Behavior problems in 5- to 11-year-old children from low-income families.

OBJECTIVE: The aims of the present study were to survey the Child Behavior Checklist (CBCL) scores (behavioral section) in a nonclinical population of US urban children from low-income families and to compare the distribution and pattern of scores with the normative data in the CBCL manual (1991). METHOD: The sample consisted of 890 low-income children and a mother or female guardian selected randomly from among Seattle public school students aged 5 to 11 years. RESULTS: In this sample the total CBCL score as well as all subscale scores were significantly higher than the norms. The proportion of children who scored in the clinical/borderline range was also higher than the norm. CONCLUSIONS: These findings support previous work showing that poverty is a risk factor for mental distress in children. They also raise questions about the validity of the CBCL norms for screening or research purpose for low-income families.

The prevalence of dental anxiety in children from low-income families and its relationship to personality traits.

The prevalence of dental anxiety and the association between dental anxiety and personality traits were examined in a population-based sample of 895 US urban children, from 5 to 11 years of age, from low-income families. Dental anxiety was reported by the child using the Dental Subscale (DS) of the Children's Fear Survey Schedule, and behavioral problems and personality traits were evaluated by parent report on the Child Behavior Checklist (CBCL). Mean DS scores were 31.1 (SD = 10.3) for boys and 34.3 (SD = 11.0) for girls. CBCL score means were 33.3 (SD = 23.2) for boys and 28.5 (SD = 19.1) for girls. The hypothesized relationship between DS and CBCL scores in this population was not demonstrated.

A randomized clinical trial of triazolam in 3- to 5-year-olds.

Triazolam has shown promise as a sedative agent for use in pediatric dentistry. However, the efficacy of triazolam has not been previously examined in a placebo-controlled study. The present clinical trial used a two-group, randomized, double-blind study design to compare the efficacy of oral triazolam with that of a placebo. The primary hypothesis tested was that triazolam would reduce negative behaviors of pediatric dental patients compared with a placebo. A secondary hypothesis was that triazolam would increase the efficiency of dental treatment by reducing the need for time-consuming behavior management by the pediatric dentist. The subjects were 54 3- to 5-year-old children, randomly assigned to the drug and placebo groups. The active drug, 0.03 mg/kg triazolam (Halcion), or lactose placebo was given orally 30 min before dental treatment. Behavior management techniques commonly used in pediatric dentistry were used during dental treatment. A single pediatric dentist provided all of the dental treatment. The procedure included an inferior block anesthesia and careful attention to anesthesia effectiveness. All sessions were video-taped and the tapes coded for child and dentist behaviors by an independent observer. There were no statistically significant differences between the groups with respect to completion of dental treatment. There were no significant differences found in either the total time or the percent of time that the subjects exhibited disruptive movements, verbal or non-verbal distress. The total use of time in the dental chair was slightly higher in the placebo than in the drug group due to more time spent preparing the child. Contrary to preliminary reports in the literature, this investigation found little or no improvement in child behavior when triazolam was used as a sedative compared with a placebo. However, triazolam did shorten the length of dental treatment, primarily by reducing dentist time in preparing the child for the dental procedure (e.g., establishing rapport and shaping behavior).

Follow-up study of sealing and filling with composite resins in the prevention of occlusal caries.

A diluted composite resin (Concise diluted with Concise Enamel Bond) was used for fissure sealing and filling in 896 permanent first molars of 281 children, initially 5--7 years of age. Ordinary fissure sealing was used for fissures with no apparent caries, while a filling method was used after an explorative drilling with a small round bur (Ash No. 1/2) in fissures with incipient caries. On the basis of clinical evaluation every 6 months, the frequency of total retention of the composite material after different observation periods was calculated using the life table method. The rate of success in the fissure sealing group was 94.8% after 6 months, falling to 75.2% after 30 months. The corresponding data for the filled teeth were 92.6 % and 83.5%. It would seem that diluted composite resin is well suited for the prevention of caries in pits and fissures.

Caries prevalence in primary teeth as a predictor of early fissure caries in permanent first molars.

The study aimed to examine the validity of employing the caries experience of the primary dentition for predicting early caries in the permanent first molar fissures. Subjects consisted of 192 children who were followed for 2 yr, 91 of whom were pursued for a further year, all receiving semiannual check-ups. The caries prevalence in the primary dentition (dmft), excluding incisors, was recorded at baseline, which was the year the children became 6. Fissure caries in the permanent first molars was recorded as being confined to enamel or dentin, based on findings during cavity preparation. The correlation between dmft and the number of intact permanent first molars was -0.368 and -0.337 after 2 and 3 yr observation respectively. When the children were grouped according to their dmft, a statistically significant relationship was found between the dmft and the number of intact molars in each individual. The positive and negative predictive values as well as the sensitivity and specificity of different dmft values were calculated, and the relationship between them illustrated by the use of ROC curves. Even if there are no specific dmft values which seem obviously favorable for the purpose, these data give information relevant in planning for large scale use of fissure sealing in preventing early fissure caries in permanent first molars.

Impact of diagnostic criteria on the prevalence of dental caries in Norwegian children aged 5, 12 and 18 years.

The study aimed to investigate caries prevalence in children using a severity grading diagnostic system, and to evaluate the influence of different diagnostic thresholds on the caries data. A group of 513 children, aged 5, 12 and 18 years, were examined clinically, and with available bitewing radiographs, by four calibrated examiners. The inter- and intra-examiner reliability, assessed by a weighted kappa, varied between 0.80 and 0.95. The mean dmft/DMFT values were 3.8, 5.8 and 11.0 for the three age groups respectively, and the corresponding dmfs/DMFS values were 5.4, 9.9 and 22.6. The d/D-component constituted the major part of the dmf/DMF index in all age groups, and enamel lesions accounted for 59%, 89% and 86% of the d/D-component in the three age groups respectively. It is concluded that enamel or initial caries lesions contributed substantially to the total caries prevalence, illustrating the importance of using diagnostic criteria that include all stages of clinical caries if a total picture of the caries situation is needed.

Reliability and validity of the Dental Indifference Scale in a population of 18-year-olds in Norway.

OBJECTIVES: The aims of this study were to estimate the reliability and validity of the Dental Indifference Scale (DIS) (Nuttall, 1996) in a population of 18-yr-olds in Norway. METHODS: The DIS-scale was mailed to a sample of 1119 18-yr-olds in two Norwegian counties. Nearly 87% completed the questionnaire and consented to the collection of data from their dental records. Ten percent of the sample, drawn at random, was asked to complete the questionnaire a second time, after a time delay of 15 weeks (response rate 83%). The reliability estimation of the sum-scores of DIS was based on Pearson's correlation between test-retest scores and internal consistency (Cronbach's alpha). The frequency of missed appointments from age 12, recorded in the dental treatment records, was used as the validating criterion. The validity was analyzed by Pearson's correlation, and step-wise multiple regression. RESULTS: The correlation coefficient (Pearson) for the test-retest comparison was 0.43. The correlation coefficient between the DIS-scores and the frequencies of missed dental appointments was 0.24. The Cronbach's Alpha coefficient for the eight DIS-questions was 0.35 (n=868). Only two of the eight DIS-questions entered the stepwise regression model and explained 15% of the variance of the frequency of missed appointments. CONCLUSIONS: The Dental Indifference Scale (DIS) was found to have a low reliability and validity in this study population, and it is recommended that it should not be used without further investigation. It may be necessary to design an alternative instrument if further work into the hypothesized trait of dental indifference is to be undertaken.

Evaluation of a routine for prevention and treatment of fissure caries in permanent first molars.

Fissure sealing as well as fluoride varnish have shown good preventive effect against fissure caries in newly erupted teeth. The purpose of this study was to evaluate a clinical routine in which these two methods were combined. The evaluation was done in a public dental clinic in Norway, and three dentists performed and evaluated the treatment. The population belonged to two different year classes (born 1978 and 1979), 196 in all, and they were followed semiannually from age 6 until 8 and 9 yr, respectively. The routine was as follows: all erupted permanent first molars without fissure caries were cleaned and painted with a fluoride varnish (Duraphat) every 6 months. Fissures showing incipient caries were opened with a rotating instrument and sealed if caries was restricted to the enamel. Amalgam fillings were placed if caries had progressed to the dentin. The operator time required for the fissure treatment was recorded. After 2 yr observation of children born in 1978 and 1979, 72% of the fissures were intact, 13% had been sealed, and 15% filled, and the corresponding figures after 3 yr (1978-children) were 65%, 15%, and 20%. In approximately 45% of the children all four permanent molars were intact, while about 12% had all molars sealed or filled. The average time spent for application of sealants was 4.1 min and for application of amalgam fillings 5.9 min.

Fissure sealing of permanent first molars in children receiving a high standard of prophylactic care.

The efficiency of sealing the occlusal fissures of permanent first molars was studied in a group of patients 6-9 yr of age receiving a high standard of prophylactic care. Very soon after the eruption one of the teeth in a homomaxillary pair was sealed, and the contralateral was used for control. The control teeth were painted with a fluoride varnish (Duraphat) every 6 months during the trial. 210 sites in 121 children were sealed and followed for a mean observation period of 23 months. At the end of the study, the retention rate was 62.9%, the percentage of effectiveness 24.2%, and the net gain 7.1%. The dmft index (primary molars and canines) was recorded for each patient at the time sealing was performed. A relationship between the caries prevalence in the primary teeth and the susceptibility for fissure caries in the control teeth was found. Effectiveness and net gain was highest in the group of children with 3-6 dmft.

Validation of the Dental Fear Scale and the Dental Belief Survey in a Norwegian sample.

The aim of this study was to validate the Kleinknecht's Dental Fear Scale and the Getz's Dental Belief Survey in a Norwegian sample by 1) testing their ability to discriminate between fearful (n = 151) and regular (n = 160) patients, and 2) correlating them. Both instruments were highly reliable (Cronbach's alpha > 0.90). Between 81% and 95% of the fearful and regular patients were correctly assigned to their appropriate groups with both instruments. It may thus be concluded that both instruments are valid. Also, the correlation between the instruments was 0.68, indicating that they to a large extent seem to measure the same concept. The most important predictor items for both instruments were related to avoidance of dental treatment.

An intervention program to reduce dental avoidance behaviour among adolescents: a pilot study.

AIM: To develop and test the methodology of an intervention to reduce avoidance of dental care among adolescents, and to measure the respondents' beliefs regarding the intervention (credibility and cognitions). METHODS: Based on a group comparison design a sample of 18 year olds (n=50) with dental non-attendance behaviour was randomly selected to three experimental and one control group. Subjects were surveyed with one baseline questionnaire and one post-intervention questionnaire, to evaluate their beliefs regarding the program. Two different instruments were tested: 1) cards representing different statements related to previous dental experiences, possible reasons for attending (pros) and not attending (cons) dental appointments, and preferences for future treatment. Cards were selected based on individual priority; 2) a brief, structured telephone interview based on Motivational Interviewing. The instruments were tested separately (groups I and II) and in combination (group III). Subjects in the control group (group IV) were given conventional health education. RESULTS: Subjects in the experimental groups had significantly higher credibility scores to the statement "How much easier do you perceive dental treatment to be for you, based on this program", compared with the control group (p<0.05). They had also more positive beliefs to the statement "I think the interviewer liked to talk to me" (p<0.05) than controls. CONCLUSION: A questionnaire sent to non-attending adolescents followed by a brief telephone call based on Motivational Interviewing appears to be a credible intervention for adolescents avoiding dental care.

Relationship between caries prevalence at 5 years of age and dental anxiety at 10.

AIM: The aim of this study was to explore a possible relationship between the individual prevalence of caries in 5-year-old children and dental anxiety in the same children when they became 10 years of age. MATERIALS AND METHODS: A group of 217 children was examined clinically and radiographically for caries at 5 years of age when initial, as well as manifest caries lesions, were recorded. A total of 180 children were available for follow-up at 10 years of age, and dental anxiety was measured by the use of the psychometric questionnaire CFSS-DS. RESULTS: The mean dmfs at 5 years of age was 5.4 (SD+/-7.3) and the mean CFSS-DS at 10 years of age 22.5 (SD+/-6.8). The correlation coefficient between dmfs and CFSS-DS was 0.255 (p < 0.001). Children with high dental anxiety (CFSS-DS sum score higher than one SD above the mean) (N = 22) had a mean dmfs of 10.7, while those with lower dental anxiety had dmfs of 4.7 (p < 0.001). The majority (68%) of the children with high dental anxiety had more than five carious lesions at 5 years of age. CONCLUSION: Children with many carious lesions at the age of 5 years are at high risk for being dentally anxious at 10 years of age. Classical conditioning, including procedural pain and other negative experiences during dental treatment as the unconditioned stimuli, is the most likely reason for this.

Caries in primary teeth at 5 and 10 years of age: a longitudinal study.

AIM: This was to explore the caries development in the primary dentition in children aged 5 and later when they were 10, with an emphasis on the caries increment according to type of teeth and surfaces. METHODS: The study was a prospective, longitudinal survey where the children were examined in 1993 when they were 5 years of age (n=217) and re-examined in 1998 when they were 10 (n=186). Caries was examined clinically and with radiographs by calibrated dentists based on a caries diagnostic grading system from 0 to 5. Primary incisors were excluded from the registrations at 10 years of age, while teeth exfoliating during the period were included, based on notes from the dental records. RESULTS: Intra- and inter-examiner reliability ranged from kappa 0.62 to 0.90. Dmfs at 5 years was 5.4 (incisors included) and 7.4 at 10 years (incisors excluded, other exfoliated teeth included). The mean caries increment during the age period showed no significant difference between children with and without caries at 5 years of age. Molar-approximal lesions dominated the increment, and when such lesions were diagnosed at 5 years of age, there was an increased risk for more severe caries (dentine lesions) during the period. CONCLUSION: The caries increment in the primary dentition is considerable for the majority of children during the age period 5-10 years. Even if a risk assessment based on the prevalence of approximal caries at 5 years of age may be useful for deciding individual recall intervals, the results of this study seem to suggest frequent check-ups are needed for the whole population.

A videotaped intervention to enhance child control and reduce anxiety of the pain of dental injections.

AIM: While the psychological literature shows that perceptions of uncontrollability contribute to anxiety and other pathologies, interventions that enhance perceived control have been shown to reduce anxiety. This study attempted to assess a brief videotape to enhance child perceived control in a dental setting. METHODS: 101 children aged 7-9 years completed warm-up procedures and viewed either: a) the experimental intervention, a 2 minutes video of a dentist explaining what an injection will feel like and proposing hand raising as a signal mechanism; or b) the control condition, a 2 minutes video of Disneyland. Fear of dental injections was assessed on a 10 cm visual analogue scale before and after the intervention. RESULTS: In the experimental group there was a significant fear reduction from pre- to post-intervention, while this was not the case in the control group. Children with higher pre-existing levels of fear benefited more from the intervention than children with lower levels of fear. CONCLUSION: The results of this pilot study suggest that intervention packages that impact child control have promise in lowering anxiety.

Caries increment and prediction from 12 to 18 years of age: a follow-up study.

AIM: This was to determine the increment of caries from 12 to 18 years of age and to explore the possibility of predicting caries increment in this period based on the caries experience at age 12 years. STUDY DESIGN: Prospective longitudinal survey. METHODS: A sample of 12-year-old children (n =159) were examined in 1993 and 70% of them re-examined at 18 years of age. Bitewing radiographs were taken and a diagnostic system using five caries grades (D(1) to D D(5)) was used at both ages. Children at risk were defined as those who developed manifest caries lesions (D(3-5)FS) on approximal surfaces during the follow-up period. Possible predictors were analysed by calculation of sensitivity, specificity, efficiency of the test, proportion that tested positive and actual proportion of the population at risk. RESULTS: The mean caries increment (D(1-5)MFS) from 12 to 18 years of age was 4.2 (SD +/- 9.1). The percentage of caries-free adolescents at 12 and 18 years of age was 10% and 1% respectively; 25% had either a reversal or no increment in caries experience while the D(1-5)MFS increased in 65% of the adolescents. Of the increment of manifest lesions (D(3-5)FS), 18% were located in incisors/canines, 40% in premolars, 26% in first molars and 16% in second molars. Premolars had the largest proportion of the approximal surfaces with manifest caries increment. The best predictors of children at risk of approximal caries increment (D(3-5)FS) were caries experience (D(1-5)FS) on the approximal surfaces of premolars and second molars at the age of 12 years. The individuals that developed four or more manifest lesions on approximal surfaces between 12 and 18 years were the easiest to predict (sensitivity + specificity = 175%). CONCLUSIONS: There was a considerable increment of manifest caries lesions from 12 to 18 years of age in all tooth groups. The best predictors for increment of manifest caries on approximal surfaces during the age period were approximal caries in premolars and second molars at the age of 12 years.

The relationship between caries in the primary dentition at 5 years of age and permanent dentition at 10 years of age - a longitudinal study.

OBJECTIVES: To explore a possible relationship between the caries experience and pattern in the primary dentition at 5 years of age and the permanent dentition at 10 years of age. Further, to examine the possibility of predicting children in a caries-risk group at 5 years verified at 10 years of age. MATERIALS AND METHODS: A sample of 186 children (90 males) were clinically examined as 5-year-olds and re-examined as 10-year-olds by calibrated dentists. A five-graded diagnostic system including enamel caries was used. Bitewing radiographs were taken. A true risk group of children at 10 years were defined as those with at least one dentin or filled lesion on the mesial surface of 6-year molars, and/or on incisors, and/or total DMFS (decayed, missing, and filled surfaces) more than 1 SD above the mean. The prediction was measured in terms of OR (odds ratio), sensitivity/specificity, and receiver operating characteristic curves. RESULTS: Statistically significant correlations (r=0.5) were found between the caries experience in the two dentitions as well as between the primary second molars at baseline and the permanent teeth at 10 years. 'Primary second molars' and 'all primary molars' were the most powerful predictors for allocation into the risk group (24% of the sample). The highest achieved sum of sensitivity and specificity, 148%, was attained at a cut-off point above two carious surfaces in enamel and/or dentin in primary second molars. CONCLUSIONS: Statistically significant relationship in disease between the dentitions was found. More than two surfaces with caries experience in primary second molars are suggested as a clinically useful predictor at 5 years of age for being at high risk at age 10.

Bond strength of composites applied to acid-etched enamel.

The adhesion to acid-etched enamel of a four-component composite, Concise Enamel Bond System, was studied. The composite was applied undiluted over an intermediate resin layer and diluted with different amounts of resin. Corresponding surfaces of contralateral premolars were used to ensure that the composite samples were tested on areas with similar enamel etch patterns. Eighty specimens were tested. The results of this study indicated that the adherence of undiluted composite to etched enamel surfaces was not improved by using an intermediate layer of low-viscous resin. Composite diluted with liquid resin had poorer adherence than undiluted composite. There was no difference in the results from two degrees of dilution.

Abrasive wear of filled and unfilled resins in vitro.

The present investigation was initiated to evaluate the wear resistance of filled and unfilled resins which may be suitable for fissure sealing. Two commercial unfilled resins (Adaptic Glaze and Delton), three degrees of diluted composite (Adaptic diluted with Adaptic Bonding Agent) and undiluted composite (Adaptic) were studied. Abrasion was caused by 400-grit silicon carbide paper in a mechanical surface grinder. Ten specimens of each of the material samples were tested. The unfilled resins were abraded three to six times more readily than the composite samples. Undiluted composite was the most resistant, whereas samples of increasing degrees of dilution were abraded to increasing extents. However, even the most diluted composite, although very fluid, was at least three times more resistant than the unfilled samples. The results of this study indicate that adding inorganic filler particles to a resin, even in small amounts, greatly enhances the wear resistance of such materials.

Microleakage around preventive composite fillings in occlusal fissures.

The purpose of this study was to evaluated the microleakage around preventive composite fillings used in occlusal fissures with incipient caries, and to assess the influence of the consistency of the composite resin upon the leakage. The fissure enamel of 30 extracted maxillary premolars were partially removed using a small round bur (Ash No. 1/2). Dentin was not exposed. The cavities were etched with phosphoric acid and filled with undiluted composite (Adaptic) or composite diluted with different amounts of liquid resin (Adaptic Bonding Agent). Five teeth were not etched before filling, and served as a control group. The teeth were cycled thermally between two dye solutions and the marginal penetration of dye was evaluated by examining sections of the crowns in a dissection microscope. Marginal leakage occurred in all the control teeth and in none of the acid-etched teeth. It may be concluded that the preventive composite filling therapy provides good sealing of pits and fissures with incipient caries, and that the consistency of the composite used is not of primary importance.