Comparative study of preventive protocols in children at high cariogenic risk

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Abstract
The aim of this study was to compare the efficacy of two preventive protocols -fluoride gel (F) alone or combined with chlorhexidine varnishes (CHX) - on sialochemical, clinical and microbiological parameters in a group of children at high cariogenic risk Two therapeutic-preventive protocols were applied in 73 children at high cariogenic risk (average age 6.2 +/- 1.4 years old) and clinical parameters (simplified oral hygiene index: OHI-S; decayed, missing and filled teeth: dmf index; sugar intake and exposure to fluoride), as well as sialochemical parameters (salivary pH and flow, buffer capacity) and microbiological parameters (CFU/mg of dental biofilm of Streptococcus mutans group) were recorded and correlated before and after the protocols. Association was found between parameters that cause deficient control of dental biofilm: high values of OHIS index, CFU/mg dental biofilm, sugar intake and the d component of dmft index, and lower values of salivary flow rate and buffer capacity. After the protocols, a significant decrease was found in OHI-S and CFU/mg dental biofilm. No significant difference was found with children's gender and age. The association observed between OHI-S and cariogenic bacteria emphasizes the importance of prevention, especially regarding the oral health of the most vulnerable children. The early inclusion of F associated with CHX in the initial step of preventive and therapeutic protocols would provide benefits regarding oral microbe control while children acquire new habits of oral hygiene.
218
Acta Odontol. Latinoam. 2012 ISSN 0326-4815 Vol. 25 Nº 2 / 2012 / 218-223
RESUMEN
El objetivo de este trabajo fue evaluar la eficacia de dos pro-
tocolos preventivos - fluoruro (F) sólo o combinando con
clorhexidina (CHX)- sobre indicadores clínicos, sialoquími-
cos y microbiológicos, en una población de niños de alto
riesgo cariogénico.
Se aplicaron dos protocolos terapéutico-preventivos en 73
niños en edad escolar de alto riesgo cariogénico y se determi-
naron y correlacionaron parámetros clínicos (índice de higiene
oral simplificado IHO-S, ceo-d, consumo de azúcar y exposi-
ción a fluoruros), sialoquímicos (pH y flujo salival, capacidad
amortiguadora) y microbiológicos (UFC/mg de biofilm dental
de Streptococcus grupo mutans) antes y después de la apli-
cación de los tratamientos.
Se observó una asociación entre los parámetros que producen
una deficiente control de placa bacteriana: altos valores de
IHO-S, de UFC/mg biofilm dental, de consumo de azúcar, del
componente c del índice ceo-d y los menores valores de flujo
salival y de capacidad amortiguadora. Luego de la aplicación
de los tratamientos, se observó una disminución significativa
de IHO-S y UFC/mg biofilm dental. No se observaron diferen-
cias significativas con el género y la edad de los niños.
La asociación observada entre los niveles de higiene oral y de
bacterias cariogénicas enfatiza la importancia de la preven-
ción y atención de la salud de los niños más vulnerables. La
incorporación del F asociada a la CHX en la etapa inicial de
los protocolos terapéutico-preventivos ofrecería temprana-
mente beneficios en el control microbiano mientras se
incorporan hábitos de higiene oral.
Palabras clave: niños, susceptibilidad a caries dental, saliva,
clorhexidina, fluoruro.
ABSTRACT
The aim of this study was to compare the efficacy of two preventive
protocols - fluoride gel (F) alone or combined with chlorhexidine
varnishes (CHX) - on sialochemical, clinical and microbiological
parameters in a group of children at high cariogenic risk.
Two therapeutic-preventive protocols were applied in 73 chil-
dren at high cariogenic risk (average age 6.2±1.4 years old)
and clinical parameters (simplified oral hygiene index: OHI-
S; decayed, missing and filled teeth: dmf index; sugar intake
and exposure to fluoride), as well as sialochemical parameters
(salivary pH and flow, buffer capacity) and microbiological
parameters (CFU/mg of dental biofilm of Streptococcus mutans
group) were recorded and correlated before and after the pro-
tocols. Association was found between parameters that cause
deficient control of dental biofilm: high values of OHIS index,
CFU/mg dental biofilm, sugar intake and the d component of
dmft index, and lower values of salivary flow rate and buffer
capacity. After the protocols, a significant decrease was found
in OHI-S and CFU/mg dental biofilm. No significant difference
was found with children’s gender and age.
The association observed between OHI-S and cariogenic bac-
teria emphasizes the importance of prevention, especially
regarding the oral health of the most vulnerable children. The
early inclusion of F associated with CHX in the initial step of
preventive and therapeutic protocols would provide benefits
regarding oral microbe control while children acquire new
habits of oral hygiene.
Key words: dental caries susceptibility, children, saliva, fluo-
ride, chlorhexidine.
COMPARATIVE STUDY OF PREVENTIVE PROTOCOLS
IN CHILDREN AT HIGH CARIOGENIC RISK
María C. Martínez
1
, Betina Tolcachir
1
, Alfonsina Lescano de Ferrer
1
, María A. Bojanich
2
,
Silvina R. Barembaum
2
, Silvia E. Calamari
2
, Ana I. Azcurra
2
1
Social and Preventive Dentistry Department, School of Dentistry, National University of Córdoba, Argentina.
2
Oral Biology Department, School of Dentistry, National University of Córdoba, Argentina.
ESTUDIO COMPARATIVO DE PROTOCOLOS PREVENTIVOS
EN NIÑOS DE ALTO RIESGO CARIOGÉNICO
INTRODUCTION
Knowledge which has come to light in recent years
regarding dental caries has led to a new paradigm and
comprehensive approach to its treatment. The multi-
factorial etiology and complex pathogenesis of dental
caries involve microbiological, histological, immune
and biochemical aspects, which lead to a diagnostic
criterion and therapeutic reformulation for a preven-
tive approach. In odontopediatric clinical practices, it
is essential to unify the criteria for a certain diagnosis,
identifying individual children or groups of more vul-
nerable children. With this purpose, clinical indexes
have been associated to sialochemical and microbio-
logical tests
1
. The former arise from dental medical
ACTA-2-2012-SEGUNDAS:3-2011 19/10/2012 10:41 a.m. Página 218
history, both personal and family histories, cultural
and socio-economic context, and clinical dental-stom-
atological examination. Among sialochemical tests,
salivary buffer capacity, pH and flow rate are consid-
ered as risk factors; while microbiological tests refer
to colony-forming units and species identification
2,3
.
Considering these indicators, a patient can be cate-
gorized as being at high or low cariogenic risk,
based on which it is possible to devise preventive
and therapeutic strategies tending towards the con-
trol each of the factors involved. It is therefore
essential to plan preventive actions according to the
needs of each group of children, thus reducing costs
and improving efficacy
1,4
.
In general, preventive actions in children at high cario-
genic risk tend to improve host resistance, control cari-
ogenic food intake and, above all, control the
pathogenic microbes
5
. The two latter can be managed
by changing eating habits and oral hygiene. Depend-
ing on their lifestyle and family environment, children
may take some time to assimilate these behavioral
changes, which require intensive interaction among the
child, his/her family and health care professional.
While these changes are being implemented, one ther-
apeutic action to control dental biofilm is the use of a
chemical that could affect adhesion, colonization
and/or bacterial metabolism, such as fluorides (F)
6
and
chlorhexidine (CHX)
7
. F has an important inhibitory
action on microbial biofilm, conditioning the neces-
sary bacterial metabolic processes for the development
and maturation of dental biofilm through enzymatic
inhibition
4
. CHX controls the microbiological load in
patients, in particular reducing salivary counts for
Streptococcus mutans, which is highly sensitive to it
8,9
.
The aim of this study was to assess and compare the
efficacy of two preventive protocols, one applying only
F and the other combining F with CHX, on sialochemi-
cal, microbiological and clinical parameters and index-
es, in a population of children at high cariogenic risk.
MATERIAL AND METHODS
The study was a randomized clinical trial on children
with clinical diagnosis of high cariogenic risk (n=73,
both sexes, average age 6.2±1.4 years old), who
received care at the Department of Pediatric Dentistry,
School of Dentistry, National University of Cordoba,
Argentina. The study was approved by the Ethics
Committee, School of Medical Sciences, National
University of Cordoba, Argentina, and
parents/guardians of all subjects signed informed con-
sent after a detailed explanation of the protocol. No
patient had any history of systemic illness, and all
underwent standardized detailed examination of the
oral cavity. High cariogenic risk criteria were estab-
lished by means of the following clinical indicators:
dental caries lesions over the past year including white
spot lesions, presence of dental pits and fissures,
Greene and Vermillion’s oral hygiene index simpli-
fied
10
(OHI-S) ≥ 0.8, sugar intake > 4 per day and low
frequency of visits to the dentist
11
. The following
parameters were determined in this high caries risk
group: Microbiological parameters: counts of S.
mutans group in dental biofilm collected from the lin-
gual face of mandibular molars with a periodontal
probe, which was immediately placed in sterile physi-
ological solution in pre-weighed tubes. Samples were
immediately cultivated (mg of dental biofilm collect-
ed) in duplicate, in mitis salivarius agar with bacitracin
(DIFCO
®
, Becton Dickinson, France), incubated for
48 hr at 37ºC in microaerophilic environment;
colonies were counted (CFU/mg of dental biofilm).
Biochemical identification was performed by means
of morphological characteristics and conventional bio-
chemical tests (Diatabs
®
, Doughnut Diagnoses, Den-
mark)
12
. Sialochemical parameters: Saliva samples
(stimulated by chewing a piece of 3x3 cm2 paraffin
film) were collected by direct salivation between 9 and
11 a.m. for 5 min in iced graduated tubes. Patients had
been advised not to eat anything for at least 2 hours
before the sample collection. Salivary flow rate, buffer
capacity and pH were determined immediately
(Orion
®
pH meter, USA)
2,3,13
.
All children received initial preventive therapy con-
sisting of oral hygiene techniques, dietary advice and
caries inactivation. After that, they were randomly
divided into two groups for the application of preven-
tive protocols under evaluation: Group I: (n=36)
received a weekly topical application of fluoride gel
for four weeks (F: acidulated gel 1.23% NaF, Gelato,
Deepak, USA), and Group II: (n=37) received com-
bined therapy, alternating topical acidulated fluoride
application with 1% chlorhexidine varnish, for the
same period and frequency (F + CHX: Periobacter
Prof, NAF, Argentina). Clinical, sialochemical and
microbiological parameters were assessed again one
week after the final application of the different treat-
ments. The analysis of correspondence association
required operationalization of variables and determi-
nation of levels, considering the median for the quan-
titative variables: level 1: lower or equal to the
Prevention in children and cariogenic risk 219
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ACTA-2-2012-SEGUNDAS:3-2011 19/10/2012 10:41 a.m. Página 219
median; level 2: above the statistical median. For
OHI-S, ≥ 0.8 values were included in level 2, while
level 1 corresponded to < 0.8 values.
Statistical Analysis
Categorical variables were summarized as propor-
tions, and comparisons of groups were made by
Student’s t test for paired samples, ANOVA and cor-
respondence analysis, considering a significance
level of p<0.05 (Infostat Professional, version 2007).
RESULTS
The sample was made up of 61.8% female and
39.2% male participants. Clinical, sialochemical
and microbiological variables at baseline (pretreat-
ment) are shown in Table 1.
Association between the parameters studied and clini-
cal indexes before the application of the treatment was
carried out by multivariate correspondence analysis.
Association was found between deficient levels of
parameters that control cariogenic dental biofilm: high
values for OHI-S, CFU/mg of dental biofilm, and sugar
intake, and poor buffer capacity; as well as high levels
of active caries with the d component of the dmf-t index
and lower values of salivary flow rate. Association was
also found between lower levels of OHI-S and
CFU/mg of dental biofilm and better buffer capacity.
Lower levels of variable active caries, the d compo-
nent of the dmf-t index and higher sugar intake values
were associated with higher values of salivary flow rate
(inertia 37.85%). No association was observed
between salivary pH and children’s gender; neverthe-
less, lower buffer capacity was found in female
patients. Regarding children’s age, a tendency towards
lower salivary flow rate was observed in younger chil-
dren (≤ 5 years old, p=0.08), probably related to the
difficulty in salivating and collecting saliva.
After both treatments, the levels of CFU/mg dental
biofilm decreased significantly in relation to pretreat-
ment values (F: p=0.004; F + CHX: p=0.001). Com-
paring both treatments, the decrease
in CFU/mg dental biofilm was greater
in Group II (F + CHX treatment)
(p <0.0001) (Fig. 1). Moreover, OHI-
S decreased significantly with treat-
ment (treatment F: p=0.0002,
treatment F + CHX: p<0.0001) (Fig.
2). No significant difference was
found between treatments. Higher
values of CFU and OHI-S were
observed in children over 6 years old,
with more significant differences. No
significant difference was found
between girls and boys.
220 M. C. Martínez, et al.
Acta Odontol. Latinoam. 2012 ISSN 0326-4815 Vol. 25 Nº 2 / 2012 / 218-223
Table 1: Clinical, sialochemical and microbiological parameters
of children before treatments.
Pre- Treatment Values
Clinical parameters
dmf-t
5.2 ± 2.4
d
component 3.7 ± 2.3
f
component 0.9 ± 1.4
OHI-S 1.5 ± 0.5
Moments of sugar per day 4.5 ± 1.5
Sialochemistry and Salivary flow 0.78 ± 0.36
microbiological Salivary pH 7.51 ± 0.35
parameters Salivary buffer capacity 5.92 ± 0.67
CFU / mg biofilm (2.06 ± 3.80) x 10
8
Data are expressed as mean ± standard deviation
Fig. 2: Effect of therapeutic preventive protocol treatment on
the oral hygiene index (OHI-S).
Fig. 1: Effect of therapeutic preventive protocol treatment on
S. mutans levels (CFU/mg biofilm).
ACTA-2-2012-SEGUNDAS:3-2011 19/10/2012 10:41 a.m. Página 220
DISCUSSION
Although there is much research on cariogenic risk
employing clinical, sialochemical and microbiolog-
ical parameters as risk indicators at baseline and
after treatment, there is very little information about
young school-age population in our region. The high
prevalence of caries among children warrants fur-
ther research on the subject, which encouraged us to
contribute this study. Clinical, microbiological and
sialochemical variables were selected from biblio-
graphic reviews
2,8,11,13
and our clinical experience
allows us to establish points of reference. Although
there are many indexes for quantifying the presence
of oral biofilm, in odontopediatric practices, the
Green and Vermillion Simplified allows biofilm in
primary teeth to be measured quickly and easily, and
to be associated to oral hygiene status
10
.
Like other researchers, we have established assess-
ment protocols and treatments for children at high car-
iogenic risk adapted to our context. Such protocols are
based on oral hygiene, history of dental caries, dietary
habits, state of oral health, oral microbial load, sali-
vary flow rate and pH
13
. In this regard, Zero et al.
14
found that the model for the assessment of risk factors
depends on the population studied; Peterson et al.
15
reinforces this idea, suggesting that geographical area
can be considered as a predictor, as well as social fac-
tors, lifestyles, and cultural and economical aspects.
Many protocolized clinical trials associate the pro-
motion and education of oral health with the applica-
tion of chemical substances, combining mainly
fluoride and chlorhexidine
7,16,17
, as well as studying
the relationship between S. mutans levels and differ-
ent stages of early childhood caries
18
. Nevertheless,
and in agreement with Rijkmo et al.
19
, it is difficult
to compare results because of the diversity of
methodological conditions and heterogeneity of pop-
ulations. This is the case for S. mutans counts, report-
ed in our study as CFU/mg dental biofilm, which are
not comparable with some published values, usually
reported as CFU/mL saliva
5,8,12
. In this study we have
considered the fact that CFU associated to dental
biofilm are much more closely related to cariogenic
risk than are planktonic bacteria in saliva.
Our study found an improvement in the level of OHI-
S and CFU/mg dental biofilm after treatments with
more statistically significant levels when the sample
was stratified according to age, which could be relat-
ed to a greater efficacy of educational protocols and
greater motor ability in the older group of children.
Regarding the observed dmf-t index values, the high
prevalence of the d component observed with a low
level of the f component indicates the lack of atten-
tion to oral health among these children; moreover,
high values of the d component determine, together
with other parameters, a future prognosis of high
caries risk
20,21
. These authors noted how powerful
the d component is as a predictor of caries on per-
manent dentition and therefore, how important edu-
cational programs to recover oral health are.
In our study, salivary flow rate values corresponded
to high and medium risk values according to Bordoni
et al.
22
, medium risk values observed by Sánchez-
Pérez et al.
23
and were lower than those reported by
Tukia-Humala et al.
24
. These findings reinforce the
need for local studies describing the special charac-
teristics of vulnerable children in our region.
The salivary buffer capacity values observed in our
study did not correlate with those reported in other
papers according to caries risk and age
25
. These
papers found that salivary buffer capacity and flow
rate improved after tooth brushing techniques were
taught, emphasizing the importance of implement-
ing preventive and educational programs. Our
results showed higher values of salivary flow rate
than those reported in the literature according to the
cariogenic risk observed
22,26
.
The decrease in S. mutans counts and improvement
in oral hygiene index after fluoride application com-
bined with CHX varnishes, added to the educational
motivation and preventive and educational actions,
were similar to those reported by Petersson et al.
15
.
Many authors
26,27
confirmed the benefits of applying
chemical compounds in order to reduce the bacterial
load and control caries, emphasizing the benefits of
the application of fluoride combined with CHX var-
nishes in patients at high cariogenic risk.
Twetman
28
showed the antimicrobial properties of
CHX, although its effectiveness on long-term preven-
tion was not proved. Experimental studies with both
antimicrobial agents also showed a greater effective-
ness in the prevention of biofilm development, and
thus of enamel demineralization
29
. The association
observed between oral hygiene index and cariogenic
bacteria counts in this study supports the need to
emphasize preventive actions for maintaining oral
health in the most vulnerable children; this could also
demonstrate that OHI-S reflects pathogenic Strepto-
coccus levels, although it must be remembered that
dental caries is a multifactorial disease, and other fac-
tors such as oral hygiene and access to fluoridated
products are also determinants of the carious process.
In this sense, prevention should be based on diet con-
trol, teaching oral hygiene techniques and reinforcing
Prevention in children and cariogenic risk 221
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ACTA-2-2012-SEGUNDAS:3-2011 19/10/2012 10:41 a.m. Página 221
host resistance. Nevertheless, including CHX during
the initial phase of clinical odontopediatric actions in
children at high cariogenic risk offers benefits in
microbial control while dietary and oral hygiene habits
are being promoted. This study shows that the appli-
cation of CHX together with fluoride varnishes is an
important complement to initial therapy in children at
high cariogenic risk and provides better control of
some indicators than does using only fluoride. Never-
theless, and considering that our work cannot be inter-
preted as an epidemiological study, further studies are
needed to assess the efficacy on long-term prevention.
222 M. C. Martínez, et al.
Acta Odontol. Latinoam. 2012 ISSN 0326-4815 Vol. 25 Nº 2 / 2012 / 218-223
ACKNOWLEDGMENTS
This work was supported by the Secretary of Science and Tech-
nology (SeCyT) of the National University of Cordoba, Nº 159/07.
CORRESPONDENCE
Dra. Ana I. Azcurra
Oral Biology Department, Faculty of Dentistry, National
University of Córdoba. Haya de la Torre SN, Pabellón Argentina
Ciudad Universitaria- 5016, Córdoba, Argentina
e-mail: anaazcurra@yahoo.com
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  • [Show abstract] [Hide abstract] ABSTRACT: To evaluate the association between saliva and prevalence of dental caries. Two-year longitudinal study in rural schoolchildren at Cruz del Eje, Argentina between 2000 and 2002. The study population comprised all schoolchildren (N=196) aged 5 to 14 years of both sexes attending eight rural schools. They were assessed at three different time points (N=46): baseline, 12 and 24 months. Salivary components and DMFT and dmft indexes were used. Nominal variables, "decay" and "new decay", were created to assess risk of decay at baseline, 12, and 24 months, respectively. Principal component analysis was applied to select salivary factors associated to decay and then they were categorized according to the median as a cutoff value. High prevalence of decay (50%-90%) was found at the three time points of study. There was significantly increase in caries at 12 months (p=0.000) compared to that seen at 24 months. At baseline there were homogeneous low levels of calcium and phosphate and a significant association (p<0.050) between calcium and phosphorus and calcium/phosphorus molar ratio and decay. Phosphorus levels and calcium/phosphorus molar ratio can be considered risk factors for the development of caries in populations with characteristics similar to those studied.
    Article · Feb 2008
  • [Show abstract] [Hide abstract] ABSTRACT: A predominant part of the cariostatic activity of fluoride is a function of its concentration in the fluid environment of the teeth. The fluoride exposure results in a slightly elevated steady-state level of fluoride in the oral fluids, primarily in saliva and plaque fluid. So far, however, little is known about the intra-oral fluoride concentration necessary to achieve a cariostatic effect at the site of action. Following fluoride intake, the fluoride remaining in the oral cavity is diluted by the saliva pool. The remaining fluoride may be found in several compartments in the oral cavity. It may be ionized in saliva, ionized in plaque (plaque fluid), bound in plaque, bound as calcium fluoride, bound to enamel, and bound to soft tissues. Fluoride is also distributed to the oral tissues and into the dental plaque by diffusion. It is well established that plaque, after fluoride exposure, becomes a fluoride reservoir which stores for some time and releases fluoride. The present review gives an insight into the important parameters that determine the disposition and fate of fluoride in the oral environment. To achieve in-depth understanding, and hence formulation of the optimal fluoride therapy, more information is needed to consolidate our understanding of the distribution, retention, and elimination of fluoride in the oral cavity. Such knowledge will form a better basis for providing our patients with more effective dental fluoride products and regimens.
    Article · Jan 2000
  • [Show abstract] [Hide abstract] ABSTRACT: The present report describes the usefulness of a microbial caries screening test in a population of children younger than 6 years. Two hundred children presenting to a private pediatric dental office were screened for Streptococcus mutans using a test adapted for the dental office. The numbers of S. mutans colonies were recorded semiquantitatively and carious lesions were assessed clinically and radiographically. Ninety-three per cent of children with caries were positive on the test (sensitivity), while 57% of the infected children had caries (specificity). Uninfected children were almost always caries free (predictive value negative 95%). The results also showed an increasing percentage of children with caries in groups of children with increasing infection level. These findings are consistent with both the central role of S. mutans in caries initiation and the multifactorial nature of caries development. The dramatically better results in the present report may reflect a closer correlation between caries activity and S. mutans infection in younger than in older children. Microbial screening may be useful for identification of young children infected with cariogenic microorganisms so that preventive and therapeutic treatments can be tailored to the needs of individual patients.
    Full-text · Article · Jul 1989
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