Evidence-based Update of Pediatric Dental Restorative Procedures: Preventive Strategies.

BACKGROUND: There has been significant advances in the understanding of preventive restorative procedures regarding the advantages and disadvantages for restorative procedures; the evidence for conservative techniques for deep carious lesions; the effectiveness of pit and fissure sealants; and the evidence for use of resin infiltration techniques. AIM: The intent of this review is to help practitioners use evidence to make decisions regarding preventive restorative dentistry in children and young adolescents. STUDY DESIGN: This evidence-based review appraises the literature, primarily between the years 1995-2013, on preventive restorative strategies. The evidence was graded as to strong evidence, evidence in favor, or expert opinion by consensus of authors Results: The preventive strategy for dental caries includes individualized assessment of disease progression and management with appropriate preventive and restorative therapy. There is strong evidence that restoration of teeth with incomplete caries excavation results in fewer signs and symptoms of pulpal disease than complete excavation. There is strong evidence that sealants should be placed on pit and fissure surfaces judged to be at risk for dental caries, and surfaces that already exhibit incipient, non-cavitated carious lesions. There is evidence in favor for resin infiltration to improve the clinical appearance of white spot lesions. CONCLUSIONS: Substantial evidence exists in the literature regarding the value of preventive dental restorative procedures.

Evidence-based Update of Pediatric Dental Restorative Procedures: Dental Materials.

BACKGROUND: The science of dental materials and restorative care in children and adolescent is constantly evolving, and the ongoing search for ideal restorative materials has led to plethora of research. AIM: To provide an evidence base to assist dental practitioners choose appropriate restorative care for children and adolescents. STUDY DESIGN: This evidence-based review appraises this literature, primarily between the years 1995-2013, for efficacy of dental amalgam, composites, glass ionomer cements, compomers, preformed metal crowns and anterior esthetic restorations. The assessment of evidence for each dental material was based on a strong evidence, evidence in favor, expert opinion, and evidence against by consensus of the authors. RESULTS: There is varying level of evidence for the use of restorative materials like amalgam, composites, glass ionomers, resin-modified glass-ionomers, compomers, stainless steel crowns and anterior crowns for both primary and permanent teeth. CONCLUSIONS: A substantial amount data is available on restorative materials used in pediatric dentistry; however, there exists substantial evidence from systematic reviews and randomized clinical trials and clinicians need to examine and understand the available literature evidence carefully to aid them in clinical decision making.

Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis.

The goal of nonrestorative or non- and microinvasive caries treatment (fluoride- and nonfluoride-based interventions) is to manage the caries disease process at a lesion level and minimize the loss of sound tooth structure. The purpose of this systematic review and network meta-analysis was to summarize the available evidence on nonrestorative treatments for the outcomes of 1) arrest or reversal of noncavitated and cavitated carious lesions on primary and permanent teeth and 2) adverse events. We included parallel and split-mouth randomized controlled trials where patients were followed for any length of time. Studies were identified with MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews. Pairs of reviewers independently conducted the selection of studies, data extraction, risk-of-bias assessments, and assessment of the certainty in the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Data were synthesized with a random effects model and a frequentist approach. Forty-four trials (48 reports) were eligible, which included 7,378 participants and assessed the effect of 22 interventions in arresting or reversing noncavitated or cavitated carious lesions. Four network meta-analyses suggested that sealants + 5% sodium fluoride (NaF) varnish, resin infiltration + 5% NaF varnish, and 5,000-ppm F (1.1% NaF) toothpaste or gel were the most effective for arresting or reversing noncavitated occlusal, approximal, and noncavitated and cavitated root carious lesions on primary and/or permanent teeth, respectively (low- to moderate-certainty evidence). Study-level data indicated that 5% NaF varnish was the most effective for arresting or reversing noncavitated facial/lingual carious lesions (low certainty) and that 38% silver diamine fluoride solution applied biannually was the most effective for arresting advanced cavitated carious lesions on any coronal surface (moderate to high certainty). Preventing the onset of caries is the ultimate goal of a caries management plan. However, if the disease is present, there is a variety of effective interventions to treat carious lesions nonrestoratively.

Evidence of Early Emergence of the Primary Dentition in a Northern Plains American Indian Population.

The purposes of this study were to describe primary tooth emergence in an American Indian (AI) population during the first 36 mo of life to compare 1) patterns of emergence between male and female children and 2) tooth emergence between these AI children and other U.S. ethnic groups. Data were derived from a birth cohort of 239 AI children from a Northern Plains tribe participating in a longitudinal study of early childhood caries, with examination data at target ages of 8, 12, 16, 22, 28, and 36 mo of age (±1 mo). Patterns of emergence in AI children were characterized and sex comparisons accomplished with interval-censored survival methodology. Numbers of erupted teeth in AI children at each age were compared via Kruskal-Wallis tests against those in children of the same age, as drawn from a cross-sectional study of dental caries patterns in Arizona; these comparisons were based on the dental examinations of 547 White non-Hispanic and 677 Hispanic children. Characterization of time to achievement of various milestones-including emergence of the anterior teeth, the first molars, and the complete primary dentition-provided no evidence of sex differences among AI children. AI children had significantly more teeth present at 8 mo (median, 3) than either White non-Hispanic (P < 0.0063) or Hispanic (P < 0.0001) children (median, 2 each). This was also true at 12 mo (P < 0.001; medians, 8 vs. 6 and 7, respectively) and 16 mo (P < 0.001; medians, 12 vs. 11 each). Less pronounced differences were seen at 22 mo (P < 0.0001). White non-Hispanic and Hispanic children did not differ at any time considered (P > 0.05). These results provide evidence of earlier tooth emergence in AI children than in the other 2 ethnicities. Although the underlying etiology of the severity of early childhood caries in AI children is likely to be multifactorial, earlier tooth emergence may be a contributing factor. Knowledge Transfer Statement: The findings of this study have practical implications for practitioners providing childhood oral health care to ethnic groups with early tooth emergence. It may be important to provide parents with information on toothbrushing, dentist visits, and other practices supportive of good oral health as early as possible to protect their children's primary dentition.

Comparison of chairside microbiological screening systems and conventional selective media in children with and without visible dental caries.

PURPOSE: The purpose of this study was to compare the results of commercial chairside microbial tests (CT) and conventional selective media (GS, gold standards) for mutans streptococci (MS) and lactobacilli (LB) using oral specimens from young children with and without visible dental caries. METHODS: Using cotton swabs to collect oral microbial specimens from children 10 to 36 months old, microbial counts of CT and GS were compared with caries experience of the subjects. Contamination levels by non-MS or non-LB isolates on CT and GS were also determined. The CT employed were: (1) CRT bacteria for MS and LB; (2) CarioCheck Plus for MS and LB; and (3) Dentocult SM and Mucount for MS. RESULTS: All CT and GS for MS represented caries status of the participants (P<.001, Fisher exact test; P<.015 linear regression), whereas only GS for LB showed significant association with caries status (P<.001, Fisher exact test; P<.001, linear regression). Non-MS or non-LB isolates were observed on most media, and CT usually exhibited higher contaminant levels than GS. Dentocult SM and Mucount did not harbor contaminants. CONCLUSIONS: Despite contamination, CT and GS for MS and GS for LB exhibited satisfactory outcomes based on cross-sectional caries experience of infants and toddlers.

Effect of SnF2 mouthrinse on initial bacterial colonization of tooth enamel.

Microbiologic quantitative methods and scanning electron microscopy were used to observe the effect of stannous fluoride (100 ppm F-) mouthrinse on early plaque formation. An in vivo plaque model system was used on two individuals to test this experimental agent. Following SnF2 mouthrinsing, the total bacterial counts of two-day-old plaque on enamel cylinders were reduced up to 50.8 times or 98% and the streptococcal counts were decreased up to 48.4 times or 97.9%. Scanning electron microscopy confirmed a marked decrease of bacteria on enamel with use of SnF2 mouthrinse. It appears that, in addition to reducing enamel solubility and other properties, SnF2 may also alter bacterial accumulations on teeth.

Epithelial cells associated with the development of dental plaque.

Transmission and scanning electron microscopy were used to study desquamated epithelial cells in the developing and mature dental plaque. Epithelial cells were found attached to enamel as early as one hour after clean enamel cylinders were placed in the mouth, and they were seen in great numbers after two days. These cells generally had bacteria attached to their surfaces. Epithelial cells adsorbed to the surface of the enamel appeared to alter their morphology, and mineralization of these structures was also observed. Desquamated epithelial cells could play a role in the initial bacterial colonization of tooth enamel since it is known that bacteria selectively adsorb onto their surfaces. Hydroxyapatite may affect the morphologic alteration of epithelial cells adsorbed to tooth enamel. From the observation of developing and mature plaque samples, it seems that certain suprasurface pelliclelike structures might be epithelial cells.

Maxillary anterior caries associated with increased caries risk in other primary teeth.

It has been suggested that children with caries of maxillary anterior primary teeth may have increased caries incidence in other teeth. This study aimed to quantify the extent of posterior dental caries in those children who initially presented with maxillary anterior caries compared with that of those who did not. Data were collected for 217 Head Start children participating in a one-year study to determine caries risk factors. Tooth surfaces were recorded as carious, restored, or extracted (missing due to caries). Caries was then categorized into the following pattern(s): maxillary anterior (MA), pit/fissure (PF), posterior proximal (PP), and posterior buccal/lingual smooth surface (BL). Compared with children who did not initially present with the maxillary anterior pattern, those with the maxillary anterior pattern had 2.5 times (p < 0.01) the mean number of posterior decayed, missing, and filled surfaces (dmfs) and approximately 3 times the prevalence (p < 0.01) of the PP and BL patterns. The positive predictive value of the MA pattern was 86.8% for children who developed the PF pattern, and the negative predictive values were greater than 91% for children who did not develop the PP and BL patterns. The prevalence of maxillary anterior caries among children in this study is associated with a significantly greater caries incidence in posterior teeth.

Anti-bacterial determinants of stannous fluoride.

The growth of bacteria on stainless steel wires was used as a model to investigate which properties of SnF2 produced anti-bacterial effects against S. mutans. Wire-adherent bacteria were exposed for one min, twice a day, to various fluoride or control compounds having similar ions, pH, valence, or atomic weights. After two days, the thickness of adherent bacteria was scored visually, and the decrease in pH of the growth medium was determined. Bacteria from each wire were then dried, weighed, and analyzed for metal content. Electron microscopy and electron microprobe were used to identify the location of heavy metal deposits in the bacteria. Only SnF2 dramatically altered S. mutans growth and metabolism, and this anti-bacterial effect was associated with a large uptake of tin into the bacterial cells. The fluoride salts of sodium, lead, zinc, and copper had little influence on S. mutans growth in this test system. The pH of the various fluoride salts or controls generally had no effect on the activity of the test compounds, except for the noted inactivation of SnF2 at elevated pH's. Since SnF4 did not alter the growth or metabolism of S. mutans, a unique property of SnF2--possibly the reactivity in an aqueous environment--may be responsible for its anti-bacterial properties.

Microbiologic effects of SnF2 and NaF mouthrinses in subjects with high caries activity: results after one year.

Twenty-two adults, considered to have high caries activity, rinsed for one yr with either SnF2 or acidulated NaF mouthrinses. Total colony-forming units and numbers of S. mutans and lactobacilli were estimated from saliva samples. Large reductions were found in the number of recoverable S. mutans in subjects rinsing with SnF2 but not in the NaF group.

Changes of subgingival total colony forming units and black pigmented bacteroides after a single irrigation of periodontal pockets with 1.64% SnF2.

Periodontal pockets of 11 subjects were irrigated once with either 1.64% SnF2 or saline applied by syringe. Changes on the total anaerobic colony forming units (CFU) and black pigmented bacteroides (BPBs) of the irrigated pockets were assessed for 31 days. The results showed little change of the CFUs by either single application of SnF2 or saline. However, SnF2 irrigation produced a decrease in the BPBs for 1 week with the greatest effect (1/2 log reduction) being seen at 3 days after the irrigation. Some subjects had more impressive reductions in BPBs, yet four of the 11 subjects showed no reductions in BPBs in those sites irrigated with SnF2. Further studies with frequent irrigation intervals are necessary to evaluate the potential usefulness of SnF2 for subgingival irrigation.

Effects of NaF and SnF2 on growth, acid and glucan production of several oral streptococci.

The effects of low concentrations of these fluorides on Streptococcus sobrinus, Streptococcus mutans, Streptococcus salivarius, Streptococcus mitior and Streptococcus sanguis were investigated. Without fluoride, mutans streptococci (Strep. mutans and Strep. sobrinus) produced more acid than the other strains; both fluorides reduced acid production in all strains. NaF had little effect on growth; SnF2 decreased growth in all strains, most evidently in the Strep. mutans. In all growth conditions, Strep. sobrinus produced the most alkali-soluble glucan. Both fluorides enhanced alkali-soluble glucan production in mutans streptococci while only SnF2 enhanced this in the other streptococci.

Multidimensional causal model of dental caries development in low-income preschool children.

Despite the decline in the incidence of dental caries in the United States over the past several years, the condition remains a significant problem for the nation's poor children. Efforts to identify the factors responsible for caries development in samples of children of low socioeconomic status have primarily focused on a limited number of variables, and those have been predominantly biological (mutans streptococci, for example). Resulting models of caries development have usually shown good sensitivity but poor specificity. They have had limited implications for treatment. In an effort to produce a comprehensive model of caries development, 184 low-income preschool children were clinically assessed for mutans streptococci and for decayed, missing, or filled surfaces of deciduous teeth twice, first at age 4 years (baseline) and again a year later (year 1 assessment). As the clinical assessments were being done, caretakers were being interviewed to obtain data from five domains: demographics, social status, dental health behaviors, cognitive factors such as self-efficacy (self-confidence) and controllability, and perceived life stress. Data were analyzed using a structural equations modeling approach in which variables from all domains, plus baseline decayed missing and filled surfaces and baseline mutants, were used together to create a model of caries development in the year 1 assessment. Results confirmed earlier work that suggested that caries development at a 1-year followup was strongly dependent on earlier caries development. Early caries development in this sample was determined in part by mutans levels and by dental health behaviors. These behaviors themselves were accounted for partly by a cognitive factor. The results support the advantages of employing multidimensional models and provide some direction for intervention to reduce caries incidence.

Dental caries prevalence and treatment levels in Arizona preschool children.

OBJECTIVES: To assess the prevalence of dental caries in a large group of preschool children, to determine the extent to which the children received dental treatment, to examine the association between demographic and socioeconomic factors and the prevalence of caries, and to compare these findings with those from previous studies of preschool populations in the United States. METHODS: Dental caries exams were performed on 5171 children ages 5 months through 4 years, and a parent or other caregiver was asked to complete a questionnaire giving information about the child and her or his household. The children were recruited from Head Start programs; Women, Infants, and Children (WIC) nutrition programs; health fairs; and day care centers in a representative sample of Arizona communities with populations of more than 1000 people. RESULTS: Of the 994 one-year-old children examined, 6.4% had caries, with a mean dmft (decayed, missing [extracted due to caries], and filled teeth) score of 0.18. Nearly 20% of the 2-year-olds had caries, with a mean dmft of 0.70. Thirty-five percent of the 3-year-olds had caries, with a mean dmft of 1.35, and 49% of the 4-year-olds had caries, with a mean dmft of 2.36. Children whose caregivers fell into the lowest education category had a mean dmft score three times higher than those with caregivers in the highest education category. Children with caregivers in the lowest income category had a mean dmft score four times higher than those with caregivers in the highest category. Children younger than age 3 had little evidence of dental treatment, and most of the children with caries in each age group had no filled or extracted teeth. CONCLUSIONS: The data show that dental caries is highly prevalent in this preschool population, with little of the disease being treated. Timing of diagnostic examinations and prevention strategies for preschool children need to be reconsidered, especially for children identified as having a high risk of caries.

Introduction to the Early Childhood Caries Conference: initial description and current understanding.

The objective of this paper is to introduce the issues discussed at the Early Childhood Caries Conference, held October 18-19, 1997, in Bethesda, Maryland. Early childhood caries (ECC) is of epidemic proportions in some US minority populations and in many developing countries. However, the inadequate information and research on dental caries in infants and toddlers appears to have fostered acceptance of some incorrect assumptions regarding its etiology and prevention. To reexamine the current knowledge of ECC, leaders in this field have critically reviewed the biological and psychosocial mechanisms, public health implications, prevention, research and policy needs. An additional goal of the conference was to convey the health implications and societal costs of this highly prevalent childhood disease to the public, health care providers and policy-makers.

Early childhood caries: a positive beginning.

Early childhood caries (ECC) is among the most prevalent health problems of low-income infants and toddlers, yet little attention and few resources have been allocated to understanding this disease. Since dental caries in infants and toddlers cannot be exclusively ascribed to feeding practices, other concepts regarding its etiology and prevention need to be examined. Furthermore, the establishment of evidence-based policies regarding this basic health problem is critical for the dissemination of consistent standards of care to health care providers and government agencies. To accomplish these objectives, the scientific community, organizations concerned with children's health and the political process need to be energized to find resources and energy to solve this public health challenge.

Mutans streptococci and caries prevalence in preschool children.

Numerous studies have reported a correlation between mutants streptococci levels and dental caries. The aim of this study was to assess the relationship between salivary mutans streptococci levels and caries in preschool children of low socioeconomic status. A total of 462 Head Start children, mean age 3.8 yr (range 2.0-5.3 yr), were examined by the modified method of Radike. Saliva samples from 458 of these children were collected with tongue blades and impressed onto mutants streptococci selective agar. Children's mutants streptococci levels were categorized as low (0 CFU), moderate (1-50 CFU) or high (> 50 CFU), and the mean dmfs was 0.40, 1.92 and 4.88, respectively. All study groups (Black, Hispanic and White) had infection rates of approximately 83%; however, 39.1% of Black children had high mutans streptococci levels compared with 28.4% of White children. Pit/fissure caries was the most prevalent disease type in children with moderate or high mutants streptococci levels, although White children in the high group had significantly less of this pattern than Blacks and Hispanics. Sensitivity, specificity, and positive and negative predictive values for the high mutants streptococci group were 91.3%, 57.5%, 69.3% and 86.3%. Results from this study indicate that differences between Black, Hispanic and White preschool children may influence caries activity within populations that have similar mutants streptococci infection levels and socioeconomic backgrounds.

Dental caries in preschool Beijing and Connecticut children as described by a new caries analysis system.

A total of 625 children, 3-4 yr old, 426 from Connecticut Head Start programs and 199 from Beijing area nursery schools, were clinically examined for dental caries. Results were analyzed using the traditional dmfs index as well as a new "Caries Analysis System". This new system differentiated between caries patterns and examined the percentage of affected children (Prevalence), the degree to which these children were affected (Severity) and the proportion of total caries each disease pattern represented (Distribution). The Caries Analysis System revealed differences in caries experience and patterns among the racial/ethnic groups that the dmfs index did not. The Beijing children experienced the greatest Prevalence of all caries patterns; however, the Severity and Distribution of the caries patterns were similar to those of the Connecticut children. Within the group of Connecticut children, White children had the lowest Prevalence but the greatest Severity when compared with the Black and Hispanic children.

Dental caries patterns and oral health behaviors in Arizona infants and toddlers.

OBJECTIVES: The aim of this study was to use tooth eruption sequence, and a tooth- and surface-specific caries analysis method to determine: (1) the temporal relationship between tooth eruption and caries onset; (2) the validity of pre-existing concepts of caries progression; and (3) the relationship of certain putative health behaviors with caries prevalence. METHODS: A total of 2,428 Arizona children aged 6-36-months, who were recruited from WIC programs (a federal program for low-income children at nutritional risk), health fairs and private day care centers, received visual dental caries examinations. Additionally, an oral health behavior survey was administered to the parents of the 1,529 children recruited from the WIC programs. RESULTS: Dental caries was detected soon after tooth eruption, and by 34-36 months of age 25% of this population had caries. Maxillary anterior caries developed as early as 10-12 months of age. Fissure caries of the molars, either by itself or with maxillary anterior caries, was seen as early as 13-15 months of age. Posterior proximal caries was seen as early at 19-21 months, and only was present in conjunction with the other patterns. Over 40% of the 13-36-month-old children whose parents completed the survey still used a bottle. Night-time bottle use was associated with maxillary anterior caries in 24-36-month-old children, but no association was found in younger children or with posterior caries patterns. Survey responses also showed that fewer than 15% of these children reported having had a dental visit. CONCLUSIONS: Dental caries was a significant health issue for these children under 3 years of age, and factors other than bottle feeding may play an important role in its etiology. Prevention of dental caries in children under age three will depend on a better understanding of the etiology as well as improved access to care.

Caries prevalence and patterns in 3-6-year-old Beijing children.

A total of 400 Beijing children, 3-6-yr-old, equally distributed by age and sex, were examined for dental cares. Results were analyzed with the traditional dmfs/t index and with the Caries Analysis System. The system differentiated between caries patterns and examined the percentage of affected children (Prevalence), the degree to which these children were affected (Severity), and the proportion of total caries each disease pattern represented (Distribution). Over 67% of the children experienced caries, a level comparable to other reports from China and other developing countries, but 50% greater than those seen in United States preschool children. Nearly all children with caries experienced fissure caries. In 3-yr-olds maxillary anterior caries was the next most prevalent pattern with 43% affected, whilst in the 6-yr-olds, posterior proximal caries was the second most prevalent pattern with 68% affected. Since maxillary anterior caries was so prevalent, and because the presence of this pattern has been shown to be a risk factor for future caries, preventing the maxillary anterior pattern may markedly reduce caries in this population.