Estimating a Dynamic Effect of Soda Intake on Pediatric Dental Caries Using Targeted Maximum Likelihood Estimation Method.

An effect of soda intake on dental caries in young children (birth to 5 years) may vary over time. Estimating a dynamic effect may be challenging due to time-varying confounding and loss to follow-up. The purpose of this paper is to demonstrate utility of targeted maximum likelihood estimation (TMLE) method in addressing longitudinal data analysis challenges and estimating a dynamic effect of soda intake on pediatric caries. Data came from the Detroit Dental Health Project, a 4-year cohort study of low-income -African-American children and caregivers. The sample included 995 child-caregiver pairs who participated in 2002-03 (W1) and were followed up in 2004-05 (W2) and 2007 (W3). The outcome was counts of caries surfaces at W3, and the exposure was child's soda intake at W1 and W2. Time-varying covariates included caregiver's smoking status, oral health fatalism, and social support. Forty-three percent of children consistently consumed soda at W1 and W2, whereas 21% were nonconsumers throughout 2 surveys. The remaining 35% switched intake status between W1 and W2. Association between soda intake patterns and caries was tested using TMLE. Children with a consistent soda intake had 1.03 more caries lesions at W3 than those with consistently no soda intake (95% CI 0.09-1.97) on average. If soda was consumed only at W1 or W2, an estimated effect of soda on caries development at W3 was no longer statistically significant. In conclusion, consistent soda intake during the early childhood led to one additional caries tooth surface. The study highlights utility of TMLE in pediatric caries research as it can handle modeling challenges associated with longitudinal data.

Tooth Surface Level Caries Progression in the Primary Dentition among Preschool Children.

The objective of this paper is to describe primary tooth surface level caries progression, over 2 years, based on the severity of the caries lesions. Data were collected from 790 low-income African-American preschool children in Detroit, Mich., USA. The caregivers of the children (aged 0-5 years) completed interviews and the dyad of child-caregiver completed dental examinations in 2002-2004 (baseline) and in 2004-2005 (follow-up). Caries were measured using the International Caries Detection and Assessment System (ICDAS). The caries status of tooth surfaces was classified into initial (ICDAS 1-2), moderate (ICDAS 3-4) and extensive (ICDAS 5-6) stages. Counts of tooth surfaces with progression, by baseline caries severity level, were used to compute rate ratios (RRs) relative to sound stages. RRs were also computed for type of tooth surfaces and frequency of intake of soda consumption at baseline. After adjusting for confounders, caries progression was more likely to occur in tooth surfaces with any baseline caries relative to sound surfaces. For surfaces with initial caries, the rate of progression to moderate caries was 9.6 times higher than that of sound surfaces. Surfaces with initial and moderate caries progressed to extensive caries 6.1 and 20.6 times, respectively, relative to sound surfaces. Baseline soda consumption was not associated with the RR of caries progression. In conclusion, the staging of caries identifies different progression risks and significant emphasis should be placed on secondary prevention of initial lesions as well as on primary prevention.

Emotional distress and risk of dental caries: Evaluating effect modification by chronic conditions among low-income African American caregivers in Detroit, Michigan.

Background/aim: Limited research has been conducted regarding the association between mental illness and dental caries. We studied the impact of emotional distress on current and new dental caries among low-income African-American caregivers in Detroit, Michigan and if this association was mediated by poor oral hygiene and sugar consumption and modified by a chronic health condition. Methods: Data came from Detroit Dental Health Project, a prospective cohort study of low-income African American caregivers and their children. We focused on baseline (n = 1,021) and 4-year follow-up participants (n = 614). Dental caries were assessed using the International Caries Detection and Assessment System. The study outcomes included two baseline caries outcomes (counts of non-cavitated lesions, baseline counts of cavitated lesions) and two outcomes of new caries over 4 years (new cavitated lesions and new non-cavitated lesions). The exposure was emotional distress. We performed multivariable quasi-Poisson regression analysis to test the association between emotional distress and caries. We tested effect modification by stratifying data by chronic health conditions and performed causal mediation analysis to test an indirect effect of oral hygiene and sugar consumption. Results: Ninety six percent of the caregivers were female, and their average age was 28 years old. Thirteen percent reported emotional distress at baseline. After accounting for potential confounding, emotional distress was positively associated with cavitated lesions at baseline (IRR = 1.36, 95% CI = 1.08, 1.70). Among those with a chronic health condition, stronger association was observed (IRR = 1.73, 95% CI = 1.27, 2.35). After 4 years, those with emotional distress and chronic health conditions had an increased risk of developing non-cavitated carious lesions (IRR = 1.41, 95% CI = 1.06, 1.88). Poor oral hygiene explained 51% of the association between emotional distress and baseline cavitated lesions (natural indirect effect = 1.16, 95% CI = 1.02, 1.33), but there was no evidence for an indirect effect of sugar consumption. Conclusion: In this group of young, African-American caregivers with low socioeconomic status, dental caries was associated with emotional distress. This association was explained by poor oral hygiene and strengthened among those who reported a chronic health condition.

Chronic Stress and Unhealthy Dietary Behaviors among Low-Income African-American Female Caregivers.

BACKGROUND: Chronic stress increases the risk of excess intake of calorie-dense foods. Low-income minority caregivers in the United States are cumulatively exposed to stressors and unhealthy foods, but evidence of this association is limited in this population group. The objective of the current study was to assess the association between chronic stress and unhealthy dietary behaviors among low-income African-American caregivers in Detroit, Michigan. METHODS: Data came from Detroit Dental Health Project, a longitudinal study of pairs of African-American caregivers and children during 2002-2007. A sample of 912 female caregivers were included and their baseline (2002-2003) survey responses were analyzed to identify those with chronic stress and patterns of dietary behaviors. The likelihood of having unhealthy dietary behaviors was compared between chronically stressed caregivers and others, and the mediator role of depressive symptoms or current smoking was tested. RESULTS: Approximately 10% of caregivers experienced chronic stress as they all reported discrimination, residential movement, and lack of social support. Twenty-five percent of the caregivers were found to have an unhealthy dietary pattern characterized by excess intake of high fatty foods and soda. Chronically stressed caregivers were more likely to exhibit unhealthy dietary behaviors (prevalence ratio: 1.39; 95% CI: 1.05, 1.84), and this relation was significantly mediated by depressive symptoms, not current smoking. CONCLUSIONS: These findings suggest that chronic stress played a role in negatively influencing dietary behaviors. As this association might be mediated by depressive symptoms, an intervention to reduce depressive symptoms can be considered as an effective strategy to promote healthy dietary behaviors among chronically stressed minority caregivers.

An innovative individual-level caries severity and progression indicator among children.

OBJECTIVE: To propose an individual-level indicator of caries severity based on the maximum score generated using the international caries detection and assessment system (ICDAS) and test validity of this individual-level indicator by assessing differences between this proposed indicator and the traditional decayed, missing, and filled surfaces (DMFS or dmfs for primary teeth) index. METHODS: Data on caries severity were collected using a representative sample of children from Detroit, Michigan, aged less than 6 years (N = 749) examined in 2002-2003 (W1) and 2004-2005 (W2). For each wave, each child was assigned to six caries severity groups based on the maximum ICDAS scores. This individual-level indicator was then compared with the surface-level dental caries measure (dmfs + DMFS). In addition, caries progression between W1 and W2 were assessed using individual-level and tooth surface-level indicators. RESULTS: Both measures were linearly related, and the relationship was statistically significant (P < 0.001). CONCLUSION: An individual-level caries progression indicator can be developed that is simple and has the ability to communicate with policymakers and the public the severity and impact of dental caries and it can add value to the conventional presentation of DMF/dmf data.

Tobacco-free community coalitions: opportunities for enhancing oral cancer prevention programs.

BACKGROUND: This study identified oral cancer (OC) education and tobacco reduction collaboration within tobacco-free community coalitions (TFCC). METHODS: Data from 4 TFCC were collected via educational intervention surveys and structured focused group Interviews. RESULTS: Of the 52 participants, 96% were aware that tobacco products are risk factors for OC, yet 33% were unaware of the high OC impact locally. About 90% agreed that primary care providers and dentists should provide OC screenings and tobacco cessation. CONCLUSION: There is a need for provider endorsement and public demand for OC screenings. Opportunity exists for partnering and collaborative OC prevention with TFCC.

Dental caries.

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.

Fluoride supplements, dental caries and fluorosis: a systematic review.

BACKGROUND: In this review, the authors examine evidence regarding the effectiveness of fluoride supplements in preventing caries and their association with dental fluorosis. METHODS: Using tested search filters, the authors searched MEDLINE, the Cochrane Central Register of Controlled Trials, OVID Evidence-based Reviews and EMBASE. The authors agreed on the inclusion of 20 reports from 12 trials that met defined criteria. They also included five studies published since 1997 regarding the association between dental fluorosis and supplements. RESULTS: Eleven of the reports evaluated dosage schedules similar to that recommended by the American Dental Association. One potentially highly biased study of primary teeth of children during the first three years of life reported a 47.2 percent reduction in dental caries experience. Investigators in one trial involving 3- to 6-year-old children found a 43.0 percent difference, and another trial of children in this age group did not find a significant benefit. Researchers in several studies involving older children detected a significant reduction in caries increments in permanent teeth with the use of fluoride supplements. Fifteen of the studies had withdrawal rates of 30 percent or higher. All of the five included studies that evaluated the association between use of fluoride supplements and dental fluorosis found that use of the supplements increased the risk of mild-to-moderate fluorosis. CONCLUSIONS: There is weak and inconsistent evidence that the use of fluoride supplements prevents dental caries in primary teeth. There is evidence that such supplements prevent caries in permanent teeth. Mild-to-moderate dental fluorosis is a significant side effect. CLINICAL IMPLICATIONS: The current recommendations for use of fluoride supplements during the first six years of life should be re-examined.

Cariogenicity of soft drinks, milk and fruit juice in low-income african-american children: a longitudinal study.

BACKGROUND: The authors conducted a study to test the hypothesis that high consumption of soft drinks, relative to milk and 100 percent fruit juice, is a risk factor for dental caries in low-income African-American children in Detroit. METHODS: Trained dentists and interviewers examined a representative sample of 369 children, aged 3 to 5 years, in 2002-2003 and again two years later. The authors used the 2000 Block Kids Food Frequency Questionnaire (NutritionQuest, Berkeley, Calif.) to collect dietary information. They assessed caries by using the International Caries Detection and Assessment System. RESULTS: Soft drinks, 100 percent fruit juice and milk represented the sugared beverages consumed by the cohort. A cluster analysis of the relative proportion of each drink at baseline and follow-up revealed four consumption patterns. Using zero-inflated negative binomial models, the authors found that children who changed from being low consumers of soft drinks at baseline to high consumers after two years had a 1.75 times higher mean number of new decayed, missing and filled tooth surfaces compared with low consumers of soft drinks at both time points. CONCLUSION: Children who consumed more soft drinks, relative to milk and 100 percent fruit juice, as they grew older were at a greater risk of developing dental caries. CLINICAL IMPLICATIONS: Health promotion programs and health care providers should emphasize to patients and caregivers the caries risk associated with consumption of soft drinks.

Determinants of early childhood caries in low-income African American young children.

PURPOSE: The aim of this longitudinal study was to evaluate the association between early childhood caries (ECC) and severe ECC (S-ECC) and social, dietary, and behavioral risk factors. METHODS: A representative sample of low-income 0- to 5-year-old children was selected from Detroit. Children and their caregivers were examined for the presence and severity of dental caries. Trained interviewers administered questionnaires assessing social, dietary, and behavioral factors. RESULTS: A total of 1,021 child and caregiver dyads were examined in wave 1. Of these, 788 (77%) were re-examined in wave 2. ECC and S-ECC were highly prevalent in this cohort By 2 years of age, 7% of the children had ECC without S-ECC (ECC-only) and 27% had S-ECC. The regression model found that age of the child and caregiver, child's gender, and caregivers' fatalistic oral health beliefs were significantly associated with higher odds ratios of developing ECC-only and S-ECC. Consumption of soda beverages was associated with developing S-ECC. Religiosity was protective against ECC-and S-ECC. CONCLUSIONS: Early childhood caries and severe early childhood caries are highly prevalent in low-income African American children. Intake of soda beverages by the children and the caregivers' fatalistic oral health beliefs and religiosity were significant determinants of ECC and S-ECC.

Caregiver's perception of child's oral health status among low-income African Americans.

PURPOSE: This study aimed to: (1) compare caregivers' perceptions of their children's oral health status with clinical findings; and (2) investigate the influence of caregivers' attitudes, beliefs, and knowledge concerning dental caries development and oral health on caregivers' perception levels of their children's oral health status. METHODS: A representative sample of low-income African American families (0- to 5-year-olds and their caregivers) in Detroit, Mich was interviewed. Caregivers were asked to assess their own and their children's oral health status. All children and their caregivers received dental examinations. This study included data from 885 caregivers with children aged 1 year or older. RESULTS: Approximately 79% of caregivers rated their children's oral health as good to excellent, and 21% rated it as fair to poor. Caregivers' perception of their children's oral health was significantly associated with their children's caries experience, as measured by the number of decayed, missing, and filled tooth surfaces. It was also associated with limitations of oral functions, such as chewing difficulty. Poorer perceptions of caregivers' oral health and fatalistic attitudes toward children's oral health were significantly associated with poorer perception of their children's oral health. CONCLUSION: Caregivers' perception of their children's oral health status is a significant indicator of the children's clinical caries experience.

Mediation analysis for count and zero-inflated count data.

Different conventional and causal approaches have been proposed for mediation analysis to better understand the mechanism of a treatment. Count and zero-inflated count data occur in biomedicine, economics, and social sciences. This paper considers mediation analysis for count and zero-inflated count data under the potential outcome framework with nonlinear models. When there are post-treatment confounders which are independent of, or affected by, the treatment, we first define the direct, indirect, and total effects of our interest and then discuss various conditions under which the effects of interest can be identified. Proofs are provided for the sensitivity analysis proposed in the paper. Simulation studies show that the methods work well. We apply the methods to the Detroit Dental Health Project's Motivational Interviewing DVD trial for the direct and indirect effects of motivational interviewing on count and zero-inflated count dental caries outcomes.

Maternal self-efficacy and 1-5-year-old children's brushing habits.

OBJECTIVES: This study investigates the relationships between maternal cognitive, behavioral, and psychosocial factors and brushing practices in low-income African-American preschool children. METHODS: Data are from a population-based sample of 1021 African-American families with at least one child <6 years of age and living in the 39 low-income Census tracts in Detroit, Michigan. Analyses were limited to 1-5-year-old children and their mothers (n = 719). Mothers were surveyed about oral health-related self-efficacy (OHSE), knowledge about appropriate bottle use (KBU), knowledge about children's oral hygiene (KCOH), oral health fatalism (OHF), their own toothbrushing behavior, depressive symptoms (CES-D), parenting stress, practical social support, and their child's dental history. Children's 1-week reported brushing frequency was the main outcome measure. Analyses were conducted in SUDAAN to account for the complex sampling design. RESULTS: Children's 1-week brushing frequency (range 0-40) averaged 8.50 times per week among 1-3-year olds and 9.75 among the 4-5-year olds. Maternal OHSE was a strong and significant predictor of children's brushing frequency; for each unit increase in OHSE, 1-3-year olds were expected to brush 18% more frequently on average during 1 week [incidence density ratios (IDR) = 1.18, 95% confidence interval (CI) 1.08-1.28; P < 0.001], and 4-5-year olds were expected to brush 9% more often (IDR = 1.09, 95% CI 1.00-1.19; P < 0.10). Mothers' KCOH score was also significantly positively associated with brushing frequency; for each unit increase on the KCOH scale, 1-3-year olds were expected to brush 22% more frequently (IDR = 1.22, 95% CI 1.10-1.35; P < 0.001) and 4-5-year olds were expected to brush 13% more frequently (IDR = 1.13, 95% CI 1.02-1.26; P < 0.05). If a mother brushed her own teeth at bedtime during the week, her 1-3-year old child's brushing frequency was expected to increase by one-third (IDR = 1.34, 95% CI 1.12-1.60; P < 0.01) and among the 4-5-year olds, the child's frequency was expected to increase by one-quarter (IDR = 1.26, 95% CI 1.12-1.42; P < 0.001). Availability of help with transportation and financial support were also relevant variables for 1-3-year olds. Higher family income and dental insurance coverage were both positively associated with brushing among 4-5-year olds. CONCLUSIONS: Several maternal cognitive, behavioral, and psychosocial factors were associated with young children's brushing practices. Oral health-specific self-efficacy and knowledge measures are potentially modifiable cognitions; findings suggest that intervening on these factors could help foster healthy dental habits and increase children's brushing frequency early in life.

Modifiable risk and protective factors for depressive symptoms in low-income African American mothers.

Low-income African American mothers of young children experience high rates of depression, but many of the risk factors that have been identified provide little direction for intervention. The authors examined modifiable risk and protective factors for probable depression (Center for Epidemiological Studies Depression Scale >or= 23) in 824 African American mothers living in the 39 poorest census tracts in Detroit. Household food insufficiency and deteriorated housing significantly increased the odds of likely depression, whereas availability of a loan in a crisis, help with childcare, and transportation were protective. However, more frequent experiences of everyday discrimination greatly increased the odds of elevated depressive symptoms. These findings support the need for interventions that operate across individual and societal levels to address the fundamental causes of poor mental health.

Caries risk-based fluoride supplementation for children.

PURPOSE: The purpose of this study was to evaluate primary care physicians' recommendation of fluoride supplements based upon a child's caries risk. METHODS: A representative sample of family physicians (FPs) and pediatricians (PDs) in the United States was mailed a letter and a questionnaire that described case scenarios of 2-year-old children-one with low and the other with high caries-risk -as well as questions about opinions on fluoride supplement use. The physicians' opinions were compared with CDC experts' consensus on the same scenarios. RESULTS: The response rates were 43% for FPs and 52% for PDs. FPs and PDs had a high agreement level (76% ond 80%, respectively) with CDC experts regarding the need for fluoride supplementation of the high-risk child. For o low risk child, all physicians showed a significantly lower level of agreement with the CDC experts (15% for FPs; 7% for PDs). CONCLUSIONS: The majority of primary care physicians follow the current fluoride supplementation guideline without considering the caries risk status of a child. If caries risk status is to be used to tailor preventive regimens, then physicians need to be educated on how to identify children with the highest need for prevention.

Dental caries and dietary patterns in low-income African American children.

PURPOSE: The purpose of this study was to assess the relationship between dietary patterns and dental caries severity in low-income African American children. METHODS: The participants were 3- to 5-year-old African American children in Detroit, Mich, with household incomes below 250% of the 2000 federal poverty level (N=436). Dietary intakes were obtained using the Block Kids Food Questionnaire. Dental caries in primary teeth were measured by the International Caries Detection and Assessment System criteria. The mean number of decoyed surfaces (noncavitated and cavitated, missing, and filled surfaces [dmfs]) for each child was estimated. Factor analysis was carried out to identify the patterns of solid food consumption. The resulting factor scores and drink variables were then used as covariates in multinomial logistic regression, with 4 levels of dmfs as the outcome. Statistical analyses were conducted using SAS and SUDAAN. RESULTS: Multinomial regression models found that age, soda consumption, and powdered/sport drink consumption were positively associated with dmfs scores. Milk and real juice (not orange) were associated with lower dmfs levels. CONCLUSIONS: Children frequently consume sugared drinks, which is associated with the prevalence of dental caries. Intervention programs that promote the adoption of noncariogenic dietary alternatives for children are needed.

Percentage and severity of periodontal diseases in Turkish adults aged 35+ years, 2009-10.

OBJECTIVE: This article presents data on the burden of periodontal diseases in Turkish adults aged 35 years or older. METHODS: Within each region of Turkey, a rural and an urban area or city were selected in 2009-10 using a probability proportional to size method. In the selected towns, local officials who were familiar with their communities assisted in recruiting subjects. Loss of Attachment (LOA) was measured at six sites around each tooth present in the mouth, excluding third molars. Additionally, the Community Periodontal Index was used to assess the severity of periodontal diseases around 12 index teeth. Self-reported data on key risk factors were also collected. Weights were computed using a raking ratio adjustment procedure and used in all analyses. RESULTS: Almost all examined adults had some loss of periodontal attachment. The proportion of those with more than 3 mm LOA ranged from 43 percent in 35-44 year olds to 91 percent in those aged 65+ years. Among females, older age, low education status, smoking 11-40+ cigarettes a day, being employed, and presence of high number of missing tooth surfaces were associated with LOA > 3 mm. Among males LOA >3 mm was associated with older age, use of alcohol, and unemployment. The CPI data did not yield the same associations with periodontal diseases and risk factors. CONCLUSIONS: Periodontal diseases in Turkish adults are highly prevalent. A tailored common risk factor health promotion program is recommended to reduce the burden of periodontal infection in Turkey.

Red fluorescence of dental plaque in children -A cross-sectional study.

OBJECTIVES: The relation between the presence of red fluorescent plaque and the caries status in children was studied. In addition, the microbial composition of dental plaque from sites with red fluorescent plaque (RFP) and from sites with no red fluorescent plaque (NFP) was assessed. METHODS: Fluorescence photographs were taken from fifty children (6-14 years old) with overnight plaque. Full-mouth caries scores (ICDAS II) were obtained. The composition of a saliva sample and two plaque samples (RFP and NFP) was assessed using 16S rDNA sequencing. RESULTS: At the site level, no clinically relevant correlations were found between the presence of RFP and the caries status. At the subject level, a weak correlation was found between RFP and the caries status when non-cavitated lesions were included (rs=0.37, p=0.007). The microbial composition of RFP differed significantly from NFP. RFP had more anaerobes and more Gram-negative bacterial taxa. The most discriminative operational taxonomic units (OTUs) for RFP were Corynebacterium, Leptotrichia, Porphyromonas and Selenomonas, while the most discriminative OTUs for NFP were Neisseria, Actinomyces, Streptococcus and Rothia. CONCLUSIONS: There were no clinical relevant correlations in this cross-sectional study between the presence of RFP and (early) caries lesions. There were differences in the composition of these phenotypically different plaque samples: RFP contained more Gram-negative, anaerobic taxa and was more diverse than NFP. CLINICAL SIGNIFICANCE: The study outcomes provide more insight in the possibilities to use plaque fluorescence in oral health risk assessments.