Predicting Dental Caries Outcomes in Children: A "Risky" Concept

Multi-ancestry Genome-Wide Association Study of Early Childhood Caries

Early childhood caries (ECC) is the most common non-communicable childhood disease. It is an important health problem with known environmental and social/behavioral influences that lacks evidence for specific associated genetic risk loci. To address this knowledge gap, we conducted a genome-wide association study of ECC in a multi-ancestry population of U.S. preschool-age children (n=6,103) participating in a community-based epidemiologic study of early childhood oral health. Calibrated examiners used ICDAS criteria to measure ECC with the primary trait using the dmfs index with decay classified as macroscopic enamel loss (ICDAS ≥3). We estimated heritability, concordance rates, and conducted genome-wide association analyses to estimate overall genetic effects; the effects stratified by sex, household water fluoride, and dietary sugar; and leveraged the combined gene/gene-environment effects using the 2-degree-of-freedom (2df) joint test. The common genetic variants explained 24% of the phenotypic variance (heritability) of the primary ECC trait and the concordance rate was higher with a higher degree of relatedness. We identified 21 novel non-overlapping genome-wide significant loci for ECC. Two loci, namely RP11-856F16 . 2 (rs74606067) and SLC41A3 (rs71327750) showed evidence of association with dental caries in external cohorts, namely the GLIDE consortium adult cohort (n=∼487,000) and the GLIDE pediatric cohort (n=19,000), respectively. The gene-based tests identified TAAR6 as a genome-wide significant gene. Implicated genes have relevant biological functions including roles in tooth development and taste. These novel associations expand the genomics knowledge base for this common childhood disease and underscore the importance of accounting for sex and pertinent environmental exposures in genetic investigations of oral health.

The Evolving Microbiome of Dental Caries

Dental caries is a significant oral and public health problem worldwide, especially in low-income populations. The risk of dental caries increases with frequent intake of dietary carbohydrates, including sugars, leading to increased acidity and disruption of the symbiotic diverse and complex microbial community of health. Excess acid production leads to a dysbiotic shift in the bacterial biofilm composition, demineralization of tooth structure, and cavities. Highly acidic and acid-tolerant species associated with caries include Streptococcus mutans, Lactobacillus, Actinomyces, Bifidobacterium, and Scardovia species. The differences in microbiotas depend on tooth site, extent of carious lesions, and rate of disease progression. Metagenomics and metatranscriptomics not only reveal the structure and genetic potential of the caries-associated microbiome, but, more importantly, capture the genetic makeup of the metabolically active microbiome in lesion sites. Due to its multifactorial nature, caries has been difficult to prevent. The use of topical fluoride has had a significant impact on reducing caries in clinical settings, but the approach is costly; the results are less sustainable for high-caries-risk individuals, especially children. Developing treatment regimens that specifically target S. mutans and other acidogenic bacteria, such as using nanoparticles, show promise in altering the cariogenic microbiome, thereby combatting the disease.

Subtypes of early childhood caries predict future caries experience

OBJECTIVES

To test whether postulated subtypes of early childhood caries (ECC) are predictive of subsequent caries experience in a population-based cohort of Swedish children.

METHODS

The study included children aged between 3 and 5 years at study entry with dental records available for at least 5 years of follow-up. Dental record data were retrieved from the Swedish Quality Registry for Caries and Periodontal disease (SKaPa) for the initial and follow-up visits. Participants who had ECC at study entry were assigned to one of five ECC subtypes (termed classes 1-5) using latent class modelling of tooth surface-level caries experience. Subsequent experience of caries was assessed using the decayed, missing and filled surfaces indices (dmfs/DMFS) at follow-up visits, and compared between ECC subtypes using logistic and negative binomial regression modelling.

RESULTS

The study included 128 355 children who had 3 or more dental visits spanning at least 5 years post-baseline. Of these children, 31 919 had caries at the initial visit. Baseline ECC subtype was associated with differences in subsequent disease experience. As an example, 83% of children who had a severe form of ECC at age 5 went on to have caries in the permanent dentition by the end of the study, compared to 51% of children who were caries-free at age 5 (adjusted odds ratio of 4.9 for new disease at their third follow-up).

CONCLUSIONS

ECC subtypes assigned at a baseline visit are associated with differences in subsequent caries experience in both primary and permanent teeth. This suggests that the development and future validation of an ECC classification can be used in addition to current prediction tools to help identify children at high risk of developing new caries lesions throughout childhood and adolescence.

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.

Behavioral and social determinants of early childhood caries among Palestinian preschoolers in Jerusalem area: a cross-sectional study

BACKGROUND

This study came to determine the prevalence of Early Childhood Carries (ECC) among preschoolers in a marginalized population and describe the influence of behavioral and social determinants on the development of ECC.

METHODS

This is a cross-sectional study that was carried out in four random preschools in the Jerusalem Governorate of the Occupied Palestinian Territories. All children aged 3-5 years old in the selected schools were screened for ECC using the decayed, missing, and filled teeth index (dmft). Data on children's socio-economic, feeding habits, hygiene habits, access to care, parental level of stress, social support, and locus of control were collected by a validated questionnaire sent to the children's main caregivers. Descriptive statistics were generated and bivariable and multivariable analyses were used to explain the influence of different behavioral and social determinants on ECC levels.

RESULTS

Four hundred and fifty-seven preschoolers completed the questionnaire and the clinical screening. Ninety-seven percent (n = 447) had experienced dental decay, with an average dmft score of 6.6 ± 4.3. After accounting for potential confounding, parents' internal locus of control was associated with lower dental caries among children (IRR = 0.97, 95% CI = 0.97, 0.98). Having routine, preventive visits versus never seeing a dentist were associated with lower dmft scores (IRR = 0.42, 95% CI = 0.33, 0.52). Night feeding habits (putting things other than water in the baby bottle at night, having children sleep while being breastfed at night) were positively associated with children's dental caries (IRR = 1.06, 95% CI = 1.04, 1.09: IRR = 1.15, 95% CI = 1.03, 1.29, respectively). Not adding sugar to the bottle was negatively associated with children's dental caries (IRR = 0.86, 95% CI = 0.74, 1.00).

CONCLUSIONS

Preschoolers in this study suffered from high dental caries experience. Although infant feeding habits were key factors in explaining the elevated level of the disease, system and socio-psychological factors were also detrimental to ECC prevalence. Policies and interventions to alleviate the burden of ECC need to address socioeconomic determinants of health in addition to feeding and hygiene practices.

Understanding topical fluoride hesitancy and refusal behaviors through the extended parallel process model and health belief model

OBJECTIVES

Topical fluoride helps prevent dental caries. However, many caregivers are hesitant about topical fluoride for their children and may refuse it during clinic visits. In this qualitative study, we assessed the relevance of the extended parallel process model (EPPM) and health belief model (HBM) in caregivers' decision-making about topical fluoride.

METHODS

We interviewed 56 fluoride-hesitant or fluoride-refusing caregivers using a semi-structured interview script that included questions based on select constructs from the EPPM (perceived severity, susceptibility, response efficacy) and HBM (perceived benefits and consequences). Two team members conducted a thematic analysis of the interview data.

RESULTS

Most caregivers acknowledged the severity of cavities but did not believe their child was susceptible. Caregivers also understood the general benefits of fluoride in preventing tooth decay, but reported low response efficacy of fluoride for their children especially compared to the other ways of reducing caries risk like reducing sugar intake and toothbrushing. Many caregivers had concerns about topical fluoride, especially regarding safety, with the potential consequences of fluoride outweighing its benefits.

CONCLUSION

Our findings were generally consistent with the EPPM and HBM, which appear to be relevant in understanding fluoride hesitancy behaviors. Additional research is needed on ways to improve provider communications about topical fluoride with caregivers.

Salivary microbiome and metabolome analysis of severe early childhood caries

BACKGROUND

Severe early childhood caries (SECC) is an inflammatory disease with complex pathology. Although changes in the oral microbiota and metabolic profile of patients with SECC have been identified, the salivary metabolites and the relationship between oral bacteria and biochemical metabolism remains unclear. We aimed to analyse alterations in the salivary microbiome and metabolome of children with SECC as well as their correlations. Accordingly, we aimed to explore potential salivary biomarkers in order to gain further insight into the pathophysiology of dental caries.

METHODS

We collected 120 saliva samples from 30 children with SECC and 30 children without caries. The microbial community was identified through 16S ribosomal RNA (rRNA) gene high-throughput sequencing. Additionally, we conducted non-targeted metabolomic analysis through ultra-high-performance liquid chromatography combined with quadrupole time-of-flight mass spectrometry to determine the relative metabolite levels and their correlation with the clinical caries status.

RESULTS

There was a significant between-group difference in 8 phyla and 32 genera in the microbiome. Further, metabolomic and enrichment analyses revealed significantly altered 32 salivary metabolites in children with dental caries, which involved pathways such as amino acid metabolism, pyrimidine metabolism, purine metabolism, ATP-binding cassette transporters, and cyclic adenosine monophosphate signalling pathway. Moreover, four in vivo differential metabolites (2-benzylmalate, epinephrine, 2-formaminobenzoylacetate, and 3-Indoleacrylic acid) might be jointly applied as biomarkers (area under the curve = 0.734). Furthermore, the caries status was correlated with microorganisms and metabolites. Additionally, Spearman's correlation analysis of differential microorganisms and metabolites revealed that Veillonella, Staphylococcus, Neisseria, and Porphyromonas were closely associated with differential metabolites.

CONCLUSION

This study identified different microbial communities and metabolic profiles in saliva, which may be closely related to caries status. Our findings could inform future strategies for personalized caries prevention, detection, and treatment.

Guardians' Self-Reported Fair/Poor Oral Health Is Associated with Their Young Children's Fair/Poor Oral Health and Clinically Determined Dental Caries Experience

In this cross-sectional, community-based study among a multi-ethnic sample of preschool-age children in North Carolina, United States, we sought to quantify the association between guardians' self-reported oral health and their children's oral health and determine whether race/ethnicity and education level modify these associations. We used questionnaire (n = 7852) responses about caregivers' and their children's oral health and clinical examination-derived (n = 6243) early childhood caries (ECC) status defined at the ICDAS ≥ 3 caries lesion detection threshold. We used multi-level mixed-effects generalized linear models to examine the associations between the guardians' reported oral health and their children's reported and clinically determined oral health among the entire sample and within strata of race/ethnicity, guardians' education, and children's dental home. The guardians' and their children's reported fair/poor oral health (FPOH) were 32% and 15%, respectively, whereas 54% of the children had ECC and 36% had unrestored disease. The guardians' FPOH was strongly associated with their children's FPOH (average marginal effect (AME) = +19 percentage points (p.p.); 95% CI = 17-21), and this association was most pronounced among Hispanics, lower-educated guardians, and children without a dental home. Similar patterns, but smaller-in-magnitude associations, were found for the guardians' FPOH and their children's clinically determined ECC (AME = +9 p.p.; 95% CI = 6-12) and unrestored disease (AME = +7 p.p.; 95% CI = 4-9). The study's findings support a strong association between guardians' and their children's reported and clinically determined oral health and implicate ethnicity, education, and having a dental home as factors possibly modifying the magnitude of these associations.

Prediction model for early childhood caries risk based on behavioral determinants using a machine learning algorithm

BACKGROUND

An easily accessible caries risk prediction model (CRPM) based on nonbiological predictors is lacking. Developing a CRPM for community screening is essential for children's dental health promotion by a public health approach.

OBJECTIVE

This study aimed to develop and validate a caries risk prediction model (CRPM) for children using a machine learning algorithm based on dental care behavioral factors and other nonbiological factors using a 3-month multicenter cohort.

METHODS

Children aged 12 months to 60 months were recruited at three primary care settings and three kindergartens in Chengdu, China. Dental examination was conducted for all enrolled children by calibrated pediatric dentists at baseline and three months later. All parents of the enrolled children were asked to complete a questionnaire with dental-related information. Machine learning algorithms, including random forest, logistic regression, and adaptive boosting, were used to develop a prediction model. Sensitivity, specificity, accuracy, precision, negative predictive value and F-score were reported to estimate the internal validation of the models.

RESULTS

A total of 481 out of 745 children without a history of caries experience at baseline remained for analysis. In the total sample population, 236 (49.1%) children were female, and the mean age was 31.2 months. During the follow-up exams, 66 (13.6%) children had new-onset caries. The child's age, height, weight, family caries status, brush teeth two minutes per time, fluoride toothpaste usage, brushing twice per day, parental monitoring brushing teeth, mother delivery method, brushing child's teeth every day, child number counts, and night feeding frequency in the last month were measured and included in a prediction model. Of the prediction models, the highest area under the curve of RF was 0.91 (95% CI: 0.87- 0.94), followed by 0.86 (95% CI: 0.81-0.91) of LR and 0.81 (95% CI: 0.76-0.86) of AdaBoost.

CONCLUSION

In this CRPM, new onset of dental caries in three months among children aged < 60 months could be predicted by answering twelve nonbiological questions. A good model performance was shown within the internal validation. Dental home care could be improved by referring the CRPM result before new caries onset.

Guardian Reports of Children's Sub-optimal Oral Health Are Associated With Clinically Determined Early Childhood Caries, Unrestored Caries Lesions, and History of Toothaches

Background: Parents'/guardians' perceptions of their children's oral health are useful proxies of their clinically determined caries status and are known to influence dental care-seeking behavior. In this study, we sought to examine (1) the social and behavioral correlates of fair/poor child oral health reported by guardians and (2) quantify the association of these reports with the prevalence of early childhood caries (ECC), unrestored caries lesions and toothaches. Methods: We used guardian-reported child oral health information (dichotomized as fair/poor vs. excellent/very good/good) obtained via a parent questionnaire that was completed for n = 7,965 participants (mean age = 52 months; range = 36-71 months) of a community-based, cross-sectional epidemiologic study of early childhood oral health in North Carolina between 2016 and 2019. Social, demographic, oral health-related behavioral data, and reports on children's history of toothaches (excluding teething) were collected in the same questionnaire. Unrestored ECC (i.e., caries lesions) was measured via clinical examinations in a subset of n = 6,328 children and was defined as the presence of one or more tooth surfaces with an ICDAS ≥ 3 caries lesion. Analyses relied on descriptive and bivariate methods, and multivariate modeling with average marginal effect (A.M.E.) estimation accounting for the clustered nature of the data. Estimates of association [prevalence ratios (PR) and adjusted marginal effects (AME) with 95% confidence intervals (CI)] were obtained via multilevel generalized linear models using Stata's svy function and accounting for the clustered nature of the data. Results: The prevalence of fair/poor oral health in this sample was 15%-it increased monotonically with children's age, was inversely associated with parents' educational attainment, and was higher among Hispanics (21%) and African Americans (15%) compared to non-Hispanic whites (11%). Brushing less than twice a day, not having a dental home, and frequently consuming sugar-containing snacks and beverages were significantly associated with worse reports (P < 0.0005). Children with fair/poor reported oral health were twice as likely to have unrestored caries lesions [prevalence ratio (PR) = 2.0; 95% confidence interval (CI) = 1.8-2.1] and 3.5 times as likely to have experienced toothaches [PR = 3.5; 95% CI = 3.1-3.9] compared to those with better reported oral health. Conclusions: Guardian reports of their children's oral health are valuable indicators of clinical and public health-important child oral health status. Those with fair/poor guardian-reported child oral health have distinguishing characteristics spanning socio-demographics, oral-health related practices, diet, and presence of a dental home.

Caries risk assessment with the 'Bangkok checklist' in preschool children: A prospective cohort study

BACKGROUND

Caries risk assessment in preschool children is poorly validated in prospective studies.

AIM

To validate the Bangkok checklist (BCL) in predicting caries development in a cohort of preschool children from low and moderate socioeconomic areas and compare it with two established risk assessment tools.

DESIGN

We followed 146 preschool children, aged 2-5 years for 2 years. At baseline, the caries risk category (low, moderate, high) was determined with three checklists: (a) BCL, (b) American Academy of Pediatric Dentistry form (CRAF), and (c) Caries Management By Risk Assessment (CAMBRA). Data were collected from questionnaires and clinical examinations. Caries increment was recorded by counting the number of surfaces that changed from sound to decayed. We used Kendall's tau, Poisson regression models and ROC analysis to assess the predictive ability of the different checklists.

RESULTS

Over 50% of the children developed new caries on a yearly basis. The BCL assigned the majority of the children (87%) into the high-risk category. Sensitivity was 88% but specificity was low (16%). Accuracy of BCL was similar to CRAF but inferior to CAMBRA.

CONCLUSIONS

Bangkok checklist had a very limited performance in accurately predicting future early childhood caries in this population.

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.

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.

Evaluation of possible biomarkers for caries risk in children 6 to 12 years of age

Background: Electrolytes, proteins, and other salivary molecules play an important role in tooth integrity and can serve as biomarkers associated with caries. Objective: To determine the concentration of potential biomarkers in children without caries (CF) and children with caries (CA). Methods: Unstimulated saliva was collected, and the biomarkers quantified in duplicate, using commercial Enzyme Linked Immunosorbent Assay (ELISA) kits to determine IgA, fibronectin, cathelicidin LL-37, and statherin levels, as well as colorimetric tests to detect formate and phosphate. Results: Significantly higher concentrations of statherin was detected in the CF group (Median: 94,734.6; IQR: 92,934.6-95,113.7) compared to the CA2 group (90,875.0; IQR: 83,580.2-94,633.4) (p = 0.03). Slightly higher median IgA (48,250.0; IQR: 31,461.9-67,418.8) and LL-37 levels (56.1; IQR 43.6-116.2) and a lower concentration of formate were detected in the CF group (0.02; IQR 0.0034-0.15) compared to the group with caries (IgA: 37,776.42; IQR: 33,383.9-44,128.5; LL-37: 46.3; IQR: 40.1011-67.7; formate: 0.10; IQR: 0.01-0.18), but these differences were not statistically significant. Conclusion: The fact that these compounds have been identified as good markers for caries among European adults highlights the difficulty of identifying universal biomarkers that are applicable to all ages or to different populations.

A Web-Based Rendering Application for Communicating Dental Conditions

The importance of visual aids in communicating clinical examination findings or proposed treatments in dentistry cannot be overstated. Similarly, communicating dental research results with tooth surface-level precision is impractical without visual representations. Here, we present the development, deployment, and two real-life applications of a web-based data visualization informatics pipeline that converts tooth surface-level information to colorized, three-dimensional renderings. The core of the informatics pipeline focuses on texture (UV) mapping of a pre-existing model of the human primary dentition. The 88 individually segmented tooth surfaces receive independent inputs that are represented in colors and textures according to customizable user specifications. The web implementation SculptorHD, deployed on the Google Cloud Platform, can accommodate manually entered or spreadsheet-formatted tooth surface data and allows the customization of color palettes and thresholds, as well as surface textures (e.g., condition-free, caries lesions, stainless steel, or ceramic crowns). Its current implementation enabled the visualization and interpretation of clinical early childhood caries (ECC) subtypes using latent class analysis-derived caries experience summary data. As a demonstration of its potential clinical utility, the tool was also used to simulate the restorative treatment presentation of a severe ECC case, including the use of stainless steel and ceramic crowns. We expect that this publicly available web-based tool can aid clinicians and investigators deliver precise, visual presentations of dental conditions and proposed treatments. The creation of rapidly adjustable lifelike dental models, integrated to existing electronic health records and responsive to new clinical findings or planned for future work, is likely to boost two-way communication between clinicians and their patients.

Factors Affecting Future Caries Occurrence Among Preschoolers in Northern Guangdong: A Longitudinal Study

Purpose

This study aimed to investigate the new development of caries among preschoolers in northern Guangdong and to assess caries-related factors to distinguish groups with different caries risk levels.

Methods

Baseline data were recorded for participants from September to November 2019, and participants were reexamined from September to November 2020. A longitudinal observation of 11,973 preschoolers was conducted. The simplified debris index (DI-S) and decayed-missing-filled tooth (dmft) index values were obtained for each participant.

Results

Factors associated with whether caries would occur in the future and one-year increase in dmft (Δdmft) included baseline dmft, baseline DI-S, and baseline age. The risk ratio (RR) of caries occurrence and the number of teeth with new-onset caries were 4.482 (95% confidence interval, 4.056-4.957) and 2.945 (2.742-3.165) in the participants with baseline dmft ≥3, which were higher than those with baseline dmft =1 or 2. In the baseline caries-free group, whether caries would occur in the future was related to the baseline DI-S (95% confidence interval, 0.022-0.062). The caries incidence of maxillary central incisors (27.9%) was the highest among teeth of preschoolers without caries at baseline, whereas the caries incidence of mandibular first deciduous molars (42.7%) was the highest among teeth of preschoolers with caries at baseline.

Conclusion

Baseline dmft is a good predictor of future caries. Children with baseline caries-free status, baseline dmft >0, and baseline dmft ≥3 should be treated with preventive interventions of different intensities and frequencies. The occurrence of future caries in baseline caries-free participants is related to oral hygiene status. Measures to prevent caries on smooth surfaces, such as topical fluoridation, should be applied to all preschoolers. Preschoolers with caries at baseline may be given priority for pit and fissure sealing.

An Automated Machine Learning Classifier for Early Childhood Caries

Purpose: The purpose of the study was to develop and evaluate an automated machine learning algorithm (AutoML) for children's classification according to early childhood caries (ECC) status. Methods: Clinical, demographic, behavioral, and parent-reported oral health status information for a sample of 6,404 three- to five-year-old children (mean age equals 54 months) participating in an epidemiologic study of early childhood oral health in North Carolina was used. ECC prevalence (decayed, missing, and filled primary teeth surfaces [dmfs] score greater than zero, using an International Caries Detection and Assessment System score greater than or equal to three caries lesion detection threshold) was 54 percent. Ten sets of ECC predictors were evaluated for ECC classification accuracy (i.e., area under the ROC curve [AUC], sensitivity [Se], and positive predictive value [PPV]) using an AutoML deployment on Google Cloud, followed by internal validation and external replication. Results: A parsimonious model including two terms (i.e., children's age and parent-reported child oral health status: excellent/very good/good/fair/poor) had the highest AUC (0.74), Se (0.67), and PPV (0.64) scores and similar performance using an external National Health and Nutrition Examination Survey (NHANES) dataset (AUC equals 0.80, Se equals 0.73, PPV equals 0.49). Contrarily, a comprehensive model with 12 variables covering demographics (e.g., race/ethnicity, parental education), oral health behaviors, fluoride exposure, and dental home had worse performance (AUC equals 0.66, Se equals 0.54, PPV equals 0.61). Conclusions: Parsimonious automated machine learning early childhood caries classifiers, including single-item self-reports, can be valuable for ECC screening. The classifier can accommodate biological information that can help improve its performance in the future.

Child Nutrition Patterns Are Associated with Primary Dentition Dental Caries

Purpose: Diet is a well-established, modifiable factor influencing dental caries risk. However, evidence regarding its association with distinct clinical patterns of dental caries is lacking. The purpose of this study was to identify the association of child nutrition patterns with two distinct clinical presentations (subtypes) of childhood dental caries. Methods: The study sample comprised 120 children who were patients of a private pediatric dental practice: 30 ages one to three years (mean equals 2.2 years) with anterior carious lesions; 30 ages four to 12 years (mean equals six years) with posterior-only carious lesions; and 60 age-, gender-, and payment method-matched caries-free controls. Participants underwent dental examinations, and their guardians completed a 17-item nutrition frequency questionnaire. A latent profile analysis was used to define distinct dietary patterns and, subsequently, test their association with dental caries subtypes. Results: Dietary patterns were differentiated by consumption frequencies of water and cariogenic solid, soft, and liquid food items; a diet cluster characterized by frequent consumption of fruit juice, cereal bars, and daily vitamins was more common (P<0.05) among one- to three-year-old patients with anterior carious lesions compared to matched caries-free controls. Conclusions: These results affirm the key role of dietary patterns in childhood oral health and demonstrate the influence of fermentable carbohydrates on specific clinical subtypes of caries.

Maternal Common Mental Disorders symptoms influence associated with early childhood dental caries: A cross-sectional study in a southern Brazilian city

BACKGROUND

Maternal mental problems can interfere with the overall health and care of the child; some oral health studies have been trying to elucidate whether there is a relationship between maternal common mental disorders (CMD) and children's oral health status.

AIM

The aim was to investigate the influence of mothers that present CMD symptoms on their child's dental caries status.

DESIGN

This cross-sectional study was carried out in Pelotas with 530 mother/child (aged 2-5 years old) dyads recruited from an epidemiological survey in August 2015 during the national vaccination campaign. A questionnaire was used to determine mother's CMD symptoms using the Self-Reporting Questionnaire (SRQ-20) and socioeconomic/demographic variables which were used for adjustment. Dental caries examination was performed. The outcome was obtained using the dmfs (decayed, missing, filled surfaces) index, based on OMS guidelines. Poisson regression with robust variance was used to estimate the risk ratio and 95% confidence interval (CI).

RESULTS

Maternal CMD was positively associated with dental caries prevalence in children; the adjusted relative risk for every 1 SRQ-20 score increase was 1.06 (95% CI 1.00-1.12).

CONCLUSIONS

Our findings suggest that maternal mental health can impair children's oral health in relation to dental caries.

Association of polymorphisms in genes involved in enamel formation, taste preference and immune response with early childhood caries in Saudi pre-school children

Dental caries is primarily elicited by modifiable factors such as inadequate oral hygiene, poor dietary practices and deficient fluoride exposure. However, there is a growing body of evidence suggesting the profound influence of genetic factors in dental caries susceptibility. The present study aimed to evaluate the association between single nucleotide polymorphisms (SNPs) in ENAM (rs12640848), MMP20 (rs1784418), TAS2R38 (rs713598), and LTF (rs4547741) genes and early childhood caries (ECC) in Saudi preschool children. This case-control study enrolled 360 Saudi preschool children (262 with ECC and 98 caries-free). Data on environmental factors were collected through a questionnaire. However, caries experience and oral hygiene data were obtained during clinical examination. Buccal swab samples were collected for DNA extraction and SNPs were genotyped using PCR and DNA sequencing. Children with ECC were compared to caries free children (control), then they were categorized into two categories based on ECC severity as follows; non-severe ECC (NS-ECC), and severe-ECC (S-ECC). Association between the SNPs, ECC, NS-ECC, and S-ECC was reported as an odds ratio (OR) with a 95% confidence interval (CI). The majority of the children (72.8%) exhibited ECC (31.7% NS-ECC and 41.1% S-ECC) with mean dmft of 4.20 ± 4.05. Multivariate analyses of environmental factors showed that nocturnal feeding was a risk factor for ECC (P = 0.008). Poor oral hygiene was also a risk factor for both NS-ECC and S-ECC (ECC: P < 0.0001, NS-ECC: P = 0.032 and S-ECC: P < 0.0001). Univariate analysis showed that the AG genotype of rs1784418 of MMP20 gene was protective against ECC (OR = 0.532; 95% CI = 0.316-0.897, P = 0.018) and against NS-ECC (OR = 0.436; 95% CI = 0.238-0.798, P = 0.007). When environmental risk factors for ECC were included as covariates during multivariate analysis, AG variant in rs1784418 of MMP20 gene remained less frequent in NS-ECC cases compared to controls with borderline significance (OR = 0.542; 95% CI = 0.285-1.033, P = 0.063). Our findings concluded that MMP20 rs1784418 SNP might be associated with protection against ECC in Saudi preschool children.

Prediction of Early Childhood Caries Based on Single Nucleotide Polymorphisms Using Neural Networks

Background: Several genes and single nucleotide polymorphisms (SNPs) have been associated with early childhood caries. However, they are highly age- and population-dependent and the majority of existing caries prediction models are based on environmental and behavioral factors only and are scarce in infants. Methods: We examined 6 novel and previously analyzed 22 SNPs in the cohort of 95 Polish children (48 caries, 47 caries-free) aged 2–3 years. All polymorphisms were genotyped from DNA extracted from oral epithelium samples. We used Fisher’s exact test, receiver operator characteristic (ROC) curve and uni-/multi-variable logistic regression to test the association of SNPs with the disease, followed by the neural network (NN) analysis. Results: The logistic regression (LogReg) model showed 90% sensitivity and 96% specificity, overall accuracy of 93% (p < 0.0001), and the area under the curve (AUC) was 0.970 (95% CI: 0.912–0.994; p < 0.0001). We found 90.9–98.4% and 73.6–87.2% prediction accuracy in the test and validation predictions, respectively. The strongest predictors were: AMELX_rs17878486 and TUFT1_rs2337360 (in both LogReg and NN), MMP16_rs1042937 (in NN) and ENAM_rs12640848 (in LogReg). Conclusions: Neural network prediction model might be a substantial tool for screening/early preventive treatment of patients at high risk of caries development in the early childhood. The knowledge of potential risk status could allow early targeted training in oral hygiene and modifications of eating habits.

Metabolomics Insights in Early Childhood Caries

Dental caries is characterized by a dysbiotic shift at the biofilm-tooth surface interface, yet comprehensive biochemical characterizations of the biofilm are scant. We used metabolomics to identify biochemical features of the supragingival biofilm associated with early childhood caries (ECC) prevalence and severity. The study's analytical sample comprised 289 children ages 3 to 5 (51% with ECC) who attended public preschools in North Carolina and were enrolled in a community-based cross-sectional study of early childhood oral health. Clinical examinations were conducted by calibrated examiners in community locations using International Caries Detection and Classification System (ICDAS) criteria. Supragingival plaque collected from the facial/buccal surfaces of all primary teeth in the upper-left quadrant was analyzed using ultra-performance liquid chromatography-tandem mass spectrometry. Associations between individual metabolites and 18 clinical traits (based on different ECC definitions and sets of tooth surfaces) were quantified using Brownian distance correlations (dCor) and linear regression modeling of log₂-transformed values, applying a false discovery rate multiple testing correction. A tree-based pipeline optimization tool (TPOT)-machine learning process was used to identify the best-fitting ECC classification metabolite model. There were 503 named metabolites identified, including microbial, host, and exogenous biochemicals. Most significant ECC-metabolite associations were positive (i.e., upregulations/enrichments). The localized ECC case definition (ICDAS ≥1 caries experience within the surfaces from which plaque was collected) had the strongest correlation with the metabolome (dCor P = 8 × 10^-3). Sixteen metabolites were significantly associated with ECC after multiple testing correction, including fucose (P = 3.0 × 10^-6) and N-acetylneuraminate (p = 6.8 × 10^-6) with higher ECC prevalence, as well as catechin (P = 4.7 × 10^-6) and epicatechin (P = 2.9 × 10^-6) with lower. Catechin, epicatechin, imidazole propionate, fucose, 9,10-DiHOME, and N-acetylneuraminate were among the top 15 metabolites in terms of ECC classification importance in the automated TPOT model. These supragingival biofilm metabolite findings provide novel insights in ECC biology and can serve as the basis for the development of measures of disease activity or risk assessment.

Cohort Profile: ZOE 2.0-A Community-Based Genetic Epidemiologic Study of Early Childhood Oral Health

Early childhood caries (ECC) is an aggressive form of dental caries occurring in the first five years of life. Despite its prevalence and consequences, little progress has been made in its prevention and even less is known about individuals' susceptibility or genomic risk factors. The genome-wide association study (GWAS) of ECC ("ZOE 2.0") is a community-based, multi-ethnic, cross-sectional, genetic epidemiologic study seeking to address this knowledge gap. This paper describes the study's design, the cohort's demographic profile, data domains, and key oral health outcomes. Between 2016 and 2019, the study enrolled 8059 3-5-year-old children attending public preschools in North Carolina, United States. Participants resided in 86 of the state's 100 counties and racial/ethnic minorities predominated-for example, 48% (n = 3872) were African American, 22% white, and 20% (n = 1611) were Hispanic/Latino. Seventy-nine percent (n = 6404) of participants underwent clinical dental examinations yielding ECC outcome measures-ECC (defined at the established caries lesion threshold) prevalence was 54% and the mean number of decayed, missing, filled surfaces due to caries was eight. Nearly all (98%) examined children provided sufficient DNA from saliva for genotyping. The cohort's community-based nature and rich data offer excellent opportunities for addressing important clinical, epidemiologic, and biological questions in early childhood.

What can we do to prevent small children from suffering from tooth decay?

Data sources Medline, Embase, CINAHL and PubMed.Study selection Studies published in peer-reviewed journals focusing on dental caries of primary teeth and risk and/or protective factors, in healthy children aged equal to or less than six years, including randomised controlled trials (RCTs) with an intervention period of at least one year for caries, other intervention studies, and observational studies (such as cohort, case-control, ecologic and cross-sectional studies); risk and/or protective factors included: breastfeeding beyond one year of age, breastfeeding beyond two years of age, consumption of liquids that contain free sugars from an infant feeding bottle, consumption of complementary drinks that contain free sugars, consumption of complementary foods that contain free sugars, oral hygiene provided by a parent/caregiver, oral health education for caregivers, water with an optimum concentration of fluoride, consumption of fluoridated milk and salt fluoridation.Data extraction and synthesis Five reviewers independently screened the title and abstract of the identified citations and 5% of them were screened by all reviewers. Data extraction was undertaken by two reviewers. The evidence was classified into 12 groups in accordance with the 12 review questions. Eligible studies were synthesised and meta-analysis performed where appropriate. Risk of bias was tested by the Cochrane 'risk of bias' tool for RCTs and the ROBINS-I for non-randomised trials. The quality of evidence related to each of the 12 review questions was assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).Results After initial search of 13,831 studies, 137 eligible studies were included in the systematic review and grouped into 10 out of 12 review questions (no eligible study was identified for two review questions). Among those ten review questions, only two review questions had RCTs to address the answers; others were answered by observational studies and/or quasi-experimental studies. A prospective cohort study displayed no significant difference was found in severity of caries among five-year-old children inbetween those breastfed for nearly 23 months and those breastfed up to one year. Observational studies showed increased risk of early childhood caries (ECC) was associated with consumption of sugar in both bottles and complementary foods. Results of meta-analysis of three RCTs stated that children of caregivers who received oral health education had lower chance of having ECC than those who had never received oral health education (OR 0.39, 95% CI 0.19 to 0.79, P = 0.009). Another result from meta-analysis demonstrated that lower pooled mean dmft was found in children living in areas with fluoridated water than those who lived in non-fluoridated areas (-1.25, 95% CI -2.14 to -0.36, P = 0.016). Children who consumed fluoridated milk and fluoridated salt reduced the risk of ECC compared to those who did not. No publication bias was observed in the meta-analysis.Conclusions Evidence with moderate quality demonstrated that children with access to fluoridated water and fluoridated supplements could lower their risk of ECC; children with caregivers who had received oral health education had lower levels of ECC. Evidence with low quality suggested that breastfeeding up to two years old did not increase the risk of ECC; consumed sugars in bottles and complementary foods increased the risk of ECC.

What Child Oral Health-Related Behaviors Can First-time Mothers Actualize? A Pragmatic Prospective Study

INTRODUCTION

First-time pregnant women are considered to be receptive to health information, rendering the prenatal period an opportune time to provide helpful information on the importance of child-related oral health. However, little is known about pregnant women's knowledge of child oral health-related behaviors (COHBs) during pregnancy and their implementation after birth. We sought to address this knowledge gap by a prospective investigation of intended and actualized oral health behaviors among first-time pregnant women.

METHODS

We examined relationships between intended and actualized COHBs and their correlations with changes in oral health knowledge, health literacy, general self-efficacy, and dental neglect in a cohort of first-time pregnant clients at Women, Infants, and Children sites in North Carolina-participants of a large community-based study. The COHBs were related to diet (i.e., frequency of fruit juice and sweet snacks consumption and nighttime bottle-feeding) and oral hygiene practices (e.g., performance of daily oral hygiene and use of fluoridated toothpaste). Analyses relied on descriptive statistics and bivariate tests (Student's t and McNemar's). Data were collected from 48 participants (White, 44%; African American, 40%; Native American, 17%) at baseline and again at least 12 months after the birth of their first child.

RESULTS

On average, most mothers actualized 3 of 5 COHBs (range, 1 to 4). Significant differences between before and after birth were noted for frequency of sweet snacks consumption and putting the baby in bed with a bottle. No correlation was found between knowledge, literacy, self-efficacy, neglect, and sociodemographic characteristics and COHB actualization.

CONCLUSION

Our findings suggest that first-time mothers in the studied population are likely to implement some but not all positive intended COHBs during pregnancy. Interventions are needed to assist women in implementing these practices. We support that, for prenatal interventional efforts to reap positive benefits, messaging should be personalized and include specific guidance on how to implement these recommendations.

KNOWLEDGE TRANSFER STATEMENT

A knowledge gap exists in our understanding of the relationship between first-time mothers' intended and actualized child oral health behaviors, with implications in the optimal timing of infant and early childhood oral health messaging. Our findings suggest that first-time mothers are likely to implement some but not all positive behaviors that they intended to adopt during pregnancy. Interventions are needed to assist women in implementing these practices.

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.

Changes in the salivary electrolytic dynamic after sucrose exposure in children with Early Childhood Caries

This study sought to explore if the effect of 20% sucrose rinse (SR) on the salivary electrolytic concentration of calcium (Ca2+), phosphate (Pi) and fluoride (F-) in children with Early Childhood Caries (ECC) is different from healthy children. Here, fifty-eight  preschoolers aged 3 to 5 years were divided into 2 groups: caries-free (CF) and with ECC. Changes in saliva flow rate, pH and buffering capacity (BC), as well as in concentrations of Ca2+, Pi, and F-, and the degree of saturation in relation to hydroxyapatite (DSS HAp) and fluorapatite (DSS FAp) were evaluated. The pre-rinse [Ca2+] was higher in the ECC group in the CF group. A significant increase in [Ca2+] was demonstrated after SR in the CF group (p = 0.05). The [Pi] was reduced by 18% after SR in the ECC group (p = 0.007). The [F-] reduced in both groups after SR (p < 0.000). There was a moderate positive correlation between [Ca2+] and the DSS HAp and DSS FAp. Multivariate analysis showed that children with a higher [Ca2+] in pre-rinse saliva are more likely to have ECC. In conclusion, the effect of a 20% sucrose rinse on the electrolytic concentration of Ca2+, Pi and F- was different when children with ECC were compared with CF children.

The building blocks of precision oral health in early childhood: the ZOE 2.0 study

Improving children's oral health is a long-standing area of priority and sustained efforts by many stakeholders. Despite these efforts, dental caries, particularly early childhood caries (ECC), persists as a clinical and dental public health problem with multilevel consequences. Despite recent successes in the non-restorative management of dental caries, remarkably little has been done in the domain of ECC prevention. There is promise and expectation that meaningful improvements in early childhood oral health and ECC prevention can be made via the advent of precision medicine in the oral health domain. We posit that precision dentistry, including genomic influences, may be best examined in the context of well-characterized communities (versus convenience clinical samples) and the impact of contextual factors including geography and social disadvantage may be explainable via mechanistic (i.e., biological) research. This notion is aligned with the population approach in precision medicine, which calls for the latter to be predictive, preventive, personalized, and participatory. The article highlights research directions that must be developed for precision dentistry and precision dental public health to be realized. In this context, we describe the rationale, activities, and early insights gained from the ZOE 2.0 study - a large-scale, community-based, genetic epidemiologic study of early childhood oral health. We anticipate that this long-term research program will illuminate foundational domains for the advancement of precision dentistry and precision dental public health. Ultimately, this new knowledge can help catalyze the development of effective preventive and therapeutic modalities via actions at the policy, community, family, and person level.

Genomics of periodontal disease and tooth morbidity

In this review we critically summarize the evidence base and the progress to date regarding the genomic basis of periodontal disease and tooth morbidity (ie, dental caries and tooth loss), and discuss future applications and research directions in the context of precision oral health and care. Evidence for these oral/dental traits from genome-wide association studies first emerged less than a decade ago. Basic and translational research activities in this domain are now under way by multiple groups around the world. Key departure points in the oral health genomics discourse are: (a) some heritable variation exists for periodontal and dental diseases; (b) the environmental component (eg, social determinants of health and behavioral risk factors) has a major influence on the population distribution but probably interacts with factors of innate susceptibility at the person-level; (c) sizeable, multi-ethnic, well-characterized samples or cohorts with high-quality measures on oral health outcomes and genomics information are required to make decisive discoveries; (d) challenges remain in the measurement of oral health and disease, with current periodontitis and dental caries traits capturing only a part of the health-disease continuum, and are little or not informed by the underlying biology; (e) the substantial individual heterogeneity that exists in the clinical presentation and lifetime trajectory of oral disease can be identified and leveraged in a precision medicine framework or, if unappreciated, can hamper translational efforts. In this review we discuss how composite or biologically informed traits may offer improvements over clinically defined ones for the genomic interrogation of oral diseases. We demonstrate the utility of the results of genome-wide association studies for the development and testing of a genetic risk score for severe periodontitis. We conclude that exciting opportunities lie ahead for improvements in the oral health of individual patients and populations via advances in our understanding of the genomic basis of oral health and disease. The pace of new discoveries and their equitable translation to practice will largely depend on investments in the education and training of the oral health care workforce, basic and population research, and sustained collaborative efforts..

Targeted metabolomics of pellicle and saliva in children with different caries activity

Pellicle is the initial proteinaceous layer that is formed almost instantaneously on all solid surfaces in the oral cavity. It is of essential relevance for any interactions and metabolism on the tooth surface. Up to now, there is no information on the metabolome of this structure. Accordingly, the present study aims to characterise the metabolomic profile of in-situ pellicle in children with different caries activity for the first time in comparison to saliva. Small molecules such as carbohydrates, amino acids, organic acids, and fatty acids, putatively involved in the formation of caries were quantified using mass spectrometry (MS)-based techniques, such as (stable isotope dilution analysis)-ultra-performance liquid chromatography-tandem MS and gas chromatography/electron ionisation-MS. Pellicle and corresponding saliva samples were collected from caries-active, caries-free and caries-rehabilitated 4- to 6-year-old children. The most abundant analytes in pellicle were acetic acid (1.2-10.5 nmol/cm2), propionic acid (0.1-8.5 nmol/cm2), glycine (0.7-3.5 nmol/cm2), serine (0.08-2.3 nmol/cm2), galactose (galactose + mannose; 0.035-0.078 nmol/cm2), lactose (0.002-0.086 nmol/cm2), glucose (0.018-0.953 nmol/cm2), palmitic acid (0.26-2.03 nmol/cm2), and stearic acid (0.34-1.81 nmol/cm2). Significant differences depending on caries activity were detected neither in saliva nor in the corresponding pellicle samples.

Searching Deep and Wide: Advances in the Molecular Understanding of Dental Caries and Periodontal Disease

During the past decades, remarkable progress has been made in the understanding of the molecular basis of the 2 most common oral diseases, dental caries and periodontal disease. Improvements in our knowledge of the diseases' underlying biology have illuminated previously unrecognized aspects of their pathogenesis. Importantly, the key role of the oral (supragingival and subgingival) microbiome is now well recognized, and both diseases are now best understood as dysbiotic. From a host susceptibility standpoint, some progress has been made in dissecting the "hyperinflammatory" trait and other pathways of susceptibility underlying periodontitis, and novel susceptibility loci have been reported for dental caries. Nevertheless, there is a long road to the translation of these findings and the realization of precision oral health. There is promise and hope that the rapidly increasing capacity of generating multiomics data layers and the aggregation of study samples and cohorts comprising thousands of participants will accelerate the discovery and translation processes. A first key element in this process has been the identification and interrogation of biologically informed disease traits-these "deep" or "precise" traits have the potential of revealing biologically homogeneous disease signatures and genetic susceptibility loci that might present with overlapping or heterogeneous clinical signs. A second key element has been the formation of international consortia with the goals of combining and harmonizing oral health data of thousands of individuals from diverse settings-these "wide" collaborative approaches leverage the power of large sample sizes and are aimed toward the discovery or validation of genetic influences that would otherwise be impossible to detect. Importantly, advancements via these directions require an unprecedented engagement of systems biology and team science models. The article highlights novel insights into the molecular basis of dental caries and chronic periodontitis that have been gained from recent and ongoing studies involving "deep" and "wide" analytical approaches.

Models to Predict Future Permanent Tooth Caries Incidence in Children Using Primary Teeth Caries Experience

Purpose: To assess permanent tooth caries incidence (ΔDMFS) among a cohort of African American children using the presence of any caries experience(decayed, missing, and filled surfaces-dmfs) in primary teeth and the presence of untreated primary tooth caries (ds) in two separate models. Methods: Data from a prospective study was used to apply two models with different clinical for predicting DMFS from ages six through 12 years. The first model used dmfs, and the second model used ds as predictors (both at age six years). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed. Results: The first model resulted in sensitivity from 81.8 percent to 100 percent, specificity from 35.6 percent to 42.6, PPV from 5.8 percent to 38.1 percent, and NPV from 90.0 percent to 100 percent. In the second model, the predictive values were from 33.3 percent to 55.6 percent, 62.7 percent to 72.7 percent, 3.4 percent to 45.5 percent, and 80 percent to 95.9 percent, respectively. Conclusions: The proposed models for permanent tooth caries incidence prediction are easy, not time consuming, and clinically applicable; if validated, they have the potential to change the current paradigm for caries risk assessment.

The Burden of Early Childhood Caries in Canadian Children and Associated Risk Factors

Introduction: Early childhood caries (ECC) is any caries in the primary dentition occurring in children under the age of six. ECC is common in many population groups in Canada. Objective: The purpose of this review was to describe the burden of ECC in Canada, the prevalence and associated risk factors for ECC, and its impact on childhood health based on the existing published literature. Methods: A review was conducted to assess published Canadian studies on ECC identified through searches of electronic databases. Databased searched included PubMed, Medline, Cinahl, and the library catalog of the University of Manitoba. Known publications on ECC that were not identified by the electronic search were also considered. Only the studies that reported the prevalence of ECC or caries in preschool aged children were considered. In-depth assessments were restricted to those studies that employed logistic regression analysis to investigate relationship between ECC and risk factors or nutritional status and quality of life. Results: A total of 36 studies were identified that related to ECC in Canadian children. Overall, 27 related to prevalence and 12 reported on risk factors, four related to the association between severe ECC and nutritional health and well-being, while only one related to the oral microbiome composition. Published studies reveal that the prevalence of ECC can be as high as 98% in some parts of Canada. Commonly identified risk factors include age, sex, socio-economic status, parental beliefs, family characteristics, debris/plaque, enamel hypoplasia, and behavioral (oral health or feeding behaviors) tendencies. Conclusions: Current literature reveals that many Canadian children are affected by ECC. The development of ECC appears to be strongly associated with social determinants of health including low household income and the level of parental education or employment status. Associations were also observed between ECC and the child's age at first dental visit and parental beliefs about child's oral health. Children with enamel hypoplasia are also at significantly greater odds for experiencing caries. Future research should include assessments of developmental defects of enamel to better understand the association between enamel hypoplasia and ECC.

Microbiota of interdental space of adolescents according to Risk of Caries: A cross-sectional study protocol

Dental caries is a major oral disease resulting from a complex interaction between the commensal microbiota, host susceptibility (heredity, immunity, diseases, etc.) and environmental factors (diet, dental hygiene, etc.). To predict the patient's risk of new carious lesions or progression of existing lesions, the Caries Risk Assessment (CRA) takes account of clinical, biological and behavioural factors. Thus, the CRA can predict whether the patient is at high or low risk of developing caries. The practitioner can thus set up a follow-up adapted to the risk of the patient. However, although bacteria are the main etiological factor of carious lesions, the CRA does not consider bacterial quantification or just focus on the level of S. mutans in the saliva. As the majority of cavities are interproximal in adolescence, the aim of this trial is to identify and quantify the interdental microbiota of adolescents aged from 15 to 17 years with low or high carious risk. So, the quantification of new biomarkers associated with carious lesion could be added to the CRA to improve it.

Development of toolkits for detecting dental caries and caries experience among children using self-report and parent report

OBJECTIVES

To develop child- and parent-reported toolkits for active caries and caries experience in children and adolescents, ages 8-17.

METHODS

A sample of 398 child/parent dyads recruited from 12 dental practices in Los Angeles County completed a computer-assisted survey that assessed oral health perceptions. In addition, children received a dental examination that identified the presence or absence of active caries and caries experience. A Multiple Adaptive Regression Splines model was used to identify a subset of survey items associated with active caries and caries experience. The splines and coefficients were refined by generalized cross-validation. Sensitivity and specificity for both dependent variables were evaluated.

RESULTS

Eleven child self-reported items were identified that had sensitivity of 0.82 and specificity of 0.45 relative to active caries. Twelve parent-reported items had a sensitivity of 0.86 and specificity of 0.50. Seven child self-reported items had a sensitivity of 0.86 and specificity of 0.34, and 11 parent-reported items had a sensitivity of 0.86 and specificity of 0.47 for caries experience.

CONCLUSIONS

The survey items identified here are useful in distinguishing children with and without active caries and with and without caries experience. This research presents a path towards using children's and their parents' reports about oral health to screen for clinically determined caries and caries exposure. The items identified in this study can be useful when clinical information is unavailable.

Dental plaque pH in predicting caries relapse after general anaesthesia - an exploratory study

OBJECTIVES

Numerous caries risk assessment tools have been proposed in the literature, with few validated in preschool children especially those receiving oral rehabilitation under general anaesthesia (GA). Past caries experience, the best predictor thus far, may not be a reliable indicator after effective clinical intervention. Hence, this longitudinal study was aimed to explore the potential role of plaque pH in predicting future caries incidence after GA among preschool children.

METHODS

Oral examination, plaque pH measurements and questionnaire survey were performed, among pre-schoolers indicated for GA, at baseline (n = 92), 6-month (6M; n = 83), 12-month (12M; n = 79) and 24-month (24M; n = 66) recall visits after GA. Multivariable logistic regression and receiver-operating characteristic analysis were performed to evaluate the predictive value of models with plaque pH and past caries experience.

RESULTS

Individuals with low resting plaque pH at 6M and 12M were shown to be at high risk of 1-year caries incidence at 12M [relative risk (RR) 1.41, 95% confidence interval (CI) 1.09-1.48] and 24M (RR 1.61, 95% CI 1.22-1.73) recall visit, respectively. Moreover, plaque pH demonstrated a statistically significant predictive value in the 12M and 24M models (12M/24M: 85%/77%) compared with past caries experience, which was not a significant predictor in both models (both P > 0.05).

CONCLUSIONS

Plaque pH may be a promising prognostic and predictive marker for early identification of high-risk children undergoing oral rehabilitation under GA.

Oral microbial biofilms: an update

Human oral cavity (mouth) hosts a complex microbiome consisting of bacteria, archaea, protozoa, fungi and viruses. These bacteria are responsible for two common diseases of the human mouth including periodontal (gum) and dental caries (tooth decay). Dental caries is caused by plaques, which are a community of microorganisms in biofilm format. Genetic and peripheral factors lead to variations in the oral microbiome. It has known that, in commensalism and coexistence between microorganisms and the host, homeostasis in the oral microbiome is preserved. Nonetheless, under some conditions, a parasitic relationship dominates the existing situation and the rise of cariogenic microorganisms results in dental caries. Utilizing advanced molecular biology techniques, new cariogenic microorganisms species have been discovered. The oral microbiome of each person is quite distinct. Consequently, commonly taken measures for disease prevention cannot be exactly the same for other individuals. The chance for developing tooth decay in individuals is dependent on factors such as immune system and oral microbiome which itself is affected by the environmental and genetic determinants. Early detection of dental caries, assessment of risk factors and designing personalized measure let dentists control the disease and obtain desired results. It is necessary for a dentist to consider dental caries as a result of a biological process to be targeted than treating the consequences of decay cavities. In this research, we critically review the literature and discuss the role of microbial biofilms in dental caries.

An alternative early childhood caries risk surveillance methodology for public policy and practice advancements

OBJECTIVES

Early childhood caries (ECC) negatively impacts many child health outcomes and can lead to greater costs for medical and dental care as well as negatively impact future oral health wellness. ECC risk factors are rooted in many social determinants of health. Addressing ECC at the population-level is a national public health priority. The purpose of this study was to identify the South Carolina counties with the greatest risk for ECC. As policy-makers seek to address inequities stemming from early childhood caries, documenting its prevalence is essential.

METHODS

Since no county level ECC rates were published for South Carolina, we identified an opportunity to strengthen ECC surveillance through public use data, so as to properly equip policy-makers and pediatric providers with an evidence based understanding of the scope of the problem. As a result we sought to develop an overall county level prevalence measure for ECC risk through an ecological analysis of public use data.

RESULTS

Ten counties with the greatest overall risk for ECC were all rural as hypothesized. Additionally, seven of the 10 highest risk counties fell into what is often referred to as the "Corridor of Shame."

CONCLUSIONS

We have found an affordable way of measuring county level risk for ECC that allows pediatric advocates and policy-makers to develop population level interventions to reduce and measure risk with public-use data.

Translating Cognitive Vulnerability Theory Into Improved Adolescent Depression Screening: A Receiver Operating Characteristic Approach

Traditionally, screening research tests how well a given symptom inventory can identify a concurrent depressive episode. Although developmental psychopathology could inform screening protocols for a myriad of depression outcomes (e.g., prospective depressive episodes), approaches typically used in research make it difficult to translate these findings. Using a translational analytic approach and multiwave longitudinal study design, we examined how screening for cognitive vulnerabilities (rumination, dysfunctional attitudes, and attributional style) may improve our ability to identify concurrent depressive episodes, prospective depressive episodes, first lifetime episodes of depression, and recurrent major depressive episodes. There were 473 sixth-grade (early adolescents) and ninth-grade (middle adolescents; AgeM = 13.15, AgeSD = 1.62) students who completed baseline self-report cognitive vulnerability and depressive symptom measures. At baseline and every 6 months for 3 years, pediatric depression interviews were completed by the caregiver and youth. A receiver operating characteristic (ROC) approach was utilized to test our aims. Distinct algorithms best forecasted our depression outcomes. Rumination and attributional style emerged as unique and incrementally valid predictors for prospective episodes after controlling for baseline depressive symptoms. Rumination was the only unique predictor for first lifetime depressive episodes. For recurrent major depression, rumination in early adolescence and attributional style in middle adolescence served as incremental predictors beyond baseline depressive symptoms. Proposed cutoffs and diagnostic likelihood ratios are offered for algorithms for each depression outcome. Assessing cognitive vulnerability represents a feasible method to improve depression screening initiatives. Using an ROC-informed approach can help prevention initiatives better leverage the considerable gains made within developmental psychopathology research.

Measurement of Early Childhood Oral Health for Research Purposes: Dental Caries Experience and Developmental Defects of the Enamel in the Primary Dentition

Epidemiological investigations of early childhood oral health rely upon the collection of high-quality clinical measures of health and disease. However, ascertainment of valid and accurate clinical measures presents unique challenges among young, preschool-age children. The paper presents a clinical research protocol for the conduct of oral epidemiological examinations among children, implemented in ZOE 2.0, a large-scale population-based genetic epidemiologic study of early childhood caries (ECC). The protocol has been developed for the collection of information on tooth surface-level dental caries experience and tooth-level developmental defects of the enamel in the primary dentition. Dental caries experience is recorded using visual criteria modified from the International Caries Detection and Assessment System (ICDAS), and measurement of developmental defects is based upon the modified Clarkson and O'Mullane Developmental Defects of the Enamel Index. After a dental prophylaxis (toothbrushing among all children and flossing as needed), children's teeth are examined by trained and calibrated examiners in community locations, using portable dental equipment, compressed air, and uniform artificial light and magnification conditions. Data are entered directly onto a computer using a custom Microsoft Access-based data entry application. The ZOE 2.0 clinical protocol has been implemented successfully for the conduct of over 6000 research examinations to date, contributing phenotype data to downstream genomics and other "omics" studies of ECC and DDE, as well as traditional clinical and epidemiologic dental research.

The Supragingival Biofilm in Early Childhood Caries: Clinical and Laboratory Protocols and Bioinformatics Pipelines Supporting Metagenomics, Metatranscriptomics, and Metabolomics Studies of the Oral Microbiome

Early childhood caries (ECC) is a biofilm-mediated disease. Social, environmental, and behavioral determinants as well as innate susceptibility are major influences on its incidence; however, from a pathogenetic standpoint, the disease is defined and driven by oral dysbiosis. In other words, the disease occurs when the natural equilibrium between the host and its oral microbiome shifts toward states that promote demineralization at the biofilm-tooth surface interface. Thus, a comprehensive understanding of dental caries as a disease requires the characterization of both the composition and the function or metabolic activity of the supragingival biofilm according to well-defined clinical statuses. However, taxonomic and functional information of the supragingival biofilm is rarely available in clinical cohorts, and its collection presents unique challenges among very young children. This paper presents a protocol and pipelines available for the conduct of supragingival biofilm microbiome studies among children in the primary dentition, that has been designed in the context of a large-scale population-based genetic epidemiologic study of ECC. The protocol is being developed for the collection of two supragingival biofilm samples from the maxillary primary dentition, enabling downstream taxonomic (e.g., metagenomics) and functional (e.g., transcriptomics and metabolomics) analyses. The protocol is being implemented in the assembly of a pediatric precision medicine cohort comprising over 6000 participants to date, contributing social, environmental, behavioral, clinical, and biological data informing ECC and other oral health outcomes.

Trends and Characteristics of Pediatric Dentistry Patients Treated under General Anesthesia

PURPOSE

The aims of this study were to describe the demographic characteristics of pediatric dentistry patients undergoing dental rehabilitation under general anesthesia (DRGA) at UNC-Chapel Hill during the last 13 years and identify factors associated with multiple (1 versus 2 or more) DRGA visits during that timeframe.

STUDY DESIGN

Administrative claims data were used to identify children and adolescents (age <18 years) who underwent DRGA between 1/1/2002 and 12/31/2014 at the UNC Hospitals system. Information on children's age, sex and all treatment-associated CDT codes were collected. Descriptive statistics and bivariate tests of association were used for data analyses.

RESULTS

There were 4,413 DRGAs among 3,973 children (median age=4 years 8 months, males=55%) during the study period. The annual rate of DRGAs increased over time, peaking (n=447) in 2013. Overall, 9% of children had ≥2 visits with repeat rates up to 18%. There was no association between children's sex and receipt of one versus multiple DRGAs; however, craniofacial cases were more likely (p<0.0005) to have multiple DRGAs compared to non-craniofacial ones.

CONCLUSION

DRGAs are on the increase-with the exception of craniofacial and special health care needs patients, multiple DRGAs may be reflective of sub-optimal adherence to preventive and continuing care recommendations.

Salivary proteins and peptides in the aetiology of caries in children: Systematic literature review

BACKGROUND

To assess the relationship of chosen salivary proteins and peptides levels with the occurrence of caries in children.

METHODS

PubMed, MEDLINE and EMBASE databases from 2000 to 2018 were researched for original observational studies published in English. The risk of bias and quality of the included papers were assessed regarding the guidelines by Fowkes and Fulton.

RESULTS

Twenty-two studies were included in the review, from which the issue of glycoproteins (including immunoglobulins), AMPs and salivary enzymes was discussed. The research involved primary dentition (13 papers), as well as mixed (7) and permanent dentition (5). Caries assessment included visual inspection, dmft/s and DMFT/S indexed; quantity of Streptococcus mutans and Lactobacillus spp. bacteria; and caries risk assessment.

DISCUSSION

The results of studies regarding the connection between salivary peptides and proteins and caries development in children are promising; however, further investigations should be undertaken. The majority of studies included are case-control and cross-sectional; however, it is necessary to conduct more cohort studies with adequate follow-up prior to considering this as markers for caries risk assessment.

Consortium-based genome-wide meta-analysis for childhood dental caries traits

Prior studies suggest dental caries traits in children and adolescents are partially heritable, but there has been no large-scale consortium genome-wide association study (GWAS) to date. We therefore performed GWAS for caries in participants aged 2.5-18.0 years from nine contributing centres. Phenotype definitions were created for the presence or absence of treated or untreated caries, stratified by primary and permanent dentition. All studies tested for association between caries and genotype dosage and the results were combined using fixed-effects meta-analysis. Analysis included up to 19 003 individuals (7530 affected) for primary teeth and 13 353 individuals (5875 affected) for permanent teeth. Evidence for association with caries status was observed at rs1594318-C for primary teeth [intronic within ALLC, odds ratio (OR) 0.85, effect allele frequency (EAF) 0.60, P 4.13e-8] and rs7738851-A (intronic within NEDD9, OR 1.28, EAF 0.85, P 1.63e-8) for permanent teeth. Consortium-wide estimated heritability of caries was low [h2 of 1% (95% CI: 0%: 7%) and 6% (95% CI 0%: 13%) for primary and permanent dentitions, respectively] compared with corresponding within-study estimates [h2 of 28% (95% CI: 9%: 48%) and 17% (95% CI: 2%: 31%)] or previously published estimates. This study was designed to identify common genetic variants with modest effects which are consistent across different populations. We found few single variants associated with caries status under these assumptions. Phenotypic heterogeneity between cohorts and limited statistical power will have contributed; these findings could also reflect complexity not captured by our study design, such as genetic effects which are conditional on environmental exposure.

Salivary antioxidant capacity of children with severe early childhood caries before and after complete dental rehabilitation

OBJECTIVE

There is a need to determine whether total antioxidant capacity (TAC) in severe early childhood caries (S-ECC) is an indicator of inflammatory response to the lesion or a marker of the disease. This study compared TAC levels in children with ECC before and after dental treatment and compared the results with those of caries-free children.

DESIGN

Prospective study.

SETTING

A teaching hospital.

PATIENT SELECTION

Salivary samples were obtained from 20 children aged 5 years and diagnosed with S-ECC, and 20 age- and sex-matched controls.

INTERVENTION DETAILS

Complete dental rehabilitation under general anesthesia was performed on the children with S-ECC, and follow-up salivary samples were obtained one week and three months postoperatively. TAC was measured using a commercially available Oxygen Radical Absorbance Antioxidant Assay measurement kit (Zen-Bio ORAC™, AMS Biotechnology, Abington, UK).

OUTCOME MEASURES

Differences between children with and without dental caries were tested using the Mann-Whitney U test; differences before and after dental treatment were analyzed using Friedman test followed by Wilcoxon sign-rank test with Bonferroni correction to compensate for multiple comparisons.

RESULTS

Median TAC (1.54 mcg/L, CI 1.15-1.92) of the control group was significantly lower than that of the treated group prior to treatment (p = 0.003). Treatment of the dental lesions significantly reduced TAC of the treated group, and no significant differences were observed between the test and control groups at either one week (p = 0.076) recall or three-month recall (p = 0.096). TAC in children posttreatment was significantly reduced compared to their pretreatment values (p < 0.001).

CONCLUSION

Total antioxidant capacity in the saliva of children with severe early childhood caries undergoes significant reduction following treatment of the carious lesions.

Promoting Oral Health in Childhood: A Quality Improvement Project

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends periodic oral health risk assessments (OHRAs) for young children to prevent early childhood caries and promote oral health. The objective of this quality improvement project was to incorporate OHRAs, including documentation of the oral screening examination, into well-child visits for patients aged 12 to 47 months to drive (1) improved rates of preventive fluoride varnish (FV) application and (2) improved dental referrals for children at high risk for caries.

METHODS

We identified a quality gap in our OHRAs, oral examination completion, FV application rates, and dental referral rates via retrospective data collection. Plan-Do-Study-Act cycles targeted modification of electronic medical record templates, oral health education, and standardization of work processes. Process and outcome measures were analyzed with statistical process control charts.

RESULTS

At baseline, OHRAs and oral screening examinations were documented in <2% of patients. Of eligible children, 42% had FV applied. Routine dental referrals before age 3 years were uncommon. After multiple Plan-Do-Study-Act cycles, documentation of OHRAs and oral screening examinations (process measures) improved to 45% and 73%, respectively. The primary outcome measure, FV rates, improved to 86%. Referral of high-risk patients to a dentist improved to 54%.

CONCLUSIONS

A systematic, evidence-based approach to improving oral health, including electronic medical record-based interventions, resulted in improved documentation of oral health risks and oral screening, improved rates of FV application in young children, and increased identification and referral of high-risk patients.