Carina Källestål

Caries-preventive effect of fluoride toothpaste: a systematic review

With a questionnaire addressed to general dental practitioners in Sweden, the Swedish Council on Technology Assessment in Health Care launched a project group in 1999 to systematically review and evaluate the existing literature on various caries preventive methods. The aim of this article was to report findings concerning the caries preventive effect of fluoride toothpastes in various age groups, with special emphasis on fluoride concentration and supervised versus non‐supervised brushing. A systematic search in electronic databases for articles published between 1966 and April 2003 was conducted with the inclusion criteria of a randomized or controlled clinical trial, at least 2 years follow‐up and caries increment in the permanent (ΔDMFS/T) or primary (Δdmfs/t) dentition as endpoint. Out of 905 articles originally identified, 54 met the inclusion criteria. These studies were assessed independently by at least two reviewers and scored A–C according to predetermined criteria for methodology and performance. The measure of effect was the prevented fraction (PF), expressed as percent. The results revealed strong evidence (level 1) (i) for the caries preventive effect of daily use of fluoride toothpaste compared to placebo in the young permanent dentition (PF 24.9%), (ii) that toothpastes with 1,500 ppm of fluoride had a superior preventive effect compared with standard dentifrices with 1,000 ppm F in the young permanent dentition (PF 9.7%), and (iii) that higher caries reductions were recorded in studies with supervised toothbrushing compared with non‐supervised (PF 23.3%). However, incomplete evidence (level 4) was found regarding the effect of fluoride toothpaste in the primary dentition. In conclusion, this review reinforced the importance of daily toothbrushing with fluoridated toothpastes for preventing dental caries, although long‐term studies in age groups other than children and adolescents are still lacking.

Caries-preventive effect of fissure sealants: a systematic review

The objectives of this study were to evaluate systematically the evidence of the caries‐preventive effect of fissure sealing of occlusal tooth surfaces and to examine factors potentially modifying the effect. The search strategies included electronic databases, reference lists of articles, and selected textbooks. Inclusion criteria were randomized or quasi‐randomized clinical trials or controlled clinical trials comparing fissure sealing with no treatment or another preventive treatment in children up to 14 years of age at the start; the outcome measure was caries increment; the diagnostic criteria had been described; and the follow‐up time was at least 2 years. Inclusion decisions were taken and grading of the studies was done independently by two of the authors. The main measure of effect was relative risk reduction. Thirteen studies using resin‐based or glass ionomer sealant materials were included in the final analysis. The results showed that most studies were performed during the 1970s and a single application had been utilized. The relative caries risk reduction pooled estimate of resin‐based sealants on permanent 1st molars was 33% (relative risk=0.67; CI=0.55-0.83). The effect depended on retention of the sealant. In conclusion, the review suggests limited evidence that fissure sealing of 1st permanent molars with resin‐based materials has a caries‐preventive effect. The evidence is incomplete for permanent 2nd molars, premolars and primary molars and for glass ionomer cements. Overall, there remains a need for further trials of high quality, particularly in child populations with a low and a high caries risk, respectively.

Incidence and Progression of Approximal Caries from 11 to 22 Years of Age in Sweden: A Prospective Radiographic Study

Using annual bite–wing radiographs, the incidence and progression of approximal caries (4d–7m) were assessed longitudinally in teenagers and adolescents whose treatment had been based on remineralizing rather than restorative strategies. A closed cohort of 536 children initially was followed from 11 to 22 years of age. The scoring system was: 0 = no visible radiolucency; 1–2 = radiolucency in the enamel up to the enamel–dentin border; 3 = radiolucency with a broken enamel–dentin border but with no obvious progression in the dentin; 4 = radiolucency with obvious spread in the outer half of the dentin, and 5 = radiolucency in the inner half of the dentin. Caries rates were estimated as the number of new lesions/100 tooth surface–years, and the Kaplan–Meier estimate was used to calculate the cumulative survival time of each approximal surface. Three events were used: the transitions from states 0 to 2, 2 to 4 and 3 to 4. The results showed a considerable variation between the surfaces in both caries rates and survival time. For all surfaces combined, the median caries rate from state 0 to 2 was 3.9 new lesions/100 tooth surface–years; from state 2 to 4, the rate was 5.4, and from state 3 to 4 it was 20.3. Of the sound surfaces (state 0), 75% survived 6.3 years without reaching state 2. Given state 2, 75% survived 4.8 years without reaching the outer half of the dentin (state 4), while given a lesion at the enamel–dentin border (state 3), 75% survived 1.3 years without doing the same. The median survival time of lesions from state 3 to 4 was 3.1 years. The group with DMFSappr>1 at the age of 11–12 years had a risk of new approximal enamel lesions (state 0–2) that was 2.5 times greater than that of the group with DMFSappr = 0–1.

Caries Development from 11 to 22 Years of Age: A Prospective Radiographic StudyPrevalence and Distribution

The aim was to assess the distribution and pattern of caries development longitudinally in teenagers and adolescents whose treatment had been based on remineralizing rather than restorative strategies. A baseline cohort of 536 children was studied, using bite-wing radiographs, from 11 to 22 years of age. The results showed a slow but continuous increase in both enamel and dentin caries of approximal surfaces. At 21, 29% of all posterior approximal surfaces had enamel caries according to the radiographic diagnoses, 14% had dentin caries and another 5% were restored. At the age of 20–21, the skewed distribution of DMFSappr apparent at 12 and 15 had given way to a more uniform picture and the percentage of individuals with no decayed approximal surfaces (DMFSappr = 0) decreased from 71 at 12–13 to 28 at 20–21 years of age. The proportion of DFSoccl in relation to all DFS decreased from 83% at 12 to 52% at 21. The occlusal, mesial and distal surfaces of the first molar accounted for 60% of all restored surfaces at 21.

The Association of Bacterial Adhesion with Dental Caries

Saliva adhesion of bacteria is a key event in oral biofilm formation. Here, we used partial least-squares (PLS) analysis to correlate adhesion of cariogenic (Streptococcus mutans Ingbritt) and commensal (Actinomyces naeslundii LY7) model bacteria, and their agglutinin and acidic proline-rich protein ligands, respectively, with high and low caries experiences in 38 children reflecting todays skewed caries distribution. Adhesion of S. mutans was among the factors correlating strongest with high caries experience when PLS modeled together with traditional factors (e.g., sugar intake, lactobacilli counts). Saliva phenotypes with high agglutinin levels and Db-s (an acidic PRP variant) coincided with both high caries experience and S. mutans adhesion. A. naeslundii adhesion correlated with low caries experience. Non-Db phenotypes (i.e., acidic PRP-1 and PRP-2 variants) coincided with both low caries experience and S. mutans, but high A. naeslundii, adhesion. Thus, bacterial adhesion may modulate susceptibility and resistance to dental caries.

The Effect of Five Years’ Implementation of Caries-Preventive Methods in Swedish High-Risk Adolescents

Aim: To study the effectiveness of four different preventive programmes within a group of adolescents at high risk of caries. Subjects and Methods: In 1995, a cohort of 12-year-olds was examined for caries and completed a questionnaire. Subjects identified as being at high risk were examined every year until 2000 when they were 17 years old. This high-risk group was subdivided into four groups, each individual randomly assigned to one of four preventive programmes: (A) information on tooth-brushing techniques; (B) prescription of fluoride lozenges; (C) semi-annual applications of fluoride varnish; (D) quarterly appointments where participants were given individualised information on oral hygiene and diet as well as an application of fluoride varnish. The outcomes examined were the caries increment in dentine, enamel and fillings. Poisson regression was used to assess the influence of background, preventive factors and habits. Results: The number of 12-year-olds in the high-risk group was 1,134 in 1995, of which 925 were still participants in 2000. The differences between the programmes in mean 5-year increment were not significant. Less risk of caries increment was shown for those who had at least one sealant and for those who belonged to the fluoride varnish group (C). A higher risk was observed for adolescents from working-class homes, and for those who reported often eating sweets and not brushing their teeth twice a day at all examinations during the whole study period. Conclusions: The preventive programmes tested were equal in showing low efficiency in adolescents with high caries risk.

Economic evaluation of dental caries prevention: a systematic review.

The aim of the present study was to perform a systematic review of economic evaluations of caries prevention. A search in Medline from 1966 until May 2003 and a manual search in a number of journals identified 154 references, 74 of which were included. There were 17 original studies including an economic evaluation, and these form the basis of the present article. The rest were reviews, model studies and reports concerning economic practice in dentistry. The results show that the reviewed original studies on economic evaluation of caries prevention do not provide support for the economic value of caries prevention. The scarcity of well‐conducted studies, as well as contradictory evidence in the reviewed articles, makes it difficult to judge the health‐economic effect of the studied caries‐prevention methods.

Geographical accessibility and spatial coverage modeling of the primary health care network in the Western Province of Rwanda

BackgroundPrimary health care is essential in improving and maintaining the health of populations. It has the potential to accelerate achievement of the Millennium Development Goals and fulfill the “Health for All” doctrine of the Alma-Ata Declaration. Understanding the performance of the health system from a geographic perspective is important for improved health planning and evidence-based policy development. The aims of this study were to measure geographical accessibility, model spatial coverage of the existing primary health facility network, estimate the number of primary health facilities working under capacity and the population underserved in the Western Province of Rwanda.MethodsThis study uses health facility, population and ancillary data for the Western Province of Rwanda. Three different travel scenarios utilized by the population to attend the nearest primary health facility were defined with a maximum travelling time of 60 minutes: Scenario 1 – walking; Scenario 2 – walking and cycling; and Scenario 3 – walking and public transportation. Considering these scenarios, a raster surface of travel time between primary health facilities and population was developed. To model spatial coverage and estimate the number of primary health facilities working under capacity, the catchment area of each facility was calculated by taking into account population coverage capacity, the population distribution, the terrain topography and the travelling modes through the different land categories.ResultsScenario 2 (walking and cycling) has the highest degree of geographical accessibility followed by Scenario 3 (walking and public transportation). The lowest level of accessibility can be observed in Scenario 1 (walking). The total population covered differs depending on the type of travel scenario. The existing primary health facility network covers only 26.6% of the population in Scenario 1. In Scenario 2, the use of a bicycle greatly increases the population being served to 58% of inhabitants. When considering Scenario 3, the total population served is 34.3%.ConclusionsSignificant spatial variations in geographical accessibility and spatial coverage were observed across the three travel scenarios. The analysis demonstrates that regardless of which travel scenario is used, the majority of the population in the Western Province does not have access to the existing primary health facility network. Our findings also demonstrate the usefulness of GIS methods to leverage multiple datasets from different sources in a spatial framework to provide support to evidence-based planning and resource allocation decision-making in developing countries.

Oral health behaviour and self-esteem in Swedish children

This study focus on the socio-psychological concept of self-esteem and examines its association with oral health behaviour and with some background variables that have been shown to be of importance in previous studies. In 1995, 3370 12-year-olds answered a questionnaire on social and demographic factors. Questions on attitudes and behaviour were also included. After reducing the number of variables and constructing new variables, multivariate analyses were performed. A polytomous regression on self-esteem showed that having very poor self-esteem as opposed to poor, good and very good self-esteem was associated with being a girl, not living with ones biological parents, poor social support, having less interest in politics, poor adaptation in school and poor oral health behaviour. The results also showed that being a boy, choosing statements reflecting less exemplary behaviour, and being less well adapted in school increased the risk of having poor oral health behaviour, as did ethnic group affiliation and having poor self-esteem. Our results showed that self-esteem is a crucial intervening variable between variables measuring social background and outcome variables, especially oral health behaviour.

The Nicaraguan health and demographic surveillance site, HDSS-León : A platform for public health research

Aim: To describe the Health and Demographic Surveillance System (HDSS) in León, Nicaragua and to present results from the 2002—2003 baseline. Design and methods: A 22% sample of the total population in León, both urban and rural, was selected in 1993. This sample was updated in 2002 and will be followed up on a biannual basis with regard to births, deaths, in-migration, and out-migration. A group of 18 female fieldworkers perform 10 household interviews per day, 20 days per month. They use a map that is produced by a Geographical Information System. It shows all the households, and is the main means of the interviewers finding the households. An extensive data quality control system is used. Results: In total, 54,647 persons lived in the area of the surveillance system, and they resided in 10,994 households. The mean age was 26 years; the sex ratio was 0.93. The infant and neonatal mortality rates were 25.4 and 20.5 per 1,000 live births, respectively. In total, 2,034 people out-migrated from the study area and 3,377 in-migrated. Of the households, 53% were classified as non-poor, 41% as poor, and 6% as extremely poor. Six per cent of the population did not have a toilet or a latrine, and only 16% in the rural area had indoor running water. The surveillance system revealed that 10% were illiterate. Conclusions: The HDSS in León has shown that it can serve as a platform for further intervention studies as well as for research training.