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Effect of a Daily Dose of Snacks Containing Maltitol or Stevia rebaudiana as Sweeteners in High Caries Risk Schoolchildren. A Double-blind RCT Study
Abstract
Purpose:
To evaluate the effect of sugar-free snacks on caries-related factors in 6- to 9-year-old schoolchildren.
Materials and methods:
Two hundred seventy-one children at risk for caries as measured through the Cariogram were randomly assigned to three groups consuming twice-daily snacks containing Stevia, maltitol or sugar for 42 days. Parents filled out a standardised questionnaire regarding personal, medical and oral behavioural information. Bleeding on probing, plaque pH and salivary mutans streptococchi (MS) and lactobacilli (LB) were assessed at baseline (t0), 42 days of snack use (t1) and 120 days after the end of use (t2). The Cariogram calculation was repeated at t1. Treatment effects were estimated using linear mixed-effects regression models.
Results:
At t2, a decrease in cariogenic bacteria (MS X2 = 8.01, p < 0.01 and LB X2 = 4.60, p = 0.03) and an increase of the minimum pH (F = 4.48, p < 0.01), maximum pH (F = 2.88 p < 0.01) and pH drop (F = 2.95 p < 0.01) was recorded in the Stevia group compared to baseline. In the maltitol group, an improvement effect was noted: LB concentration decreased (p = 0.04) and maximum pH (F = 3.16 p < 0.01) increased. Subjects classified by the Cariogram as have a low probability of developing caries increased in the Stevia and maltitol groups (X2(4) = 25.44, p < 0.01, C*sV = 0.38 and X2(4) = 12.85, p = 0.01, C*sV = 0.27, respectively). Regression analysis underlines the effect of Stevia snacks on the cariogenic microflora, mainly on MS and plaque pH variations.
Conclusion:
The short-term administration of Stevia or maltitol snacks improves some important factors related to caries. This preventive strategy might be an additional means of combatting this common childhood disease.
... In the included studies, the age of participants ranged from 1 month to 98 years, the sample size from 20 to 892, and the study duration from 2 weeks to 39 months. Twenty-three studies included children and adolescents ≤18 years old, 21,30,31,33,34,[36][37][38][40][41][42][43][46][47][48][49][50]53,54,[57][58][59][60] and 9 studies included adults. 32,35,39,44,45,51,52,55,56 Various delivery forms of sugar substitutes were included, such as chewing gum, milk, and candies (gummy bears/tablets/slow-release pacifiers). ...
... Besides MS changes as the primary finding, 5 studies also mentioned other cariogenic bacteria changes in the saliva. 21,51,56,57,59 Three studies mentioned Lactobacilli changes in saliva 21,51,56 in which the results of 1/3 (33.3%) studies showed there was a significant decrease in Lactobacilli by consumption of maltitol and stevia. 21 The other 2 studies investigated multiple bacteria changes in saliva. ...
... Besides MS changes as the primary finding, 5 studies also mentioned other cariogenic bacteria changes in the saliva. 21,51,56,57,59 Three studies mentioned Lactobacilli changes in saliva 21,51,56 in which the results of 1/3 (33.3%) studies showed there was a significant decrease in Lactobacilli by consumption of maltitol and stevia. 21 The other 2 studies investigated multiple bacteria changes in saliva. ...
Background
The use of sugar substitutes in food products has recently increased. Limited information regarding the role of various sugar substitutes in caries prevention was found. This systematic review and meta-analysis was conducted to investigate the effects of sugar substitute consumption on reducing cariogenic bacteria in dental plaque and saliva.
Methods
We systematically searched PubMed, EMBASE, and Web of Science (inception to July 2023) for prospective controlled trials published in English and investigated the effects of sugar substitute consumption on cariogenic bacteria in dental plaque and saliva. The primary outcome was the changes in cariogenic bacteria. Two independent reviewers screened the papers. Quality was assessed using the Cochrane risk-of-bias tools.
Results
From 977 studies identified, 32 trials were included. Almost half (14/32, 44%) of the included studies had a high risk of bias. Almost all (31/32, 96.88%) were investigations of xylitol and other sugar alcohols (low-intensity sweeteners), such as sorbitol, erythritol, and maltitol. Only one trial investigated stevia, a high-intensity sweetener, whereas no studies on other high-intensity sweeteners, such as sucralose, saccharin, or aspartame, were found. Almost all studies (30/32, 93.75%) showed the consumption of low-intensity sweeteners led to a significant reduction of different types of cariogenic bacteria. The results of the meta-analysis showed that consumption of low-intensity sweeteners led to a significant reduction of cariogenic bacteria in both dental plaque and saliva compared to no treatment.
Conclusion
The consumption of low-intensity sweeteners helps reduce cariogenic bacteria in dental plaque and saliva. There is limited clinical evidence regarding the role of high-intensity sweeteners in reducing cariogenic bacteria.
... In another in vitro study, extracts of stevia leaf showed protective actions against causing agents of dental caries including E. coli, S. mutans, Bacillus subtilis, S. aureus, and Curvularia lunata [147]. Moreover, daily consumption of snacks containing stevia in comparison to sugar-based snacks for caries-related variables in 271 elementary school children (aged 6-9) resulted in reduced plaque acidogenicity and cariogenic microflora, thus reducing the risk of further development of caries [148]. There has been a growing interest in the antimicrobial and antiplaque activity of stevia mouthrinse and chewing gums [149]. ...
Introduction
Herbal products are increasingly being used for their potential to promote oral health. Phytochemicals can act as scavengers of reactive or toxic chemicals, selective growth factors for beneficial oral bacteria, fermentation substrates for beneficial oral bacteria, and selective inhibitors of harmful oral microflora. Plant-derived secondary metabolites encompass a variety of natural products, including alkaloids, polyphenols (including flavonoids and tannins), terpenes, terpenoids, steroids, saponins, quinones, coumarins, glycosides, and carotenoids.
Objectives
This review explores medicinal plant-based products for preventing and treating oral diseases, offering updated insights into the scientific basis for using herbs as active ingredients in oral health care. Hence, we focused on: (1) phenolic compounds, the most abundant and common phytochemicals and (2) terpenes and terpenoids, the most diverse and widely distributed group in the plant kingdom.
Methods
Several databases were queried to acquire peer-reviewed studies focusing on the major phytochemical compositions – phenolic compounds, terpenes, and terpenoids – and their oral health benefits.
Results
The review lists numerous medicinal herbs in various forms and applications for treating dental caries, gingivitis, and periodontitis.
Conclusion
This review explores the evidence supporting the oral health-promoting effects of specific constituents in herbs with the potential for incorporation into pharmaceutical formulations.
... (16) El Sorbitol, manitol y maltitol son sustancias con menor aporte de sabor dulce que el xilitol y se consideran como agentes anticariogénicos pues favorecen la remineralización temprana y estimula el flujo salival, además de aumentar el pH salival y en el biofilm. (17) El uso de xilitol resulta más beneficioso porque la mayoría de las bacterias cariogénicas no lo fermentan. ...
Introducción:
la salud bucal repercute en el estado de salud del individuo. Las caries dentales presentan una elevada incidencia, donde factores como el consumo de alimentos azucarados favorece su aparición.
Objetivo:
describir la influencia de los edulcorantes en el desarrollo de caries dental.
Métodos:
se realizó una revisión narrativa de la literatura mediante una búsqueda de información en las bases de dato SciELO y PubMed. Se utilizaron los términos caries AND edulcorante. Se identificó 22 documentos comprendidos entre los años 2017 - 2023, dentro de los cuales se incluye sólo un artículo de autoría ecuatoriana.
Resultado:
La aparición de la caries está favorecida por el consumo de azúcar, que es sustrato de la bacteria. Existen compuestos con propiedades similares, que pueden ser usados como sustitutos. La literatura muestra a los edulcorantes como alternativa para sustituir el azúcar, donde algunos poseen efecto preventivo para las caries.
Conclusiones:
los edulcorantes presentan de forma general un bajo potencial cariogénico, teniendo algunos efectos preventivos. En dependencia del edulcorante, su forma de presentación y composición química, los efectos pueden variar, teniendo los polialcoholes mayor potencial preventivo. La Stevia rebaudiana es una adecuada candidata para reemplazar la sacarosa y exhibe propiedades potenciales para disminuir la incidencia de las caries.
... Human studies performed with rebaudioside A or commercially available products containing stevia extract (Ajami et al., 2020;Cocco et al., 2019;Higgins and Mattes, 2019;Farhat et al., 2019;Stamataki et al., 2020;Sanchez-Delgado et al., 2020) were submitted within the application dossier. The Panel noted that the purpose of these studies was to investigate beneficial effects of products containing stevia (e.g. on dental caries), and efficacy of steviol glycosides on body weight and glucose handling, insulin levels, immunological parameters. ...
The EFSA Panel on Food Additive and Flavourings (FAF Panel) provides a scientific opinion on the safety of a new process to produce steviol glycosides by fermentation of simple sugars using a genetically modified strain of Yarrowia lipolytica (named Y. lipolytica VRM). The manufacturing process may result in impurities different from those that may be present in the other steviol glycosides E 960a‐d, therefore the Panel concluded that separate specifications are required for the food additive produced as described in the current application. Viable cells and DNA from the production strain are not present in the final product. The Panel considered that the demonstration of the absence of kaurenoic acid in the proposed food additive, using a method with a limit of detection (LOD) of 0.3 mg/kg, is adequate to dispel the concerns for potential genotoxicity. Given that all steviol glycosides follow the same metabolic pathways, the Panel considered that the current steviol glycosides would fall within the same group of substances. Therefore, the Panel considered that the already existing data on rebaudioside M and structurally related steviol glycosides are sufficient, and a similar metabolic fate and toxicity is expected for the food additive. The results from the bacterial reverse mutation assay and the in vitro micronucleus assay were negative and indicated absence of genotoxicity from the food additive. The existing acceptable daily intake (ADI) of 4 mg/kg body weight (bw) per day, expressed as steviol equivalents, was considered to be applicable to the proposed food additive. The Panel concluded that there is no safety concern for steviol glycosides, predominantly Rebaudioside M, produced by fermentation using Y. lipolytica VRM, to be used as a food additive at the proposed uses and use levels.
... In addition to not being cariogenic, the stevioside and rebaudioside A extracts are non-acidogenic (Brambilla et al., 2014). Childhood tooth decay can be combated by the sweetener of stevia instead of artifcial sugars with high calories in snacks (Cocco et al., 2019). ...
... Gingival inflammation did not decrease, but a small decrease was found in plaque scores [38]. The few existing clinical studies suggest a decrease in plaque scores in association with consumption of high-concentration maltitol products [50,51]. Sorbitol and maltitol are considered microbiologically rather inert but they are sweet and, thus, add to the saliva secretion-enhancing effect of gum base. ...
Objectives
A systematic review of published data was conducted with the aim of assessing the effects of sugar-free polyol chewing gums on gingival inflammation.
Materials and methods
Electronic and hand searches were performed to find clinical studies concerning the effects of sugar-free chewing gums on gingival scores. Prospective randomized controlled clinical trials published between 1971 and 2021 were included in the review.
Results
The initial search identified 46 erythritol, 102 xylitol, 23 sorbitol, and nine maltitol chewing gum articles. After applying inclusion and exclusion criteria, seven xylitol chewing gum studies, one sorbitol, and one maltitol chewing gum study with either high or fair quality were reviewed. In five out of the seven xylitol studies, xylitol gum decreased gingival scores. In two studies, xylitol decreased gingival scores compared to a polyol gum, and in three studies compared to no gum/gum base. As for sorbitol and maltitol, only sorbitol gum chewing showed a small decrease in gingival scores compared to the controls.
Conclusions
Habitual xylitol gum chewing may reduce gingival inflammation. The low number of studies and their heterogeneity provide clear indications that the effects of sugar-free polyol chewing gums on gingival inflammation need further, well-controlled studies.
Clinical relevance
Sugar-free chewing gums, especially xylitol gum, may function as adjuncts to toothbrushing for reducing gingival inflammation, but the evidence so far is inconclusive.
... In one RCT, snacks containing stevia or sugars were given twice daily to children for 6 weeks. At the end of the trial, the concentrations of cariogenic Streptococcus mutans bacteria and lactobacilli (χ2 8.01; P < 0.01), and the probability of developing caries (measured by a cariogram) in the stevia arm had decreased compared with baseline, whereas there were no statistically significant changes in the sugars arm (209). ...
Non-sugar sweeteners have been developed as an alternative to sugars and are widely used both as an ingredient in pre-packaged foods and beverages and added to food and beverages directly by the consumer. Individual non-sugar sweeteners undergo toxicological assessment by the by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) and other authoritative bodies to establish safe levels of intake (i.e. acceptable daily intake or ADI). While results of randomized controlled trials have generally suggested non-sugar sweeteners may have little impact on glucose metabolism and result in lower body weight when coupled with energy restriction in the short-term, there is no clear consensus on whether non-sugar sweeteners are effective for long-term weight loss or maintenance, or if they are linked to other long-term health effects at intakes within the ADI. This systematic review brings together the most current scientific evidence on health effects of non-sugar sweetener use. https://www.who.int/publications/i/item/9789240046429
... A number of scientific reports showed that stevia preparations or its isolated compounds can exert several health-promoting effects, for instance: antimicrobial/antifungal [9], antioxidant [10], antihypertensive [11], and anti-inflammatory [12], anti-caries [13], and antidiabetic activity [14]. ...
A number of health-promoting properties of Stevia rebaudiana Bertoni and its glycosides, including the antihyperglycemic activity, have been found. The mechanisms of the antidiabetic action of stevia have not been fully understood. The aim of this study was to evaluate the effects of supplementary steviol glycosides on high-fat fed streptozotocin-induced diabetic rats with particular attention to lipid metabolism. The experiment was conducted on 70 male Wistar rats, of which 60 were fed a high-fat diet for 8 weeks followed by intraperitoneal injection of streptozotocin, to induce type 2 diabetes. Afterwards, rats were divided into six groups and fed a high-fat diet supplemented with pure stevioside or rebaudioside A, at two levels (500 or 2500 mg/kg body weight (b.w.)) for 5 weeks. Three additional groups: diabetic untreated, diabetic treated with metformin, and healthy, served as respective controls. Blood and dissected internal organs were collected for hematological, biochemical, and histopathological tests. It was found that dietary supplementation with steviol glycosides did not affect blood glucose, insulin, and insulin resistance indices, antioxidant biomarkers, but normalized hyperlipidemia and affected the appetite, as well as attenuated blood liver and kidney function indices, and reduced tissular damage in diabetic rats. Steviol glycosides normalize lipid metabolism and attenuate internal organs damage in diabetes.
... Actualmente está incluida en el portafolio de pequeñas extensiones de Cajamarca, en la ceja de la selva, Amazonas, San Martin, Ucayali, Apurímac y Arequipa (Linares et al., 2008). A nivel mundial se han realizado estudios con relación a la efectividad de Stevia rB en el control de la caries dental (Korte et al., 2019), obteniendo resultados favorables (Slavutzky, 2010;Mehta et al., 2016;Abdul Razak et al., 2017;Vandana et al., 2017;Cocco et al., 2019;Ganapathi et al., 2019;Siraj et al., 2019). Existen estudios (Pérez, 2013;Becerra, 2016;Cáceres, 2017), que han encontrado efecto antibacteriano de Stevia rB natural de Perú contra S. mutans, pero poco se sabe acerca de los mecanismos subyacentes a este proceso y que estarían cumpliendo con la función antimicrobiana y anticariogénica específica, con relación al efecto sobre los factores de virulencia de S. mutans. ...
El objetivo de la investigación fue determinar el efecto in vitro del extracto etanólico de Stevia Rebaudiana sobre los factores de virulencia cariogénicos de Streptococcus mutans ATCC 25175. Se evaluó el efecto del extracto etanólico 70° de Stevia Rebaudiana a diferentes concentraciones. El efecto sobre el potencial acidogénico se determinó evaluando cambio de pH pre y post-incubación. El efecto sobre la formación de polisacáridos insolubles se determinó utilizando método fenol-ácido sulfúrico. Los datos fueron evaluados mediante análisis de varianza y análisis post hoc con prueba Tukey. La significancia fue considerada si p < 0,05. Las seis concentraciones presentaron efecto inhibitorio sobre ambos factores de virulencia. Del potencial acidogénico, la concentración 1,07% presentó menor efecto que las concentraciones 25%, 50% y 75%; la de 5% menor efecto que las de 50% y 75%; la de 10% menor efecto que la de 75%. Con relación a la formación de polisacáridos insolubles: las concentraciones 1,07%, 5%, 10% y 25% presentaron menor efecto que las de 50% y 75%. Se concluye que el extracto etanólico de Stevia rebaudiana posee efecto inhibitorio in vitro sobre el potencial acidogénico y la formación de polisacáridos extracelulares insolubles en agua de Streptococcus mutans ATCC 25175.
... The results showed that short administration of stevia containing snacks decreased plaque acidogenicity and cariogenic microflora compared to sugar-based snacks, and thus decreasing the probability of developing new caries in the future. This preventive strategy can be helpful in fighting this common childhood disease (Cocco et al., 2019). ...
Background
Stevia (Stevia rebaudiana Bertoni), a perennial shrub of the Compositae family, is cultivated in many regions across the world. It is famous for its sweetness, which is due to the presence of steviol glycosides, having 100–300 times the sweetness of sucrose. It has been used as a sweetener and a sugar substitute in the food and drug industry. Due to its rich nutritional and phytochemical profile, stevia also provides beneficial effects against a plethora of health conditions.
Scope and approach
The main aim of this review is to present an updated overview on stevia and isolated phytochemical, steviol glycosides, highlighting the health benefits, phytochemistry, industrial applications, and safety.
Key findings and conclusions
Various studies have highlighted promising health benefits of stevia against diabetes, obesity, hypertension, cancer, dental caries, oxidative stress and microbial infections. Besides its health benefits, industrial applications of stevia particularly as food and food ingredient, as sucrose replacer, as fertilizers and animal feed, and as solubilizing or foaming agents have been discussed. Novel approaches to improve the taste profile of steviol glycosides have also been highlighted. Moreover, a large body of evidence tend to show that stevia is safe for human consumption. However, its clinical efficacy and uses still remain controversial. Therefore, this study advocates for long-term clinical studies to provide in-depth insights into its safety, health benefits, and physiological mechanisms.
Dondurma besin değeri yüksek bir sütlü tatlı olmasına rağmen veganlar, süt alerjisi olan bireyler ve içerdiği yüksek rafine şeker sebebiyle diyabetik hastalar tarafından tüketilemeyen bir gıdadır. Bu araştırmada, Stevia rebaudiana ve bitki sütü alternatifi olarak yulaf kullanılarak şekersiz ve şekeri azaltılmış vegan dondurmalar geliştirmek hedeflenmiştir. Vegan ve şekersiz dondurmalar, chia tohumu, stabilizatör, stevia ve yulaf sütü kullanılarak kabul edilebilir duyusal ve tekstürel özellikler elde etmek amacıyla formüle edilmiştir. Analizler, sakkarozun °Brix değerini arttırırken erime direncini azalttığını ortaya koymuştur. Stabilizatörlerin hacim artışı ve viskozite üzerinde olumlu etkilerinin olduğu belirlenmiştir. Ancak stevianın tatlandırıcı olarak kullanımının tatlılık ve diğer duyusal özellikleri olumsuz etkilediği belirlenmiştir. Chia tohumu ve stevia kombinasyonunun erime oranı ve hacim artışı üzerinde iyileştirici etkiler sağladığı görülmüştür. Sonuçlar, chia ve stevianın duyusal kalite üzerinde olumsuz sonuçlar duyurmasına rağmen fiziksel kaliteyi iyileştirdiğini göstermiştir.
Background:
Assessing caries risk is an essential element in the planning of preventive and therapeutic strategies. Different caries risk assessment (CRA) models have been proposed for the identification of individuals running a risk of future caries. This systematic review was designed to evaluate whether standardized caries risk assessment (CRA) models are able to evaluate the risk according to the actual caries status and/or the future caries increment.
Methods:
Randomized clinical trials, cross-sectional studies, cohort studies, comparative studies, validation studies and evaluation studies, reporting caries risk assessment using standardized models (Cariogram, CAMBRA, PreViser, NUS-CRA and CAT) in patients of any age related to caries data recorded by DMFT/S or ICDAS indices, were included. PubMed, Scopus and Embase were searched from 2000 to 2016. A search string was developed. All the papers meeting the inclusion criteria were subjected to a quality assessment.
Results:
One thousand three-undred ninety-two papers were identified and 32 were included. In all but one, the Cariogram was used both as sole model or in conjunction with other models. All the papers on children (n = 16) and adults (n = 12) found a statistically significant association between the risk levels and the actual caries status and/or the future caries increment. Nineteen papers, all using the Cariogram except one, were classified as being of good quality. Three of four papers comprising children and adults found a positive association. For seven of the included papers, Cariogram sensibility and specificity were calculated; sensibility ranged from low (41.0) to fairly low (75.0), while specificity was higher, ranging from 65.8 to 88.0. Wide 95% confidence intervals for both parameters were found, indicating that the reliability of the model differed in different caries risk levels.
Conclusions:
The scientific evidence relating to standardized CRA models is still limited; even if Cariogram was tested in children and adults in few studies of good quality, no sufficient evidence is available to affirm the method is effective in caries assessment and prediction. New options of diagnosis, prognosis and therapy are now available to dentists but the validity of standardized CRA models still remains limited.
Noncaloric sweeteners (NCS) are food additives used to provide sweetness without adding calories. Their consumption has become more widespread around the world in all age groups, including children. The aim of this study is to show the state of the art about the intake of noncaloric sweeteners in children, as well as their benefits and consumption risk. Scientific searchers were used (PUBMED, Scopus, and Scielo) to analyze articles that included keywords (noncaloric sweeteners/saccharin/cyclamate/acesulfame potassium/aspartame/sucralose/stevia/children) in English, Spanish, and Portuguese. Authors conclude that it is imperative that health professionals judiciously and individually evaluate the overall benefits and risks of NCS use in consumers before recommending their use. Different subgroups of the population incorporate products containing NCS in their diet with different objectives, which should be considered when recommending a diet plan for the consumer. In childhood, in earlier age groups, this type of additives should be used as a dietary alternative when other forms of prevention in obesity are not sufficient.
Background: Sugar alcohols such as xylitol are incorporated in a number of oral hygiene products for their anti-cariogenic properties while chewing gum is known to be beneficial to oral hygiene.
Objective: The aim of this study was to determine the composition of the dental plaque microbiota in patients with active caries before and after using a chewing gum supplemented with maltitol.
Design: Forty subjects with active caries were randomly allocated to chew maltitol gum or gum base for two weeks. A healthy control group used gum base for two weeks. Plaque samples were collected before and after treatment and the microbiota analysed by pyrosequencing of 16S rRNA genes.
Results: A total of 773,547 sequences were obtained from 117 samples. There was no difference in structure of the bacterial communities between groups (AMOVA). There was a significant difference in community membership between groups, (AMOVA, p=0.009). There was a significant difference between the control group after treatment and the maltitol patient group after treatment (p<0.001). A. naeslundii HOT-176 and Actinomyces HOT-169 were significantly reduced following use of maltitol chewing gum in patients.
Conclusions: This study has shown that chewing gum containing maltitol had minor effects on the composition of the plaque microbiome.
Purpose:
To assess the effect of consuming tea with stevia on salivary pH.
Materials and methods:
This randomised controlled trial employed a Latin square design. Twenty-four male students aged 20-23 years were randomly allocated to 4 different groups, 3 experimental with tea sweetened by sucrose, jaggery or stevia, and one unsweetened control. Salivary pH assessments were performed at baseline and 1 min, 20 and 60 min after consumption of the respective tea. One-way ANOVA and repeated measures ANOVA followed by Tukey's post-hoc tests were employed to analyse the data.
Results:
One minute after tea consumption, the salivary pH of the sucrose group significantly decreased compared to the stevia group (p = 0.01). There was a significant difference between baseline mean salivary pH and post-interventional mean salivary pH values at all time intervals in the tea + sucrose, tea + jaggery, and plain tea groups (p < 0.01). One hour after consumption of tea, the salivary pH values reached the baseline pH in stevia and plain tea groups, but it remained lower in the sucrose and jaggery groups.
Conclusion:
The results of the present study, in which the salivary pH values returned to baseline pH 1 h after drinking stevia-sweetened tea, suggest stevia's potential as a non-cariogenic sweetener.
Dental caries is the most prevalent disease in humans globally. Efforts to control it have been invigorated by an increasing knowledge of the oral microbiome composition. This study aimed to evaluate the bacterial diversity in occlusal biofilms and its relationship with clinical surface diagnosis and dietary habits. Anamneses were recorded from thirteen 12-year-old children. Biofilm samples collected from occlusal surfaces of 46 permanent second molars were analyzed by 16S rRNA amplicon sequencing combined with the BLASTN-based search algorithm for species identification. The overall mean decayed, missing and filled surfaces modified index [DMFSm Index, including active white spot lesions (AWSL)] value was 8.77±7.47. Biofilm communities were highly polymicrobial collectively, representing 10 bacterial phyla, 25 classes, 29 orders, 58 families, 107 genera, 723 species. Streptococcus sp_Oral_Taxon_065, Corynebacterium matruchotii, Actinomyces viscosus, Actinomyces sp_Oral_Taxon_175, Actinomyces sp_Oral_Taxon_178, Actinomyces sp_Oral_Taxon_877, Prevotella nigrescens, Dialister micraerophilus, Eubacterium_XI G 1 infirmum were more abundant among surfaces with AWSL, and Streptococcus gordonii, Streptococcus sp._Oral_Taxon_058, Enterobacter sp._str._638 Streptococcus australis, Yersinia mollaretii, Enterobacter cloacae, Streptococcus sp._Oral_Taxon_71, Streptococcus sp._Oral_Taxon_F11, Centipeda sp._Oral_Taxon_D18 were more abundant among sound surfaces. Streptococcus mutans was detected on all surfaces in all patients, while Streptococcus sobrinus was detected only in three patients (mean relative abundances 7.1% and 0.6%, respectively). Neither species differentiated healthy from diseased sites. Diets of nine of the subjects were scored as high in fermentable carbohydrates (≧2X/day between meals). A direct association between relative abundances of bacteria and carbohydrate consumption was observed among 18 species. High consumption of fermentable carbohydrates and sound surfaces were associated with a reduction in bacterial diversity. PCoA plots displayed differences in bacterial community profiles between sound and diseased surfaces. Our study showed that, in addition to mutans streptococci, other species may be associated with the initiation of dental caries on occlusal surfaces, and that biofilm diversity of tooth surfaces is influenced by carbohydrate consumption and a surface’s health status.
Objective
To explore the potential presence of a social/behavioural gradient in dental health among Italian adults using a cross-sectional study.
Methods
Caries indices were recorded among 480 subjects (52.9% men, 47.1% women) who also completed a structured self-administered social and behavioural questionnaire. A social/behavioural gradient was generated as the sum of the worst circumstances recorded on the questionnaire (cariogenic diet, smoking, lowest occupational profile, brushing teeth < twice daily, lowest educational level, uneven dental examination attendance).
Results
Caries figures (DMFT) and the number of filled sound teeth (FS-T) were statistically significantly linked to the social/behavioural gradient (DMFT: χ²(9) = 20.17 p = 0.02, Z = 0.02 p = 0.99; FS-T: χ²(9) = 25.68 p < 0.01, Z = −4.31 p < 0.01). DMFT was statistically significantly associated with gender and with social and behavioural variables. FS-T was higher in women (p = 0.03) and was linked to smoking (p < 0.01).
Conclusions
The proposed social/behavioural gradient demonstrated how subjects reporting the worst circumstances on the questionnaire exhibited the worst dental health. The use of the gradient demonstrates that health promotion and prevention cannot be compartmentalized.
Background
Actual caries figures emphasize the need to identify the risk indicators involved in the disease’s development. The hypothesis that certain risk indicators might affect the dynamic evolution of the caries process was assessed; to clarify this premise, a cross-sectional survey was performed in school children. MethodsA total of 390 subjects aged 6–8 years old were randomly selected. Caries was assessed, and the subjects were stratified as follows: i) highest caries score; ii) most prevalent caries score; and iii) number of affected teeth. Parents/guardians completed a questionnaire regarding vital statistics, socio-economic indicators, dietary habits, oral hygiene habits and oral health behaviours. ResultsCaries was detected in 42.31% of the subjects. Maternal nationality, parental education level, use of a sweetened pacifier at night, intake of lactose-free milk and toothbrushing frequency were statistically significant associated (p < 0.05) with subjects stratified according to the highest caries score. Parental educational level, maternal occupational status and use of a sweetened pacifier at night were associated (p < 0.05) with affected children stratified according to the most prevalent caries score. Maternal educational level and intake of lactose-free milk were associated with subjects with moderate caries stages compared to being caries-free (p = 0.01 and p = 0.02, respectively). Maternal nationality (p < 0.01) and toothbrushing frequency (p = 0.01) were associated with subjects affected by extensive lesions compared to caries-free children. In subjects affected by initial lesions as the most prevalent figure, gender (male) and paternal occupation status (unemployed) were statistically significant associated (p = 0.03 and p = 0.04, respectively) compared to those affected by highest prevalence of extensive caries lesions. In children with the highest prevalence of moderate caries lesions, maternal education level (p < 0.01), paternal occupational status (p = 0.03) and use of a sweetened pacifier at night (p < 0.01) were statistically significantly associated. Conclusions
Maternal nationality, maternal low level of education, intake of lactose-free milk and low toothbrushing frequency were involved in the change from caries-free status to different caries stages. Gender, paternal unemployment, maternal low educational level and use of a sweetened pacifier were correlated with caries progression, showing how distinctive risk indicators were associated with different caries stages.
Abstract
Background: Parents receive diet recommendations for their children from dentists and dietitians, but a conflict of diet suggestions has been reported. This research was conducted to investigate dental caries experiences in children consuming snacks that were recommended by dentists and/or dietitians.
Material and methods: A total of 442 kindergarteners underwent dental examinations, and their caregivers filled out questionnaires. Snacks were sorted by name. Three dentists and three dietitians determined whether they would recommend these snacks. The snacks were divided into four categories: snacks recommended by both groups, snacks recommended by neither, snacks recommended only by dentists, and snacks recommend only by dieticians. Children were assigned to particular groups based on their primary snack consumption. The children’s caries experiences (dft) were compared among the four groups.
Results: The agreement level on the recommended snacks between dietitians and dentists was moderate (Kappa=0.43). Thirty-nine snacks were identified; 13 recommended by neither, 4 recommended by dietitians, 7 were recommended only by dentists, and 15 were recommended by both. The mean (standard deviation) of dft among the children was 4.66 (3.81), 2.66 (3.17), 3.21 (3.37), and 4.02 (4.02), and respectively. The ANOVA and Tukey post-hoc tests indicated that children who consumed snacks recommended only by one professional, dietitian or dentist, have significantly fewer dental caries than children who consumed snacks recommended by neither professional. (ANOVA: F=4.494, p=0.004, Tukey post-hoc test: p=0.007 and p=0.046, respectively)
Conclusion: Dentists can recommend snacks that are nutrient dense, even though it contains sucrose.
Objective:
To identify the types, food sources, and pattern of carbohydrates that significantly contribute to dental caries in Puerto Rican children.
Methods:
As part of an island-wide cross-sectional oral health study in 1,587 twelve-year-olds, diet intake was assessed in a representative subset (n = 801) with a 24-hour dietary recall. Carbohydrate intake was quantified using a computer-based diet analysis program. Caries was assessed using the National Institute of Dental and Craniofacial Research diagnostic criteria. Odds ratios were used to associate carbohydrate intake quartiles with caries, after controlling for important confounders.
Results:
A total of 723 subjects had complete data. Most were females (54%) and attended public schools (77%). The caries prevalence was 33%. The highest quartile intake for the following sugars significantly increased the odds of caries compared to the lowest quartile: total carbohydrates (OR = 1.93, 95% CI = 1.08-3.46), total sugars (OR = 1.88, 95% CI = 1.01-351), sucrose (OR = 2.05, 95% CI = 1.13-3.70), fructose (OR = 1.95, 95% CI = 1.05-3.62), and inositol (OR = 2.52, 95% CI = 1.38-4.63). The main food sources of these sugars were juices, including natural juices with no added sugars, and sweetened beverages. The odds of caries also increased significantly in children whose 10% of total energy intake was from total sugars (OR = 3.76, 95% CI = 1.03-13.7).
Conclusion:
After adjusting for important caries risk factors, total carbohydrates, total sugars, ≥10% kilocaloric energy from total sugars, and sucrose, fructose, and inositol intake significantly increased caries risk. Our findings can help raise awareness about the potential caries risk from the main sources of these sugars, natural fruit juices and sweetened beverages, which are consumed in great quantities in many societies.
Background:
Tooth decay is one of the greatest unmet treatment needs among children. Pain and suffering associated with untreated dental disease can lead to problems with eating, speaking, and learning. School-based dental sealant programs (SBSP) deliver a highly effective intervention to prevent tooth decay in children who might not receive regular dental care. SBSPs benefits exceed their costs when they target children at high risk for tooth decay.
Methods:
CDC used data from the National Health and Nutrition Examination Survey (NHANES) 2011-2014 to estimate current prevalences of sealant use and untreated tooth decay among low-income (≤185% of federal poverty level) and higher-income children aged 6-11 years and compared these estimates with 1999-2004 NHANES data. The mean number of decayed and filled first molars (DFFM) was estimated for children with and without sealants. Averted tooth decay resulting from increasing sealant use prevalence was also estimated. All reported differences are significant at p<0.05.
Results:
From 1999-2004 to 2011-2014, among low- and higher-income children, sealant use prevalence increased by 16.2 and 8.8 percentage points to 38.7% and 47.8%, respectively. Among low-income children aged 7-11 years, the mean DFFM was almost three times higher among children without sealants (0.82) than among children with sealants. Approximately 6.5 million low-income children could potentially benefit from the delivery of sealants through SBSP.
Conclusions and implications for public health practice:
The prevalence of dental sealant use has increased; however, most children have not received sealants. Increasing sealant use prevalence could substantially reduce untreated decay, associated problems, and dental treatment costs.
Objective
The aim of our study was to evaluate the efficacy of an herbal lollipop containing licorice root extract on salivary Streptococcus mutans in caries-free and high-caries-risk children.
Materials and methods
The study was conducted in caries-free and high-caries-risk children, aged 5–11 years (n = 108). The groups were caries-free children (group A); high-caries-risk children whose dental treatment was completed before lollipop use (group B); and high-caries-risk children who did not comply with dental treatment (group C). The groups were divided into two subgroups: herbal (A-1, B-1, C-1) and placebo lollipops (A-2, B-2, C-2). Saliva samples were taken before dental treatment, before and after consuming lollipops, and at 3 months after consuming lollipops. The results were statistically analyzed with chi-squared test.
Results
Only in group C-1 (high-risk, using herbal lollipops) that significant reduction was observed in salivary S. mutans levels after lollipop use (p = 0.033), and only in the same group (C-1), there was significant difference between after lollipop use and third month levels (p = 0.006).
Conclusions
Herbal lollipops could be recommended to children with high-caries risk who do not comply with dental treatment in place of high-carbohydrate snacks.
Clinical relevance
The paper provides a perspective on using herbal products in high-risk children for reducing salivary S. mutans counts.
Stevia rebaudiana Bertoni is a small perennial shrub of the Asteraceae (Compositae) family that is native to South America, particularly Brazil and Paraguay, where it is known as “stevia” or “honey leaf” for its powerful sweetness. Several studies have suggested that in addition to their sweetness, steviosides and their related compounds, including rebaudioside A and isosteviol, may offer additional therapeutic benefits. These benefits include anti-hyperglycaemic, anti-hypertensive, anti-inflammatory, anti-tumor, anti-diarrheal, diuretic, and immunomodulatory actions. Additionally, critical analysis of the literature supports the anti-bacterial role of steviosides on oral bacteria flora. The aim of this review is to show the emerging results regarding the anti-cariogenic properties of S. rebaudiana Bertoni. Data shown in the present paper provide evidence that stevioside extracts from S. rebaudiana are not cariogenic. Future research should be focused on in vivo studies to evaluate the effects on dental caries of regular consumption of S. rebaudiana extract-based products.
Objectives:
To evaluate the accuracy of different methods used to identify individuals with increased risk of developing coronal dental caries.
Data:
Studies on following methods were included: previous caries experience, tests using microbiota, buffering capacity, salivary flow rate, dental plaque, dietary habits and sociodemographic variables. QUADAS-2 was used to assess risk of bias. Sensitivity, specificity, predictive values, and likelihood ratios (LR) were calculated. Quality of evidence based on ≥3 studies of a method was rated according to GRADE.
Sources:
PubMed, Cochrane Library, Web of Science and reference lists of included publications were searched up to January 2015.
Study selection:
From 5,776 identified articles, 18 were included. Assessment of study quality identified methodological limitations concerning study design, test technology and reporting. No study presented low risk of bias in all domains. Three or more studies were found only for previous caries experience and salivary mutans streptococci and quality of evidence for these methods was low. Evidence regarding other methods was lacking. For previous caries experience, sensitivity ranged between 0.21 and 0.94 and specificity between 0.20 and 1. Tests using salivary mutans streptococci resulted in low sensitivity and high specificity. For children with primary teeth at baseline, pooled LR for a positive test was 3 for previous caries experience and 4 for salivary mutans streptococci, given a threshold ≥10(5) CFU/ml.
Conclusions:
Evidence on the validity of analysed methods used for caries risk assessment is limited. As methodological quality was low, there is a need to improve study design.
Clinical significance:
Low validity for the analysed methods may lead to patients with increased risk not being identified, whereas some are falsely identified as being at risk. As caries risk assessment guides individualized decisions on interventions and intervals for patient recall, improved performance based on best evidence is greatly needed.
The aim of this study was to examine the correlation among socio-behavioral factors, caries status and caries risk, calculated through Cariogram, in an adult population. Four hundred eighty subjects (mean age 40.73, SE ± 0.33) randomly selected from the municipal electoral registry consented to participate in the survey. Subjects were examined, and the International Caries Detection Assessment System (ICDAS) index was registered. A highly structured questionnaire was submitted to investigate (1) personal data (i.e., age, gender, educational level, job categorization), (2) life-style behavior (i.e., smoking and dietary habits), and (3) oral health behavior (i.e., tooth brushing, use of fluoride and dental check-up frequency). An evaluation of the mutans streptococci concentration in saliva was also performed. Information on caries-related factors was entered into the Cariogram in order to generate an individual caries risk profile for each subject. Multinomial logistic regression was performed using Cariogram levels as the dependent variable. The possible correlated variables were analyzed using the principal component analysis (PCA). Considering ICDAS scores, 5.62% of the sample had at least an initial decay (ICDAS = 1-2), whereas 40.83% of the sample presented at least one moderate decay (ICDAS = 3-4) and 17.08% a severe decay (ICDAS = 5-6). Decay at ICDAS levels 5-6 and more than 5 missing teeth were statistically associated with Cariogram scores (OR = 2.36, 95%CI = 1.83–3.03 and OR = 1.43, 95%CI = 1.13–1.82, respectively). The results suggest that the Cariogram model was able to identify caries-related factors in an adult population. A direct association among the risk categories from Cariogram, the caries status and some socio-behavioral variables was verified.
Dental caries is considered as the most common polymicrobial oral disease in the world. With the aim of developing alternative approaches to reduce or prevent the decay, numerous papers showed the potential anticaries activity of a number of natural products. The natural products with anticaries effects are selected from e.g. food, beverages, flowers or traditional herbs. Most of the effective components are proven to be polyphenol compounds. Many of the natural products are studied as antibacterial agents, while some of them are found to be effective in shifting the de-/remineralization balance. However, the mechanisms of the anticaries effects are still unclear for most of the natural products. In the future, more efforts need to be made to seek novel effective natural products via in vitro experiment, animal study and in situ investigations, as well as to enhance their anticaries effects with the help of novel technology like nanotechnology.
Background
There is a clear relation between sugars and caries. However, no analysis has yet been made of the lifetime burden of caries induced by sugar to see whether the WHO goal of 10% level is optimum and compatible with low levels of caries. The objective of this study was to re-examine the dose-response and quantitative relationship between sugar intake and the incidence of dental caries and to see whether the WHO goal for sugar intake of 10% of energy intake (E) is optimum for low levels of caries in children and adults.
Methods
Analyses focused on countries where sugar intakes changed because of wartime restrictions or as part of the nutritional transition. A re-analysis of the dose-response relation between dietary sugar and caries incidence in teeth with different levels of susceptibility to dental caries in nationally representative samples of Japanese children. The impact of fluoride on levels of caries was also assessed.
Results
Meticulous Japanese data on caries incidence in two types of teeth show robust log-linear relationships to sugar intakes from 0%E to 10%E sugar with a 10 fold increase in caries if caries is assessed over several years’ exposure to sugar rather than only for the first year after tooth eruption. Adults aged 65 years and older living in water fluoridated areas where high proportions of people used fluoridated toothpastes, had nearly half of all tooth surfaces affected by caries. This more extensive burden of disease in adults does not occur if sugar intakes are limited to <3% energy intake.
Conclusions
There is a robust log-linear relationship of caries to sugar intakes from 0%E to 10%E sugar. A 10%E sugar intake induces a costly burden of caries. These findings imply that public health goals need to set sugar intakes ideally <3%E with <5%E as a pragmatic goal, even when fluoride is widely used. Adult as well as children’s caries burdens should define the new criteria for developing goals for sugar intake.
Sucrose, extracellular polysaccharide, and glucosyltransferases (GTFs) are key factors in sucrose-dependent adhesion and play important roles in the process of severe early-childhood caries (S-ECC). However, whether sucrose concentration regulates gtf expression, extracellular polysaccharide synthesis, and sucrose-dependent adhesion is related to the different genotypes of S. mutans isolated from ECC in children and still needs to be investigated. In this study, 52 strains of S. mutans were isolated from children with S-ECC and caries-free (CF) children. Water-insoluble glucan (WIG) synthesis was detected by the anthrone method, adhesion capacity by the turbidimetric method, and expression of gtf by RT-PCR in an in vitro model containing 1%-20% sucrose. The genotypes of S. mutans were analyzed by AP-PCR. The results showed that WIG synthesis, adhesion capacity, and gtf expression increased significantly when the sucrose concentration was from 1% to 10%. WIG synthesis and gtfB as well as gtfC expression of the 1% and 5% groups were significantly lower than those of the 10% and 20% groups (p < 0.05). There were no significant differences between the 10% and 20% groups. The fingerprints of S. mutans detected from individuals in the S-ECC group exhibited a significant difference in diversity compared with those from CF individuals (p < 0.05). Further, the expression of gtfB and gtfC in the S-ECC group was significantly different among the 1- to 5-genotype groups (p < 0.05). It can be concluded that sucrose-dependent adhesion might be related to the diversity of genotypes of S. mutans, and the 10% sucrose level can be seen as a "turning point" and essential factor for the prevention of S-ECC.
THE AIMS OF THIS STUDY WERE TO: (1) evaluate the caries risk in young adults using Cariogram and (2) compare the efficiency of Cariogram with the regression risk models created using the same variables in Cariogram by examining the actual caries progression over a 2-year period.
This study included 100 subjects that were either twenty or twenty-one years-old. Data on general health, diet, oral hygiene and use of fluoride were obtained. Saliva analyses were performed, including mutans streptococci and lactobacilli counts, secretion rate and buffer capacity. DMFT and DMFS values were calculated by clinical examinations and radiographs. The participants were divided into 5 groups according to their Cariogram caries risk scores at baseline. Re-examination for caries was done after 2-years. The data were analyzed using Kruskall Wallis, Mann Whitney-U, and logistic regression analyses.
Diet frequency, plaque amount and secretion rate were significantly associated with caries increment (P<.05). Cariogram and the regression risk models explained the caries formation at a higher rate than single-variables. However, the regression risk model developed by diet frequency, plaque amount and secretion rate explained the caries formation similar to Cariogram, while the other regression model developed by all variables used in Cariogram explained the caries formation at a higher rate than this computer program.
Cariogram is effective and can be used for caries risk assessment instead of single variables; however, it is possible to develop simplier models with regression analyses to determine caries risk.
Dental caries is caused by a combination of infection and diet. This disease, if left untreated, may lead to pain, and impair the quality of life, nutritional status and development of young children. The objective was to investigate the association between snacking and caries in a population at high risk of dental caries. American preschool children (n = 1,206) were recruited in the offices of paediatricians. Data on sociodemographic characteristics, oral hygiene, breast-feeding, use of bottle and snacking were collected by questionnaire. Plaque presence, the number of teeth and their caries status (deft) were scored. The children sampled were 61% Black, 27% White and 10% Asian. Of the 1- to 2-, 2- to 3- and 3- to 4-year-old children, 93.8, 82.4 and 77.3% were caries free, and their mean caries scores were 0.16, 0.58 and 0.93, respectively. Multivariate partial least squares (PLS) modelling revealed plaque presence, lowest income, descriptors for tooth exposure time (number of teeth and age) and cariogenic challenge (total intake of sugar-containing snacks and chips/crisps, and chips intake with a sugar-containing drink) to be associated with more caries. These differences were also found in univariate analyses; in addition, children who continued breast-feeding after falling asleep had significantly higher deft values than those who did not. PLS modelling revealed that eating chips clustered with eating many sweet snacks, candies, popcorn and ice cream. We conclude that, in addition to the traditional risk indicators for caries - presence of plaque, sugar intake and socioeconomic status -, consumption of chips was associated with caries in young children.
An in vitro adherence experiment was designed to mimic the transmission of Streptococcus mutans from mother to child to test the hypothesis that differences in initial adherence reflect differences in susceptibility to infection. The data show that the pretreatment of S. mutans cells with the saliva of the mother in a mother-child pair and the pretreatment of spheroidal hydroxyapatite with that of the child may result in combinations which counteract or foster the initial adherence to a varying extent. The findings indicate that such combinations may determine the risk of S. mutants infection.
Dental caries, otherwise known as tooth decay, is one of the most prevalent chronic diseases of people worldwide; individuals are susceptible to this disease throughout their lifetime. Dental caries forms through a complex interaction over time between acid-producing bacteria and fermentable carbohydrate, and many host factors including teeth and saliva. The disease develops in both the crowns and roots of teeth, and it can arise in early childhood as an aggressive tooth decay that affects the primary teeth of infants and toddlers. Risk for caries includes physical, biological, environmental, behavioural, and lifestyle-related factors such as high numbers of cariogenic bacteria, inadequate salivary flow, insufficient fluoride exposure, poor oral hygiene, inappropriate methods of feeding infants, and poverty. The approach to primary prevention should be based on common risk factors. Secondary prevention and treatment should focus on management of the caries process over time for individual patients, with a minimally invasive, tissue-preserving approach.
This paper describes early findings of evaluations of the International Caries Detection and Assessment System (ICDAS) conducted by the Detroit Center for Research on Oral Health Disparities (DCR-OHD). The lack of consistency among the contemporary criteria systems limits the comparability of outcomes measured in epidemiological and clinical studies. The ICDAS criteria were developed by an international team of caries researchers to integrate several new criteria systems into one standard system for caries detection and assessment. Using ICDAS in the DCR-OHD cohort study, dental examiners first determined whether a clean and dry tooth surface is sound, sealed, restored, crowned, or missing. Afterwards, the examiners classified the carious status of each tooth surface using a seven-point ordinal scale ranging from sound to extensive cavitation. Histological examination of extracted teeth found increased likelihood of carious demineralization in dentin as the ICDAS codes increased in severity. The criteria were also found to have discriminatory validity in analyses of social, behavioral and dietary factors associated with dental caries. The reliability of six examiners to classify tooth surfaces by their ICDAS carious status ranged between good to excellent (kappa coefficients ranged between 0.59 and 0.82). While further work is still needed to define caries activity, validate the criteria and their reliability in assessing dental caries on smooth surfaces, and develop a classification system for assessing preventive and restorative treatment needs, this early evaluation of the ICDAS platform has found that the system is practical; has content validity, correlational validity with histological examination of pits and fissures in extracted teeth; and discriminatory validity.
Purpose:
To elucidate the efficacy of strategies for preventing dental caries in Japanese children by examining trends over time in the prevalence of dental caries, the number of decayed, missing, or filled teeth (the DMFT index), and their association with factors affecting oral hygiene.
Materials and methods:
Several national surveys performed between 1955 and 2015 were reviewed. The prevalence of dental caries in children aged 5-15 years, the DMFT index in children aged 9 or 14 years, individual consumption of added sugars and snacks, the number of dentists in Japan, and the percentage of children who received fluoride varnish were analysed. Additionally, the relative poverty rate among Japanese children was assessed.
Results:
The prevalence of caries and the DMFT index in Japanese children reflected the trend of individual added-sugar consumption from 1955 to 2015, and also seemed to decrease inversely with the number of dentists and the percentage of children who had received fluoride varnish since 1969. However, there seemed to be no relation to the relative poverty rate.
Conclusion:
The main preventive strategies for caries in Japan are to reduce sugar intake and educate school children and their caregivers about oral hygiene.
Periodontal diseases and dental caries are the most common diseases of humans and the main cause of tooth loss. Both diseases can lead to nutritional compromise and negative impacts upon self-esteem and quality of life. As complex chronic diseases, they share common risk factors, such as a requirement for a pathogenic plaque biofilm, yet they exhibit distinct pathophysiologies. Multiple exposures contribute to their causal pathways, and susceptibility involves risk factors that are inherited (e.g. genetic variants), and those that are acquired (e.g. socio-economic factors, biofilm load or composition, smoking, carbohydrate intake). Identification of these factors is crucial in the prevention of both diseases as well as in their management.
Aim:
To systematically appraise the scientific literature to identify potential risk factors for caries and periodontal diseases.
Methods:
One systematic review (genetic risk factors), one narrative review (role of diet and nutrition) and reference documentation for modifiable acquired risk factors common to both disease groups, formed the basis of the report.
Results & conclusions:
There is moderately strong evidence for a genetic contribution to periodontal diseases and caries susceptibility, with an attributable risk estimated to be up to 50%. The genetics literature for periodontal disease is more substantial than for caries and genes associated with chronic periodontitis are the vitamin D receptor (VDR), Fc gamma receptor IIA (Fc-γRIIA) and Interleukin 10 (IL10) genes. For caries, genes involved in enamel formation (AMELX, AMBN, ENAM, TUFT, MMP20, and KLK4), salivary characteristics (AQP5), immune regulation and dietary preferences had the largest impact. No common genetic variants were found. Fermentable carbohydrates (sugars and starches) were the most relevant common dietary risk factor for both diseases, but associated mechanisms differed. In caries, the fermentation process leads to acid production and the generation of biofilm components such as Glucans. In periodontitis, glycaemia drives oxidative stress and advanced glycation end-products may also trigger a hyper inflammatory state. Micronutrient deficiencies, such as for vitamin C, vitamin D or vitamin B12, may be related to the onset and progression of both diseases. Functional foods or probiotics could be helpful in caries prevention and periodontal disease management, although evidence is limited and biological mechanisms not fully elucidated. Hyposalivation, rheumatoid arthritis, smoking/tobacco use, undiagnosed or sub-optimally controlled diabetes and obesity are common acquired risk factors for both caries and periodontal diseases.
Background:
Dental caries and periodontitis are the most common oral diseases and major causes of tooth loss.
Aim:
To perform a review of global prevalence and incidence of dental caries and periodontitis.
Methodology:
Inclusion and exclusion criteria were developed. MEDLINE database and EMBASE database were used to search for eligible publications using keywords and MeSH terms. Additionally, WHO databank was used for obtaining dental caries information and PUBMED for a search on trends of dental caries prevalence and severity.
Results:
Over the last four decades, the prevalence and severity of dentine carious lesions among 5- and 12-year-olds have declined; the decay-component is very high, with the lowest prevalence among 12-year-olds in high-income countries, which also had the lowest prevalence among 35- to 44-year-olds; and the number of retained teeth has increased around the globe. The prevalence of periodontitis is high, with approximately 10% of the global population affected by severe periodontitis. Study heterogeneity and methodological issues hamper comparisons across studies and over time.
Conclusion:
While the prevalence of dental caries has decreased, the disease is prevalent in all age groups. The prevalence of periodontitis is high. There is insufficient evidence to conclude that the prevalence of periodontitis has changed over time.
Objectives:
The aim of this study was to evaluate the association between caries experience in primary teeth and caries experience in permanent teeth in a longitudinal study.
Methods:
Teeth were examined at 5 years of age and a follow-up examination was conducted 7 years later at 12 years of age in all children from Jiading District, Shanghai, China. A total of 1885 participants were recruited in the study; 1683 students were followed up and 202 students (10.7%) were lost to follow up. Data were analyzed using the chi-square test, t-test and risk ratio.
Results:
The followed-up samples comprised 883 boys (52.5%) and 800 girls (47.5%). At initial examination, the prevalence of dental caries was 67.4% in boys and 66.5% in girls (χ² = 0.2, P = 0.70), with mean decayed, missing and filled teeth (dmft) scores of 3.5 ± 0.1 and 3.4 ± 0.1, respectively (t = 0.1, P = 0.90). At follow-up, the prevalence of dental caries was 33.9% in boys and 37.9% in girls (χ² = 2.9, P = 0.11), with mean DMFT scores in permanent teeth of 0.7 ± 0.0 and 0.8 ± 0.1, respectively (t = 1.2, P = 0.24). The group of 5-year-olds with caries had a significantly higher prevalence of caries in permanent teeth (45.5%) at 12 years of age than the group of 5-year-olds without caries (16.0%) (χ(2) = 141.1, P < 0.001, risk ratio = 1.5). Caries risk in permanent teeth was significantly higher with greater dmft scores (χ(2) for trend = 31.1, P < 0.001).
Conclusions:
Caries in primary teeth is a major risk factor for caries in permanent teeth. The likelihood of caries in permanent teeth is higher with greater dmft scores in primary teeth.
Objective:
To examine pH in the approximal dental biofilm after acid and alkali formation from sucrose and urea, after an adaptation period to these substances, in caries-free (CF) and caries-active (CA) individuals. Saliva flow and buffer capacity, and aciduric bacteria in saliva and plaque were also examined.
Material and methods:
Twenty adolescents and young adults (15-21 years) with no caries (n = 10, D(m + i)MFS = 0) or ≥1 new manifest lesions/year (n = 10, DmMFS = 3.4 ± 1.8) participated. After plaque sampling, interproximal plaque pH was measured using the strip method before (baseline) and up to 30 min (final pH) after random distribution of a 1-min rinse with 10 ml of 10% sucrose or 0.25% urea. This procedure was repeated after a 1-week adaptation period of rinsing 5 times/day with 10 ml of the selected solution. After a 2-week washout period the second solution was similarly tested. Mutans streptococci, lactobacilli and pH 5.2-tolerant bacteria were analyzed by culturing.
Results:
In the CF group, acid adaptation resulted in lowering of baseline and final plaque pH values after a sugar challenge, and in increased numbers of bacteria growing at pH 5.2, which was increased also after alkali adaptation. In the CA group, the final pH was decreased after acid adaptation. No clear effects of alkali adaptation were seen in this group.
Conclusion:
One-week daily rinses with sucrose and urea had the most pronounced effect on the CF group, resulting in increased plaque acidogenicity from the sugar rinses and increased number of acid-tolerant plaque bacteria from both rinses.
Dental caries is a multifactorial disease with various risk factors. Oral hygiene and diet-specifically, the consumption of snacks and beverages with added sugars-have been shown to be risk indicators for this disease. It is critical for dental professionals to understand the relative roles of each of these food categories in the dental caries process. This article presents a cross-sectional study of 76 people living in a Southern Illinois fluoridated community. The amount of sugar-sweetened beverages, snack food consumption, plaque index, and age showed statistically significant relationships with the outcome variable-dental caries (P < 0.05). The results indicated that dietary factors and oral hygiene both contribute equally to dental caries in young adults living in a fluoridated community. Sugar-sweetened beverage consumption was a much stronger indicator of dental caries than snack food consumption in our study population.
High level of caries activity is related to organisms in the dental plaque with high acidogenesis capacity.
To test salivary pH in children of the same family and compare it with their caries status. To compare pH levels between children and their parents. To examine the relationship between pH and caries status among children of the same family and their parents.
We examined 123 children and adolescents aged 3-18, (73 boys and 50 girls) and 33 adults, (12 men and 21 women), parents of these children. Caries status was examined clinically, using DMF index. Salivary pH measurements were made by a digital pH meter.
Among adults, increase in patient age led to increased DMF (p = 0.005). The higher the pH, the lower the DMF (p = 0.037). Among men, DMF was lower by 3 compared to women (p = 0.049). Children's pH correlated with the parents' (p = 0.004). Children's DMF correlated to their pH (p = 0.001). Children's pH was the best predictor of their DMF (R2 = 0.309, p = 0.001).
Among children, the higher the pH, the lower the DMFT. Children's pH was the best predictor of their DMF.
The aim of this study was to determine the effects of short-term xylitol gum chewing on the salivary microbiota of children.
The study was a randomised, controlled, double-blind trial. Healthy children used xylitol chewing gum (xylitol group, n = 35) or sorbitol chewing gum (control group, n = 38) for 5 weeks. The daily dose of xylitol/sorbitol was approximately 6 g/day. At baseline and at the end of the test period, unstimulated and paraffin-stimulated saliva were collected. The microbial composition of the saliva was assessed using human oral microbe identification microarray (HOMIM). Mutans streptococci (MS) were plate cultured.
As judged by HOMIM results, no xylitol-induced changes in the salivary microbiota took place in the xylitol group. In the control group, Veillonella atypica showed a significant decrease (p = 0.0001). The xylitol gum chewing decreased viable counts of MS in both stimulated (p = 0.006) and unstimulated (p = 0.002) saliva, but similar effects were also seen in the control group.
The use of xylitol gum decreased MS, in general, but did not change the salivary microbial composition.
Short-term consumption of xylitol had no impact on the composition of the salivary microbiota, but resulted in a decrease in the levels of MS.
A systematic review of studies in humans was conducted to update evidence on the association between the amount of sugars intake and dental caries and on the effect of restricting sugars intake to < 10% and < 5% energy (E) on caries to inform the updating of World Health Organization guidelines on sugars consumption. Data sources included MEDLINE, EMBASE, Cochrane Database, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences, China National Knowledge Infrastructure, Wanfang, and South African Department of Health. Eligible studies reported the absolute amount of sugars and dental caries, measured as prevalence, incidence, or severity. The review was conducted and reported in accordance with the PRISMA statement, and the evidence was assessed according to GRADE Working Group guidelines. From 5,990 papers identified, 55 studies were eligible - 3 intervention, 8 cohort, 20 population, and 24 cross-sectional. Data variability limited meta-analysis. Of the studies, 42 out of 50 of those in children and 5 out of 5 in adults reported at least one positive association between sugars and caries. There is evidence of moderate quality showing that caries is lower when free-sugars intake is < 10% E. With the < 5% E cut-off, a significant relationship was observed, but the evidence was judged to be of very low quality. The findings are relevant to minimizing caries risk throughout the life course.
The effect of Stevia extracts on in vitro Streptococcus mutans biofilm formation and in vivo plaque pH was evaluated in this paper. Three 10% solutions containing stevioside, rebaudioside A or sucrose were prepared. MTT assay was used to evaluate microbiological counts in vitro. Twenty volunteers rinsed for 1 min with each solutions, and plaque pH was measured at 7 time points after each rinse. Higher in vitro S. mutans biofilm formation was observed in sucrose solution (p < 0.01). After 5, 10, 15 and 30 min, the sucrose in vivo rinse produced a statistically significantly lower pH value compared to the Stevia extracts (F = 99.45, p < 0.01).Stevia extracts can be considered nonacidogenic. © 2013 S. Karger AG, Basel.
The purpose of the study was to evaluate the combined use of two rapid, semiquantitative detection kits (Saliva-Check Mutans and Saliva-Check IgA Mutans) to assess caries risk using the Cariogram computer-based program as a reference method. Stimulated saliva samples were collected from 71 subjects, 20-73 yr of age, and the number of Streptococcus mutans per ml of saliva was measured using Saliva-Check Mutans. After 15 min, a red line in the test detection window indicated >5 × 10(5) colony-forming units (CFU) of S. mutans per ml of saliva. The concentration of salivary IgA in relation to the number of mutans streptococci was examined using the Saliva-Check IgA Mutans test kit. The presence or absence of a red line after 15 min indicated a high or a low concentration of IgA, respectively. By combining the results obtained from these two test systems, each patient was classified into one of four groups of low to high caries risk. Compared with the Cariogram data, the combined results of both detection kits showed that 39 (95%) of 41 subjects had a high chance of avoiding caries and 20 (67%) of 30 subjects had a low chance. The data suggest that the combination of Saliva-Check Mutans and Saliva-Check IgA Mutans could be used for caries risk assessment.
The validity of Cariogram in relation to caries increment over a 2-year period was evaluated. In 2007, the caries risk profile in a group of Sardinian schoolchildren (957) aged 7-9 years was assessed using the Cariogram software. A re-examination using the same criteria was performed 2 years later on 861 individuals from the original sample (drop-out 10.0%). The possible correlated variables were analyzed using the principal component analysis (PCA). The performances of Cariogram in predicting caries increment were evaluated by receiver operating characteristic (ROC) analysis. At follow-up examination, 54.4% of the sample had developed new carious lesions (mean DFS 1.6, 95% CI 1.5-1.8). The mean caries increment (ΔDFS) was 0.5, 95% CI 0.4-0.5. PCA showed that Cariogram, gingival status and dietary sugar frequency, both at baseline and at follow-up, tend to form a separate cluster (goodness of fit ≥0.75). Sensitivity and specificity measured by ROC analysis were 0.83 and 0.85, respectively, so the gain in certainty was 1.68, while the area under the ROC curve was 0.93. A strong correlation between caries risk profiles at baseline and caries incidence in the permanent teeth after 2 years was found. The validity of Cariogram was confirmed, the software fulfilling the criteria for a good risk assessment model: precision, accuracy and ease of use.
In the elderly, the necessity to promote oral health is increasing to improve their quality of life. The prediction of dental caries risk makes it possible to prolong the life span of teeth. To develop a quick diagnosis system for caries risk, two methods, the modified Saliva Check SM and Saliva Check sIgA, were investigated in elderly patients.
We developed a caries risk quick assessment system using Saliva Check sIgA that specifically recognizes secretory IgA (sIgA) in saliva against the binding site of the mutans streptococci (MS) to the salivary-coated tooth surface; and combined it with a modified Saliva Check SM to determine the number of MS. One hundred eighty three patients (80 females, 103 males) who participated in 2005 (average age 77 years) and in 2006 (average age 78 years) were assessed for caries risk using the systems in this cohort study.
Subjects with a positive Saliva Check sIgA showed a significantly lower increment of decayed and filled teeth number (DFT) on the coronal surface; whereas those testing negative had root decay and increased filled teeth numbers (RDFT) at the root surface during the following year. The combination of Saliva Check sIgA and modified Saliva Check SM showed the subjects with Saliva Check sIgA positive and modified Saliva Check SM negative had less than half of the increment of DFT than other groups. In the other groups, Saliva Check sIgA negative and modified Saliva Check SM positive detected >90% of the subjects with an MS level of >5 x 10(5)/mL of saliva in patients that were assessed in 2006. This suggests these subjects may need extensive care.
This new combination system significantly evaluates the caries risk to predict future incidence for dental caries on the coronal surface and may be useful for risk diagnosis of caries during a visit to the dental office.
Dental biofilms produce acids from carbohydrates that result in caries. According to the extended caries ecological hypothesis, the caries process consists of 3 reversible stages. The microflora on clinically sound enamel surfaces contains mainly non-mutans streptococci and Actinomyces, in which acidification is mild and infrequent. This is compatible with equilibrium of the demineralization/remineralization balance or shifts the mineral balance toward net mineral gain (dynamic stability stage). When sugar is supplied frequently, acidification becomes moderate and frequent. This may enhance the acidogenicity and acidurance of the non-mutans bacteria adaptively. In addition, more aciduric strains, such as 'low-pH' non-mutans streptococci, may increase selectively. These microbial acid-induced adaptation and selection processes may, over time, shift the demineralization/remineralization balance toward net mineral loss, leading to initiation/progression of dental caries (acidogenic stage). Under severe and prolonged acidic conditions, more aciduric bacteria become dominant through acid-induced selection by temporary acid-impairment and acid-inhibition of growth (aciduric stage). At this stage, mutans streptococci and lactobacilli as well as aciduric strains of non-mutans streptococci, Actinomyces, bifidobacteria, and yeasts may become dominant. Many acidogenic and aciduric bacteria are involved in caries. Environmental acidification is the main determinant of the phenotypic and genotypic changes that occur in the microflora during caries.
The aim of the study was to evaluate if pH indicator strips could be used for measurements of plaque pH acidogenicity in situ.
Interproximal plaque pH was measured before and up to 60 min after a 10% sucrose rinse in 30 healthy volunteers using pH indicator strips and the microtouch method in parallel.
It was found that the 'strip method' could determine changes in plaque pH to the same extent as the microtouch method (correlation coefficient 0.99).
Since the 'strip method' is inexpensive and easy to handle, it may be applicable for assessment of plaque acidogenicity in the clinic.
A dietary habit assessment should be an integral component of oral health care. The author outlines strategies that oral health care professionals can use to assess dietary habits associated with caries risk and to develop dietary recommendations.
A caries risk assessment tool can be used to identify dietary habits that may contribute to caries risk.
The caries risk assessment tool can provide structure for evaluating patients' dietary habits and food choices and helping oral care health professionals provide preventive dietary recommendations.
The aim of our study was to assess the caries risk profile in a group of Sardinian schoolchildren and to compare the outcome with their history of caries.
Using the computer-based program "Cariogram", 957 subjects aged 7, 8, and 9 years were enrolled in this cross-sectional study. The children were examined to evaluate dmfs/DMFS and gingival conditions. Data on dietary and oral hygiene habits were collected and saliva was analyzed, including levels of mutans streptococci (MS) and lactobacilli (Lb). Based on the Cariogram profiles, the children were divided into five risk groups in accordance with "chance of avoiding caries".
Almost 50% of the children had a low caries risk, while more than a quarter had less than 40% "chance of avoiding caries". A significant linear trend between the five Cariogram categories and dmfs/DMFS was observed in the three age groups (p<0.001).
The Cariogram risk profile showed strong correlations to the caries experience of Sardinian schoolchildren and that efforts to reduce caries risk are necessary.
Following active periodontal therapy, 41 patients were incorporated in a maintenance program for 2 1/2 years with recall intervals varying between 2-6 months. At the beginning of each maintenance visit, the periodontal tissues were evaluated using "bleeding on probing" (BOP). Reinstrumentation was only performed at sites which bled on probing. However, supragingival plaque and calculus was always removed. Pocket probing depths and probing attachment levels were recorded after active treatment and at the conclusion of the study. Progression of periodontal disease was defined by an observed loss of probing attachment of greater than or equal to 2 mm. The reliability of the BOP test as a predictor was evaluated by calculating sensitivity, specificity, accuracy, and positive and negative predictive values. While only a 29% sensitivity was calculated for frequent bleeding, the specificity was 88%. The fact that the positive predictive value for disease progression was only 6% and the negative predictive value was 98% renders continuous absence of BOP a reliable predictor for the maintenance of periodontal health.
A selective medium was developed for the isolation of Streptococcus mutans from human dental plaque. Mitis-salivarius agar was modified by adding 0.2 units/ml bacitracin and by increasing the sucrose concentration to 20 per cent. At these concentrations, the selective agents allowed the undiminished recovery of Strep. mutans with maximum inhibition of the balance of the streptococcal flora normally encountered on this medium. Enterococci or yeasts were sometimes observed upon direct culturing of plaque samples from children with advanced dentinal lesions.RésuméUn milieu sélectif pour l'isolement du Streptococcus mutans de la plaque dentaire humaine a été mis au point. Le mitis salivarius agar a été modifié en ajoutant 0,2 unités/ml de bacitracine et en augmentant la concentration de saccharose de 20 pour cent. A ces concentrations, les agents sélectifs permettent d'obtenir un maximum de Strep. mutans, avec une inhibition élevée du reste de la flore streptococcique normalement présente dans le milieu. Les entérocoques et les levures sont parfois présents en culture directe d'échantillons de plaques d'enfants présentant des lesions dentinaires avancées.ZusammenfassungZur Isolation von Streptococcus mutans aus menschlicher Zahnplaque wurde ein selektives Medium entwickelt. Durch Zusatz von 0,2 E./ml Bacitracin und durch Erhöhung der Rohrzuckerkonzentration auf 20 Prozent wurde der Mitis-Salivarius Agar modifiziert. Bei diesen Konzentrationen der selektiven Wirkstoffe war es möglich, Strep. mutans unvermindert zurückzugewinnen bei gleichzeitiger maximaler Hemmung des in diesem Medium normalerweise vorhandenen Gleichgewichts der Streptokokkenflora. Bei direkter Kultivierung von Plaqueproben von Kindern mit fortgeschrittenen Dentinläsionen wurden gelegentlich Enterokokken oder Hefen beobachtet.
Sucrose and starches are the predominant dietary carbohydrates in modern societies. While the causal relationship between sucrose and dental caries development is indisputable, the relationship between food starch and dental caries continues to be debated and is the topic of this review. The current view of dental caries etiology suggests that in-depth evaluation of the starch-caries relationship requires the consideration of several critical cariogenic determinants: (1) the intensity (i.e., the amount and frequency) of exposure of tooth surfaces to both sugars and starches, (2) the bioavailability of the starches, (3) the nature of the microbial flora of dental plaque, (4) the pH-lowering capacity of dental plaque, and (5) the flow rate of saliva. Studies of caries in animals, human plaque pH response, and enamel/dentin demineralization leave no doubt that processed food starches in modern human diets possess a significant cariogenic potential. However, the available studies with humans do not provide unequivocal data on their actual cariogenicity. In this regard, we found it helpful to distinguish between two types of situations. The first, exemplified by our forebears, people in developing countries, and special subject groups in more modern countries, is characterized by starch consumption in combination with a low sugar intake, an eating frequency which is essentially limited to two or three meals per day, and a low-to-negligible caries activity. The second, exemplified by people in the more modern societies, e.g., urban populations, is characterized by starch consumption in combination with significantly increased sugar consumption, an eating frequency of three or more times per day, and a significantly elevated caries activity. It is in the first situation that food starches do not appear to be particularly caries-inducive. However, their contribution to caries development in the second situation is uncertain and requires further clarification. Although food starches do not appear to be particularly caries inducive in the first situation, the possibility cannot be excluded that they contribute significantly to caries activity in modern human populations. The commonly used term "dietary starch content" is misleading, since it represents a large array of single manufactured and processed foods of widely varying composition and potential cariogenicity. Hence, increased focus on the cariogenicity of single starchy foods is warranted. Other aspects of starchy foods consumption, deserving greater attention, include the bioavailability of starches in processed foods, their retentive properties, also in relation to sugars present (starches as co-cariogens), their consumption frequency, the effect of hyposalivation on their cariogenicity, and their impact on root caries. The starch-caries issue is a very complex problem, and much remains uncertain. More focused studies are needed. At present, it appears premature to consider or promote food starches in modern diets as safe for teeth.
This paper reviews some common methods for the assessment of caries risk. It also describes a new way of illustrating the caries risk profile of an individual, the Cariogram. Past caries experience and socioeconomic factors are often used for prediction of caries. As prediction models, the methods are simple, inexpensive and fast. However, they are not risk models, as they do not specify which particular risk factors are operating. Various biological factors can be used for risk assessment. Common ones are bacteria, diet and host factors. Taken separately, these biological factors often have limited predictive values. Socioeconomic factors often have a heavy impact on the biological factors as they can explain why an individual, for example, has a cariogenic diet or neglects oral hygiene. The biological factors are the immediate cause of the cavities. Caries experience is an illustration of how the host copes up with the biological activity. To facilitate the interpretation of biological data, the Cariogram was developed. It is a computer program showing a graphical picture that illustrates a possible overall caries risk scenario. The program contains an algorithm that presents a 'weighted' analysis of the input data, mainly biological factors. It expresses as to what extent different etiological factors of caries affect caries risk. The Cariogram identifies the caries risk factors for the individual and provides examples of preventive and treatment strategies to the clinician.
A new semiquantitative enumeration system was developed to detect Streptococcus mutans in saliva. Using species-specific monoclonal antibodies, the system quickly detected salivary S. mutans in 30 min and classified the results into three levels. In this study, saliva samples collected from 28 young adults aged between 22 and 24 years were subjected to the monoclonal antibody-based detecting system and selective medium-based detecting methods. The results generated from the PCR-confirmed culture method indicated the mean salivary S. mutans counts at level 1, 2 and 3 were 5.7 x 10(4), 1.3 x 10(5) and 3.4 x 10(6) CFU/ml, respectively. The differences between level 3 and 1 and level 3 and 2 were statistically significant (one-way ANOVA; p < 0.01). The results generated from the system were consistent with the data generated from two culture-based commercial products.
Multivariate multilevel modeling was applied to analyze repeated measures data on the influence of heavy smoking on the association between the amount of supragingival plaque and gingival bleeding on probing (BOP) in a steady-state plaque environment. Data acquired in 65 systemically healthy young adults with mild plaque-induced gingivitis were analyzed. 33 heavy smokers consumed at least 20 cigarettes per day while 32 were non-smokers. Periodontal examinations at the outset consisted of periodontal probing depth, clinical attachment level, BOP, plaque index, and presence of calculus at 6 sites of every tooth present. They were repeated 3 times every 8 weeks. A multivariate 4-level variance component model revealed that the odds of BOP was twice as high in smokers. In addition, females had a lower likelihood for BOP but, with increasing bleeding scores during the course of the study, this effect attenuated. Low biserial correlations for BOP at the site level of between 0.11 and 0.2 were found. At the tooth level, correlations were moderate (0.2-0.5), and highest at the subject level (0.8-0.9). Variations at subject and tooth levels were very large at the outset but notably attenuated in the course of the study. Plaque consistently influenced the tendency for BOP with an odds ratio of about 1.7-1.8 for each increase in score in both smokers and non-smokers. The present study did not reveal evidence for attenuation of the plaque/gingival bleeding relationship in heavy smokers.
To investigate existing caries risk factors in preschool children and to illustrate their caries risk profiles graphically with aid of a computer-based program.
All 2-year-old children from a small town in northern Sweden were invited and 87% (n = 125) accepted to participate. Data was collected with a questionnaire concerning the child's normal diet and sugar consumption. Special care was taken to note the intake of sweet drinks and sugary between-meal products. Questions on general health and medication, toothbrushing frequency with parental help and use of fluorides were also included. The caries prevalence was recorded with mirror and probe and the level of oral mutans streptococci was enumerated with a chair-side technique. The obtained data were computerised in a risk assessment program (Cariogram) and a graphical profile of each child was constructed.
The caries prevalence was 6%, and 18% had detectable levels of oral mutans streptococci. The sugar consumption was strikingly high with 82% and 97% having ice cream and sweets once a week or more often. In 22% of the families, toothbrushing with parental help was not a daily routine. Of the children, 51% displayed a low chance (0-20%) of avoiding caries in the future. The frequency of sugar consumption was the most pertinent factor in the children's caries risk profiles.
Half of the subjects exhibited a low chance of avoiding caries in the near future and the strongest single factor was frequent sugar consumption. Thus efforts to limit and reduce the sugar intake in young children are important measures for primary caries prevention.
To evaluate the dental status of 12-year-old children in 2004, an epidemiological survey called 'National pathfinder about children's oral health in Italy' was planned. The present paper describes the clinical calibration method.
Thirty children (20 caries-affected and 10 caries-free) were selected. Seven examiners received 35 hours of training and calibration in making clinical measurements by a single trainer. The trainer's diagnosis was the benchmark validity reference. Increase in sensitivity was tested using paired Student's t-test. Inter-examiner reliability for DMFS was evaluated using Pearson's correlation coefficients and ANOVA. Percent agreement and Kappa statistics were calculated for dichotomous judgments (tooth-by-tooth analysis and caries prevalence).
The raters' sensitivity increased from calibration I to calibration II (p < 0.05). For DMFS a good agreement between raters was found without significant differences among them at both calibration exercises. The Pearson's correlation coefficients between all pairs of raters were significant (p < 0.001) after both calibration exercises. Tooth-by-tooth reliability was high: the strength of agreement was substantial or almost perfect in calibration I (Kappa statistics from 0.81 to 0.95) and almost perfect in calibration II (Kappa statistics from 0.92 to 0.97). Regarding caries prevalence, sensitivity, specificity, percent agreement and Kappa statistics results were high but without significant differences between individual pairs of observations in the two calibration sessions (p > 0.05).
The results suggest that sensitivity measurements should be used for agreement assessments in addition to the other World Health Organization-recommended reliability measurements. Kappa statistics are the eligible measurement of reliability for dichotomous judgments.