Caries risk assessment by a cross-sectional discrimination model

Effect of adhesive components in experimental fluoride varnish on fluoride release within 30 days in vitro study

We aimed to determine whether adhesive components could increase the release time of effective fluoride concentration from an experimental fluoride varnish applied to bovine teeth. An experimental fluoride varnish containing 5% sodium fluoride (EX1) was prepared and combined with 35% hydroxyethyl methacrylate (HEMA) (EX2), 5% glutaraldehyde (EX3), or 35% HEMA/5% glutaraldehyde mixture (EX4). Two commercially available fluoride varnishes were used for comparison. Each group was applied to bovine incisors, and the fluoride release and pH were monitored for 30 days. Cell viability analysis, scanning electron microscopy, and energy-dispersive spectroscopy were performed. EX4 released the highest and most effective concentration of fluoride for the longest period and reached neutral pH at the earliest; the release was maintained for up to 30 days without cytotoxicity. In conclusion, EX4 is considered to be the most effective varnish to prevent dental caries.

Evidence-Based Caries Management for All Ages-Practical Guidelines

Introduction: The purpose of the present paper is to provide step-by-step guidelines for dental healthcare providers to manage dental caries based upon caries risk assessment (CRA) for ages 0–6 years and 6 years through adult. The manuscript reviews and updates the CAMBRA (caries management by risk assessment) system which includes CRA and caries management recommendations that are guided by the assessed risk level.

Caries Risk Assessment: CAMBRA CRA tools (CRAs) have been evaluated in several clinical outcomes studies and clinical trials. Updated CAMBRA CRAs for ages 0–6 years and 6 years through adult are provided. These CRAs have been refined by the addition of a quantitative method that will aid the health care provider in determining the caries risk of individuals.

Caries Management Based Upon Risk Assessment: Guidelines for individualized patient care are provided based upon the caries risk status, results of clinical exams and responses of the patient to questions in the CRA. These guidelines are based upon successful outcomes documented in several clinical outcomes studies and clinical trials. The paper includes a review of successful caries management procedures for children and adults as previously published, with additional emphasis on correct use of silver diamine fluoride (SDF) for children. The caries management plan for each individual is based upon reducing the caries risk factors and enhancing the protective factors with the additional aid of behavior modification. Beneficially altering the caries balance is coupled with minimal intervention restorative dentistry, if appropriate. These methods are appropriate for the management of dental caries in all patients.

A Qualitative and Comprehensive Analysis of Caries Susceptibility for Dental Fluorosis Patients

Dental fluorosis (DF) is an endemic disease caused by excessive fluoride exposure during childhood. Previous studies mainly focused on the acid resistance of fluorotic enamel and failed to reach a consensus on the topic of the caries susceptibility of DF patients. In this review, we discuss the role of DF classification in assessing this susceptibility and follow the “four factors theory” in weighing the pros and cons of DF classification in terms of host factor (dental enamel and saliva), food factor, bacteria factor, and DF treatment factor. From our analysis, we find that susceptibility is possibly determined by various factors such as the extent of structural and chemical changes in fluorotic enamel, eating habits, fluoride levels in diets and in the oral cavity, changes in quantity and quality of saliva, and/or oral hygiene. Thus, a universal conclusion regarding caries susceptibility might not exist, instead depending on each individual’s situation.

Efficacy of an adenosine triphosphate meter for evaluating caries risk in clinical dental practice

BACKGROUND

Adenosine triphosphate bioluminescence (ATP-B) readings have been proposed as markers of caries risk. ATP readings may indicate bacteria or oral streptococci activity in microbial plaque. The authors of this study aimed to evaluate whether readings using a commercial ATP meter (CariScreen Testing Meter, Oral BioTech) are significantly different for patients with low, moderate, and high caries risk in the Caries Management by Risk Assessment Practice-Based Research Network study.

METHODS

Twenty practice-based research network dentists enrolled 460 patients; 271 returned for 2 or more semiannual follow-up visits over 2 years. Dentists were trained and calibrated to perform ATP-B testing and caries risk assessment (CRA) using established protocols. ATP-B readings were compared via CRA category (low, moderate, high). Generalized estimating equations were used to compare the risk of experiencing incident clinical outcomes (newly recorded decayed, missing, or restored tooth surfaces and CRA disease indicators) according to ATP-B reading at prior patient visits (≥ 1,500 versus < 1,500 relative light units).

RESULTS

Median ATP-B readings did not differ statistically significantly by clinician-assessed caries risk level (low, 2,323; moderate, 2,940; high, 3,217; P = .65). Adjusted for patient demographics and trial intervention assignment, higher readings were not associated with newly developed decayed, missing, or restored tooth surface (relative risk, 1.57; 95% confidence interval, 0.55 to 4.45) or disease indicators (relative risk, 1.08; 95% confidence interval, 0.85 to 1.37) at the following visit, whereas clinician-assessed caries risk level was strongly associated.

CONCLUSIONS

ATP-B readings poorly predicted caries risk and future clinical outcomes. CRA incorporating multiple risk, protective, and disease indicators has superior predictive performance.

PRACTICAL IMPLICATIONS

The findings of this study do not provide evidence supporting the use of ATP-B to predict caries risk.

Dental Data Mining: Potential Pitfalls and Practical Issues

Knowledge Discovery and Data Mining (KDD) have become popular buzzwords. But what exactly is data mining? What are its strengths and limitations? Classic regression, artificial neural network (ANN), and classification and regression tree (CART) models are common KDD tools. Some recent reports ( e.g., Kattan et al., 1998 ) show that ANN and CART models can perform better than classic regression models: CART models excel at covariate interactions, while ANN models excel at nonlinear covariates. Model prediction performance is examined with the use of validation procedures and evaluating concordance, sensitivity, specificity, and likelihood ratio. To aid interpretation, various plots of predicted probabilities are utilized, such as lift charts, receiver operating characteristic curves, and cumulative captured-response plots. A dental caries study is used as an illustrative example. This paper compares the performance of logistic regression with KDD methods of CART and ANN in analyzing data from the Rochester caries study. With careful analysis, such as validation with sufficient sample size and the use of proper competitors, problems of naïve KDD analyses ( Schwarzer et al., 2000 ) can be carefully avoided.

Candida albicans Carriage in Children with Severe Early Childhood Caries (S-ECC) and Maternal Relatedness

Introduction

Candida albicans has been detected together with Streptococcus mutans in high numbers in plaque-biofilm from children with early childhood caries (ECC). The goal of this study was to examine the C. albicans carriage in children with severe early childhood caries (S-ECC) and the maternal relatedness.

Methods

Subjects in this pilot cross-sectional study were recruited based on a convenient sample. DMFT(S)/dmft(s) caries and plaque scores were assessed during a comprehensive oral exam. Social-demographic and related background information was collected through a questionnaire. Saliva and plaque sample from all children and mother subjects were collected. C. albicans were isolated by BBL^™ CHROMagar^™ and also identified using germ tube test. S. mutans was isolated using Mitis Salivarius with Bacitracin selective medium and identified by colony morphology. Genetic relatedness was examined using restriction endonuclease analysis of the C. albicans genome using BssHII (REAG-B). Multilocus sequence typing was used to examine the clustering information of isolated C. albicans. Spot assay was performed to examine the C. albicans Caspofungin susceptibility between S-ECC children and their mothers. All statistical analyses (power analysis for sample size, Spearman’s correlation coefficient and multiple regression analyses) were implemented with SAS 9.4

Results

A total of 18 S-ECC child-mother pairs and 17 caries free child-mother pairs were enrolled in the study. Results indicated high C. albicans carriage rate in the oral cavity (saliva and plaque) of both S-ECC children and their mothers (>80%). Spearman’s correlation coefficient also indicated a significant correlation between salivary and plaque C. albicans and S. mutans carriage (p<0.01) and caries severity (p<0.05). The levels of C. albicans in the prepared saliva and plaque sample (1ml resuspension) of S-ECC children were 1.3 ± 4.5 x10⁴ cfu/ml and 1.2 ± 3.5 x10⁴ cfu/ml (~3-log higher vs. caries-free children). Among 18 child-mother pairs, >60% of them demonstrated identical C. albicans REAG-B pattern. C. albicans isolated from >65% of child-mother pairs demonstrated similar susceptibility to caspofungin in spot assay, while no caspofungin resistant strains were seen when compared with C. albicans wild-type strain SC5314. Interestingly, the regression analysis showed that factors such as antibiotic usage, birth weight, inhaler use, brushing frequency, and daycare attendance had no significant effect on the oral carriage of C. albicans in the S-ECC children.

Conclusions

Our results reveal that both the child with S-ECC and the mother were highly infected with C. albicans, while most of the strains were genetically related, suggesting that the mother might be a source for C. albicans acquisition in the oral cavity of children affected by the disease.

Oral Bacterial Acid-Base Metabolism in Caries Screening: A Proof-Of-Concept Study

The objective of this cross-sectional study was to clinically validate an array of biochemical tests for oral acid/alkali generation as caries screening instruments. 185 adult subjects (mean 33.6±10.6 years) were examined clinically for dental caries using the ICDAS criteria. Bitewing radiographs were used to confirm interproximal surfaces of posterior teeth. For the purposes of this study, subjects were classified as "caries-active" if they had at least one untreated caries lesion with ICDAS 4 or higher. Pooled supragingival plaque and unstimulated saliva samples were collected and assayed for pH changes from sucrose and urea metabolism using colorimetric tests. The validity of each test to discriminate between "caries-inactive" and "caries-active" subjects was assessed and compared to a commercial bacteriological caries-screening test using roc regression and logistic regression models. The AUCs of the plaque-urea (PU: 0.59 (0.51, 0.67)), plaque-urea-glucose (PUG: 0.59 (0.51, 0.67)) and saliva-urea-glucose (SUG: 0.59 (0.51, 0.67)) tests did not differ significantly from the bacteriological tests (CRT-mutans: 0.62 (0.54, 0.70); CRT-lactobacillus: 0.63 (0.56, 0.71) (P>0.05), but the plaque-glucose (SG), saliva-glucose (SG), saliva-urea (SU) and saliva-plaque-glucose (SPG) tests had significantly smaller AUCs (P<0.05). The AUCs for the PU, PUG, SUG, and the CRT-mutans tests were higher in subjects who had no existing dental restorations (PU: 0.90 (0.77, 1.04); PUG: 0.90 (0.79, 1.01); SUG: 0.89 (0.69, 1.08); CRT-mutans: 0.90 (0.73, 1.08)). The incorporation of the biochemical tests into a multidimensional bacteriological/psychosocial caries screening model significantly increased its diagnostic values (Se+Sp: 160.6, AUC: 0.846). In conclusion, as a proof of concept, the results of this study indicate that measuring the ability of dental plaque and saliva to metabolize urea together with the ability to generate acid from sugars may have a promising role in caries screening either independently, or as part of a multidimensional biological test.

Efficacy of three-tone disclosing agent as an adjunct in caries risk assessment

BACKGROUND

Today, most approaches to caries viewed that catastrophic change in normal plaque biofilm is responsible for the disease. The behavior and composition of the biofilm are a reflection of the oral environment; the caries is a reflection of adverse changes occurring in that environment. Thus, it is important to identify the pathogenicity of the plaque biofilm so as to predict the caries risk. The recently developed three-tone plaque disclosing agent was used to test its ability in identifying the pathogenicity of plaque.

AIM

To assess the efficacy of three-tone plaque disclosing agent in identifying the plaque pathogenicity and correlate with the clinical caries status and microbiological findings.

MATERIALS AND METHODS

Sixty children of 6-13 years age group of both sexes were clinically examined for caries and plaque scores, and then disclosing agent was applied; the color stained plaque samples were collected and cultured for microbiological assessment, and the data were analyzed based on the caries status of the children.

RESULTS

There was a significant difference between the pathological plaque of caries active and caries free group (P < 0.05). The pathological plaque scores and the total colony counts, Streptococcus counts and mutans streptococci counts increased with the increase in caries.

CONCLUSION

Three-tone plaque disclosing agent was effective in identifying pathological plaque and can be used as one of the chairside adjuvants in caries risk assessment.

Characterizing Diversity of Lactobacilli Associated with Severe Early Childhood Caries: A Study Protocol

Lactobacilli have been consistently associated with dental caries for decades; however, knowledge of this group of bacteria in the etiology of the disease is limited to quantitative elucidation. Nowadays, explicit identification of oral Lactobacillus species is possible, despite their taxonomic complexity. Here we describe a combined approach involving both cultivation and genetic methods to ascertain and characterize the diversity and abundance of the Lactobacillus population in the oral cavities of children with severe early childhood caries (S-ECC). Eighty 3- to 6-year-old children (40 S-ECC and 40 caries free) who were seeking dental care at the Pediatric Dental Clinic of Bellevue Hospital in New York City were invited to participate in this study. Clinical data on socio-demographic information and oral health behavior were obtained from the primary caregiver. The data included a detailed dental examination, children's medical history, and a questionnaire survey. Combined non-stimulated saliva and supra-gingival plaque samples were collected from each child and cultivated on selective media for quantitative measures of lactobacilli levels. The procedure for Lactobacillus species screening will include the random selection of 50 colonies per plate, extraction of DNA from each colony, and genotyping by arbitrarily primed polymerase chain reaction (AP-PCR). Each unique Lactobacillus AP-PCR genotype will be selected for taxonomic assessment by 16S rRNA gene sequencing analysis. Lactobacillus species will be identified by comparing the 16S rRNA sequences with the Ribosomal Database and the Human Oral Microbiome Database. Meanwhile, the same set of clinical samples will be independently subjected to genomic DNA isolation, 16S rRNA amplification with Lactobacillus genus-specific primers, sequencing, and taxonomic identification, both at genus and species levels with a customized pipeline. The distribution and phylogenetic differences of these Lactobacillus species will be compared between children with or without S-ECC. One of the main objectives of this study is to establish a study protocol for the identification and characterization of lactobacilli in the oral cavity. Future caries risk assessments can include lactobacilli counts (quantitative) and the presence/absence of specific cariogenic genetic signatures of a Lactobacillus species (qualitative) associated with S-ECC.

Understanding treatment effect mechanisms of the CAMBRA randomized trial in reducing caries increment

The Caries Management By Risk Assessment (CAMBRA) randomized controlled trial showed that an intervention featuring combined antibacterial and fluoride therapy significantly reduced bacterial load and suggested reduced caries increment in adults with 1 to 7 baseline cavitated teeth. While trial results speak to the overall effectiveness of an intervention, insight can be gained from understanding the mechanism by which an intervention acts on putative intermediate variables (mediators) to affect outcomes. This study conducted mediation analyses on 109 participants who completed the trial to understand whether the intervention reduced caries increment through its action on potential mediators (oral bacterial load, fluoride levels, and overall caries risk based on the composite of bacterial challenge and salivary fluoride) between the intervention and dental outcomes. The primary outcome was the increment from baseline in decayed, missing, and filled permanent surfaces (ΔDMFS) 24 mo after completing restorations for baseline cavitated lesions. Analyses adjusted for baseline overall risk, bacterial challenge, and fluoride values under a potential outcome framework using generalized linear models. Overall, the CAMBRA intervention was suggestive in reducing the 24-mo DMFS increment (reduction in ΔDMFS: -0.96; 95% confidence interval [CI]: -2.01 to 0.08; P = 0.07); the intervention significantly reduced the 12-mo overall risk (reduction in overall risk: -19%; 95% CI, -7 to -41%;], P = 0.005). Individual mediators, salivary log10 mutans streptococci, log10 lactobacilli, and fluoride level, did not represent statistically significant pathways alone through which the intervention effect was transmitted. However, 36% of the intervention effect on 24-mo DMFS increment was through a mediation effect on 12-mo overall risk (P = 0.03). These findings suggest a greater intervention effect carried through the combined action on multiple aspects of the caries process rather than through any single factor. In addition, a substantial portion of the total effect of the CAMBRA intervention may have operated through unanticipated or unmeasured pathways not included among the potential mediators studied.

Preparation and optimization of calcium fluoride particles for dental applications

Fluorides are used in dental care due to their beneficial effect in tooth enamel de-/remineralization cycles. To achieve a desired constant supply of soluble fluorides in the oral cavity, different approaches have been followed. Here we present results on the preparation of CaF2 particles and their characterization with respect to a potential application as enamel associated fluoride releasing reservoirs. CaF2 particles were synthesized by precipitation from soluble NaF and CaCl2 salt solutions of defined concentrations and their morphology analyzed by scanning electron microscopy. CaF2 particles with defined sizes and shapes could be synthesized by adjusting the concentrations of the precursor salt solutions. Such particles interacted with enamel surfaces when applied at fluoride concentrations correlating to typical dental care products. Fluoride release from the synthesized CaF2 particles was observed to be largely influenced by the concentration of phosphate in the solution. Physiological solutions with phosphate concentration similar to saliva (3.5 mM) reduced the fluoride release from pure CaF2 particles by a factor of 10-20 × as compared to phosphate free buffer solutions. Fluoride release was even lower in human saliva. The fluoride release could be increased by the addition of phosphate in substoichiometric amounts during CaF2 particle synthesis. The presented results demonstrate that the morphology and fluoride release characteristics of CaF2 particles can be tuned and provide evidence of the suitability of synthetic CaF2 particles as enamel associated fluoride reservoirs.

Lactobacillus: host-microbe relationships

Lactobacilli are a subdominant component of the human intestinal microbiota that are also found in other body sites, certain foods, and nutrient-rich niches in the free environment. They represent the types of microorganisms that mammalian immune systems have learned not to react to, which is recognized as a potential driving force in the evolution of the human immune system. Co-evolution of lactobacilli and animals provides a rational basis to postulate an association with health benefits. To further complicate a description of their host interactions, lactobacilli may rarely cause opportunistic infections in compromised subjects. In this review, we focus primarily on human-Lactobacillus interactions. We overview the microbiological complexity of this extraordinarily diverse genus, we describe where lactobacilli are found in or on humans, what responses their presence elicits, and what microbial interaction and effector molecules have been identified. The rare cases of Lactobacillus septicaemia are explained in terms of the host impairment required for such an outcome. We discuss possibilities for exploitation of lactobacilli for therapeutic delivery and mucosal vaccination.

Saliva fluoride before and during 3 years of supervised use of fluoride toothpaste

OBJECTIVES

The purpose of the study was to examine pre-brushing saliva fluoride concentrations before and during a large, 3-year, prospective toothpaste study on the effect of post-brushing rinsing on dental caries. The aims were to study saliva fluoride over time and the effect of rinsing on saliva fluoride and to relate saliva fluoride to caries increments and accumulation of plaque.

MATERIALS AND METHODS

Saliva samples (baseline and 1, 2, and 3 years) were collected from 11-year-old children attending two schools (A and B) in Kaunas, Lithuania, who refrained from brushing the evening and morning before saliva collection. Numbers of saliva samples collected varied from 264 at baseline to 188 at the 3-year follow-up. Children in school A rinsed with water after daily brushing, while children in school B did not rinse. Total caries and visible plaque were registered at baseline and after 3 years.

RESULTS

Mean saliva fluoride concentrations at baseline and after 1, 2, and 3 years from school A (rinsing) were 0.014, 0.026, 0.029, and 0.034 ppm and from school B (no rinsing) were 0.013, 0.028, 0.031, and 0.031 ppm, respectively. Increases in saliva fluoride from baseline were significant (Wilcoxon's test, p < 0.001), but the increase from baseline to year 1 was not statistically significantly different between schools. Saliva fluoride did not increase beyond year 1 and did at no time point differ between schools. Reductions in numbers of tooth surfaces with dental plaque were significantly positively related to the number of caries reversals over the 3 years.

CONCLUSIONS

Background saliva fluoride concentration is increased by brushing at least once daily on schooldays, does not increase further over 3 years, and is not affected by rinsing after brushing.

CLINICAL RELEVANCE

Continuous use of fluoride toothpaste produces ambient saliva fluoride levels similar to saliva fluoride in areas with fluoridated water.

Oral hygiene and dental caries in 5- to 6-year-old children in Ajman, United Arab Emirates

OBJECTIVE

To investigate the association between oral hygiene and dental caries in young children in the Emirate of Ajman, United Arab Emirates.

METHODS

A one-stage cluster sample was used to randomly select children. Clinical examinations were conducted by a single examiner. Parents completed questionnaires seeking information on child and family characteristics, dietary habits and oral hygiene practices.

RESULTS

The total number of children sampled was 1297. Dental examination and questionnaire data were obtained for 1036 (79.9%). Frequency of eating per day and snack consumption level were both significantly associated with plaque score. Children who brushed their teeth more often had lower plaque scores. The observed association between mean plaque score and mean decayed, missing, filled teeth suggests that children with high plaque scores are more likely to experience caries.

CONCLUSIONS

Brushing with fluoride toothpaste was under-utilized in Ajman. Tooth brushing therefore needs better promotion and reinforcement.

A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment)

This randomized parallel group clinical trial assessed whether combined antibacterial and fluoride therapy benefits the balance between caries pathological and protective factors. Eligible, enrolled adults (n = 231), with 1-7 baseline cavitated teeth, attending a dental school clinic were randomly assigned to a control or intervention group. Salivary mutans streptococci (MS), lactobacilli (LB), fluoride (F) level, and resulting caries risk status (low or high) assays were determined at baseline and every 6 months. After baseline, all cavitated teeth were restored. An examiner masked to group conducted caries exams at baseline and 2 years after completing restorations. The intervention group used fluoride dentifrice (1,100 ppm F as NaF), 0.12% chlorhexidine gluconate rinse based upon bacterial challenge (MS and LB), and 0.05% NaF rinse based upon salivary F. For the primary outcome, mean caries increment, no statistically significant difference was observed (24% difference between control and intervention groups, p = 0.101). However, the supplemental adjusted zero-inflated Poisson caries increment (change in DMFS) model showed the intervention group had a statistically significantly 24% lower mean than the control group (p = 0.020). Overall, caries risk reduced significantly in intervention versus control over 2 years (baseline adjusted generalized linear mixed models odds ratio, aOR = 3.45; 95% CI: 1.67, 7.13). Change in MS bacterial challenge differed significantly between groups (aOR = 6.70; 95% CI: 2.96, 15.13) but not for LB or F. Targeted antibacterial and fluoride therapy based on salivary microbial and fluoride levels favorably altered the balance between pathological and protective caries risk factors.

Establishment of Streptococcus mutans in infants induces decrease in the proportion of salivary α-haemolytic bacteria

OBJECTIVE

For paediatric dentists, an indicator to assess caries risk of infants is very important. Conventionally, the number and/or proportions of Streptococcus mutans have been employed as risk indicator; however, because such figures reflect the existing situation, they are not suitable for assessing caries risk of infants that have not yet been infected with S. mutans. Thus, we searched for an indicator for the establishment of S. mutans.

METHODS

To evaluate the changes caused by the establishment of S. mutans in the microbiota of the infant oral cavity, we monitored changes in the oral microbiota of two pre-dentate infants over a 3-year period and in a cross-sectional study of 40 nursery school-aged children by cultivation of saliva on nonselective blood agar, Mitis-Salivarius agar, and Mitis-Salivarius agar supplemented with bacitracin combined with identification of selected isolates.

RESULTS

Two longitudinal observations suggested that the establishment of S. mutans would induce a decrease in α-haemolytic bacteria in the microbial population of the oral cavity. This suggestion was compensated with the results of cross-sectional study, and it was revealed that the establishment of 10(3)  CFU/mL of mutans streptococci in saliva might be predicted by a microbiota comprising less than approximately 55% of α-haemolytic.

CONCLUSION

Decrease in the proportion of α-haemolytic bacteria in saliva of infant was found to be applicable as an indicator to predict the establishment of S. mutans and to assess dental caries risk as a background for planning of dental care and treatment in the infants before infection with S. mutans.

Dental caries experience and salivary Streptococcus mutans, lactobacilli scores, salivary flow rate, and salivary buffering capacity among 6-year-old Indian school children

Context:

Dental caries is a disease of multifactorial etiology. A variety of potential predictors have been examined for the association with caries increments in longitudinal and cross-sectional studies.

Aims:

The aim of this study was to assess the possible relationship among salivary cariogenic microflora, buffer capacity, secretion rate, and caries experience among 6-year-old school-going children in Davangere city, India.

Settings and Design:

A total of 196 6-year-old school children were selected by a two-stage random sampling method.

Materials and Methods:

Parents were interrogated regarding sociodemographic details. Clinical examination of children was conducted to assess dental caries experience, and stimulated saliva was collected to assess S. mutans levels, lactobacilli, salivary flow, and buffering capacity of saliva.

Statistical Analysis:

The difference in proportions was tested using Kruskal–Wallis analysis of variance (ANOVA) followed by the Mann–Whitney U-test for intragroup comparison, and the difference in mean was tested using ANOVA and independent sample t-test as necessary. Caries experience was correlated with salivary factors using Spearman's correlation coefficient.

Results:

Out of 196 children, 96 were boys and 100 were girls. Overall, 97 (49.49%) children were caries free (dmft, DMFT = 0) and 99 (50.51%) children presented with caries (dmft, DMFT>0). The mean dmft and dmfs score for the overall group was 3.20 and 5.43, respectively. The mean DMFT and DMFS score was 0.23 and 0.25, respectively. A highly significant correlation was seen between mean the caries score and salivary variables.

Conclusions:

High levels of salivary microbiological counts in correlation with the caries data stress the importance of these factors and urge the necessity of elective preventive programs in this region.

In vitro and in vivo assessment of newly developed slow-release fluoride glass device

BACKGROUND

The concept of constant and low levels of F intra-orally has been applied in dentistry using a controlled release delivery system in different forms of slow-release F intra-oral devices.

AIM

To investigate the effect of newly shaped plastic brackets on the level of fluoride released by the devices in vitro and to compare the level of fluoride released by unilateral versus bilateral slow-release fluoride glass devices in adults in vivo.

STUDY DESIGN

The phase I, in vitro assessment involved 15 slow-release fluoride glass devices divided into three groups. Group A contained five glass beads, Group B, five fluoride devices placed with the plastic brackets facing down, and Group C, five fluoride devices placed with the plastic brackets facing up. Evaluation of fluoride release was carried out daily for a week, weekly for a month, and monthly for 18 months. The In vivo phase II involved 20 adults (mean age 29.7+/-2.3 years) randomly divided and had unilateral or bilateral slow-release fluoride glass devices placed for six months.

RESULTS

Groups A and B released fluoride for up to ten months. In Group C, the glass beads became loose at the end of the first month and were excluded from further analysis. There was no statistical significant difference in the mean of total fluoride released by Groups A and B. All participants showed higher salivary fluoride levels than at baseline. There was no statistically significant difference in the level of fluoride released by the bilateral and unilateral groups.

CONCLUSIONS

The newly shaped slow-release fluoride glass devices showed continuous, safe, and effective fluoride release.

Novel technologies for the prevention and treatment of dental caries: a patent survey

IMPORTANCE OF THE FIELD

Dental caries is one of the most common preventable childhood diseases; people are susceptible to this ailment throughout their lifetime. In the US, 90% of late adolescents and young adults have dental caries, while 94% of all dentate adults had evidence of treated or untreated coronal caries. Dental caries is often not self-limiting and without proper care can progress until the tooth is destroyed.

AREAS COVERED IN THIS REVIEW

In this paper, the etiology of dental caries is briefly introduced. It is followed by a thorough review of patents and literatures on the recent development of various novel technologies for the prevention and treatment of dental caries.

WHAT THE READER WILL GAIN

Recent advances in anti-plaque agents, including chemoprophylactic agents, antimicrobial peptides, vaccines, probiotics/replacement therapy and sugar substitutes, and remineralization agents including fluorides and casein phosphopeptides are analyzed. TAKE HOME MASSAGE: Both the discovery of new anti-caries agents and the development of dentotropic delivery systems will be the future focus of this research field.

A review of slow-release fluoride devices

BACKGROUND

Fluoride has been used to combat dental caries using a number of different clinical approaches. An exciting relatively new development is fluoride slow-releasing devices that consistently elevate intra-oral fluoride levels of plaque and saliva for prolonged periods of up to two years.

METHODS

The literature on the use of slow-releasing fluoride devices in dentistry were reviewed. A Medline search on key words was carried out. All papers in English were individually reviewed.

RESULTS

Slow-releasing fluoride devices have been shown to be effective in elevating salivary fluoride levels in both animals and human studies and to enhance the remineralisation of dental enamel. They have been demonstrated to be safe to use and without the risk of fluoride toxicity. A double blind randomised clinical trial demonstrated 76% fewer new carious surface increment in high caries-risk children after two years.

CONCLUSIONS

These devices have a number of potential uses in dentistry and in particular have great potential for caries prevention of non-compliant high caries-risk groups.

Adjunctive chemotherapeutic suppression of mutans streptococci in the setting of severe early childhood caries: an exploratory study

OBJECTIVES

This investigational study assessed the suppressive effect of 10 percent povidone iodine (PI) coupled with elimination of active carious lesions on salivary mutans streptococci (MS) populations in children with severe early childhood caries (S-ECC).

METHODS

77 children (38 females, 39 males) were treated for S- ECC in one session; a 0.2 ml PI solution was applied to the dentition after dental surgery was completed and immediately wiped off. The subjects aged from 2 to 5 years (mean = 3.78 years) at baseline. Whole nonstimulated saliva samples were obtained at baseline, 30 days, 60 days, and 90 days post dental surgery. Samples were placed on ice and processed within 2 hours. The MS level in each sample was expressed as colony forming units (CFUs) per ml of saliva.

RESULTS

Approximately 50 percent of subjects had a >95 percent reduction in CFU/ml of saliva at each time point after baseline. The percentages of subjects with a >50 percent reduction in MS level were 85 percent at 30 days, 83 percent at 60 days, 84 percent at 90 days. The median (25th, 75th percentiles) CFUs/ml of saliva counts were 8.40 x 10(5) (1.49 x 10(5), 5.00 x 10(6)) at baseline (n= 77), 4.12 x 10(4) (8.40 x 10(3), 1.89 x 10(5)) at 30 days (n = 74), 4.62 x 10(4) (7.00 x 10(3), 1.36 x 10(5)) at 60 days (n = 70), and 5.09 x 10(4) (1.16 x 10(4), 1.00 x 10(5)) at 90 days (n = 70). The changes from baseline to 30 days, 60 days, and 90 days were statistically significant (P < 0.0001).

CONCLUSIONS

PI coupled with dental surgery has a significant suppressive effect on salivary MS levels in the setting of S-ECC for at least 90 days. These data strongly suggest that treatment with PI may be an important adjunct to dental surgery for S-ECC.

Slow-release fluoride devices: a literature review

Although the prevalence of caries has decreased dramatically over the past decades, it has become a polarised disease, with most of subjects presenting low caries levels and few individuals accounting for most of the caries affected surfaces. Thus it become evident for the need of clinical approaches directed at these high-risk patients, in order to overcome problems related to compliance and low attendance at dental care centres. Slow-release fluoride devices were developed based on the inverse relationship existing between intra-oral fluoride levels and dental caries experience. The two main types of slow-release devices - copolymer membrane type and glass bead - are addressed in the present review. A substantial number of studies have demonstrated that these devices are effective in raising intra-oral F concentrations at levels able to reduce enamel solubility, resulting in a caries-protective effect. Studies in animals and humans demonstrated that the use of these devices was able to also protect the occlusal surfaces, not normally protected by conventional fluoride regimens. However, retention rates have been shown to be the main problem related to these devices and still requires further improvements. Although the results of these studies are very promising, further randomised clinical trials are needed in order to validate the use of these devices in clinical practice. The concept of continuously providing low levels of intra-oral fluoride has great potential for caries prevention in high caries-risk groups.

Salivary glucosyltransferase B as a possible marker for caries activity

Bacteria-derived glucosyltransferases (Gtf) (EC 2.4.1.5), through synthesizing glucan polymers from sucrose and starch hydrolysates, play an essential role in the etiology and pathogenesis of caries. We attempted to correlate the levels of Gtf in whole saliva with the prevalence of carious lesions in young children. We examined saliva from children who were either free of overt carious lesions, or had severe early childhood caries (mean dmfs = 18.72 +/- 9.0 SD), for Gtf by direct enzyme assay. The levels of GtfB, GtfC and GtfD from Streptococcus mutans in the saliva using monoclonal/specific antibodies in an enzyme-linked immunosorbent assay were determined. Multiple logistic regression analyses with model selection showed that GtfB levels correlated with dmfs values of the subjects (p = 0.006). There was no correlation between total Gtf activity as measured by direct enzyme assay and dmfs values. There was a strong correlation between mutans streptococci populations in saliva and caries activity. Collectively, these data show that GtfB levels in saliva correlate strongly with presence of clinical caries and with number of carious lesions in young children. It is also possible to measure different Gtfs, separately, in whole saliva. These observations may have important clinical implications, may lead to development of a chair side caries activity test and support the importance of GtfB in the pathogenesis of dental caries.

Influences on children's oral health: a conceptual model

OBJECTIVES

Despite marked improvements over the past century, oral health in America is a significant problem: caries is the most common chronic disease of childhood. Much oral health research examines influences primarily in the oral cavity or focuses on a limited number of individual-level factors. The purpose of this article was to present a more encompassing conceptual model of the influences on children's oral health.

METHODS

The conceptual model presented here was derived from the population health and social epidemiology fields, which have moved toward multilevel, holistic approaches to analyze the complex and interactive causes of children's health problems. It is based on a comprehensive review of major population and oral health literatures.

RESULTS

A multilevel conceptual model is described, with the individual, family, and community levels of influence on oral health outcomes. This model incorporates the 5 key domains of determinants of health as identified in the population health literature: genetic and biological factors, the social environment, the physical environment, health behaviors, and dental and medical care. The model recognizes the presence of a complex interplay of causal factors. Last, the model incorporates the aspect of time, recognizing the evolution of oral health diseases (eg, caries) and influences on the child-host over time.

CONCLUSIONS

This conceptual model represents a starting point for thinking about children's oral health. The model incorporates many of the important breakthroughs by social epidemiologists over the past 25 years by including a broad range of genetic, social, and environmental risk factors; multiple pathways by which they operate; a time dimension; the notion of differential susceptibility and resilience; and a multilevel approach. The study of children's oral health from a global perspective remains largely in its infancy and is poised for additional development. This work can help inform how best to approach and improve children's oral health.

Caries patterns in primary dentition in 3-, 5- and 7-year-old children: spatial correlation and preventive consequences

This study aimed to contribute to the descriptive information of oral health status in the primary dentition, especially concerning the distribution and spatial correlation of lesions. Data were obtained from two surveys. In the Signal-Tandmobiel project 4,468 7-year-old children in Flanders (Belgium) were selected by a stratified clustered random sample. In the Tandje de Voorste - Smile for Life (TDV) project, data were obtained from 1,291 3-year-old and 1,315 5-year-old children. The children were examined by trained dentists, using standardized and widely accepted criteria, based on the British Association for the Study of Community Dentistry criteria. At the population level, symmetry in the prevalence of caries experience across the midline was tested at the tooth and tooth surface levels using generalized estimating equations and alternating logistic regression (ALR) approaches. Individual symmetry was tested using an approach described by Hujoel et al. [J Dent Res 1994;73:1575-1580]. Descriptive observations suggested a symmetrical distribution of caries experience at the population level. The null hypothesis of symmetry could not be rejected at a 0.05 level, suggesting that caries experience might be symmetric in the deciduous dentition. Based on the ALR approach, 2 x 2 associations of caries experience at the tooth and surface levels, both in 5- and 7-year-olds, appeared to be strongest for the left-right pairs in the mandible, followed by the left-right pairs in the maxilla. At the individual level the hypothesis of random caries pattern was rejected (p < 0.0001). In conclusion, at the population level the null hypothesis of left-right symmetry could not be rejected, while at the individual level lesions tended to cluster on one side of the mouth.

Deposition of fluoride on enamel surfaces released from varnishes is limited to vicinity of fluoridation site

The aim of the in-situ study was to determine fluoride uptake in non-fluoridated, demineralized enamel after application of fluoride varnishes on enamel samples located at various distances from the non-fluoridated samples. All enamel samples used were demineralized with acidic hydroxyethylcellulose before the experiment. Intra-oral appliances were worn by ten volunteers in three series: (1, Mirafluorid, 0.15% F; 2, Duraphat, 2.3% F and 3, unfluoridated controls) of 6 days each. Each two enamel samples were prepared from 30 bovine incisors. One sample was used for the determination of baseline fluoride content (BFC); the other was treated according to the respective series and fixed in the intra-oral appliance for 6 days. Additionally, from 120 incisors, each four enamel samples were prepared (one for BFC). Three samples (a–c) were placed into each appliance at different sites: (a) directly neighboured to the fluoridated specimen (=next), (b) at 1-cm distance (=1 cm) and (c) in the opposite buccal aspect of the appliance (=opposite). At these sites, new unfluoridated samples were placed at days 1, 3 and 5, which were left in place for 1 day. The volunteers brushed their teeth and the samples with fluoridated toothpaste twice per day. Both the KOH-soluble and structurally bound fluoride were determined in all samples to determine fluoride uptake and were statistically analyzed. One day, after fluoridation with Duraphat, KOH-soluble fluoride uptake in specimen a (=next) was significantly higher compared to the corresponding samples of both the control and Mirafluorid series, which in turn were not significantly different from each other. At all other sites and time points, fluoride uptake in the enamel samples were not different from controls for both fluoride varnishes. Within the first day after application, intra-oral-fluoride release from the tested fluoride varnish Duraphat leads to KOH-soluble fluoride uptake only in enamel samples located in close vicinity to the fluoridation site.

Delivery challenges for fluoride, chlorhexidine and xylitol

The progression or reversal of dental caries is determined by the balance between pathological and protective factors. It is well established that a) fluoride inhibits demineralization and enhances remineralization, b) chlorhexidine reduces the cariogenic bacterial challenge, and c) xylitol is non-cariogenic and has antibacterial properties. The challenge that we face is how best to deliver these anti-caries entities at true therapeutic levels, over time, to favorably tip the caries balance. High caries risk people, including children with Early Childhood Caries (ECC), are a special challenge, since high cariogenic bacterial activity can override fluoride therapy. Current fluoride and chlorhexidine varnishes deliver all their activity within about 24 hours. Early studies with experimental slow release fluoride devices retained elevated levels of fluoride for months in a therapeutic range but have not been pursued. Preventive dentistry has largely ignored the benefits of reducing the bacterial challenge, partially due to primitive and inadequate delivery systems. For example, Chlorhexidine applied as a rinse partially reduces some bacteria but not others that are hiding within the biofilm. Better antibacterials and better delivery systems are needed. Xylitol delivered by gum or lozenge appears to be effective clinically in reducing cariogenic bacteria and caries levels, but novel systems that deliver therapeutic amounts when needed would be a major advance, especially for young children. Reducing the cariogenic bacterial challenge and enhancing the effect of fluoride by the use of new sustained-delivery systems would have a major effect on dealing with caries as a disease.

Quantitative detection of Streptococcus mutans in the dental plaque of Japanese preschool children by real-time PCR

AIMS

To detect quantitatively the total bacteria and Streptococcus mutans in dental plaque by real-time PCR with prbac, Sm and GTF-B primers, and to compare their presence with the prevalence of dental caries in Japanese preschool children.

METHODS AND RESULTS

Human dental plaque samples were collected from the labial surfaces of the upper primary central incisors of 107 children. The dental status was recorded as dft by WHO caries diagnostic criteria. Positive dt and dft scores by the Sm or GTF-B primer were significantly higher than negative scores (P < 0.01). The proportions of Strep. mutans to the total bacteria from sound, and sound and/or filled upper primary incisors were significantly lower than those from decayed or filled, and decayed incisors, respectively (P < 0.01).

CONCLUSIONS

The ratios of Strep. mutans to total bacteria in plaque detected by real-time PCR with Sm and GTF-B primers were closely associated with the prevalence of dental caries in Japanese preschool children.

SIGNIFICANCE AND IMPACT OF THE STUDY

These assays may be useful for the assessment of an individual's risk of dental caries.

Application of nonhomogenous Markov models for analyzing longitudinal caries risk

OBJECTIVES

Markov modeling is a useful mathematical procedure for calculating probabilities of disease prognosis. Increasingly, Markov models are being applied in medical and health services research and also in social sciences research. The purpose of our study was to use the Markov process to determine time-dependent transition probabilities for caries-free children to convert to a caries-active state and to assess the impact of salivary mutans streptococci (MS) levels on caries status.

METHODS

Our analysis was based on data obtained from a 6-year longitudinal study of risk factors associated with caries onset in children.

RESULTS

Based on a two-state Markov model, the probability that a caries-free child would convert to a caries-active state during the study ranged between 0.0046 and 0.0471. The highest probability of converting from a caries-free state to a caries-active state was 0.0471 at age 8.5 years.

CONCLUSIONS

In addition to standard statistical methods of analyzing longitudinal caries data, Markov models show promise for use in the analysis of caries risk.

Dental sealant longevity in a cohort of young U.S. naval personnel

BACKGROUND

The U.S. Navy emphasizes caries prevention and encourages the placement of dental sealants on the caries-susceptible teeth of patients at risk of developing caries. The authors analyzed dental records to assess the longevity of dental sealants placed in naval personnel.

METHODS

A cluster sample of dental records from 1,123 personnel who entered naval service in 1997 was drawn from eight Navy dental treatment facilities. The authors determined the number of sealants provided, the number of sealants that failed over the observation period (1997-2001), the dates of sealant failure and the longevity of sealants placed during and after recruit training.

RESULTS

A total of 319 personnel received sealants during their first two years of service. The authors evaluated 1,467 sealed teeth. They followed the sealants for an average of 35 months. They noted 179 sealant failures in 102 subjects; 69 previously sealed teeth required sealant replacement, and 110 sealed teeth required restoration of the occlusal surface. Among those sealants that failed, the mean length of time from placement to failure was 26 months. Sealant failure rates were significantly higher among subjects at moderate risk or high risk of developing caries than among subjects at low risk.

CONCLUSIONS

After an average of 35 months, 87.8 percent of the sealants placed in this population were retained and functional. Subjects who were at moderate or high risk of developing caries demonstrated significantly higher sealant failure rates than those at low risk of developing caries.

CLINICAL IMPLICATIONS

Dental sealants can be retained successfully in adults. They should be considered a viable treatment alternative for adult patients who are susceptible to caries; however, patients at elevated risk of developing caries may require more frequent re-evaluation and maintenance to achieve maximum benefit.

Salivary fluoride levels following application of fluoride varnish or fluoride rinse

OBJECTIVES

This study examined the concentration of fluoride in whole saliva over time following the application of a fluoride varnish or a single rinse with a fluoride solution.

METHODS

A two-period, two-treatment randomized cross-over experimental trial with a 2-week washout period was used with 16 adult subjects. In the first period, eight subjects rinsed once with a 0.05% NaF solution and 8 subjects had 5.0% NaF varnish applied to facial and lingual surfaces of 20 teeth. Stimulated whole saliva was collected at baseline, 5 and 15 min, 1, 2, 4, 8, 12, 24, 32, 48, 56, 72, 80, 96, 104 h. After the washout period each subject was switched to the other treatment and saliva was collected at the same intervals. Salivary fluoride content was measured with the micro-diffusion method.

RESULTS

The NaF levels peaked at 5 min after application for both varnish (mean +/- SE 24.5 +/- 5.0 ppm) and rinse (3.2 +/- 0.8 ppm). Mean NaF levels returned to baseline, on average, within 2 h for the rinse and within 24 h for the varnish. The maximum fluoride levels were significantly greater (P < 0.01) with the varnish than with the rinse and remained above baseline levels for a longer duration.

CONCLUSIONS

Salivary fluoride levels with the rinse returned to baseline, on average, in 2 h while they remained elevated for, on average, 24 h with the varnish. Salivary fluoride levels from the varnish were found to be comparable with those in previous studies for 1.1% neutral NaF.

Production and characterization of species-specific monoclonal antibodies against Actinomyces naeslundii and Lactobacillus casei

Dental caries is a disease induced by a few cariogenic bacterial species. Quantitative detection of these cariogenic bacteria could provide useful information for caries risk assessment. In this study, we developed highly species-specific monoclonal antibodies (MAbs) against the type strains of Actinomyces naeslundii ATCC 12104 and Lactobacillus casei ATCC 11578. Assayed with immunoprecipitation and immunofluorescent microscopy, these antibodies showed high sensitivities and specificities in detecting A. naeslundii and L. casei in saliva. Examining 100 saliva samples using these MAb-based techniques, we found that the number of A. naeslundii in saliva ranges from 0.5 x 10(4) to 4.8 x 10(5) and that the number of L. casei in saliva ranges from 1 x 10(4) to 1.2 x 10(6). With fluorescent imaging techniques and confocal laser scanning microscopy (CLSM), these antibodies were used to visualize A. naeslundii and L. casei within dental plaques derived from stimulated whole human saliva in vitro. The study demonstrated that these MAbs were also able to effectively detect A. naeslundii and L. casei in plaque.

Health care savings from microbiological caries risk screening of toddlers: a cost estimation model

OBJECTIVES

Modeling new biomedical technologies and determining their expected cost is necessary before initiating formal clinical trials. This paper estimates an economic model for the potential cost impact of microbiological screening of toddlers for caries risk compared to the traditional method of managing pediatric caries.

METHODS

Potential cost savings were calculated based on screening test properties (sensitivity and specificity) derived from a population of 1,180 children aged 1 to 3 years with a caries prevalence of 15 percent. An algorithm was then developed to allocate prevalent and anticipate incident caries, treatment effectiveness assumptions, and existing regional treatment costs.

RESULTS

The cost analysis model conservatively predicts savings of 7.3 percent from screening and early intervention. Cumulative dental treatment costs for a child at age 4 years are $367.90 if the child has been screened and $396.70 otherwise. The model further predicts that cost savings increase significantly as caries prevalence increases.

CONCLUSIONS

Microbiologic risk assessment for pediatric caries may be an example of a preventive public health screening technique that results in both clinical benefits and cost savings. If the model is validated by randomized clinical trials, microbiologic screening could be used by pediatric primary care providers to identify toddlers who require early referral to dentists for further risk assessment and early caries management.

The science and practice of caries prevention

BACKGROUND AND OVERVIEW

Dental caries is a bacterially based disease. When it progresses, acid produced by bacterial action on dietary fermentable carbohydrates diffuses into the tooth and dissolves the carbonated hydroxyapatite mineral--a process called demineralization. Pathological factors including acidogenic bacteria (mutans streptococci and lactobacilli), salivary dysfunction, and dietary carbohydrates are related to caries progression. Protective factors--which include salivary calcium, phosphate and proteins, salivary flow, fluoride in saliva, and antibacterial components or agents--can balance, prevent or reverse dental caries.

CONCLUSIONS

Caries progression or reversal is determined by the balance between protective and pathological factors. Fluoride, the key agent in battling caries, works primarily via topical mechanisms: inhibition of demineralization, enhancement of remineralization and inhibition of bacterial enzymes.

CLINICAL IMPLICATIONS

Fluoride in drinking water and in fluoride-containing products reduces caries via these topical mechanisms. Antibacterial therapy must be used to combat a high bacterial challenge. For practical caries management and prevention or reversal of dental caries, the sum of the preventive factors must outweigh the pathological factors.

Trends in preventive care: caries risk assessment and indications for sealants

BACKGROUND

In the 21st century, risk assessment models will continue to be developed. By understanding patients' susceptibility to disease, better treatment and preventive regimens can be offered. As the causative agent of dental caries is bacterial, the interaction between the susceptible host, the causative agent and the environment determine whether caries occurs--regardless of the patient's age.

CLINICAL IMPLICATIONS

This article reviews risk assessment for dental caries and the implication for developing preventive strategies. It also describes the indications and uses of sealants in the prevention of dental caries.

A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride: is there any anti-caries benefit from swallowing fluoride?

The belief that fluoridated water reduces caries incidence by half stems from years of fluoridation studies where the caries rates of people in various fluoridated and non-fluoridated communities were compared. By their nature, the water fluoridation trials were not able to distinguish between the topical effects of the fluoride in the water and the systemic effects of the fluoride that is inevitably swallowed and incorporated into developing teeth. Some attempts have been made to estimate the contribution of systemic fluoride to the control of dental caries but researchers are discovering that the topical effects of fluoride are likely to mask any benefits that ingesting fluoride might have. In this updated review of the pre-eruptive vs. post-eruptive benefits of fluoride in the prevention of dental caries, a re-examination of the literature, which is often cited to support the notion that swallowing fluoride, either in water or in pill form, was done in recognition of the mounting evidence for the topical mechanism as being the primary mechanism for the prevention of dental caries. Maximum benefits from exposing newly erupted teeth to topical fluoride in the oral cavity may have been seriously under-estimated. This has obvious implications for the use of systemic fluorides to prevent dental caries and forces everyone working in the field to examine more closely the risks and benefits of fluoride in all its delivery forms.

Prevention and reversal of dental caries: role of low level fluoride

Dental caries is a bacterially based disease that progresses when acid produced by bacterial action on dietary fermentable carbohydrates diffuses into the tooth and dissolves the mineral, that is, demineralization. Pathological factors including acidogenic bacteria (mutans streptococci and lactobacilli), salivary dysfunction, and dietary carbohydrates are related to caries progression. Protective factors which include salivary calcium, phosphate and proteins, salivary flow, and fluoride in saliva can balance, prevent or reverse dental caries. Fluoride works primarily via topical mechanisms which include (1) inhibition of demineralization at the crystal surfaces inside the tooth, (2) enhancement of remineralization at the crystal surfaces (the resulting remineralized layer is very resistant to acid attack), and (3) inhibition of bacterial enzymes. Fluoride in drinking water and in fluoride-containing products reduces tooth decay via these mechanisms. Low but slightly elevated levels of fluoride in saliva and plaque provided from these sources help prevent and reverse caries by inhibiting demineralization and enhancing remineralization. The level of fluoride incorporated into dental mineral by systemic ingestion is insufficient to play a significant role in caries prevention. The effect of systemically ingested fluoride on caries is minimal. Fluoride "supplements" can be best used as a topical delivery system by sucking or chewing tablets or lozenges prior to ingestion.

The oral health of children with clefts--a review

A review of the studies of the caries prevalence and periodontal health of patients with cleft lip and palate (CLP) revealed that only five investigations of caries prevalence in CLP patients included children. One reported that CLP children did not have a higher caries prevalence in the permanent dentition, whereas more recent studies have reported a higher caries prevalence in both the primary and permanent dentitions of CLP children than in those of noncleft children. However, there is wide variation in the teeth examined and the method of presenting data on caries prevalence. Six papers have reported on the periodontal health of adult CLP patients, and only one has done so on that of children. The adult CLP patients had poorer oral hygiene and more gingivitis, but there is no conclusive evidence that they have a higher risk of developing periodontal disease. No data on the oral hygiene of CLP children were available, but it has been emphasized that they have significantly more gingivitis than noncleft children, especially in the maxillary anterior teeth.

Caries prediction--state of the art

This paper considers the question of whether, by using the currently available measures for assessing caries risk, one can identify with sufficient accuracy the high caries-risk susceptible individuals who need individual protection to avoid having an unacceptably high number of new cavities. In addition, the outline of a typical caries prediction study is presented with an example, Finally, the accuracy of an actual caries prediction is compared with the accuracy of predicting the onset of acute myocardial infarction in order to point out the fact that the risk of any disease is difficult to assess accurately.

The association of early dental caries patterns with caries incidence in preschool children

OBJECTIVES

This study assessed the development of caries in preschool children over two years according to baseline caries pattern.

METHODS

Connecticut Head Start children (n = 142, mean age = 3.8 years) were examined for dental caries at baseline (spring 1991) and once annually for two years. Children were categorized at baseline as caries-free, having pit and fissure (PF) caries, or having maxillary anterior (MA) caries.

RESULTS

After two years, children who presented at baseline with MA or PF caries had a mean posterior dmfs of greater than seven and four times, respectively, that of children who were caries-free at baseline. When dental caries of the primary dentition was categorized by specific posterior patterns (i.e., posterior proximal [PP] and buccal/lingual [BL]), change in dmfs for the PP and BL patterns in the group that presented with pit/fissure caries at baseline were nearly four and three times greater, respectively, than for those in the caries-free group. The group that presented with maxillary anterior caries at baseline had PP and BL caries increments eight times those of children who began caries-free.

CONCLUSION

Dental caries presentation in 3- to 4-year-old children can identify those children and tooth surfaces that will be at the greatest risk for future caries development.

The impact of recent changes in the epidemiology of dental caries on guidelines for the use of dental sealants

This paper reviews recent changes in the epidemiology of dental caries and assesses their potential impact on the diagnosis and management of the disease and the planning and operation of sealant programs. These changes, such as the decline in caries and slowing of the rate of progression of the disease, have important implications for diagnosing and treating incipient lesions, predicting caries risk, and conducting effective disease preventive programs. Traditional paradigms for restoring carious lesions are being replaced by newer strategies that emphasize disease prevention and conservation of tooth structure. The search continues for the identification of practical models for predicting caries risk at the individual level. This paper describes a method useful for targeting resources in sealant placement programs by enabling one to determine the relative effectiveness of sealing alternative tooth surfaces in the oral cavity. One guide serves as a widely adopted manual for those who use or intend to use dental sealants in caries prevention programs. This paper provides a brief review of that document, "Preventing Pit and Fissure Caries: A Guide to Sealant Use," as well as guidelines for sealant utilization provided by the American Dental Association, and information regarding dental sealant programs under Medicaid. The final portion of the paper provides a synthesis of the epidemiology reviewed and summarizes the implications of findings for sealant programs.

Inverse correlation between the proportion of salivary bacteria inhibiting Streptococcus mutans and the percentage of untreated carious teeth

To evaluate the role of inhibitory substances produced by bacteria in the oral cavity, we estimated, by a deferred test on Todd-Hewitt agar enriched with hemin and vitamin K, the proportion of bacteria that inhibited or stimulated the growth of Streptococcus mutans and Porphyromonas gingivalis, from the saliva of 109 patients (54 males and 55 females) attending our dental clinics. The patients, aged from 8 to 75 years old (mean: 31 +/- 18 years), were randomly selected whatever the reason for their visit. The results, evaluated with the Spearman rank test, indicated that there was no statistically significant (P > 0.05) correlation between the proportion of salivary bacteria inhibiting or stimulating P. gingivalis with the Community Periodontal Index of Treatment Needs (CPITN), the number of carious, missing and filled teeth, or with the decayed, missing and filled teeth index (DMFT). Also, no statistically significant correlation was observed between the proportion of salivary bacteria stimulating the growth of S. mutans and the above mentioned health indexes. However, a statistically significant (P < 0.005) negative correlation was found between the percentage of cultivated bacteria that inhibit S. mutans and the percentage of untreated carious teeth as well as with the CPITN. The results thus indicate a possible role for inhibitory substances produced by bacteria in the maintenance of oral health.

Prediction of the need for bitewing radiography in detecting caries in the primary dentition

In recent literature some controversy has been reported regarding the prescription of bitewing radiography for caries diagnosis, particularly in children. While the low prevalence of caries justified the decision not to take radiographs, it has also been reported that the benefits of detecting slowly progressing, clinically undetectable lesions could outweigh the "costs" of radiography. It was the aim of this study to investigate whether specific risk factors could predict the presence of additional dentinal lesions (ADL) in the primary dentition on radiographs which could not be detected by visual inspection. Bitewing radiographs were taken in 182 children aged 5 yr. Risk factors for ADL were identified and appropriate rating scales were designed. Sensitivities, specificities and relative risks expressing the relation between scale values and ADL were computed for each of the risk factors and direct and stepwise discriminant analyses were performed. The results indicate that particularly the presence of lactobacilli and mutans streptococci in saliva and the detection of three or more discolored enamel lesions or dentinal lesions were good predictors of ADL. It is suggested that these risk factors be used in the timing of bitewing radiography in children with a primary dentition.