Comparison of the intakes of sugars by young children with and without dental caries experience

BACKGROUND: Relationships among sugars and dental caries in contemporary societies are unclear. The authors describe young children's intakes of nonmilk extrinsic (NME) and intrinsic/milk sugars and relate those intakes to dental caries. METHODS: The authors conducted cross-sectional analyses of dietary data collected from the Iowa Fluoride Study using three-day diaries for subjects at ages 1, 2, 3, 4 and 5 years and for subjects aged 1 through 5 years according to dental caries experience at 4.5 to 6.9 years of age. They categorized foods and beverages as containing NME or intrinsic/milk sugars. RESULTS: Subjects' total, NME, food NME and intrinsic/milk sugars intakes at ages studied did not differ between subjects with and without caries experience. Beverage NME sugars intakes at age 3 years predicted caries (P < .05) in logistic regression models adjusted for age at dental examination and for fluoride intake. CONCLUSIONS: Dental caries is a complex, multifactorial disease process dependent on the presence of oral bacteria, a fermentable carbohydrate substrate and host enamel. A simple NME-intrinsic/milk sugars categorization appears insufficient to capture the complex dietary component of the caries process. CLINICAL IMPLICATIONS: Cariogenicity is more likely a function of the food and/or beverage vehicle delivering the sugar and the nature of exposure-that is, frequency and length of eating events-than of the sugar's categorization.     

Early childhood caries screening tools: a comparison of four approaches

BackgroundEarly childhood caries (ECC) is prevalent and consequential. Risk assessment tools have been proposed that can be used to identify children who require intensive interventions. In this study, the authors compare four approaches for identifying children needing early and intensive intervention to prevent or minimize caries experience for their accuracy and clinical usefulness.MethodsThe authors screened 229 predominantly low-income Hispanic children younger than 3 years with ECC and 242 without ECC by using the American Academy of Pediatric Dentistry's Caries-risk Assessment Tool (CAT) and the optional screening measure of culturing Streptococcus mutans. The authors compared four approaches (CAT, CAT minus socioeconomic status, CAT minus socioeconomic status plus mutans streptococci [MS] and MS alone) for accuracy and clinical usefulness.ResultsThe results of the CAT demonstrated high sensitivity (100.0 percent) and negative predictive value (NPV) (100.0 percent) but low specificity (2.9 percent) and positive predictive value (PPV) (49.4 percent). The MS culture alone had the highest combination of accuracy and clinical usefulness (sensitivity, 86.5 percent; specificity, 93.4 percent; PPV, 92.5 percent; NPV, 87.9 percent). When we removed the socioeconomic status element, the CAT's performance improved.ConclusionsSalivary culture of MS alone in a population of young, low-income Hispanic childrenoutperformed the CAT and variations on the CAT for test accuracy (sensitivity and specificity) and clinical usefulness (predictive values).Clinical ImplicationsScreening for ECC by using salivary MS cultures and variations on the CAT are promising approaches for identifying children who need early and intensive intervention to prevent or minimize caries experience.     

Correlates of root caries experience in middle-aged and older adults in the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry research network

BackgroundThe authors examined the correlates of root caries experience for middle-aged adults (aged 45–64 years) and older adults (65 years and older) to test the hypothesis that the factors related to root caries are different for middle-aged adults than they are for older adults.MethodsThe authors conducted an observational cross-sectional study that focused on adult patients aged 45 to 97 years recruited from the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry research network (N = 775). The outcome variable was any root caries experience (no/yes). The authors hypothesized that sociodemographic, intra- oral and behavioral factors were root caries correlates. The authors used Poisson regression models to generate overall and age-stratified prevalence ratios (PRs) of root caries, and they used generalized estimating equations to account for practice-level clustering of participants.ResultsA total of 19.6 percent of adults had any root caries. A dentist’s assessment that the patient was at high risk of developing any caries was associated with greater prevalence of root caries experience in both middle-aged adults (PR, 2.70; 95 percent confidence interval [CI], 1.63–4.46) and older adults (PR, 1.87; 95 percent CI, 1.19–2.95). The following factors were associated significantly with increased root caries prevalence but only for middle-aged adults: male sex (P = .02), self-reported dry mouth (P < .001), exposed roots (P = .03) and increased frequency of eating or drinking between meals (P = .03). No other covariates were related to root caries experience for older adults.ConclusionsWithin a practice-based research network, the factors associated with root caries experience were different for middle-aged adults than they were for older adults. Research is needed to identify relevant root caries correlates for adults 65 years and older.Practical ImplicationsInterventions aimed at preventing root caries are likely to be different for middle-aged adults than for older adults. Dentists should use root caries prevention programs that address appropriate aged-based risk factors.     

The impact of the Great Recession on untreated dental caries among kindergarten students in North Carolina

BackgroundThe authors conducted a study to determine the impact of the Great Recession on untreated dental caries in kindergarten-aged children in North Carolina (NC).MethodsDuring the seven school years from 2003–2004 through 2009–2010, the state dental public health program assessed 608,339 kindergarten students for untreated decayed primary teeth (dt) as part of the statewide public health surveillance system. The authors aggregated observations to the school level and matched 7,660 school-year observations for 1,215 schools to National School Lunch Program (NSLP) participation rates, their primary economic indicator of the Great Recession. The authors included additional county-level economic indicators and measures of dentist supply and Medicaid enrollment. They used ordinary least squares regression with school-and year-fixed effects to examine the association of variables with the proportion of children with more than one dt for all schools and for schools with a greater than 10 percent increase in NSLP participation after 2006.ResultsThe authors found a small but statistically significant association between the proportion of children in the schools participating in the NSLP and the proportion of kindergarten students who had more than one dt (β, 0.031; 95 percent confidence interval [CI], 0.001 to 0.0604). This association was greater in schools that had a greater than 10 percent increase in NSLP participation (β, 0.068; 95 percent CI, ?0.007 to 0.143). Regression estimates indicate a 1.3– and 3.1–percentage point cumulative increase in the proportion of children with more than one dt during the period from 2008 through 2009 for all schools and high-risk schools, respectively.ConclusionIncreased NSLP enrollment was associated with less treatment for dental caries in 5-year-old children.Practical ImplicationsFewer children are receiving needed dental treatment because of the Great Recession. Recent gains made in the treatment of dental caries in children in NC have slowed as a result.     

Preventing dental caries associated with sugar-sweetened beverages

BackgroundDietary intake of sugar-sweetened beverages (SSBs) has increased during the past 30 years, and SSB intake is associated with caries.

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ConclusionsSSBs vary in the quantity and nature of sugars they contain; however, all of the sugars are fermentable by oral bacteria and potentially cariogenic.Practical ImplicationsOral health care practitioners should assess patients’ SSB intakes by asking questions regarding the quantity, frequency and duration of SSB intake. In response to individual behaviors, practitioners should tailor recommendations when providing anticipatory guidance to help patients decrease their exposure to SSBs for caries prevention. In light of the association between SSB intake and caries risk, as well as the increased consumption of SSBs, all dental practices should assess patients’ SSBs intake.     

Chemomechanical caries removal in children: an operator's and pediatric patients' responses

BACKGROUND: This study investigated an operator's and pediatric patients' responses to chemo-mechanical caries removal (CMCR) versus the traditional method (TM) of caries removal using a handpiece and a round bur when treating dentinal-depth occlusal lesions with minimal enamel access in primary molars. METHODS: Data were collected from 50 children at baseline and before, during and after caries removal using CMCR or TM. The subjects in the CMCR group were on average younger than the subjects in the TM group and had more deep lesions. RESULTS: The operator rated CMCR as needing more clinical and technical effort and more total effort than TM. He was less satisfied with CMCR than with TM. Subjects in the CMCR group perceived the time needed for treatment as significantly longer than did the subjects in the TM group. Fear of the dentist decreased in subjects in the TM group from before to after the operative appointment, while it increased in subjects in the CMCR group. CONCLUSIONS: The authors found no direct advantage in using CMCR over using TM. CLINICAL IMPLICATIONS: CMCR cannot be recommended as an alternative to TM when treating dentinal depth occlusal lesions with minimal access in primary molars.     

The effect of dental sealants on bacteria levels in caries lesions: a review of the evidence

BACKGROUND: Concern about inadvertently sealing over caries often prevents dentists from providing dental sealants. The objective of the authors' review was to examine the effects of sealants on bacteria levels within caries lesions under dental sealants. METHODS: The authors searched electronic databases for comparative studies examining bacteria levels in sealed permanent teeth. To measure the effect of sealants on bacteria levels, they used the log(10) reduction in mean total viable bacteria counts (VBC) between sealed and not-sealed caries and the percentage reduction in the proportion of samples with viable bacteria. RESULTS: Six studies--three randomized controlled trials, two controlled trials and one before-and-after study-were included in the analysis. Although studies varied considerably, there were no findings of significant increases in bacteria under sealants. Sealing caries was associated with a 100-fold reduction in mean total VBC (four studies, 138 samples). Sealants reduced the probability of viable bacteria by about 50.0 percent (four studies, 117 samples). CONCLUSIONS: The authors found that sealants reduced bacteria in carious lesions, but that in some studies, low levels of bacteria persisted. These findings do not support reported concerns about poorer outcomes associated with inadvertently sealing caries. CLINICAL IMPLICATIONS: Practitioners should not be reluctant to provide sealants-an intervention proven to be highly effective in preventing caries-because of concerns about inadvertently sealing over caries.     

Twenty-month follow-up of occlusal caries lesions deemed questionable at baseline: Findings from The National Dental Practice-Based Research Network

Background.A questionable occlusal caries (QOC) lesion can be defined as an occlusal surface with no radiographic evidence of caries, but caries is suspected because of clinical appearance. In this study, the authors report the results of a 20-month follow-up of these lesions.Methods.Fifty-three clinicians from The National Dental Practice-Based Research Network participated in this study, recording lesion characteristics at baseline and lesion status at 20 months.Results.At baseline, 1,341 QOC lesions were examined; the treatment that was planned for 1,033 of those at baseline was monitoring (oral hygiene instruction, applying or prescribing fluoride or varnish, or both), and the remaining 308 received a sealant (n = 192) or invasive therapy (n = 116). At the 20-month visit, clinicians continued to monitor 927 (90 percent) of the 1,033 monitored lesions. Clinicians decided to seal 61 (6 percent) of the 1,033 lesions (mean follow-up, 19 months) and invasively treat 45 (4 percent) of them (mean follow-up, 15 months). Young patient age (< 18 years) (odds ratio = 3.4; 95 percent confidence interval, 1.7-6.8) and the lesion&apos;s being on a molar (odds ratio = 1.8; 95 percent confidence interval, 1.3-2.6) were associated with the clinician&apos;s deciding at some point after follow-up to seal the lesion or treat it invasively.Conclusions.Almost all (90 percent) QOC lesions for which the treatment planned at baseline was monitoring still were planned to undergo monitoring after 20 months. This finding suggests that noninvasive management is appropriate for these lesions.Practical Implications.Previous study results from baseline indicated a high prevalence of QOC lesions (34 percent). Clinicians should consider long-term monitoring when making treatment decisions about these lesions.     

The impact of oral disease and nonsurgical treatment on bacteremia in children

BACKGROUND: The authors examine the role of dental disease and nonsurgical dental procedures in the incidence and duration of bacteremia in children. METHODS: The authors randomized a group of children to receive amoxicillin or a placebo before dental rehabilitation in an operating room setting. They collected eight blood draws at the following times: two minutes after intubation (draw 1); after dental restorations, pulp therapy and cleaning (draw 2); 10 minutes later (draw 3); and five draws during and after dental extractions (draws 4-8). The authors compared dental disease parameters and the type of dental procedures performed with the incidence and duration of bacteremia. RESULTS: The authors enrolled 100 children (aged 1-8 years) in the study. The incidence of bacteremia from draw 2 was 20 percent in the placebo group and 6 percent in the amoxicillin group (P = .07), and the incidence from draw 3 was 16 percent in the placebo group and zero percent in the amoxicillin group (P = .03). Subjects with higher gingival scores were more likely to have a bacteremia for draw 2 (P = .01). The authors found that subjects in the group with bacteremia for draw 3 had undergone more pulpotomies than did subjects in the group without bacteremia for draw 3 (3 +/- 2.5 standard deviation [SD] versus 1.5 +/- 1.6 SD, P = .04), while they found almost no differences for draw 2. CONCLUSIONS: This study suggests that gingival disease has an impact on bacteremia after dental restorations and prophylaxis. Although antibiotics have an impact, they do not eliminate bacteremia altogether.     

Salivary characteristics and dental caries: Evidence from general dental practices

BackgroundSaliva is one of the intraoral host factors that influence caries development. The authors conducted a study to investigate whether salivary characteristics are associated with recent dental caries experience.MethodsDentist-investigators and dental staff members collected data pertaining to a two-year cumulative incidence of dental caries (previous 24 months) and salivary characteristics during baseline assessment in an ongoing longitudinal study. The systematic random sample consisted of patients (n = 1,763) visiting general dental practices (n = 63) within the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry (PRECEDENT). The authors estimated adjusted rate ratios (RRs) by using generalized estimating equations log-linear regression to relate salivary characteristics to coronal carious lesions into dentin.ResultsLow resting pH (≤ 6.0) in the overall sample and low stimulated salivary flow rate (≤ 0.6 milliliter/minute) in older adults (≥ 65 years old) were associated with increased dental caries (RR, 1.6; 95 percent confidence interval [CI], 1.1–2.2; RR, 2.4; 95 percent CI, 1.5–3.8, respectively). Low buffering capacity was associated with decreased dental caries in children and adolescents (RR, 0.3; 95 percent CI, 0.1–1.0; RR, 0.2; 95 percent CI, 0.1–0.7, respectively). A thick, sticky or frothy salivary consistency also was associated with decreased dental caries in adults (RR, 0.6; 95 percent CI, 0.4–1.0). Associations between other salivary characteristics and dental caries for the overall sample and within each age group were not statistically significant.ConclusionsSalivary characteristics were associated weakly with previous dental caries experience, but the authors did not find consistent trends among the three age groups. Different salivary characteristics were associated with an increased caries experience in older adults and a lowered caries experience in children and adolescents and adults.Practical ImplicationsFurther investigations are needed in this population setting to understand the study’s conflicting results. The study findings cannot support the use of salivary tests to determine caries risk in actual clinical settings.     

Reduced or painful jaw movement after collision-related injuries: a population-based study

BACKGROUND: The authors report the incidence of and factors associated with reduced and/or painful jaw movement after motor vehicle collisions that resulted in whiplash-associated disorders (WADs). METHODS: All adults filing collision-related personal injury claims during an 18-month period in Saskatchewan, Canada, were evaluated via questionnaire to determine demographic characteristics, precollision health (including jaw pain), collision parameters and collision-related symptoms, including reduced and/or painful jaw movement and injury-related neck pain. The authors excluded patients who were hospitalized for more than two days and those who sustained injuries as a pedestrian, bicyclist or motorcyclist. In determining incidence rates, the authors also excluded those who had had jaw pain before the collision. RESULTS: The incidence of reduced and/or painful jaw movement was 14.9 percent (n = 1,158), and it was higher in subjects with WADs (15.8 percent) than in those without WADs (4.7 percent; relative risk = 3.36, 95 percent confidence interval, 2.36 to 4.78). Within the WAD injuries, multivariable logistic regression revealed that the onset of reduced and/or painful jaw movement was associated with female sex; age < 50 years; having hit one's head in the collision; and postinjury symptoms of difficulty swallowing, ringing in the ears, dizziness or unsteadiness, and more intense neck pain. Collision parameters, such as head position at the time of the crash and headrest use and type, were not associated with onset of jaw symptoms. CONCLUSIONS: Reduced or painful jaw movement was more common in people with WADs than in those with other collision-related injuries. Among those with WADs, reduced or painful jaw movement was more common in women and younger people. CLINICAL IMPLICATIONS: Reduced or painful jaw movement is an important aspect of WADs, and more studies are needed to determine how to best assess and treat this problem.     

Diagnostic capability of questionnaires and clinical examinations to assess sleep-disordered breathing in children: A systematic review and meta-analysis

BackgroundThe reference standard for the diagnosis of pediatric sleep-disorder breathing (SDB) is a full polysomnography (PSG) (an overnight sleep study). There are many obstacles to children being able to undergo a full PSG; therefore, the authors evaluated the diagnostic value of alternative diagnostic methods (clinical history and physical examination) for pediatric SDB.Types of Studies ReviewedThe authors selected articles in which the investigators' primary objective was to evaluate the diagnostic capability of physical evaluations and questionnaires compared with the current reference standard (that is, a full PSG) to diagnose SDB in children younger than 18 years. The authors searched several electronic databases without limitations.ResultsUsing a two-step selection process, the authors identified 24 articles and used them to conduct a qualitative analysis. They conducted a meta-analysis on 11 of these articles. Among these articles, only one involved a test that had diagnostic accuracy good enough to warrant its use as a screening method for pediatric SDB, but its diagnostic accuracy was not sufficient to be considered a true diagnostic tool (that is, a replacement for full PSG) for pediatric SDB.Practical ImplicationsThe involvement of dentists in the screening process for pediatric SDB can contribute significantly to children's health. The identified questionnaire could be considered an acceptable screening test to determine which children to refer to a sleep medicine specialist.     

How willing are dentists to treat young children?: A survey of dentists affiliated with Medicaid managed care in New York City, 2010

BackgroundDespite recommendations for children to have a dental visit by the age of 1 year, access to dental care for young children, including children enrolled in Medicaid, remains limited. The authors conducted a survey to assess the availability of dentists to see young children enrolled in Medicaid managed care (MMC) in New York City (NYC), to determine barriers to the provision of dental care to young children and, within the context of MMC, to identify strategies to facilitate the delivery of dental care to children.MethodsThe authors mailed a survey to assess the provision of dental services to young children and perceived barriers and facilitators to 2,311 general dentists (GDs) and 140 pediatric dentists (PDs) affiliated with NYC MMC. A total of 1,127 surveys (46 percent) were received. The authors analyzed the responses according to provider type, youngest aged child seen, provider’s ability to see additional children and practice location. The authors compared responses by using the χ² test.ResultsFewer than one-half (47 percent) of GDs saw children aged 0 through 2 years. Provider type, years in practice and percentage of Medicaid-insured patients were associated significantly (P χ .005) with youngest age of child seen. Among respondents seeing children aged 0 through 2 years, PDs were significantly more likely to provide preventive therapy (P = .004) and restorative treatment (P χ .001). Additional training and access to consulting PDs were identified by GDs as potential facilitators to seeing young children.ConclusionA high proportion of NYC GDs affiliated with MMC do not see young children.Practice ImplicationsNinety-four percent of NYC MMC– affiliated dentists are GDs, but 53 percent of GD respondents did not see children aged 0 through 2 years in their practices. Improving access to dental care for young children requires changes in GDs’ practices, possibly by means of additional training and access to consulting PDs.     

Breastfeeding: An overview of oral and general health benefits

Background

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Breastfeeding is the reference against which alternative infant feeding models must be measured with regard to growth, development and other health outcomes. Although not a systematic review, this report provides an update for dental professionals, including an overview of general and oral health–related benefits associated with breastfeeding.Types of Studies ReviewedThe authors examined the literature regarding general health protections that breastfeeding confers to infants and mothers and explored associations between breastfeeding, occlusion in the primary dentition and early childhood caries. To accomplish these goals, they reviewed systematic reviews when available and supplemented them with comparative studies and with statements and reports from major nongovernmental and governmental organizations.ResultsWhen compared with health outcomes among formula-fed children, the health advantages associated with breastfeeding include a lower risk of acute otitis media, gastroenteritis and diarrhea, severe lower respiratory infections, asthma, sudden infant death syndrome, obesity and other childhood diseases and conditions. Evidence also suggests that breastfed children may develop a more favorable occlusion in the primary dentition. The results of a systematic review in which researchers examined the relationship between breastfeeding and early childhood caries were inconclusive.Conclusions and Clinical ImplicationsThe American Academy of Pediatric Dentistry, Chicago, suggests that parents gently clean infants' gums and teeth after breastfeeding. The American Academy of Pediatrics, Elk Grove Village, Ill., recommends that breastfeeding should be exclusive for about the first six months of life and should continue, with the introduction of appropriate complementary foods, to at least age 12 months or beyond, as desired by mother and child. Dentists and staff members can take steps to ensure they are familiar with the evidence and guidelines pertaining to breastfeeding and to oral health. They are encouraged to follow the surgeon general's recommendations to promote and support optimal breastfeeding and oral health practices among their patients.     

Cost-effectiveness of treatments for temporomandibular disorders: biopsychosocial intervention versus treatment as usual

BACKGROUND: The authors conducted a randomized clinical trial to evaluate the cost-effectiveness of a biopsychosocial intervention with patients who are at high risk (HR) of progressing from acute to chronic TMD-related pain. METHODS: The authors classified 96 patients with acute TMD (less than six months' duration) as HR according to a predictive algorithm and randomized them into an early intervention (EI) or a nonintervention (NI) group. The NI group received a biopsychosocial treatment that included cognitive behavioral skills training and biofeedback. Both groups were followed up for one year. The authors collected TMD cost data throughout the year. RESULTS: The authors found that the EI group spent significantly fewer jaw-related health care dollars, relative to the NI group, from intake to the one-year follow-up. CONCLUSION AND CLINICAL IMPLICATIONS: The reduced jaw-related health care expenditures for patients in the EI group compared with expenditures for patients in the NI group at one year suggest that an early biopsychosocial intervention is a cost-effective measure in dealing with often unnecessarily costly TMD-related pain.     

Risk of adrenal crisis in dental patients: Results of a systematic search of the literature

BackgroundThe authors performed a systematic search of the literature to identify the frequency of, risk of experiencing and factors associated with adrenal crises in dental patients.MethodsThe authors searched PubMed and Ovid MEDLINE (1947-June 20, 2012) and Embase (1974-2012) for English-language articles related to cases of adrenal crisis in dentistry and extracted and analyzed data from the articles. The six authors determined whether the cases identified met a consensus definition of adrenal crisis.ResultsOf 148 articles identified in the initial screening, 34 articles were included in the final review, from which six cases met the criteria of adrenal crisis. The authors categorized four cases as “suggestive of adrenal crisis” and two cases as “consistent with adrenal crisis.” Risk factors were significant adrenal insufficiency, pain, infection, having undergone an invasive procedure, having received a barbiturate general anesthetic, and poor health status and stability at the time of presentation. The authors estimated risk to be less than one in 650,000 in patients with adrenal insufficiency.ConclusionsAdrenal crisis is rare in dental patients, with only six reports of it having been published in the past 66 years. Risk is associated with unrecognized adrenal insufficiency, poor health status and stability at the time of treatment, pain, infection, having undergone an invasive procedure and having received a barbiturate general anesthetic.Clinical ImplicationsRisk of adrenal crisis is reduced through proper evaluation of the patient, identification of risk factors and following appropriate preventive measures.     

Implications of medical screenings of patients arriving for dental treatment: The results of a comprehensive laboratory screening

BackgroundThe authors conducted medical laboratory screenings in a dental setting to determine the relationships between the laboratory test results and self-reported medical health findings.MethodsThe authors collected serum, urine and medical histories from 171 patients (116 [68 percent] women; mean age, 43.4 years) who arrived for dental treatment as a component of a clinical trial and performed complete blood cell counts, standard blood chemistry panels and urinalysis on the samples.ResultsThe authors found 414 abnormal laboratory test results (an average of 2.42 per patient). Eighty-three percent of participants had one or more abnormal test results, 83 percent had abnormal test results and did not indicate a relevant disease in their medical history, and 18 percent had laboratory test results outside the 99 percent reference range (that is, > three standard deviations from the mean). Abnormal test results were significantly associated with sex, age, race and medical history (P < .05). Abnormal test results associated with kidney disease were related to patients with cardiovascular disease and diabetes, as well as those who tended to be on average older than 50 years.ConclusionsThe high frequency of significant abnormal laboratory test results detected in this study suggests that many patients may be unaware of their medical statuses.Practical ImplicationsAbnormal laboratory test results are detected frequently in the serum and urine of patients arriving for dental treatment, which could indicate undiagnosed disease and less than optimal medical management.