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Brazilian Journal of Oral Sciences
Piracicaba Dental School - UNICAMP
EISSN: 1677-3225
Vol. 7, Num. 27, 2008, pp. 1678-1681

Brazilian Journal Oral Sciences, Vol. 7, No. 27, Oct/Dec, 2008, pp. 1678-1681

An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007)

Elaine Pereira da Silva Tagliaferro1;Vanessa Pardi1,2; Gláucia Maria Bovi Ambrosano3; Marcelo de Castro Meneghim4; Antonio Carlos Pereira5

1DDS, MS, PhD, Postdoctoral Student 2DDS, MS, PhD, Professor, Graduate Program in Community Health, Dental School, University of Sagrado Coração, Brazil 3Agr.Eng., MS, PhD Professor, Department of Community Dentistry, Dental School of Piracicaba, State University of Campinas, Brazil 4 DDS, MS, PhD, Professor, Department of Community Dentistry 5 DDS, MPH, DrPH, Professor, Department of Community Dentistry Department of Community Dentistry, Piracicaba Dental School, University of Campinas, Brazil
Correspondence to: Prof. Dr. Antonio Carlos Pereira, Av. Limeira 901 - 13414-903, Piracicaba, SP, Brasil, Phone: +55-19-2106-5209. Fax: +55-19-2106-5218 E-mail: apereira@fop.unicamp.br

Received for publication: September 05, 2008 Accepted: October 15, 2008

Code Number: os08044

Abstract

This study aimed to review the dental literature about caries risk assessment over the last 10 years in order to show which variables have been considered risk predictors and risk factors of dental caries in infants, preschool-, schoolchildren and adolescents. A Medline search of the published English language literature from 1997 to 2007 was made for papers of longitudinal studies that reported on caries risk assessment. A total of 39 papers were included in this review. Most studies were conducted in schoolchildren (n=19), followed by preschool children (n=9), adolescents (n=7) and infants (n=4). Variables such as caries experience, gingival status, microbiological counts, oral hygiene, plaque mineral concentration, fluoride history, socioeconomic and educational level, demographic, anthropometrical, oral, dietary and toothbrushing habits were studied. Past caries experience has been the predominant predictor for future caries in 0-18year-old subjects. Other variables, such as dietary habits, including sugar intake, and toothbrushing habits may also help identifying high-risk individuals. In conclusion, the variables related to caries experience continue to be the main predictor of caries increment.

Key words: dental caries; risk; assessment; prediction

Introduction

One of the main goals of Dentistry has been to prevent dental caries, which has been, according to Aoba and Fejerskov1 , the predominant cause of tooth loss in all populations worldwide.

In general, two preventive strategies can be used to prevent and/or control caries disease: the “high-risk strategy”, which is directed towards individuals particularly susceptible to developing dental caries2 , and the“population strategy”, which endeavors to protect all the people, including high and low caries risk individuals. Burt3 has referred to the “geographically targeted strategy”, in which the preventive measures are targeted to a subgroup or a specific area of the city/country, such as schools in deprived areas of the city or an area of immigrant population. However, all strategies have the same goal: to prevent and/or to control the development of new carious lesions or to arrest the progression of preexisting lesions. In spite of increase in the adoption of preventive measures, it seems that for a minority of children these procedures have been insufficient for preventing and controlling the disease, as the majority of carious lesions are concentrating in this group. Therefore, oral health care providers have been adopted the “high risk strategy” for these individuals.

If individuals with a risk for developing dental caries are correctly identified, planning specific measures for caries control and prevention may become a biological and socioeconomic measure, increasing the efficiency of preventive programs, as emphasized by Giannoni et al.4. Moreover, identifying caries risk factors/predictors allows selecting the individuals or population groups that will really benefit from preventive measures. This makes it possible to use specific and appropriate preventive measures in target people and may work as an alert for conducting a more detailed dental examination. In addition to the aforementioned advantages, knowing caries risk factors is decisive in detecting those with initial carious lesions, who may benefit from novel and emergent preventive technologies5. Fontana and Zero6 discussing caries risk assessment in private practice have recommended that factors such as caries experience, dietary habits, fluoride exposure, presence of cariogenic bacteria, salivary status, general medical history and sociodemographic characteristics should be evaluated when assessing the patient’s caries risk.

Assessing caries risk consists of determining which individuals are more or less likely to prevent or to control dental caries in the future by means of knowing the variables associated with the disease5. Caries risk assessment studies can be performed using cross-sectional data, in which the subjects’ data, usually about a disease prevalence or severity, are collected once or longitudinal data, in which the individuals are examined repeatedly over time. In addition to clinical variables, several others such as, socioeconomics, demographics, and behavioral characteristics can be used to assess their effects on caries levels (cross-sectional studies) or in caries incidence and/or increment (longitudinal studies). Although longitudinal studies are expensive, difficult to conduct and depend on the participants´ willingness, their results are stronger than those obtained in cross-sectional studies7. Moreover, when assessing caries risk, the use of multiple regression analysis is preferable8-9 since the etiology of dental caries is multifactorial.

The aim of this work was to review the dental literature about caries risk assessment over the last 10 years (19972007), in order to show which variables have been considered caries risk factors/predictors in longitudinal studies conducted in infants, preschool-, schoolchildren and adolescents.

Concepts and Terminology

As one of the study’s aims is to review the dental literature about risk factors and risk predictors in longitudinal studies of dental caries, it is important to consider the following terms. Risk factor has been defined by Beck8 as “an environmental, behavioral or biologic factor confirmed by temporal sequence, usually in longitudinal studies, which if present directly increases the probability of a disease occurring, and if absent or removed reduces the probability. Risk factors are part of the causal chain, or expose the host to the causal chain. Once disease occurs, removal of a risk factor may not result in a cure”.

Risk predictor is also named by Beck8 as a risk marker, and is defined as a characteristic associated with a high risk for the disease. The risk predictor predicts well but it is not thought to be part of the causal chain. As a good example, past caries experience has been strongly associated with a high risk for caries increment in the future. However, this variable is not part of the causal chain and is therefore considered a risk predictor. Moreover, it has been reported that in case of preventive measures being introduced in the studied caries risk group to reduce the disease activity, past caries experience becomes a risk predictor with reduced worth.

In this study, the expressions “risk factor” (RF) and “risk predictor” (RP) will be used for classifying those variables statistically associated with caries increment in multivariate regression analyses, if they were either part (RF) or not (RP) of the causal chain of dental caries.

Material and Methods

A search of the English Language literature published from 1997 to 2007 was made in the Medline database for articles that reported on caries risk assessment using the following descriptors: longitudinal caries risk. Furthermore, MeSH Database PubMed Service was used with some of the cited terms: “Longitudinal Studies”[MeSH] AND “Dental Caries”[MeSH] AND “Risk”[MeSH]. The limits for the search included: “Publication Date from 1997 to 2007”; Language: English; Ages: “All Child: 0-18 years”. Studies were selected if they met the following criteria: longitudinal study conducted with children aged 0-18 years, providing information on sample size, age at initial examination (baseline), variables collected at baseline, study lasting, statistical tests used and a measure of caries increment/ incidence as an outcome variable. In accordance with the search criteria, 189 papers were retrieved. A total of 59 were selected by reading the title and among them 30 were selected by reading the abstract and/or the full text. Twenty-nine papers were excluded because they did not report the outcome variable as caries incidence/increment (n=9), were review articles (n=2), validation study (n=1) evaluation/comparative studies (n=11) or used crosssectional data (n=6). Moreover, hand searching was performed from the citations of the identified reports (n=3) and other key papers (n= 6). Therefore, a total of 39 papers were included in this review.

A variable that is part or expose the host to the causal chain of dental caries and remained statistically significant in multivariate regression models was considered risk factor. Risk predictor was considered the variable that is not part of the causal chain of dental caries and remained statistically significant in multivariate regression models.

Results and Discussion

Researches on caries risk assessment have been conducted since the 1980’s, focused on developing an easy tool for identifying high-caries-risk individuals10. Published studies in general have studied clinical, microbiological, salivary, socioeconomic and demographic data, medical history, dietary habits, fluoride history, use of dental services and dental health behaviors, separately and in combination to identify high-caries-risk individuals.

According to the dental literature, the use of caries increment during a period of time is the primary outcome measure11 and statistical analysis based on logistic regression with multiple factors are preferable because of the complex and multifactorial etiology of the caries process8 .

Tables 1, 2, 3, and 4 present a detailed review of the papers published over the last 10 years (1997-2007) about caries risks assessment in infants (<2 years), preschool children (2-5 years), schoolchildren (6-12 years) and adolescents (13-18 years) is presented. The age groups were established based on those of Medline. The studies on caries risk assessment during the last 10 years were conducted mainly in schoolchildren (n=19), followed by preschool children (n=9), adolescents (n=7), and infants (n=4). The majority of them were related to data collected in Finland (n=7), followed by Brazil (n=4), Sweden (n=3), China (n=3), Norway (n=3), USA (n=3), the Netherlands (n=3), Belgium (n=2), Greece (n=2), Japan (n=2), Australia (n=1), Denmark (n=1), Germany (n=1), Israel (n=1), Italy (n=1), Mexico (n=1) and New Zealand (n=1). As one can see, European countries have contributed a great deal to the dental literature on caries risk assessment over the last decade. For classifying a variable as a risk factor (RF) or risk predictor (RP), the study had to use multivariate regression analyses including several variables in the regression models.

There are few studies targeting infants at baseline examination, and these collected mainly dental variables (Table 1). Only one study12 used logistic regression models with multiple variables for identifying risk predictors/ factors (RP/RF) for caries development, which are the preferable model for this type of study, as dental caries presents a multifactorial and complex etiology8 . In the Pienihäkkinen’s et al.12 study the mutans streptococcus counts, the presence of incipient caries lesions, and the use of candies were predictors for caries increment after a 3-year-follow-up. Another study13 used survival analysis and identified the consumption of candies and the lack of daily toothbrushing as the variables that impacted on caries onset. As one can see, sugar consumption is an important variable that may identify children at risk of caries in this age group. It is an important finding since according to Zero14 , the relationship between sugar consumption and dental caries is less strong in comparison to that from the prefluoride era. Therefore dietary counseling is highly recommended to mothers and should be part of oral health preventive programs in public health services. Considering the small number of studies in this age group during the last 10 years, further studies should be conducted and make use of more appropriate statistical analysis.

As regards studies concerning preschool children (Table 2), 9 papers published over the last 10 years were selected. Variables such as dental, socioeconomic, behavioral, dietary, microbiological, medical and demographic data have been collected in study periods ranging from 0.5 to 10 years. Most studies (n=7) used regression models as statistical analyses and showed that the main risk predictor was caries experience and the risk factors were sugar consumption and the presence of plaque/toothbrushing related habits. Caries experience detected at baseline has been a strong variable in identifying children at risk because it shows that the oral environment was prone to develop caries. Sugar consumption has played an important role in caries risk assessment in young children, as previously described for infants. Others variables related to oral hygiene also showed their significance in identifying children at risk. The presence of plaque on teeth, due to the lack and/or deficiency in toothbrushing, offers substrates to cariogenic bacteria favoring caries development.

Schoolchildren have been the most studied group in caries risk assessment (Table 3). From 1997 to 2007, 19 papers were selected and reviewed. Study duration ranged from 1 to 8 years and, as usual, dental variables were collected at baseline in all the papers. Other variables that also were collected in a considerable number of studies were: socioeconomic, microbiological and behavioral characteristics. Among the studies that used regression techniques (n=16) in statistical analysis the predominant RP was past caries experience followed by others related to socioeconomic level. The main RFs were the variables related to oral hygiene. As previously reported, past caries experience detected at baseline is the variable that best indicates those at risk for developing new lesions and poor oral hygiene increases the probability of caries increment. Seven studies involving caries risk assessment in adolescents (Table 4) were found from 1997 to 2007. The researchers followed-up the participants from 1 to 10 years, and collected data on dental, behavioral, demographic, socioeconomic, anthropometric, medical and microbiological variables and dietary habits. Caries experience at baseline was the main RP obtained in regression techniques.

In general, review of the papers demonstrated that past dental caries was the risk predictor of the future disease for all age groups. Others important RP include socioeconomic level and fluoride usage. The risk factors obtained in regression analyses were variables related to oral hygiene, sugar consumption and microbiological counts.

Collecting data on dental caries is very easy and may help in caries risk assessment. However, the disease has to be present. Others risk factors such as sugar consumption and oral hygiene related characteristics are also not difficult to gather information on them from a community point of view and help dental professionals in selecting those cariesfree individuals at risk. In fact, it has been suggested that in caries risk assessment, variables such as caries experience and severity, plaque index, fluoride use, socioeconomic level status should be collected before the application of the test for e.g. mutans streptococcus15. As reported by Kopycka-Kedzierawski and Billings16, “a caries risk assessment protocol must involve the use of measures that are easily obtained, widely accepted, simple to use, reproducible and cost-effective”.

It is important to take into consideration that this study presents some limitations such as the absence of quality criteria for selecting the papers (no score for papers), and the selection of studies mainly from Medline database. In spite of its limitations, by reviewing the published papers over the last 10 years, this study could clearly demonstrate that past caries experience has been the predominant predictor for future caries in subjects from 0 to 18 years of age. Therefore, those with previous contact with the disease should receive good oral health education, preventive measures and should be made aware that they are subjects at risk for developing caries. Continuous monitored is necessary to prevent the onset of new lesions.

On the other hand, as discussed by Tinanoff17, it would be unwise to wait for the presence of caries to know which subject will be more susceptible to develop lesions in the future. Further studies involving a large number of cariesfree individuals should be conducted on caries risk assessment. Nevertheless, the use of other variables such as dietary habits, including sugar consumption, and toothbrushing habits or presence of dental plaque may help identifying those caries-free subjects who might be more prone to have new carious lesions in the future. In conclusion, the variables related to caries experience collected at the initial examination continue to be the main risk predictor of caries increment. Moreover, those related to sugar consumption and oral hygiene could identify subjects at caries risk.

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