John P. Brown

Interaction of age and specific saliva component output on caries

Background and aims: The purpose of this study was to explore the relationship between individual salivary components, dental caries and age, utilizing the data from the Oral Health: San Antonio Longitudinal Study of Aging (OH:SALSA). Methods: The study population comprised a well-defined stratified sample of 811 dentate men and women. Subjects were divided into four age groups from 35 to 75+ years old. Unstimulated and stimulated submandibular/sublingual saliva flow rates, unstimulated and stimulated parotid saliva flow rates, total protein, 6 individual proteins and 4 inorganic constituents were measured. Specific salivary components were lactoferrin, secretory IgA, albumin, lysozyme, mucin, cystatin, K+, Ca+2, Na+ and Cl−. Caries measurements were the DMFT Index for crowns and for roots, Tooth Health Index for crowns and roots, Tooth caries, Root caries and Tooth restoration. The data on saliva components were square root transformed for linearity prior to analysis. Analysis was carried out in two stages. Partial correlation was performed, in order to identify significant relationships between specific salivary components and caries measurements, controlling for age group. In the second stage, using caries measurement as the dependant variable, the effects of age, flow rate and specific salivary component output (product of flow rate and concentration) were examined. Results: Significant associations were found between caries, age and specific individual submandibular/sublingual salivary proteins (lactoferrin, albumin, lysozyme, mucin and cystatin) and specific inorganic constituents (K+, Ca+2, Na+ and Cl− ). Conclusions: Changes in submandibular/sublingual salivary component output during aging are correlated with high caries prevalence. These changes in saliva components over age may represent caries risk indicators.

Design of the Xylitol for Adult Caries Trial (X-ACT)

BackgroundDental caries incidence in adults is similar to that in children and adolescents, but few caries preventive agents have been evaluated for effectiveness in adults populations. In addition, dentists direct fewer preventive services to their adult patients. Xylitol, an over-the-counter sweetener, has shown some potential as a caries preventive agent, but the evidence for its effectiveness is not yet conclusive and is based largely on studies in child populations.Methods/DesignX-ACT is a three-year, multi-center, placebo controlled, double-blind, randomized clinical trial that tests the effects of daily use of xylitol lozenges versus placebo lozenges on the prevention of adult caries. The trial has randomized 691 participants (ages 21-80) to the two arms. The primary outcome is the increment of cavitated lesions.DiscussionThis trial should help resolve the overall issue of the effectiveness of xylitol in preventing caries by contributing evidence with a low risk of bias. Just as importantly, the trial will provide much-needed information about the effectiveness of a promising caries prevention agent in adults. An effective xylitol-based caries prevention intervention would represent an easily disseminated method to extend caries prevention to individuals not receiving caries preventive treatment in the dental office.Trial RegistrationClinicalTrials.Gov NCT00393055

Tuberculin skin test conversion rate in dental health care workers : results of a prospective study

OBJECTIVES The tuberculin skin test conversion rate over 12 months in dentists, dental hygienists, and dental assistants was assessed in 3 US-Mexico border counties of Texas in which reported tuberculosis rates were high compared with the rates for Texas and the United States. METHODS Tuberculin skin tests were administered to 284 subjects and repeated on nonreactors 12 months later. Participants also completed self-administered questionnaires. RESULTS The baseline positive tuberculin skin test prevalence was 4. 6%. Nonreactors were more likely to have been born in the United States (P <.001). The tuberculin skin test conversion rate over 12 months was 1.7%. CONCLUSION Results indicate a need for heightened awareness of tuberculosis transmission and annual surveillance by dental health care workers, as recommended by the Centers for Disease Control and Prevention.

The Dynamic Behavior of the Early Dental Caries Lesion in Caries-active Adults and Implications

OBJECTIVE To describe the full range of behavior of the visible, noncavitated, early caries lesion in caries-active adults with substantial fluoride exposure, and to consider implications. METHODS The data were from the Xylitol for Adult Caries Trial (X-ACT) collected annually for 33 months using condensed ICDAS caries threshold criteria. Individual tooth surfaces having a noncavitated caries lesion were included, and the patterns of transition to each subsequent annual clinical examination to sound, noncavitated or cavitated, filled or crowned were determined. The resulting sets of patterns for an individual tooth surface, looking forward from its first appearance as a noncavitated lesion, were combined into one of four behavior profiles classified as reversing, stable, oscillating, or continuously progressing, or were excluded if not part of the caries continuum. The distributions of profile types were assessed using the Rao-Scott chi-square test, which adjusts for clustering of tooth surfaces within teeth. RESULTS Inter- and intra-examiner kappa scores demonstrated acceptable calibration at baseline and annually. 8084 tooth surfaces from 543 subjects were included. The distribution of profile types differed significantly between coronal and root surfaces. Overall, two-thirds of all coronal noncavitated lesions were first seen at baseline, half reversed, over a fifth were stable, 15% oscillated, and only 8.3% progressed to cavitation, filled, or crowned in 33 months or less (6.3% consistently Progressed plus 2.0% inconsistently, a subset of oscillating, which oscillated before progressing to cavitation). Approximal, smooth, and occlusal coronal surfaces each were significantly different in their individual distributions of profile types. Xylitol showed no significant and consistent effect on this distribution by tooth surface type. This was in keeping with the X-ACTs lack of effect of xylitol at the noncavitated plus cavitated lesion thresholds combined. CONCLUSIONS This study demonstrated the full dynamic range of early caries lesion behavior. The great majority were not progressive, and few (8.3%) became cavitated over 33 months in caries-active adults using fluorides. Important caries management implications favoring recorded longitudinal monitoring, prevention of active risks, and minimal restoration only after direct visual determination of cavitation are discussed.

Visual scoring of non cavitated caries lesions and clinical trial efficiency, testing xylitol in caries-active adults

OBJECTIVES To better understand the effectiveness of xylitol in caries prevention in adults and to attempt improved clinical trial efficiency. METHODS As part of the Xylitol for Adult Caries Trial (X-ACT), non cavitated and cavitated caries lesions were assessed in subjects who were experiencing the disease. The trial was a test of the effectiveness of 5 g/day of xylitol, consumed by dissolving in the mouth five 1 g lozenges spaced across each day, compared with a sucralose placebo. For this analysis, seeking trial efficiency, 538 subjects aged 21-80, with complete data for four dental examinations, were selected from the 691 randomized into the 3-year trial, conducted at three sites. Acceptable inter- and intra-examiner reliability before and during the trial was quantified using the kappa statistic. RESULTS The mean annualized noncavitated plus cavitated lesion transition scores in coronal and root surfaces, from sound to carious favoured xylitol over placebo, during the three cumulative periods of 12, 24, and 33 months, but these clinically and statistically nonsignificant differences declined in magnitude over time. Restricting the present assessment to those subjects with a higher baseline lifetime caries experience showed possible but inconsistent benefit. CONCLUSIONS There was no clear and clinically relevant preventive effect of xylitol on caries in adults with adequate fluoride exposure when non cavitated plus cavitated lesions were assessed. This conformed to the X-ACT trial result assessing cavitated lesions. Including non cavitated lesion assessment in this full-scale, placebo-controlled, multisite, randomized, double-blinded clinical trial in adults experiencing dental caries did not achieve added trial efficiency or demonstrate practical benefit of xylitol. TRIAL REGISTRATION ClinicalTrials.Gov NCT00393055.

Dental caries prediction to target high-risk individuals in community-based preventive programs is problematic.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Life course dental caries determinants and predictors in children aged 12 years: a population-based birth cohort. Peres MA, Barros AJ, et al. Community Dent Oral Epidemiol 2009;37:123-33. REVIEWER John P. Brown, BDS, MS, PhD. PURPOSE/QUESTION To define selected life course social, biological, and behavioral exposures as determinants and predictors of dental caries in children at 12 years of age. SOURCE OF FUNDING Brazilian National Council for Scientific and Technological Development CNPq Grant No. 403362/2004-0. TYPE OF STUDY/DESIGN Cohort study. LEVEL OF EVIDENCE Level 2: limited-quality patient-oriented evidence STRENGTH OF RECOMMENDATION GRADE Not applicable.

Validation of School Nurses to Identify Severe Gingivitis in Adolescents

This project created a mechanism to identify adolescents with marked gingival disease with a visual screening instrument that can be administered by a school nurse or health care worker. The prevailing paradigm in management of periodontal disease is that plaque removal controls gingivitis,1 and gingival inflammation is a prerequisite for development of destructive periodontal disease.2 Prior investigation3 of a similar population in San Antonio, Tex, showed a high prevalence of severe gingival inflammation. Because school-based interventions are effective in oral health promotion,4 establishment of an intervention strategy focused on (1) identification of the health problem; (2) referral for diagnosis, treatment, and follow-up; (3) education and counseling about risk behaviors and impediments to access to care; and (4) evaluation of the intervention methods. Examinations were conducted in a mobile dental van at a middle school located in a predominantly Hispanic and dentally underserved community in the greater San Antonio area. Following a training session in which dentist and nurse were in agreement on the indices, a school nurse visually screened each student with a penlight, tongue depressor, and photographic reference that pictorially identified each visual index category to score the gingival health of each student. Descriptions of the Visual Periodontal Index and the Visual Oral Hygiene Index categories are presented in Table 1 ▶. The dentist screened each student independently of the school nurse and conducted a routine dental diagnostic examination. For this study, supragingival plaque,5 gingival index,1 and probing depth data were collected on Ramjford teeth6 with a mirror and Michigan ‘O’ probe. TABLE 1 —Visual Periodontal Index and Visual Oral Hygiene Index Criteriaa This project addressed 3 issues: (1) agreement of the nurse and dentist in the outcome of the visual examination, (2) effectiveness of the screening tool in detecting marked gingival disease, and (3) effectiveness of the screening process determined by referral for treatment. Of the 84 seventh-grade students who were screened, 92.8% were Hispanic and 56.6% were female. One third of the students presented with edematous gingival tissue with gross loss of contour and bleeding along the gingival margin corresponding to a Visual Periodontal Index of 2. For the Visual Periodontal Index, the level of agreement was 83.33% (P = .00), and for the Visual Oral Hygiene Index, the level of agreement was 87.70% (P = .00), and both κ values indicated good reproducibility (Visual Periodontal Index = 0.5794, P < .00; Visual Oral Hygiene Index = 0.5006, P < .00), despite the subjectivity of the indexes (Table 2 ▶). Comparison of the dentists visual screening to the clinical examination (Visual Periodontal Index to gingival index1; Visual Oral Hygiene Index to supragingival plaque5) showed a high level of sensitivity (Visual Periodontal Index = 96.23%; Visual Oral Hygiene Index = 98.44%) but less specificity (Visual Periodontal Index = 50.00%; Visual Oral Hygiene Index = 40.00%). Positive predictive value (Visual Periodontal Index = 80%; Visual Oral Hygiene Index = 66.67%) and negative predictive value (Visual Periodontal Index = 86.44%; Visual Oral Hygiene Index = 95.45%) indicated that this test was effective in detecting gingivitis in this population. False-negative findings were low (Visual Periodontal Index = 3.77%; Visual Oral Hygiene Index = 1.56%). The strength of the sensitivity of both visual tests increased the inclusion of cases, although individuals without gingival disease were being referred. Because the outcome of the screening was referral to a dental professional, maximization of the sensitivity at the expense of the specificity was considered an optimal end point. TABLE 2 —Kappa Statistic Comparing the Accuracy of the School Nurse and Dentist With Visually Identified Gingival Disease To determine whether the visual screening examination could accurately identify those individuals who were diagnosed as requiring treatment, the nurses visual examination was compared with referrals. Both of the nurses scores were associated with referral (odds ratio [OR] for Visual Periodontal Index = 5.94; P = .00; OR for Visual Oral Hygiene Index = 5.75; P = .05). Of the 25 students referred for emergent needs, 5 (20%) either had scheduled an appointment or were seen by a dental professional after 4 months. Seven of the parents or guardians did not intend to schedule a dental visit, and the remainder were lost to follow-up. Ultimately, the referral of patients with disease is a primary criterion determining the success of any screening program. Correlation to referral suggested that this visual screening examination was successful in the identification of patients with plaque accumulation resulting in gingivitis. The response rate of the parent or guardian to seek additional treatment was low because of the lack of oral health education of both adolescents and parents associated with the screening and other barriers but consistent with previous studies indicating that between 19% and 22% of referred patients seek treatment after screening.7 Almost all of the parents who did not seek treatment noted access to and availability of a dentist and finances as primary reasons to not obtain treatment. These barriers are high for Mexican American populations.8 Although a list of low-cost clinics was provided, access for the working parent was problematic because most clinics operate during daytime hours and have prolonged waiting times for appointments. This screening tool provides the school nurse with defined criteria to identify students with severe gingival inflammation. The surgeon generals report cited disparities in oral health care among minority groups and recommended that nondental professionals participate in oral health promotion.9 Screening and successful referral, not only for caries but also for early-onset gingival disease, can eliminate progression to frank periodontal disease. With demonstrable associations between periodontal disease and diabetes10 and the increased prevalence of diabetes in adolescent Hispanic populations, this tool may be even more significant in maintaining overall health into adulthood.

Is MOOSE a loose goose

A proposal for reporting meta-analysis of observational studies in epidemiology (‘MOOSE’) has been published. Meta-analysis of observational studies is outwardly similar in methodology to that applied to randomised controlled trials (RCT), but it does differ inherently. It is less certain and less definitive. Single summary estimates of effect derived from it are suspect. RCT and observational studies are complementary in nature, however, and they provide assessments of efficacy and effectiveness respectively. Meta-analysis of both types of study is needed, and the MOOSE proposal is a useful one.