Caries risk assessment : state of the art and longitudinal study on risk predictors in schoolchildren

Orientador: Antonio Carlos PereiraTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de PiracicabaResumo: A avaliação de risco de cárie é uma ferramenta importante na odontologia, uma vez que favorece o planejamento das ações em saúde com base em evidência científica. Esta tese, composta por dois estudos, teve como objetivos: a) apresentar uma visão geral e atual da avaliação de risco de cárie dentária (Capítulo 1); e b) determinar quais variáveis clínicas, comportamentais, socioeconômicas e demográficas identificaram indivíduos com maior probabilidade de desenvolver incremento de cárie, em estudo longitudinal realizado em um período de sete anos (Capítulo 2). No primeiro estudo, uma revisão da literatura odontológica sobre avaliação de risco de cárie nos últimos 10 anos foi realizada, a fim de identificar os fatores/preditores de risco da doença em crianças e adolescentes. Para isso, uma busca de artigos científicos publicados entre 1997 e 2007 foi conduzida na base de dados MEDLINE. Os estudos foram conduzidos principalmente com escolares (n= 19), seguidos pelas pesquisas realizadas em crianças em idade pré-escolar (n=l1), adolescentes (n=8) e crianças de até dois anos (n=5). A experiência de cárie, condição gengival, contagem microbiológica, hábitos de higiene oral, concentração de minerais no biofilme dental, exposição ao fluoreto, nível socioeconômico e educacional, características demográficas, antropométricas, bem como hábitos bucais, dietéticos e de escovação foram as variáveis estudadas. A experiência passada de cárie foi o preditor dç risco predominante em todas as faixas etárias pesquisadas. Outras variáveis como os hábitos dietéticos, incluindo o consumo de açúcar, e os de escovação também podem ajudar a identificar indivíduos de alto risco de cárie. No segundo estudo, 206 escolares de três escolas de Piracicaba, estado de São Paulo, foram examinados no baseline e após sete anos pelos mesmos cirurgiões-dentistas, previamente calibrados, sob luz natural, usando espelho e sonda e seguindo as recomendações da Organização Mundial da Saúde para levantamentos epidemiológicos em saúde bucal. Os examinadores coletaram dados sobre as seguintes variáveis clínicas: cárie dentária, fluorose, higiene oral e presença de selante. Adicionalmente, informações sobre nível socioeconômico, uso de fluoreto, acesso a serviços odontológicos, hábitos dietéticos e de higiene oral foram obtidas no baseline por meio de questionário semi-estruturado enviado aos pais. Para testar a associação entre o incremento de superficies cariadas, perdidas e obturadas (CPOS) e as variáveis independentes, uma análise univariada foi conduzida utilizando-se o teste de Qui-quadrado ou o Exato de Fisher. A regressão logística múltipla foi usada para obter estimativas de Odds Ratios (OR), seus intervalos de confiança (IC) ao nível de 95% e níveis de significância. O modelo de predição demonstrou que os escolares com experiência de cárie em dentes permanentes (OR=2,49; IC=1,02-6,04; p=0,04) ou em dentes decíduos (OR=2,29; IC=1,24-4,23; p=0,00l), bem como aqueles cuja escolaridade máxima da mãe era de oito anos de estudo (OR=1,88; IC=1,03-3,45; p=0,03) apresentaram probabilidades significativamente superiores de apresentar incremento de CPOS. Os resultados desta tese demonstraram que o nível educacional materno pode identificar os escolares com risco de desenvolver a doença e que as variáveis relacionadas à experiência passada de cárie continuam sendo o principal preditor de riscoAbstract: Caries risk assessment is an important tool for dentistry, because it may help planning health actions based on scientific evidences. This thesis, composed of two studies, aimed to a) present an overview of caries risk assessment (Chapter 1); and b) determine which clinical, behavioral, socioeconomic and demographic variables could identify children with higher probability of developing caries increment in a seven-year longitudinal study (Chapter 2). In the first study, a search of the published English language literature from 1997 to 2007 was made for articles that reported on caries risk assessment in the MEDLINE database. The studies were conducted mainly in schoolchildren (n=19), followed by preschool children (n=11), adolescents (n=8), and infants (n=5). Variables such as caries experience, gingival status, microbiological counts, oral hygiene, plaque mineral concentration, fluoride history, socioeconomic and educationallevel, demographic, anthropometrical, oral, dietary and toothbrushing habits were studied. Past caries experience has been the predominant predictor of caries risk in 0-18-years old subjects. Other predictors such as dietary habits, including sugar intake, and toothbrushing habits may also help to identify high-risk individuals. Variables related to caries experience continue to be the main predictor of caries incremento In the second study, two hundred and six children from three schools in Piracicaba, Brazil, were examined at baseline and after 7 years by the same calibrated dentists in an outdoor setting, under natural light, using a dental mirror and probe following the World Health Organization recommendations for oral health surveys. The examiners collected data on the following clinical variables: dental caries, fluorosis, oral hygiene and presence of sealant. Moreover, information on socioeconomic level, fluoride usage, dental service utilization, dietary and oral hygiene habits was also obtained at baseline by means of a semi-structured questionnaire sent to the parents. In order to evaluate the association between the decayed, filling and missed surfaces (DMFS) increment and independent variables, a univariate analysis was performed using the Chi-square or Fisher exact tests. The multivariate logistic regression was used to estimate the adjusted Odds Ratio (OR), their 95% confidence intervals (C I) and significance levels. The prediction model demonstrated that the schoolchildren with caries experience in permanent (OR=2.49; CI=1.02-6.04; p=0.04) or primary teeth (OR=2.29; CI=1.24-4.23; p=0.001), as well as those whose mothers' educational level was up to eight years of schooling (OR=1.88; CI=1.03-3.45; p=0.03) were more prone to have DMFS increment. The results of this thesis demonstrated that the educational leveI of mothers could identify the schoolchildren at risk of developing the disease and that variables related to past caries experience continue to be the main risk predictorDoutoradoSaude ColetivaDoutor em Odontologi

Risk indicators and risk predictors of dental caries in schoolchildren

The purpose of this study was to identify risk indicators of high caries level at baseline (HCLB) based on cross-sectional data and predictors of high caries increment (HCI) based on a 7-year-follow-up examination in 6-8-year-old schoolchildren. Two hundred and six schoolchildren were examined in 1997 and in 2004 by the same two calibrated dentists, in Piracicaba, Brazil. At baseline, dental caries, presence of sealants, fluorosis, and oral hygiene status were recorded. The children\u27s parents completed a questionnaire concerning socioeconomic level, fluoride use, dental service utilization, dietary and oral hygiene habits. HCLB and HCI were defined considering the upper quartile of the total caries experience distribution (dmfs+DMFS) and caries increment distribution, respectively. Logistic regression models were adjusted estimating the Odds Ratio (OR), 95% confidence intervals and p-values. Having white spot lesions (OR=5.25) was found to be a risk indicator of HCLB. Schoolchildren with dental fluorosis (OR=0.17) or those who brushed the teeth more than two times a day (OR=0.37) presented less probability of HCLB. The predictors of HCI were: dmfs>;0 (OR=2.68) and mothers\u27 educational level up to 8 years of schooling (OR=2.87). Clinical and socioeconomic variables were found to be risk indicators and/or predictors of dental caries in schoolchildren

Use of occlusal sealant in a community program and caries incidence in high- and low-risk children

OBJECTIVE: The aims of this study were to investigate the effectiveness of sealant placement under the guidelines of the Oral Health Promotion Program for Children and Adolescents (Portugal), and to test the influence of clinical and socioeconomic variables on the DMFT increment in 277 children, born in 1997. MATERIAL AND METHODS: A dental hygienist performed the initial examinations and sealant placement (Helioseal, Vivadent) on the permanent first molars in 2005. These activities were registered in dental records that were assessed in 2007. Children were classified according to caries risk at baseline [high (HR: DMFT+dmft>;0); low (LR: DMFT+dmft=0) risk] and sealant placement as follows: HR-S and LR-S Groups (with sealant placement); HR-NS and LR-NS Groups (without sealant placement). A calibrated dentist performed the final examination in 2007 at school, based on the World Health Organization recommendations. The variables collected were: dental caries, visible dental plaque, malocclusions, and socioeconomic level (questionnaire sent to children's parents). For univariate (Chi-square or Fisher tests) and multivariate (Multiple logistic regression) analyses the DMFT increment >;0 was selected as dependent variable. RESULTS: Approximately 17.0% of the children showed DMFT increment>;0 (mean=0.25). High-risk children presented a significant increase in the number of decayed and/or filled teeth. These children had 7.94 more chance of developing caries. Children who did not receive sealant were 1.8 more prone to have DMFT increment >;0. CONCLUSION: It appears that sealant placement was effective in preventing dental caries development. Moreover, the variables "risk" and "sealant placement" were predictors for DMFT increment in the studied children

Estimate Of Dmft Index Using Teeth Most Affected By Dental Caries In Twelve-year-old Children.

The objective of the study was to develop regression models to describe the epidemiological profile of dental caries in 12-year-old children in an area of low prevalence of caries. Two distinct random probabilistic samples of schoolchildren (n=1,763) attending public and private schools in Piracicaba, Southeastern Brazil, were studied. Regression models were estimated as a function of the most affected teeth using data collected in 2005 and were validated using a 2001 database. The mean (SD) DMFT index was 1.7 (2.08) in 2001 and the regression equations estimated a DMFT index of 1.67 (1.98), which corresponds to 98.2% of the DMFT index in 2001. The study provided detailed data on the caries profile in 12-year-old children by using an updated analytical approach. Regression models can be an accurate and feasible method that can provide valuable information for the planning and evaluation of oral health services.43179-8

Methods for Caries Prevention in Children Reported by Dentists from a Brazilian Community

Objective: To describe the dental practice patterns related to caries prevention in children aged 6-18 years and associated factors. Material and Methods: Dentists (n=162) from Araraquara, Brazil, completed two paper questionnaires: (1) one about characteristics of their practice and their patient population; and (2) a translated version of the “Assessment of Caries Diagnosis and Caries Treatment” Questionnaire from the National Dental Practice-Based Research Network. Regression analyses were used for data analysis (p<0.05). Results: Dentists reported using in-office fluoride (IOF) and dental sealants (DS) in 74.2% and 45.1% of their pediatric patients, respectively. Regression analysis showed that female dentists (p=0.035 for DS; p=0.044 for IOF; p=0.011 for non-prescription fluoride rinse), those with advanced degrees (p=0.032 for prescription of fluoride), those who graduated from a private dental school (p=0.018 for chlorhexidine rinse), those who provided caries prevention regimens (p<0.001 for DS; p=0.004 for IOF; p=0.013 for non-prescription fluoride rinse), those with a greater percentage of patients interested in a caries prevention regimen (p=0.007 for non-prescription fluoride rinse), those working in a private practice model (p=0.047 for prescription of fluoride) were more likely to recommend some type of preventive methods to their pediatric patients. Conclusion: Dentists reported recommending IOF to most of their pediatric patients. Certain dentists’, practices’, and patients’ characteristics were associated to some caries prevention regimens recommended by dentists

Estimativa do Índice CPOD usando os dentes mais afetados pela cárie dentária aos doze anos

The objective of the study was to develop regression models to describe the epidemiological profile of dental caries in 12-year-old children in an area of low prevalence of caries. Two distinct random probabilistic samples of schoolchildren (n=1,763) attending public and private schools in Piracicaba, Southeastern Brazil, were studied. Regression models were estimated as a function of the most affected teeth using data collected in 2005 and were validated using a 2001 database. The mean (SD) DMFT index was 1.7 (2.08) in 2001 and the regression equations estimated a DMFT index of 1.67 (1.98), which corresponds to 98.2% of the DMFT index in 2001. The study provided detailed data on the caries profile in 12-year-old children by using an updated analytical approach. Regression models can be an accurate and feasible method that can provide valuable information for the planning and evaluation of oral health services.O objetivo do estudo foi desenvolver modelos de regressão para delinear o perfil epidemiológico da cárie dentária em localidade com baixa prevalência de cárie aos 12 anos de idade. Foram examinadas duas amostras probabilísticas (n=1.763) de indivíduos de escolas públicas e privadas de Piracicaba,(SP). Dados sobre os dentes mais afetados foram coletados em 2005 e validados utilizando um banco de dados (2001). A média (dp) do CPOD foi de 1,7 (2,08) em 2001 e os modelos de regressão desenvolvidos estimaram um CPOD de 1,67 (1,98) em 2005, o qual representa 98,2% do CPOD em 2001. Os resultados apresentaram detalhes do perfil da cárie dentária aos 12 anos, usando uma abordagem analítica atual. Os modelos de regressão poderiam ser considerados como uma forma acurada e factível no auxílio do planejamento e avaliação dos serviços em saúde bucal.El objetivo de este estudio fue desarrollar modelos de regresión para describir el perfil epidemiológico de caries dentales en niños de 12 años en un área de baja prevalencia de caries. Fueron estudiados dos muestras distintas aleatorias y probabilísticas de niños escolares (n= 1.763) que estudiaban en colegios públicos y privados en Piracicaba, Sureste de Brasil. Modelos de regresión fueron estimados como una función de los dientes más afectados usando datos colectados en 2005 y fueron validados usando una base de datos del 2001. El índice promedio (SD) de DMFT fue 1,7 (2,08) en 2001 y las ecuaciones de regresión estimaron un índice de DMFT de 1,67 (1,98), lo cual corresponde a 98,2% del índice en 2001. El estudio provee datos detallados sobre el perfil de caries en niños de 12 años usando una aproximación analítica. Los modelos de regresión pueden ser un método confiable y factible que puede proporcional información valiosa para la planificación y evaluación de servicios de cuidado oral

Association between Pacifier Use, Bottle-Feeding, and Pre- Postnatal Variables: A Cohort Study

Objective: To determine the prevalence and analyze the variables associated with the use of pacifiers and/or bottles by infants up to 6 months of age. Material and Methods: Data on sociodemographic characteristics, intention to offer pacifier and bottle-feeding, pregnancy and breastfeeding (BF) variables were collected at baseline by interviews and a self-administered questionnaire among pregnant women in the 3rd trimester. After delivery, mother-baby binomials were followed by phone calls at the 1st, 3rd, and 6th months of the baby\u27s life (n=467) to gather information on the type of delivery, baby’s gender, BF in the first hour of the newborn’s life, baby’s weight, mother’s return to work, and oral habits. Association analyses were performed using logistic regression models with a 5% significance level with the pacifier/bottle-feeding use as the outcome. Results: Most mothers (52.5%) reported their babies used bottle-feeding, 48.2% used pacifiers and 33.4% used both of them throughout the 6 months. Intention to offer pacifier and bottle-feeding was reported by 45.0% and 54.8% of the mothers at the 3rd trimester of the pregnancy, respectively. Not living in one’s own residence (OR=1.53; 95%CI: 1.05-2.24) and having the prenatal intention of offering a pacifier (OR=2.50; 95%CI: 1.63-3.83) to the baby were significantly associated with pacifier use. Variables significantly associated with bottle-feeding were mother’s return to work (OR=2.48; 95%CI: 1.54-3.97), baby’s lower birth weight (OR=1.58; IC95%: 1.07-2.33), and prenatal intention to offer bottle-feeding (OR=2.51; 95%CI 1.56-4.04). Conclusion: About half of the babies used pacifiers or were bottle-fed, which were associated with the mother’s prenatal intention to offer them to their babies and socioeconomic factors

Epidemiological assessment of predictors of caries increment in 7-10- year-olds: a 2-year cohort study

OBJECTIVE: The aim of this 2-year cohort study (2003 to 2005) was to investigate how caries experience, at initial lesions (early or non-cavited lesions) and cavited stages, predicts caries increment in permanent teeth in 7-10- year-olds. MATERIAL AND METHODS: The random sample of 765 children attending public schools in the city of Piracicaba, SP, Brazil, was divided into two groups: 423 children aged 7-8 years and 342 children aged 9-10 years. All subjects were examined by a calibrated examiner, using dental mirror and ball-ended probes, after tooth brushing and air-drying in an outdoor setting, based on the World Health Organization criteria. Active caries with intact surfaces were also recorded as initial lesion (IL). Univariate analysis was used for statistical analysis (Odds Ratios and Chi-square). RESULTS: The association between the DMFT (decayed, missing and filled teeth) increment and the presence of IL was significant only for 9-10-year-old children. The children with DMFT>;0 at baseline were more prone to have DMFT increment, with the highest risk for caries increment occurring in children aged 7-8 years. CONCLUSIONS: The predictors of caries increment were the presence (at baseline) of caries experience in permanent teeth for both age groups (7-8; 9-10-year-olds) and the presence of the IL (at baseline) for 9-10-year-olds

Cárie dentária, alterações de esmalte e necessidades de tratamento em pré-escolares e escolares de Araras, SP

The aim of this cross-sectional study was to describe the prevalence of dental caries and enamel defects, such as hypoplasia, demarcated opacity and fl uorosis, as well as to report the treatment needs in 5-year-old pre-schoolchildren and 12-year-old schoolchildren, from Araras, São Paulo State, Brazil, in 2004. The probabilistic sample consisted of 382 5-year-old pre-schoolchildren (n=186) and 12-year-old schoolchildren (n=196). The epidemiologicalexaminations were performed by four calibrated examiners, under natural light, using mirrors and “ball point” probes, following the WHO recommendations. Dental caries was recorded using dmft and DMFT indexes. Fluorosis was recorded following the Dean index in 12-yearolds. The results showed that the dmft index in 5 year-olds was 1.74 (dp=3.04) and that the DMFT in 12-year-olds was 1.58 (dp=2.39). Among the 5- and 12-year-old children, 52.2% and 42.3% were caries free, respectively. Approximately one third of examined children presented signs of caries activity. The one surface fi lling was the most required treatment in both pre-schoolchildren (42.1%) and schoolchildren (39.0%). The demarcated enamel opacity was detected in 65.4% of pre-schoolchildren and 14.4% of schoolchildren and the hypoplasia in 5.9% and 1.5%, respectively. Regarding fl uorosis, 18% of 12-year-olds presented enamel disturb. The results indicate that the pre-schoolchildren and schoolchildren examined presented treatment needs of low complexity, since the proportion of caries free was high and the disease activity was low.O objetivo deste estudo transversal foi descrever a prevalência de cárie dentária, hipoplasia, fluorose e opacidade demarcada de esmalte, assim como relatar as necessidades de tratamento em pré-escolares de 5 anos e de escolares de 12 anos, do município de Araras, em 2004. A amostra probabilística consistiu de 381 indivíduos, sendo 186 pré-escolares de 5 anos e 195 escolares de 12 anos. Os exames epidemiológicos foram realizados por quatro examinadores previamente calibrados, sob luz natural, utilizando-se espelho bucal sonda “ball point”, seguindo as recomendações da OMS. Cárie dentária foi registrada utilizando-se os índices ceod e CPOD. As lesões sem cavidades ativas, necessidades de tratamento, hipoplasia e opacidade demarcada também foram avaliadas. A fluorose foi registrada seguindo o Índice de Dean nos escolares de 12 anos. Os resultados mostraram que o índice ceod aos 5 anos foi 2,07 (dp=3,21) e o CPOD aos 12 anos foi de 2,14 (dp=2,56). Dentre as crianças de 5 e 12 anos examinadas, 52,2% e 42,3% estavam livres de cárie, respectivamente. Aproximadamente um terço dos examinados apresentaram sinais de atividade de cárie. As restaurações de uma face foram as necessidades de tratamento predominantes tanto nos pré-escolares (42,1%) quanto nos escolares (39,0%). A opacidade demarcada esteve presente em 65,1% dos pré-escolares e 14,4% dos escolares; a hipoplasia em 5,9% e 1,5%, respectivamente e 18% dos escolares de 12 anos apresentaram fluorose. Pode-se concluir que os pré-escolares e os escolares examinados apresentaram necessidades de baixa complexidade, uma vez que a proporção de livres de cárie foi alta e a atividade da doença foi baixa

Breastfeeding, deleterious oral habits and malocclusion in 5-year-old children in São Pedro, SP, Brazil

OBJECTIVE: To estimate the frequency of malocclusion and their associations with the type and period of breastfeeding, deleterious oral habits, and information received by mothers during the pre-natal period, in 5-year-old children attending municipal daycare centers. METHODS: The sample consisted of 162 children resident in the municipality of São Pedro, SP, Brazil. In an interview with each of the mothers, information was collected about the time and form of breastfeeding, presence of deleterious habits, and information the mother received during the pre-natal period. The epidemiological exam was performed at the daycare center facilities by a single, previously calibrated examiner, under direct lighting. The following variables were evaluated: presence and severity of malocclusion [slight overcrowding and spacing (OS)], open occlusal relationship (open bite) (OPB), vertical overlap (over bite) (OVB), uni- or bilateral cross bite (CB), positive overjet (OV) and the primary second molar terminal plane relationship (TPR)]. Data analysis consisted of univariate analysis (chi-square test) and multiple logistic regressions. RESULTS: The prevalence of malocclusions was 95.7% (OS = 22.8%; OPB = 24.7%; OVB = 20.4%; CB = 14.8%; and OV = 13.0%). In TPR the straight terminal plane was predominant (85.0%). Among the deleterious oral habits, the use of a pacifier was the only risk indicator (OR = 5.25; p = 0.001) for open occlusal relationship (open bite) in children that used it for over three years, detected in the logistic regressions. CONCLUSION: The prevalence of malocclusions and deleterious oral habits in the studied sample was high. Children that used a pacifier for over three years showed greater probability of presenting with open occlusal relationship (open bite).OBJETIVO: estimar a frequência de oclusopatias e suas associações com o tipo e o período de amamentação, hábitos bucais deletérios e informações recebidas pelas mães no pré-natal, em crianças com cinco anos de idade que frequentavam creches municipais. MÉTODOS: a amostra consistiu de 162 crianças residentes no município de São Pedro, SP. Em entrevista com cada mãe, informações sobre o tempo e a forma de aleitamento, a presença de hábitos deletérios, e orientações recebidas pela mãe durante o pré-natal foram coletadas. O exame epidemiológico foi realizado nas dependências das creches, por um único examinador, previamente calibrado, sob iluminação direta. As seguintes variáveis foram avaliadas: presença e severidade de oclusopatias [ligeiro apinhamento e espaçamento (AE), mordida aberta (MA), sobremordida (SM), mordida cruzada uni ou bilateral (MC), overjet positivo (OV) e relação terminal dos segundos molares decíduos (RTM)]. A análise dos dados consistiu de análise univariada (teste qui-quadrado) e de regressão logística múltipla. RESULTADOS: a prevalência de oclusopatias foi de 95,7% (AE = 22,8%; MA = 24,7%; SM = 20,4%; MC = 14,8%; e OV = 13,0%). Na RTM, o terminal reto foi predominante (85,0%). Dentre os hábitos bucais deletérios, o uso de chupeta foi o único indicador de risco (OR = 5,25; p = 0,001) para mordida aberta em crianças que a utilizaram por mais de três anos, detectado nas regressões logísticas. CONCLUSÃO: a prevalência de oclusopatias e de hábitos bucais deletérios na amostra estudada foi alta. As crianças que usavam chupeta por mais de três anos mostraram maior probabilidade de apresentar mordida aberta.718