourty-two subjects were randomly allocated to Group 1 and 2 who received BLIS K12^TM and BLIS M18^TM probiotics (Blis Probiotics, Dunedin, New Zealand) respectively along with oral hygiene instructions and Group 3 (control) received only oral hygiene instructions with 1:1:1 allocation ratio. Subjects were instructed to follow the instructions and use the probiotics for a period of three months. Their caries risk was assessed using Cariogram software at baseline and 30 days after the use of probiotics. Change in the chance to avoid new cavities was recorded and statistically analysed using appropriate statistical tests.

Results: About 38 subjects completed the trial with a drop-out count of eight. Multiple imputations were carried out for the missing data using an expectation-maximization algorithm. The mean percentage of actual chance to avoid new cavities was found to be 47.14 ± 6.837; 41.36 ± 16.04 and 32.50 ± 14.54 among the subjects in Group 1, Group 2, and Group 3 respectively. The mean percentage difference between the three groups was found to be statistically significant (p-value = 0.047). Dunn’s pair-wise comparison showed a significant mean percentage difference between Group 1 (BLIS K12) and Group 3 (control) (p=0.020).

Conclusion: It can be concluded that the use of BLIS K12^TM and BLIS M18^TM probiotics for three months resulted in a considerable decrease in the caries risk. Further long-term clinical trials are needed to evaluate the difference in caries risk following the use of BLIS K12^TMand BLIS M18^TM among different age and risk groups.

Effectiveness of the ICCMS caries management system for children: a 3-year multicentre randomised controlled trial

OBJECTIVE

This 3-year multicentre randomised controlled trial compared, in 6-7-year-old Colombian children, the effectiveness of the ICCMS (International Caries Classification and Management System) with a conventional caries-management system (CCMS) in terms of individual caries-risk, caries lesions, and secondarily, oral-health-related knowledge/attitudes/practices, and number of appointments.

MATERIAL AND METHODS

With ethical approval, 240 6-7-year olds from six Colombian clinics were recruited. Trained examiners conducted the following baseline/follow-up assessments: Caries risk (Cariogram-ICCMS); caries severity/activity staging (ICDAS-merged combined radiographic/visual); sealants/fillings/missing teeth, and oral-health-related knowledge, attitudes and practices. Children received their randomly allocated (ICCMS/CCMS) care from dental practitioners. Outcomes: caries-risk control (children); caries-progression control (tooth surfaces); oral-health-related knowledge/attitudes/practices improvement (parents/children), and appointments' number (children). Descriptive and non-parametric/parametric bivariate analyses were performed.

RESULTS

Three-year-follow-up: n = 187 (77.9%; ICCMS: n = 92; CCMS: n = 95) disclosed a baseline-to-3-year overall high-caries-risk children decrease (ICCMS: 60.9-0%, p < .001; CCMS: 54.7-5.3%, p < .001) (p > .05). ICCMS versus CCMS showed: fewer tooth-surface caries progression (6.2% vs 7.1%, p = .010) and fewer active-caries lesions (49.8% vs. 59.1%, p < .05); higher proportion of children with ≥2/day fluoride-toothpaste tooth-brushing practice (p < .05); similar mean number of appointments (10.9 ± 5.9 vs. 10.0 ± 3.8, p = .15).

CONCLUSION

Both caries-management systems showed similar effectiveness in caries-risk control, with ICCMS more effectively controlling tooth-surface caries progression and improving toothbrushing practices.

Randomized clinical trial to evaluate two methods of caries risk assessment in schoolchildren: the CARDEC-PEL 04 study protocol

Background

Caries risk assessment is an essential element for managing and preventing dental caries in children. Individual caries risk assessment can be conducted to evaluate the presence or absence of single factors, or using multivariate models, a combination of factors. The subject has been extensively studied, but no previous research has compared whether a more elaborate and individualized method of caries risk benefits the patient than more straightforward strategies. Thus, this protocol evaluates the efficacy of two risk assessment methods for caries control in children, a simplified method based on caries experience evaluation and a multivariate method described in the literature.

Methods

This is a randomized, double-blind, controlled, parallel-treatment trial protocol. Two groups will be tested for two forms of caries risk assessment: an individualized and detailed multivariate method based on the guidelines of the Caries Care International 4D and another simplified process, based only on caries experience in primary and/or permanent dentition, considering the presence of decayed, missing and filled teeth using the DMFT/dmft index. Participants will be children aged 8 to 11 years, followed up at 12 and 24 months. The primary outcome will be a composite outcome representing the number of tooth surfaces requiring operative intervention (account variable). In addition, the Shapiro–Wilk normality test and Student's t-test will be performed. A multivariate analysis using negative binomial regression will compare groups in the intention-to-treat population, considering a two-tailed significance level of 5%.

Discussion

This is the first randomized clinical trial aiming to compare dental caries-related treatment and follow-up based on a detailed, multivariate and individualized assessment of caries risk in school-age children to a simpler risk assessment strategy based on caries experience. This study will define whether there are essential benefits to the patient that justify the choice of one method over the other.

Trial registration Clinicaltrials.gov registration: NCT03969628. Registered on May 31th, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-02010-3.

Nomogram prediction of caries risk among schoolchildren age 7 years based on a cohort study in Shanghai

Objective

Caries risk assessment tools are essential for identifying and providing treatment for individuals at high risk of developing caries. We aimed to develop a nomogram for the assessment and evaluation of caries risk among Chinese children.

Methods

We enrolled schoolchildren age 7 years from a primary school in Shanghai. Baseline information of participants was collected using a questionnaire completed by children’s caregivers. A nomogram of a novel prediction scoring model was established based on predictors detected in univariate and multivariate analyses. Predictive accuracy and discriminative ability of the nomogram were calculated using the concordance index (C index). The bootstrap method (1000 samples) was used to decrease overfitting. The net benefit of the model was validated using decision curve analysis.

Results

Overall, 406 children with complete information and two completed dental examinations were included in the final analysis. The nomogram based on logistic regression model coefficients demonstrated a C index of 0.766 (95% confidence interval: 0.761–0.771) for caries risk. The net benefit of the decision curve analysis was 38.6% at 55% threshold probability.

Conclusion

This nomogram model, derived using dietary habits, oral hygiene status, and caries experience, showed promising predictive ability to assess the caries risk among Chinese children.

The relationship between claimed restorations and future restorations in children and adolescents: An observational follow-up study on risk categories for dental caries

Various models are available to assess caries risk in individuals. In general past caries experience is considered as the best single predictor for future caries development in populations. Likewise, recent restorations have been used to predict future restorations. We aimed to evaluate a classification model for risk categories for dental caries in children based on claims data from Dutch healthcare insurance company Zilveren Kruis. The baseline caries risk categories were derived from the number of claimed restorations in two baseline years (2010 through 2011). These categories were defined as low (no new restorations), moderate (1 new restoration), and high (2 or more new restorations). First, we analyzed the relationship between baseline caries risk categories and the number of new restorations during 3 years of follow-up (2012 through 2014). Secondly, we used negative binominal two-level analyses to determine the accuracy of our classification model in predicting new restorations during follow-up. Thirdly, we reclassified the participants after 3 years and determined the changes in the categorization. We included insurance claims data for the oral healthcare services in 28,305 children and adolescents from 334 dental practices for the period 2010–2014. At baseline, 68% of the participants were in risk category low, 13% in moderate and 19% in high. The mean number of new restorations during follow-up was 0.81 (SD 1.72) in baseline risk category low, 1.61 (SD 2.35) in moderate, and 2.65 (SD 3.32) in high. The accuracy of the multivariate model for predicting 0/>0 restorations was 50%. After 3 years, 60% of the study participants were in the same risk category, 20% were in a lower, and 21% in a higher risk category. Risk categories based on claimed restorations were related to the number of new restorations in groups. As such, they could support planning and evaluation of oral healthcare services.

A systematic review to inform the development of a Canadian caries risk assessment tool for use by primary healthcare providers

BACKGROUND

Caries risk assessment (CRA) tools may assist in identifying children at risk of early childhood caries.

AIM

To complete a systematic review of CRA and develop a Canadian CRA tool for preschool children for use in non-dental clinical settings.

DESIGN

Systematic searches of relevant databases were conducted. Potential variables were based on strength of associations (odd ratios, relative risk, hazard ratios, etc), frequency of occurrence, and existing CRA tools. Quality of the evidence assessments were performed by at least two review teams through consensus following GRADE.

RESULTS

Overall, 25 publications met the inclusion criteria, all prospective in design. Based on this review, variables to be considered when developing a new CRA tool for use with preschool children are as follows: age, socioeconomic status, family toothbrushing habits, fluoride exposure, infant feeding practices, dietary habits/behaviours, dental home, caries experience, visible plaque, and enamel defects. The environmental scan identified 22 CRA tools suggesting other additional variables to consider including in a CRA tool, including special healthcare needs, enamel defects, and dental attendance.

CONCLUSIONS

This review informed the development of a Canadian CRA tool for use by primary healthcare professionals, which may improve access to oral health assessments and increase interprofessional collaboration.

Associations between dental caries and systemic diseases: a scoping review

BACKGROUND

The objective of this study was to evaluate and present evidence from animal and human clinical studies on associations between dental caries and systemic diseases, and to suggest potential mechanisms that might explain such associations.

METHODS

An electronic search was conducted of PubMed, Embase and Cochrane Central Register of Controlled Trials for articles published from 2010 to 2020 in the English language. From the initial search, 404 full-text studies were assessed for eligibility. After excluding studies for technical and study limitations, a total of 67 studies were included in the summary tables and additional studies were included in the review to support evidence.

RESULTS

Few systemic disease and conditions were found to be clinically meaningfully associated with caries experience. Best evidence from human and animal studies described association between metabolic diseases and dental caries. Several interesting animal studies were noted that could generate clinical hypotheses and further investigations in rodent models for cardiovascular injury and hyperglycemia. Inadequate data was found to suggest any modifications to current clinical practice or prevention guidelines.

CONCLUSIONS

Limited clinical evidence was found connecting several systemic diseases and dental caries. Inadequate data was found to suggest any modifications to current clinical practice or prevention guidelines.

CLINICAL SIGNIFICANCE

Understanding of associations between dental caries and systemic diseases play a crucial role in the treatment planning and education of the dental patient.

Validation of a Subjective Caries Risk Assessment Tool

OBJECTIVE

The objective was to evaluate the predictive validity of the American Dental Association's caries risk assessment (CRA) tool, adapted with permission, and used by the U.S. Department of Veterans Affairs dental services within their electronic dental record.

METHODS

This analytic epidemiologic study with a retrospective longitudinal design included Veterans who had a minimum of three years of available data. The primary outcome was caries-related treatment during the twelve-month predictive period following the CRA category identification.

RESULTS

The sample included 57,675 Veterans; 50.1% classified as low, 33.2% as moderate and 16.8% as high caries risk. During the twelve-month predictive period, both teeth/person and teeth with caries-related treatment rose sequentially from low to high CRA categories. However, poor sensitivity (0.34-0.58) and better specificity (0.53-0.78) values were observed. Similarly, better negative predictive values (0.72-0.79) compared to positive predictive values (0.28-0.34) were found. Adjusted logistic regression models showed that current treated caries (caries detected at the time of the CRA exam) was more strongly associated with future caries-related treatment than the subjective CRA determination.

CONCLUSIONS

The subjective CRA tool evaluated in this study is better at identifying patients at low risk of requiring future caries-related treatment versus those at higher risk. This makes it difficult to target the most caries susceptible patients with preventive measures. Furthermore, we found that the amount of caries treatment required at the time of the CRA exam had the strongest association with caries-related treatment during the subsequent twelve-month predictive period.

CLINICAL SIGNIFICANCE

The amount of caries-related treatment required at the time of the caries risk classification is the strongest predictor of future caries.

An Ecological Model to Frame the Delivery of Pediatric Preventive Care

Screening and surveillance are integral aspects of child health promotion and disease prevention. The American Academy of Pediatrics recommends that primary care clinicians screen children and adolescents for a broad array of conditions, conduct surveillance of growth and development, identify social determinants of health, and identify protective and risk factors that might impact health over time. However, access to and outcomes of preventive services vary based on features of children’s social ecology, including family and community contexts. The proposed five-stage socio-ecological model considers multiple contextual dimensions of pediatric screening: (1) individual, (2) interpersonal, (3) organizational, (4) community/population, and (5) public policy. Incorporating this model into routine care might improve outcomes at the individual and population level. Future endeavors should focus on integration of this model with validated risk screening tools as part of a supportive electronic health record, culture, and incentive structure. Further research assessing the contributors and outcomes of differences in beliefs, resources, practices, and opportunities among individuals, families, providers, primary care organizations, communities, health systems, and policy partners will be essential in advancing knowledge and policies to improve preventive services delivery.

Caries prevalence using ICDAS visual criteria and risk assessment in children and adolescents with cerebral palsy: A comparative study

AIMS

To compare the dental caries prevalence using the International Caries Detection and Assessment System (ICDAS) and the caries risk by Caries Management by Risk Assessment (CAMBRA) in individuals with cerebral palsy (CP) and normoactives (NAs).

METHODS AND RESULTS

Sixty children and adolescents aged 6-12 years (30 CP/30 NA) were clinically evaluated by one calibrated examiner using two-digit ICDAS criteria and converted into components of dmf/DMF indices: d2mf2/D2MF2 (enamel and dentin lesions) and d3mf3/D3MF3 (dentin lesions). An adapted CAMBRA was used for risk classification. The mean d2mf2s/d2mf2t and D2MF2S/D2MF2T for CP were 17.0 ± 16.8/7.5 ± 4.3 and 10.7 ± 17.6/5.3 ± 5.8, respectively, and for NA were 17.2 ± 16.9 /6.9 ± 4.8 and 11.1 ± 11.7/5.5 ± 4.7, respectively. The mean d3mf3s/d3mf3t and D3MF3S/D3MF3T for CP were 10.1 ± 16.7/3.0 ± 4.1 and 4.9 ± 15.6/0.2 ± 0.4, respectively, while for NA the mean values were 9.8 ± 13.0/3.5 ± 3.8 and 2.1 ± 5.7/0.9 ± 2.0, respectively. There were no statistically differences for caries prevalence and risk in both groups (p > 0.05).

CONCLUSIONS

Dental caries was highly prevalent in CP and NA children and adolescents. Enamel and dentin lesions and high caries risk were the most common condition.

Oral Microbiota Composition Predicts Early Childhood Caries Onset

As the most common chronic disease in preschool children in the United States, early childhood caries (ECC) has a profound impact on a child's quality of life, represents a tremendous human and economic burden to society, and disproportionately affects those living in poverty. Caries risk assessment (CRA) is a critical component of ECC management, yet the accuracy, consistency, reproducibility, and longitudinal validation of the available risk assessment techniques are lacking. Molecular and microbial biomarkers represent a potential source for accurate and reliable dental caries risk and onset. Next-generation nucleotide-sequencing technology has made it feasible to profile the composition of the oral microbiota. In the present study, 16S ribosomal RNA (rRNA) gene sequencing was applied to saliva samples that were collected at 6-mo intervals for 24 mo from a subset of 56 initially caries-free children from an ongoing cohort of 189 children, aged 1 to 3 y, over the 2-y study period; 36 children developed ECC and 20 remained caries free. Analyses from machine learning models of microbiota composition, across the study period, distinguished between affected and nonaffected groups at the time of their initial study visits with an area under the receiver operating characteristic curve (AUC) of 0.71 and discriminated ECC-converted from healthy controls at the visit immediately preceding ECC diagnosis with an AUC of 0.89, as assessed by nested cross-validation. Rothia mucilaginosa, Streptococcus sp., and Veillonella parvula were selected as important discriminatory features in all models and represent biomarkers of risk for ECC onset. These findings indicate that oral microbiota as profiled by high-throughput 16S rRNA gene sequencing is predictive of ECC onset.

Risk factors for dental caries in Latin American and Caribbean countries

Identifying the risk factors for dental caries is vital in epidemiology and clinical practices for developing effective preventive strategies, both, at the individual and collective levels. Different causality/determination models have been proposed to understand the development process of dental caries. In the present review, we designed a model inspired by the world-known social determinants models proposed in the 90s and more recently in the 10s, wherein the contextual factors are placed more externally and encompass the individual factors. The contextual factors included those related to the cultural and societal values, as well as the social and health government policies. The individual factors were classified into the following categories: socioeconomic (social class, occupation, income, and education level), demographic characteristics (age, sex, and ethnicity), behavioral factors (non-use of fluoride dentifrice, sugar consumption, poor oral hygiene, and lack of preventive dental care), and biological factors (recent caries experience/active caries lesions, biofilm retentive factors, developmental defects of the enamel, disabilities, saliva amount and quality, cariogenic biofilm). Each of these variables was addressed, while focusing on the current evidence from studies conducted in Latin American and Caribbean countries (LACC). Based on the proposed model, educational aspects were addressed, and individual caries risk assessment and management decisions were proposed; further, implications for public health policies and clinical practice were described. The identification of modifiable risk factors for dental caries should be the basis for multi-strategy actions that consider the diversity of Latin American communities.

Assessment of predictive performance of caries risk assessment models based on a systematic review and meta-analysis

OBJECTIVES

To assess the predictive performance of caries risk assessment (CRA) models for prediction of caries increment for individuals based on a systematic review and meta-analyses.

DATA/SOURCES

We included external validation studies assessing the predictive performance of CRA models for prediction of caries increment for individuals, using discrimination and calibration as the outcome parameters. PubMed, EMBASE, and CINAHL were searched electronically on 10th September 2020 to identify prediction modeling studies on external validation of CRA models. The risk of bias of the included studies was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

STUDY SELECTION

A total of 22 studies with seven different CRA models were included. As for full Cariogram, the pooled area under the receiver operating characteristic curve (AUC) was 0.78 (95 %CI: 0.68; 0.85) based on eight studies regardless of the risk of bias levels, and 0.82 (95 %CI: 0.58; 0.93) based on four studies with low risk of bias only. The pooled observed: expected ratio (O:E ratio) of full Cariogram was 0.91 (95 %CI: 0.72; 1.14) based on 12 studies regardless of the risk of bias levels, and 0.89 (95 %CI: 0.71; 1.12) based on five studies with low risk of bias only. As for reduced Cariogram, the pooled AUC was 0.72 (95 %CI: 0.67; 0.77) based on six studies regardless of the risk of bias levels, and 0.74 (95 %CI: 0.45; 0.91) based on two studies with low risk of bias only. The pooled O:E ratio of reduced Cariogram was 0.84 (95 %CI: 0.59; 1.18) based on six studies regardless of the risk of bias levels, and 1.05 (95 %CI: 0.43; 2.59) based on two studies with low risk of bias only. Based on an insufficient number of studies for the other CRA models, the pooled AUCs ranged from 0.50 to 0.88, while the pooled O:E ratio ranged from 0.38 to 1.00.

CONCLUSION

The average predictive performance of both full and reduced Cariogram seems to be acceptable. However, the evidence from research does not allow a firm conclusion on the performance of the other included CRA models, due to the insufficient number of high-quality studies.

CLINICAL SIGNIFICANCE

Both full and reduced Cariogram were found to be reliable CRA models for prediction of caries increment in clinical practices for dental patients and communities for general populations. The reduced Cariogram showed better predictive performance and less burden in terms of time and resources to individuals than the full Cariogram. Therefore, the reduced Cariogram could be more recommended than the full Cariogram.

A Comparison of Four Caries Risk Assessment Methods

Introduction: Caries risk assessment (CRA) is essential as the basis for successful management of dental caries. Of the many published CRA tools, four well-known ones are CAMBRA, Cariogram, American Dental Association (ADA), and American Academy of Pediatric Dentistry (AAPD) CRAs. The predictive accuracy of CAMBRA and Cariogram CRA tools have been examined in clinical outcomes studies in thousands of patients and the tools are widely used all over the world. The purpose of the present paper is three-fold, namely (1) to briefly review, compare and contrast these four CRA methods, (2) to provide a concise method for CRA introducing a quantitative component to the CAMBRA forms (CAMBRA 123), and (3) to guide the choice of CRA methods that will support caries management decisions. Comparison of Caries Risk Assessment Methods: In the present evaluation, the above-mentioned four CRA methods for ages 0-6 years and 6 years-adult were compared using 26 hypothetical patients (13 per age group). Comparison results show that Cariogram and CAMBRA categorized patients into identical risk categories. Each of the ADA and AAPD tools gave different results than CAMBRA and Cariogram in several comparison examples. CAMBRA 123 gave the same caries risk level results as the Cariogram and the CAMBRA methods for all hypothetical patients for both age groups. Conclusions: Both the Cariogram and the CAMBRA CRA methods are equally useful for identifying the future risk of dental caries. CAMBRA 123 shows promise as an easy-to-use quantitative method for CRA in clinical practice. The health care providers will be the ones to decide which CRA method will allow them to establish individualized, successful caries management therapies and how to combine these for the best care of their patients.

There is a paucity of economic evaluations of prediction methods of caries and periodontitis-A systematic review

Objectives

Direct cost for methods of prediction also named risk assessment in dentistry may be negligible compared with the cost of extensive constructions. On the other hand, as risk assessment is performed daily and for several patients in general dental practice, the costs may be considerable. The objective was to summarize evidence in studies of economic evaluation of prognostic prediction multivariable models and methods of caries and periodontitis and to identify knowledge gaps (PROSPERO registration number: CRD42020149763).

Material and methods

Four electronic databases (PubMed, Web of Science, The Cochrane Library, NHS Economic Evaluation Database) and reference lists of included studies were searched. Titles and abstracts were screened by two reviewers in parallel. Full‐text studies reporting resources used, costs and cost‐effectiveness of prediction models and methods were selected and critically appraised using a protocol based on items from the CHEERS checklist for economic evaluations and the CHARMS checklist for evaluation of prediction studies.

Results

From 38 selected studies, six studies on prediction fulfilled the eligibility criteria, four on caries and two on periodontitis. As the economic evaluations differed in method and perspective among the studies, the results could not be generalized. Our systematic review revealed methodological shortcomings regarding the description of predictive models and methods, and particularly of the economic evaluation.

Conclusions

The systematic review highlighted a paucity of economic evaluations regarding methods or multivariable models for prediction of caries and periodontitis. Our results indicate that what we currently practice using models and methods to predict caries and periodontitis lacks evidence regarding cost‐effectiveness.

Evaluation of caries risk reduction following preventive programs in orthodontic patients, using Cariogram computer model: A quasi-experimental trial

Objective:

This study evaluated the effectiveness of preventive strategies on caries risk reduction in patients undergoing orthodontic treatment, using the Cariogram program.

Methods:

In this quasi-experimental study, samples were selected using a convenience quota sampling technique, in a public dental school. At first, caries risk profile was determined for each subject using the Cariogram before brackets bonding. The sample size consisted of 36 patients. The intervention group (n = 18) received preventive programs, and the control group (n = 18) was trained based on the routine oral health education by means of pamphlets. Then, Cariogram parameters were calculated for patients in both groups after six months.

Results:

The age range of participants was from 12 to 29 years. The mean percentage of the “Actual chance of avoiding new cavities” section in the intervention group increased from 45.72 ± 21.64 to 62.50 ± 17.64. However, the mean percentage of other parameters - such as “Diet”, “Bacteria” and “Susceptibility” - decreased after six months (p< 0.001). Besides, the differences in the mean percentage between intervention and control group at the end of the study period (T₁) related to the Cariogram parameters were statistically significant (p< 0.001). Accordingly, the mean percentage of ‘Actual chance of avoiding new cavities’’ parameter in the intervention group (62.50) was statistically higher than in the control group (42.44) (p< 0.001).

Conclusion:

Implementing different preventive approaches is able to reduce the caries risk in patients undergoing fixed orthodontic treatment, which can be clearly demonstrated using Cariogram program.

Follow-up interval for dental appointments: a randomized clinical trial with children with low caries risk

The objective of this study was to evaluate the effect of different follow-up consultation intervals on caries incidence in children with low caries risk. The study was composed of 224 children aged between 3 and 5 years and with low risk of caries. The children were randomly allocated into two groups, according to two different follow-up consultation intervals: Group 1 (G1) - 12-month follow-up interval; Group 2 (G2) - 18-month follow-up interval. All oral clinical examinations were performed by a single examiner who was previously calibrated and blinded in relation to the study groups. An external dentist provided the advice on oral hygiene and diet and evaluated the children's socioeconomic conditions. The Chi-square and Mann-Whitney tests were used to evaluate the differences between groups. Poisson regression analyses were performed to assess the association of caries incidence with the other variables. At the end of the study there was a significant difference between the groups regarding initial active lesions (p = 0.012), and children in G2 were at a higher risk of developing initial active lesions than those in G1 (p = 0.047). Children who had a higher number of teeth with initial active lesions in the follow-up consultations were at a higher risk of developing cavitated dentin caries (p = 0.001). Both follow-up intervals are justifiable. Although significant results have been observed for initial active caries lesions within the 18-month follow-up interval, it should be noted that these lesions can be treated using just preventive measures. Besides, different return interval had no effect in cavitated dentin lesions.

Caries risk assessment in dental practices by dentists from a Brazilian community

Data on dental practices related to caries risk assessment (CRA) are scarce among Brazilian dentists. This study aimed to determine the prevalence of CRA use by dentists and factors associated with its use, as well as to quantify dentists' ratings of the importance of specific factors when treatment planning. Dentists registered at the Regional Council of Dentistry of São Paulo State - Araraquara region were sent two paper questionnaires that comprised: a) characteristics of dentists themselves, their practices, and their patients; and b) the translated version of the "Assessment of Caries Diagnosis and Caries Treatment" Questionnaire from the U.S. National Dental Practice-Based Research Network. Participants were 206 dentists who currently practiced in Araraquara and treated dental caries. Descriptive statistics and multiple logistic regression analyses were used for data analysis. Thirty-six percent of the dentists reported they perform CRA and, among them, 36% indicated they record the assessment on a special form that is kept in the patient chart. More years since dental school graduation (OR = 1.1, p = 0.002) and holding an advanced academic degree (OR=2.6, p=0.005) were associated with a higher likelihood of performing CRA, whereas exclusively using a private practice model (OR = 0.5, p = 0.016) was associated with a lower likelihood of performing CRA. The current oral hygiene and commitment to return for follow-up were the most important risk factors for treatment planning. In conclusion, CRA was not a routine procedure in daily practice among the majority of participating dentists. Specific demographic, practice and academic education characteristics were associated with performing CRA.

Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents

BACKGROUND

Most of the detected increment in dental caries among children above the age of six years and adolescents is confined to occlusal surfaces of posterior permanent molars. Dental sealants and fluoride varnishes are much used to prevent caries. As the effectiveness of both interventions in controlling caries as compared with no intervention has been demonstrated previously, this review aimed to evaluate their relative effectiveness. It updates a review published originally in 2006 and updated in 2010 and in 2016.

OBJECTIVES

Our primary objective was to evaluate the relative effectiveness of dental sealants (i.e. fissure sealant) compared with fluoride varnishes, or fissure sealants plus fluoride varnishes compared with fluoride varnishes alone, for preventing dental caries in the occlusal surfaces of permanent teeth of children and adolescents. Our secondary objectives were to evaluate whether effectiveness is influenced by sealant material type and length of follow-up, document and report on data concerning adverse events associated with sealants and fluoride varnishes, and report the cost effectiveness of dental sealants versus fluoride varnish in caries prevention.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 19 March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 2), MEDLINE Ovid (1946 to 19 March 2020) and Embase Ovid (1980 to 19 March 2020). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on the language or date of publication.

SELECTION CRITERIA

We included randomised controlled trials with at least 12 months of follow-up comparing fissure sealants, or fissure sealants plus fluoride varnishes, versus fluoride varnishes, for preventing caries in the occlusal surfaces of permanent posterior teeth (i.e. premolar or molar teeth), in participants younger than 20 years of age at the start of the study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened search results, extracted data from included studies and assessed their risk of bias. We attempted to contact study authors to obtain missing or unclear information. We grouped and analysed studies on the basis of sealant material type: resin-based sealant or glass ionomer-based sealant (glass ionomer and resin-modified glass ionomer sealant), and different follow-up periods. We calculated the odds ratio (OR) for risk of caries on occlusal surfaces of permanent molar teeth. For trials with a split-mouth design, we used the Becker-Balagtas OR. One cluster-randomised trial provided precise estimates in terms of risk ratio (RR), which we used. For continuous outcomes and data, we used means and standard deviations to obtain mean differences (MD). For meta-analysis, we used the random-effects model when we combined data from four or more studies. We presented all measures with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE criteria.

MAIN RESULTS

We included 11 trials with 3374 participants aged five to 10 years when trials started. Three trials are new since the 2016 update. Two trials did not contribute data to our analysis. Sealant versus fluoride varnish Resin-based fissure sealants versus fluoride varnishes Seven trials evaluated this comparison (five contributing data). We are uncertain if resin-based sealants may be better than fluoride varnish, or vice versa, for preventing caries in first permanent molars at two to three years' follow-up (OR 0.67, 95% CI 0.37 to 1.19; I² = 84%; 4 studies, 1683 children evaluated). One study measuring decayed, missing and filled permanent surfaces (DMFS) and decayed, missing and filled permanent teeth (DMFT) increment at two years suggested a small benefit for fissure sealant (DMFS MD -0.09, 95% CI -0.15 to -0.03; DMFT MD -0.08, 95% CI -0.14 to -0.02; 542 participants), though this may not be clinically significant. One small study, at high risk of bias, reported a benefit for sealant after four years in preventing caries (RR 0.42, 95% CI 0.21 to 0.84; 75 children) and at nine years (RR 0.48, 95% CI 0.29 to 0.79; 75 children). We assessed each of these results as having very low certainty. Glass ionomer-based sealants versus fluoride varnishes Three trials evaluated this comparison: one trial with chemically cured glass ionomer and two with resin-modified glass ionomer. Studies were clinically diverse, so we did not conduct a meta-analysis. In general, the studies found no benefit of one intervention over another at one, two and three years, although one study, which also included oral health education, suggested a benefit from sealants over varnish for children at high risk of caries. We assessed this evidence as very low certainty. Sealant plus fluoride varnish versus fluoride varnish alone One split-mouth trial analysing 92 children at two-year follow-up found in favour of resin-based fissure sealant plus fluoride varnish over fluoride varnish only (OR 0.30, 95% CI 0.17 to 0.55), which represented a clinically meaningful effect of a 77% reduction in caries after two years; however, we assessed this evidence as very low certainty. Adverse events Five trials (1801 participants) (four using resin-based sealant material and one using resin-modified glass ionomer) reported that no adverse events resulted from use of sealants or fluoride varnishes over one to nine years. The other studies did not mention adverse events.

AUTHORS' CONCLUSIONS

Applying fluoride varnish or resin-based fissure sealants to first permanent molars helps prevent occlusal caries, but it has not been possible in this review to reach reliable conclusions about which one is better to apply. The available studies do not suggest either intervention is superior, but we assessed this evidence as having very low certainty. We found very low-certainty evidence that placing resin-based sealant as well as applying fluoride varnish works better than applying fluoride varnish alone. Fourteen studies are currently ongoing and their findings may allow us to draw firmer conclusions about whether sealants and varnish work equally well or whether one is better than the other.

Caries Risk Assessment and Referral Tool (CRA-RT)-A novel risk scoring system for early childhood caries in community settings

OBJECTIVE

To develop a brief and simple, easy-to-administer, culturally sensitive, reliable and valid risk scoring system for early childhood caries based only on behavioural and other nonclinical risk factors. The purpose was to allow risk scoring by child care providers without clinical examination in order to guide dental referral in a community setting.

METHODS

A cross-sectional study using stratified multistage cluster sampling was conducted among 559 preschool children and their mothers in Anganwadi centres and Preprimary schools in Thiruvananthapuram district, Kerala, India. All steps in the development of a new tool were carried out. Exploratory factor analysis and principal component analysis with Varimax rotation were employed for item reduction. Reliability and validity assessments were also performed. Past caries experience was recorded as dmft scores and the validity hypothesis of higher dmft scores in children with higher caries risk scores was also verified as an additional measure of construct validity.

RESULTS

The newly developed Caries Risk Assessment and Referral Tool (CRA-RT) is presented as a unidimensional, 11-item, discriminative tool which showed high test-retest reliability (ICC = 0.8), high inter-rater reliability (ICC = 0.8) and acceptable internal consistency (Cronbach's alpha = 0.6). Face, content and construct validity have been demonstrated. Children with higher CRA-RT scores were having higher dmft scores, and it provided an additional evidence for the construct validity of the tool.

CONCLUSION

CRA-RT is a simple, valid and reliable novel risk scoring system for ECC, to be used in a nondental, nonmedical setting. The proposed tool contains those behavioural risk or protective factors, the presence or absence of which could be assessed by interviewing the mother. The quick and the easy risk scoring pattern with a cut-off score can guide the dental referral of preschool children by child care providers in a community setting.

Greater caries-free survival of first permanent molars: Findings from a 7-year follow-up evaluation of a community-based oral health preventive program

BACKGROUND

The occlusal surface of the first permanent molar is the most frequently affected site by dental caries.

AIM

To assess the caries-free survival of first permanent molars in children participating in a community-based oral health preventive program.

DESIGN

This was a retrospective study conducted on 426 children under 12 years of age, beneficiaries of a preventive program from 2009 to 2015, in El Cedro, Colombia. The program offered oral health care education, supervised brushing and mouth washing, and application of topical fluoride. By using parametric survival models for interval-censored data, primary and secondary caries-free survival of any first permanent molar was estimated and analyzed.

RESULTS

Before program implementation, dental caries lesions presented at an average age, adjusted by age of eruption, of 8.3 years for primary caries lesion and 9.3 years for secondary caries lesion. After 7 years of the program, the estimated average age for presenting primary dental caries lesion was delayed by 4.6 years and by 5.3 years for secondary caries.

CONCLUSION

The implementation of the oral health program led to improved caries-free survival of first permanent molars.

Improving Caries Risk Prediction Modeling: A Call for Action

Dentistry has entered an era of personalized/precision care in which targeting care to groups, individuals, or even tooth surfaces based on their caries risk has become a reality to address the skewed distribution of the disease. The best approach to determine a patient's prognosis relies on the development of caries risk prediction models (CRPMs). A desirable model should be derived and validated to appropriately discriminate between patients who will develop disease from those who will not, and it should provide an accurate estimation of the patient's absolute risk (i.e., calibration). However, evidence suggests there is a need to improve the methodological standards and increase consistency in the way CRPMs are developed and evaluated. In fact, although numerous caries risk assessment tools are available, most are not routinely used in practice or used to influence treatment decisions, and choice is not commonly based on high-quality evidence. Research will propose models that will become more complex, incorporating new factors with high prognostic value (e.g., human genetic markers, microbial biomarkers). Big data and predictive analytic methods will be part of the new approaches for the identification of promising predictors with the ability to monitor patients' risk in real time. Eventually, the implementation of validated, accurate CRPMs will have to follow a user-centered design respecting the patient-clinician dynamic, with no disruption to the clinical workflow, and needs to operate at low cost. The resulting predictive risk estimate needs to be presented to the patient in an understandable way so that it triggers behavior change and effectively informs health care decision making, to ultimately improve caries outcomes. However, research on these later aspects is largely missing and increasingly needed in dentistry.

Assessing the Predictive Performance of Probabilistic Caries Risk Assessment Models: The Importance of Calibration

Probabilistic caries risk assessment models (P-CRA), such as the Cariogram, are promising tools to planning treatments in order to control and prevent caries. The usefulness of these models for informing patients and medical decision-making depends on 2 properties known as discrimination and calibration. Current common assessment of P-CRA models, however, ignores calibration, and this can be misleading. The aim of this paper was to provide tools for a proper assessment of calibration of the P-CRA models and improve calibration when lacking. A combination of standard calibration tools (calibration plot, calibration in-the-large, and calibration slope) and 3 novel measures of calibration (the Calibration Index and 2 related metrics, E50 and E90) are proposed to evaluate if a P-CRA model is well calibrated. Moreover, an approach was proposed and validated using data from a previous follow-up study performed on children evaluated by means of a reduced Cariogram model; Platt scaling and isotonic regression were applied showing a lack of calibration. The use of the Cariogram overestimates the actual risk of new caries for forecast probabilities <0.5 and underestimates the risk for forecast probabilities >0.6. Both Platt scaling and isotonic regression were able to significantly improve the calibration of the reduced Cariogram model, preserving its discrimination properties. The average specificity and sensitivity for both Platt scaling and isotonic regression using the cut-off point p= 0.5 were >83 and their sum well exceeded 160. The benefits of the proposed calibration methods are promising, but further research in this field is required.

Evaluation of CRAFT as a Tool for Caries Risk Assessment in 3- to 6-year-old Children and its Validation against Alban's Test: A Pilot Study

Introduction

Dental caries is a multifactorial disease and a dynamic process that can be prevented and reversed during the early stage. Risk assessment is an important step in decision-making and treatment planning. There are no valid tools available for the Indian population. Caries risk assessment for treatment (CRAFT) is a chairside tool for caries risk assessment and management. Valid, reliable, economical, and chairside caries risk assessment tool is the need of the hour for general and pediatric dentists.

Aim

To evaluate CRAFT as a tool for caries risk prediction among 3-years to 6-years-old children and to validate it against Alban test.

Materials and methods

A pilot study was conducted, including forty 3-years to 6-years-old children. Salivary samples were collected and inoculated on B.C.G.-Dextrose Agar. Caries activity was assessed using Alban test. Their parents/guardians completed the CRAFT assessment in entirety.

Results

The data were tabulated and subjected to suitable statistical analysis. High positive correlation between CRAFT scores and Alban's test (Spearman's Rho = 0.874) was found.

Conclusion

CRAFT scores were highly correlated with Alban scores in 3- to 6-year-old children. CRAFT could be successfully employed as a reliable, economical, chairside, and clinically feasible risk assessment tool with further research on a larger sample size.

Clinical significance

CRAFT can provide a framework for the clinician for preventive care and enhance patient–participation for CRA.

How to cite this article

Thakur JH, Subhadra HN, Jawdekar A. Evaluation of CRAFT as a Tool for Caries Risk Assessment in 3- to 6-year-old Children and its Validation against Alban's Test: A Pilot Study. Int J Clin Pediatr Dent 2019;12(6):538–542.

Dentists’ Decision to Conduct CRA in Adult Patients in Turkey: A Questionnaire-based Survey

Aim:

The concept of minimal intervention in dentistry is one of the most important stages of the preventive dentistry, and caries risk assessment (CRA) is an application that needs to be primarily evaluated in order to perform minimal intervention approaches. This study was aimed to evaluate the awareness of CRA and whether CRA is included in daily practice by dentists in Turkey.

Materials and Methods:

This study used a questionnaire survey. A survey was prepared and sent to the dentists who were registered with the Turkish Dental Association via e-mail. A total of 790 dentists returned and 95 respondents were excluded. All the registered dentists filled and returned their survey. Descriptive and logistic regression analyses were performed (n = 695).

Results:

A total of 86.9 percent dentists who took the survey said that they performed CRA in daily practice. “Lack of time” was specified as the most important factor by the respondents who did not perform CRA in daily practice (61.5%). Current oral hygiene status (96.4%) and the presence of one or more active caries lesions (74.5%) were considered the most important risk factors for not performing CRA. Results of multiple logistic regression analysis showed that clinical experience, number of patients treated per day, and type of practice were mostly associated with whether or not performing CRA ( P = .012, .018, and .035, respectively).

Conclusions:

It can be concluded that most of the dentists are aware of the importance of conducting CRA and, with differences in the factors considered, CRA is required in their daily practice in Turkey. The concept of minimal intervention in dentistry is one of the most important stages of preventive dentistry, and CRA is an application that needs to be primarily evaluated in order to perform minimal intervention approaches.

Comparison of two caries prevention programs among Thai kindergarten: a randomized controlled trial

Background

Intensified preventive regimen based on a ‘high-risk’ approach has been proposed instead the routine prevention that is generally given to the whole population. The effectiveness of these regimens may still be an issue. Therefore, the aim of this study was to compare two preventive programs carried out in a Public School for kindergarten children.

Methods

The data from clinical examinations were used to assess the caries risk for 121 children. Children with at least 2 carious lesions were considered as high risk for dental caries development. These children were randomized into two groups. Half (High risk basic-HRB group) were provided the basic prevention regimen (oral-hygiene instruction and hands-on brushing practice for teachers and caregivers, daytime tooth brushing supervised by teachers at least once a week, newly erupted first permanent molar sealant, provision of toothbrush, fluoride-containing dentifrice, and a guidebook), which was also given to low-risk children (Low risk basic-LRB group). The other half (High risk intensive-HRI group) were additionally given an intensified preventive regimen (F-varnish application, primary molar sealant, and silver diamine fluoride (SDF) application on carious lesions). Clinical examinations were performed semiannually to determine the dmfs caries increment of the three groups.

Results

The 89 children completed the 24-month examination were 3- to 5-year-old with 19, 35, and 35 children in the LRB, HRB, and HRI group, respectively. The new caries development at 24 months of the HRB group (75%) was higher than that of the HRI group (65.7%) and the LRB group (21.1%). One-way analysis of variance (ANOVA) indicated no significant differences of caries increment between the HRB and HRI groups at the end of our study (p = 0.709).

Conclusions

The negligible difference in caries increment between the HRI and HRB groups implies that intensified prevention produced minimal additional benefit. Offering all children only basic prevention could have obtained virtually the same preventive effect with substantially less effort and lower cost.

Trial registration

Thai Clinical Trials Registry (TCTR), TCTR20180124001. Registered 24 January 2018 - Retrospectively registered.

Quantitative Analysis of Salivary Oral Bacteria Associated with Severe Early Childhood Caries and Construction of Caries Assessment Model

To construct a saliva-based caries risk assessment model, saliva samples from 176 severe early childhood caries (S-ECC) children and 178 healthy (H) children were screened by real-time PCR-based quantification of the selected species, including Streptococcus mutans, Prevotella pallens, Prevotella denticola and Lactobacillus fermentum. Host factors including caries status, dmft indices, age, gender, and geographic origin were assessed in their influence on abundance of the targeted species, which revealed host caries status as the dominant factor, followed by dmft indices (both P < 0.01). Moreover, levels of S. mutans and P. denticola in the S-ECC group were significantly higher than those in the healthy group (P < 0.001 for S. mutans and P < 0.01 for P. denticola). Interestingly, the co-occurrence network of these targeted species in the S-ECC group differed from that from the healthy group. Finally, based on the combined change pattern of S. mutans and P. pallens, we constructed an S-ECC diagnosis model with an accuracy of 72%. This saliva-based caries diagnosis model is of potential value for circumstances where sampling dental plague is difficult.

Radiographic Yield for Clinical Caries Diagnosis in Young Adults: Indicators for Radiographic Examination

This prospective cohort study investigated the distribution pattern of carious lesions diagnosed by visual tactile and radiographic examinations, assessed the radiographic yield for clinical caries diagnosis, and estimated how accurately commonly used indicators for caries identified young adults who would benefit from radiographs at different thresholds. Overall, 576 patients aged 16-32 years seeking a first consultation were included. Patients were examined for caries and answered a validated questionnaire on sociodemographics and oral health behavior. Almost 10% of clinically sound approximal surfaces presented radiolucency in enamel/dentine. Of the clinically diagnosed noncavitated approximal and occlusal lesions, 22.5 and 17.7%, respectively, presented radiolucency reaching dentine at the radiographic examination. Noncavitated/enamel lesions detected radiographically were mainly at approximal surfaces (73.2%), while at occlusal surfaces these were negligible (0.7%). More than half of approximal dentine lesions were only detected radiographically (61.3%), while more than half of occlusal dentine lesions were only clinically diagnosed (57.1%). The hierarchical logistic regression analysis showed that patient's caries activity, D1MFS scores ≥17, and frequent consumption of soft drinks were significantly associated with detection of approximal enamel/dentine lesions. Also, patient's caries activity and frequent consumption of soft drinks were significantly associated with occlusal dentine caries (p ≤ 0.05). The indicator power of grouping these indicators as a predictor for the presence of radiographically detected lesions showed high sensitivity (0.84-0.91) and moderate specificity (0.64-0.73) for all surfaces and thresholds tested. In conclusion, radiographs increased significantly the number of approximal enamel/dentine and occlusal dentine lesions diagnosed. The ability to identify young adults with approximal lesions from the predictor was satisfactory. Bearing in mind that an essential contribution of bitewing radiographs to clinical examination is the detection of approximal noncavitated/enamel lesions that can be inactivated by nonoperative interventions, our results support the prescription of radiographs in young adults seeking a first consultation. Updating of current guidelines' recommendation of radiographs is warranted.