Fluoride ingestion is related to fluid consumption patterns.

OBJECTIVES: There have been few reports regarding variations of fluoride intake by fluid consumption patterns. The purpose of this study was to estimate fluoride intake among children in the United States based on their fluid consumption patterns. METHODS: Fluid intakes of children aged 1-10 years from plain water, beverages, and water from foods were assessed in a 24-hour recall diet survey as a part of the third National Health and Nutritional Examination Survey (NHANES III, 1988-1994). The amount of fluoride ingested from fluids in NHANES III was estimated from several assumptions about the concentration of fluoride in drinking water and beverages. Logistic regression analysis was conducted using SAS and SUDAAN. RESULTS: Children at the 75th percentile or higher of F intake from fluids (not including water used in cooking) ingested 0.05 mg F/kg/day or more, and children at the 90th percentile or higher ingested 0.07 mg F/kg/day or more. This finding held across all age groups. There was substantial variation in the estimated amount of fluoride ingestion depending on the children's fluid consumption patterns as well as age, gender, and race/ethnicity. African-American children ingested significantly more fluoride than White children in bivariate analysis. This association remained significant after accounting for fluid consumption pattern and other confounding factors in the model. CONCLUSION: Our results raise concerns that some children are ingesting significantly more fluoride than others depending on sociodemographic factors and fluid consumption patterns. Additional research is warranted to investigate the variation in the amounts of fluoride ingestion by these factors and its impact on fluorosis prevalence in different population groups.

The association between antibiotics usage in early childhood and early childhood caries.

PURPOSE: The objectives of this study were to learn if the intake of systemic antibiotics during the first year of age (period of primary teeth development) was associated with an increased risk for early childhood caries during the following years; and after the first year of age (following the formation of primary teeth) was associated with a lower risk for early childhood caries during the following years. CONCLUSIONS: Children who used systemic antibiotics during the first year of age had a significantly greater risk for early childhood caries (ECC) during follow-up compared to children who did not use antibiotics. After the first year of life, only children who used systemic antibiotics at 13 to 18 months old showed a significant increase in the risk of ECC. A child's racial background was a determining factor in the association between antibiotic intake and ECC.

Social factors and periodontitis in an older population.

OBJECTIVES: We assessed the prevalences of periodontitis by education and income levels among US adults with data from the third National Health and Nutrition Examination Survey. METHODS: The study was limited to non-Hispanic Blacks, Mexican Americans, and non-Hispanic Whites 50 years of age or older with a complete periodontal assessment during the dental examination. RESULTS: Blacks with higher education and income levels had a significantly higher prevalence of periodontitis than their White and Mexican-American counterparts. The relationship between income level and periodontitis was modified by race/ethnicity. High-income Blacks exhibited a higher prevalence of periodontitis than did low-income Blacks and high-income Whites. CONCLUSIONS: Our findings call attention to the importance of recognizing socioeconomic status-related health differences across racial/ethnic groups within the social, political, and historical context.

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.

Middle ear and respiratory infections in early childhood and their association with early childhood caries.

PURPOSE: The purpose of this study was to examine the risk of early childhood caries (ECC) in children who had middle ear infections (MEI) or respiratory tract infections (RTI) during early childhood. METHODS: Medicaid data from Michigan were analyzed for all continuously enrolled children born in 2001 for whom enrollment, medical, and dental claims were filed during 2001-2004. Proportional hazards survival models were used to assess the risk of ECC in children who had MEl or RTI during the first year of life. RESULTS: Included in the study were 29,485 children (51% males and 49% females). By first year of life, 47% and 69% of children had a claim for MEI and RTI, respectively. Children with at least one claim for MEI or RTI were at 29% higher risk for developing ECC compared to those with no claims (P < .001). Hispanic children with 8 or more claims showed 91% greater risk for developing ECC than those with less than 8 claims (P = .01). CONCLUSIONS: The occurrence of middle ear infections or respiratory tract infections during the first year of life is associated with a significantly increased risk for developing early childhood caries during subsequent years. Race and ethnicity are possible predictors for ECC in the studied models.

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.

The role of individual and neighborhood social factors on periodontitis: the third National Health and Nutrition Examination Survey.

BACKGROUND: This study investigates whether race/ethnicity, individual income, education, and neighborhood socioeconomic characteristics are independently associated with periodontitis in adults>or=18 years of age who participated in the third National Health and Nutrition Examination Survey (NHANES III). METHODS: Analyses were limited to participants in NHANES III who self-identified as non-Hispanic black, non-Hispanic white, or Mexican American, received a periodontal examination, and whose records were linked to the 1990 U.S. Census data (N=13,090). Periodontitis was investigated using a combination of clinical attachment loss and probing depth. Marginal logistic regression models were used to assess the association of race/ethnicity, individual income, education, and neighborhood socioeconomic characteristics with periodontitis before and after adjusting for selected covariates. A survey program was used to account for the survey sampling design and for the intraneighborhood correlation of outcomes of participants selected from the same neighborhood. RESULTS: Race/ethnicity, education, and neighborhood socioeconomic conditions were associated with periodontitis before and after controlling for selected covariates. After adjustment, blacks were twice (1.58 to 2.53) as likely to have periodontitis as whites. Compared to those with more than a high school education, those with less than a high school diploma were twice (1.48 to 2.89) as likely to have periodontitis. Individuals living in a neighborhood in the lowest tertile of the socioeconomic score were 1.81 times (1.36 to 2.41) more likely to have periodontitis than those living in a neighborhood in the highest tertile of the socioeconomic score. CONCLUSION: This study indicates that race/ethnicity, individual education, and neighborhood socioeconomic circumstances are important for periodontal health.

Assessment of the relationship between neighborhood characteristics and dental caries severity among low-income African-Americans: a multilevel approach.

OBJECTIVES: To assess the relationship between neighborhood effects and the severity of dental caries among low-income African-Americans. METHODS: A multistage probability sample of African-American families living in the poorest 39 census tracts in Detroit was drawn. During 2002-03, cross-sectional data of a cohort that includes 1021 caregivers were collected in the first of three waves of interviews and examinations. Multilevel analyses focused on 27 neighborhood clusters and involved a combination of individual (Level-1) and neighborhood (Level-2) data including census and geocoded (address matching to census geographic areas) information. RESULTS: There is significant variation in the severity of caries between low-income neighborhood clusters. Caries severity decreases with a higher number of churches, while it increases with a higher number of grocery stores in the clusters after accounting for individual characteristics. Only 14% of the inter-individual variability in caries was explained by classical individual risk factors for this condition. CONCLUSION: Neighborhoods contribute something unique to caregivers' oral health, beyond socioeconomic position and individual risk factors. Multilevel interventions are necessary to reduce disparities among African-Americans and churches may offer a promising venue from which to conduct them.

The use of sorbitol- and xylitol-sweetened chewing gum in caries control.

BACKGROUND: The author compared the caries-inhibitory action of sorbitol- and xylitol-sweetened chewing gum and assessed the role of these products in caries prevention. TYPES OF STUDIES REVIEWED: The author reviewed studies including randomized field trials with substantial numbers of participants and observational studies. He did not review case studies. He found studies through a MEDLINE search and by hand searching. RESULTS: When compared with sugar-sweetened gum, sorbitol-sweetened gum had low cariogenicity [corrected] when it was chewed no more than three times per day. Xylitol-sweetened gum was noncariogenic in all of the protocols tested. Some studies claimed that xylitol-sweetened gum had an anticariogenic effect, though these claims need further study. There also is good evidence that when mothers of infants and young children chew xylitol-sweetened gum, it will block transmission of mutans streptococci from mother to child. CLINICAL IMPLICATIONS: The evidence is strong enough to support the regular use of xylitol-sweetened gum as a way to prevent caries, and it can be promoted as a public-health preventive measure. Chewing xylitol-sweetened gum, especially for patients who like chewing gum, can be fitted readily into a regimen that includes frequent fluoride exposure, good oral hygiene and regular dental appointments.

Concepts of risk in dental public health.

The purpose of this paper is to review the concepts of risk as we use them today in dental public health practice, and to suggest that we should broaden our view of risk. Use of terms like risk factor in the literature can be quite vague, and it is recommended that a clear definition of that and related terms be adhered to. A broader view of risk in dental research would take in the concepts of social determinants of health and population health. While some progress has been made in our understanding of these issues, better knowledge would give the public health administrator more readily available information to use in program planning. The skewed distribution of caries in the high-income countries has led to the emergence of targeted prevention programs toward those considered to be at high risk. In public health programs, targeting at the individual level is not practical: the risk assessment methods are not yet sufficiently precise, and even when individuals are identified there are practical problems with schools and with the children themselves. (For private practice, however, high-risk child patients can be identified as those with at least one approximal lesion in permanent teeth.) For public health purposes, an argument is made for geographic targeting, i.e. identification of areas of social deprivation where whole schools or school districts can be targeted. Geographic targeting is something between individual targeting and whole-population approaches. Ideally, geographic targeting would supplement population measures like water fluoridation and dental health education. Examples of geographic targeting from Ohio and New York are presented as illustrations.

Radiographic versus clinical extension of Class II carious lesions using an F-speed film.

This study investigated the difference in the apparent radiographic and true clinical extension of Class II carious lesions. Sixty-two lesions in both maxillary and mandibular premolars and molars were radiographed using Insight bitewing film. Class II lesions were scored independently by two masked examiners using an 8-point lesion severity scale. During the restoration process the lesions were dissected in a stepwise fashion from the occlusal aspect. Intraoperative photographs (2x) of the lesions were made, utilizing a novel measurement device in the field as a point of reference. Subsequently, the lesions were all given clinical scores using the same 8-point scale. Statistical analysis showed a significant difference between the true clinical extension of the lesions compared to the radiographic score. "Aggressive" and "Conservative" radiographic diagnoses underestimated the true clinical extent by 0.66 mm and 0.91 mm, respectively. No statistical difference was found between premolars and molars or maxillary and mandibular arches. The results of this study help to define the parameters for making restorative treatment decisions involving Class II carious lesions.

Is there homogeneity in periodontal health between African Americans and Mexican Americans?

OBJECTIVES: This study identified and contrasted prevalence and predictors of periodontitis among African Americans, Mexican Americans, and non-Hispanic Whites in the US adult population. DESIGN: Cross-sectional study. This study compared those with and without periodontitis in each racial/ethnic group. METHODS: This study was limited to records of US African-American, Mexican-American, and non-Hispanic White adults at least 17 years of age who received a complete periodontal assessment as part of the dental examination in the third National Health and Nutrition Examination Survey (1988-1994). RESULTS: Despite the findings that Mexican Americans were less educated, poorer, and had less insurance coverage than African Americans, Mexican Americans had a similar prevalence of periodontitis as non-Hispanic Whites. African Americans had the highest prevalence among all groups. A similar scenario was observed in the multiple logistic analyses. CONCLUSIONS: Mexican Americans had periodontal health profiles closer to non-Hispanic Whites than did African Americans, despite the shared "minority" status. Public health research and practice should explicitly recognize that while "minorities" are considered a homogeneous group, they do not necessarily share the same health profiles.

Fluoridation and social equity.

The overall reduction in caries prevalence and severity in the United States over recent decades is largely due to widespread exposure to fluoride, most notably from the fluoridation of drinking waters. Despite this overall reduction, however, caries distribution today remains skewed, with the poor and deprived carrying a disproportionate share of the disease burden. Dental caries, like many other diseases, is directly related to low socioeconomic status (SES). In some communities, however, caries experience has now diminished to the point where the need for continuing water fluoridation is being questioned. This paper argues that water fluoridation is still needed because it is the most effective and practical method of reducing the SES-based disparities in the burden of dental caries. There is no practical alternative to water fluoridation for reducing these disparities in the United States. For example, a school dental service, like those in many other high-income countries, would require the allocation of substantial public resources, and as such is not likely to occur soon. But studies in the United States, Britain, Australia, and New Zealand have demonstrated that fluoridation not only reduces the overall prevalence and severity of caries, but also reduces the disparities between SES groups. Water fluoridation has been named as one of the 10 major public health achievements of the 20th century by the Centers for Disease Control and Prevention, and promoting it is a Healthy People objective for the year 2010. Within the social context of the United States, water fluoridation is probably the most significant step we can take toward reducing the disparities in dental caries. It therefore should remain as a public health priority.

Using insurance claims and demographic data for surveillance of children's oral health.

OBJECTIVES: This paper examines the utility of using private insurance and Medicaid dental claims as well as demographic data for assessing the oral health of children aged 5-12 years in Genesee County, Michigan, communities. METHODS: Dental insurance claims data from Delta Plan of Michigan and Michigan Medicaid, plus demographic data from the 1990 US Census (percent poverty) and from the 1995 National Center for Educational Statistics (percent free or reduced lunch eligibility), were compared to findings from two school-based oral health surveys. These surveys were the 1995 Genesee County Oral Health Survey and the 1998-2001 Mott Children's Health Center oral health screenings. Data were analyzed using zip codes, representing communities, as the comparison unit. Statistical comparisons using correlation coefficients were used to compare the findings from the six data sets. RESULTS: Using the insurance claims and school-based data, some communities consistently demonstrated high levels of dental caries or treatment for the primary dentition. The demographic measures were significantly associated with many of the primary dentition survey measures. The demographic data were more useful in identifying communities with high levels of dental disease, particularly in the primary teeth, than the insurance claims data. CONCLUSIONS: When screening is not practical, readily available demographic data may provide valuable oral health surveillance information for identification of high-risk communities, but these data do not identify high-risk individuals. In these analyses, demographic data were more useful than dental insurance claims data for oral health surveillance purposes.

Periodontitis in the United States: beyond black and white.

OBJECTIVES: This paper examines whether historical disparities in periodontal status between African Americans and whites in the United States have increased, decreased, or remained the same over the 15-year period between the First National Health and Nutrition Examination Survey (NHANES I, 1971-74) and the Third National Health and Nutrition Examination Survey (NHANES III, 1988-94). METHODS: This study compared the magnitude of the relative and absolute differences in the periodontal status of African-American and white adults in NHANES I and again in NHANES III. RESULTS: The prevalence of periodontitis in the US adult population in NHANES I was 31.6 percent, with African Americans exhibiting higher prevalence than whites. In NHANES III, using a different case-definition for periodontitis, the overall prevalence was 11.9 percent, with African Americans again exhibiting higher prevalence than whites. The magnitude of the intrasurvey relative and absolute differences between African Americans and whites increased between NHANES I and NHANES III. This finding remained after adjustment in the logistic regression analyses. After adjustment for all covariates in the model, African Americans were more likely to exhibit periodontitis than whites in both NHANES I (odds ratio [OR] = 1.31; 95% confidence intervals [CI] = .78, 2.19) and NHANES III (OR = 2.09; 95% CI = 1.68, 2.60). However, the CI included 1.00 in NHANES I. CONCLUSIONS: Disparities in periodontitis between African Americans and whites are pervasive and have increased over time. This increase appears to be driven by social, cultural, and behavioral factors.

Don't children grow out of their obesity? Weight transitions in early childhood.

BACKGROUND: Expert opinion and cross-sectional analyses posit that obese young children will likely "outgrow" their obesity. However, given the nature of the US childhood obesity epidemic, this assertion may no longer hold true. OBJECTIVE: To compare the weight transitions between early childhood (3-5 years) and midchildhood (7-10 years) in 2 different longitudinal cohorts: black preschool children from the inner city and from a nationally representative sample. RESULTS: Weight transitions for children who were normal weight at baseline were not markedly different between cohorts. However, overweight and obese low-income black children had a very high probability of becoming or remaining overweight or obese by follow-up (>90% probability) in comparison with the nationally representative cohort (50%-60% probability). CONCLUSION: Low-income black preschool children do not necessarily "outgrow" their obesity. These findings have implications for optimal timing of obesity interventions and suggest the need for an increasing focus on children during the early preschool years.

Obesity and sugar-sweetened beverages in African-American preschool children: a longitudinal study.

A representative sample of 365 low-income African-American preschool children aged 3-5 years was studied to determine the association between sugar-sweetened beverage consumption (soda, fruit drinks, and both combined) and overweight and obesity. Children were examined at a dental clinic in 2002-2003 and again after 2 years. Dietary information was collected using the Block Kids Food Frequency Questionnaire. A BMI score was computed from recorded height and weight. Overweight and obesity were defined by national reference age-sex specific BMI: those with an age-sex specific BMI>or=85th, but <95th percentile as overweight and those with BMI>or=95th age-sex specific percentile as obese. The prevalence of overweight was 12.9% in baseline, and increased to 18.7% after 2 years. The prevalence of obesity increased from 10.3 to 20.4% during the same period. Baseline intake of soda and all sugar-sweetened beverages were positively associated with baseline BMI z-scores. After adjusting for covariates, additional intake of fruit drinks and all sugar-sweetened beverages at baseline showed significantly higher odds of incidence of overweight over 2 years. Among a longitudinal cohort of African-American preschool children, high consumption of sugar-sweetened beverages was significantly associated with an increased risk for obesity.

Dietary patterns related to caries in a low-income adult population.

The aim of this study was to examine the relationship between dietary patterns and caries experience in a representative group of low-income African-American adults. Participants were residents of Detroit, Michigan, with household incomes below 250% of the federally-established poverty level (n = 1,021). Dietary histories were obtained by trained interviewers in face-to-face interviews with the adult participants, using the Block 98.2 food frequency questionnaire. Caries was measured by the ICDAS criteria (International Caries Detection and Assessment System). There were 200 dietary records whose data were judged to be invalid; these participants were omitted from the dietary analyses to leave n = 821. Factor analysis identified patterns of liquid and solid food consumption, and the resulting factor scores were used as covariates in multivariable linear regression. Caries was extensive, with 82.3% of the 1,021 participants (n = 839) having at least one cavitated lesion. Nearly three quarters of the adult participants were overweight or obese. This population had severe caries, poor oral hygiene, and diets that are high in sugars and fats and low in fruits and vegetables. Apart from tap water, the most frequently consumed food item by adults of all ages was soft drinks; 19% of all energy from sugar came from soft drinks alone. In both the bivariate analyses and in the regression model, frequency of soft drink consumption and the presence of gingival plaque deposits were significantly associated with caries. Interventions to promote oral health are unlikely to be successful without improvements in the social and physical environment.