Development of dental caries and risk factors between 1 and 7 years of age in areas of high risk for dental caries in Stockholm, Sweden.

PURPOSE: To explore caries predictors at age 1 year and caries development at ages 5 and 7 years in two groups of children following different fluoride-based preventive programs. METHODS: We conducted a prospective cluster-randomized controlled intervention trial with two parallel arms comparing two prevention programs: one program included fluoride varnish applications every 6 months, the other did not; otherwise, the programs were the same. Participants were 1- and 3-year-old children enrolled at 23 dental clinics in high-risk areas in Stockholm, Sweden. The baseline examination included structured interviews. Caries data were extracted from dental records. The primary outcome measures were ICDAS 1-6 > 0 at baseline (age 1 year) and defs > 0 at ages 2, 3, 5, and 7 years. The secondary outcome measure at age 7 was DFS > 0. RESULTS: Continuous caries development occurred: defs > 0 in 23% at 5 years and in 42% at 7 years. We found no difference in caries development between children who had or had not received fluoride varnish as toddlers. At age 1-year, significant predictors for dental caries in later preschool years were immigrant background, family income, and sweets consumption. Fluoride toothpaste > once a day at 1 year had an OR < 1 for defs > 0 at 5- and 7 years. CONCLUSIONS: For toddlers, fluoride varnish does not seem to be an adequate prevention tool. Brushing with fluoride toothpaste from 1 year of age could not arrest caries development. Immigrant background was the strongest predictor. A new toolbox as well as collaborative upstream actions for reducing free-sugar intake are needed.

Dental treatment and caries prevention preceding treatment under general anaesthesia in healthy children and adolescents: a retrospective cohort study.

AIM: This was to examine healthy children and adolescents treated under general anaesthesia (GA) and a matched control group not receiving GA to compare treatment and preventive care received prior to GA treatment. METHODS: This retrospective cohort study included 71 healthy subjects and 213 age- and gender-matched control subjects. The treatment group had been consecutively referred from the Public Dental Health Service (PDS) in Stockholm to the Department of Paediatric Dentistry, Eastman Institute, Stockholm during 2006-2007. Data was extracted from the patient records at the PDS, including variables such as number of dental visits, treatment/prophylaxis prior to GA, number of missed and cancelled appointments, and number of decayed teeth. RESULTS: On average, the treatment group had significantly more decayed teeth (p < 0.001) than the control group. Furthermore, the treatment group had significantly more restorations (p < 0.01), had visited the dentist significantly more often (p < 0.001), and had undergone significantly more behaviour management treatment and preventive treatment (p < 0.001). In the treatment group 65% of the children and adolescents, had received no behaviour management treatment and 48%, no preventive treatment. CONCLUSIONS: In the Stockholm PDS, over half of the children and adolescents referred by general dentists to paediatric specialists had no behaviour management treatment and nearly half, no preventive treatment, despite receiving significantly more operative treatment compared with matched controls. General dentists should target high caries-risk patients for additional behaviour management and preventive care to reduce the need for treatment under GA.

Dental erosion, prevalence and risk factors among a group of adolescents in Stockholm County.

AIMS: To investigate the prevalence and risk factors of dental erosion (DE) among a group of adolescents in Stockholm County. MATERIALS AND METHODS: This cross sectional cohort study was conducted at three clinics of the Public Dental Service in Stockholm County. Fifteen and 17 year old adolescents (1335) who scheduled their regular dental health examination were asked to participate. After drop-outs a sample of 1071 individuals, 547 males and 524 females were enrolled in the study. Presence of erosive wear was diagnosed (yes/no) on marker teeth by trained dentists/dental hygienists and photographs were taken. The adolescents answered a questionnaire regarding oral symptoms, dietary and behavioural factors. Two calibrated specialist dentists performed evaluation of the photographs for severity of DE using a modified version of the Simplified Erosion Partial Recording System (SEPRS). RESULTS: DE was clinically diagnosed in 28.3% of 15 years old and 34.3% of 17 years old. Severe erosive wear (grade 3 and 4 according to SEPRS) was found in 18.3% of the adolescents based upon the intra-oral photographs. DE was more prevalent and severe among males than females. Clinically diagnosed erosive lesions correlated significantly with soft drink consumption (p < 0.001), the use of juice or sport drinks as a thirst quencher after exercise (p = 0.006) and tooth hypersensitivity when eating and drinking (p = 0.012). Furthermore, self-assessed gastric reflux was a factor strongly associated with DE (p < 0.001). CONCLUSION: The study indicated that DE was common among adolescents in Stockholm County and associated with both internal and external risk factors.

Cognitive Behavioral Therapy for Children with Dental Anxiety: A Randomized Controlled Trial.

Dental anxiety affects approximately 9% of children and is associated with poor oral health, pain, and psychosocial problems. The objective of this study was to investigate the efficacy of cognitive behavioral therapy (CBT) for children with dental anxiety in specialist pediatric dentistry. The study used a parallel-group superiority randomized controlled trial design. The primary outcome measure was the behavioral avoidance test; assessors were blind to treatment allocation. Participants were 8 boys and 22 girls 7 to 18 y old (mean ± SD, 10 ± 3.1). Children fulfilling the diagnostic criteria for dental anxiety were randomized to CBT (n = 13) or treatment as usual (n = 17), such as various sedation methods. Psychologists provided 10 h of CBT based on a treatment manual. Treatments were conducted in a naturalistic real-world clinical setting. Assessments were conducted before the treatment, 3 mo after the start of treatment, and at 1-y follow-up. The analyses of the primary outcome measure by repeated-measures analysis of variance and independent t test showed that children receiving CBT made superior, statistically significant improvements at follow-up (16.8 ± 2.4) compared with treatment as usual (11.4 ± 3.1, P < 0.01). A large between-group effect size (Cohen's d = 1.9) was found. Following treatment, 73% of those in the CBT group managed all stages of the dental procedures included in the behavioral avoidance test compared with 13% in the treatment-as-usual group. Furthermore, 91% in the CBT group compared with 25% in the treatment-as-usual group no longer met the diagnostic criteria for dental anxiety at the 1-y follow-up according to the secondary outcome measure. Measures of dental anxiety and self-efficacy showed larger improvements in the CBT group compared with controls. We conclude that CBT is an efficacious treatment for children and adolescents with dental anxiety and should be made accessible in pediatric dentistry (ClinicalTrials.gov: NCT01798355). Knowledge transfer statement: The results of this study can be used by decision makers and clinicians when planning to implement evidence-based treatment in pediatric dentistry and give children and adolescents access to methods for treating dental anxiety. The results can also be used by parents of children with dental anxiety when asking dentists to cooperate with psychologists using cognitive behavioral therapy.

Idiopathic resorption of impacted mesiodentes: a radiographic study.

BACKGROUND: Although a large number of mesiodentes are left in situ, only a few are found in radiographs from epidemiological studies of adult populations. This leads to the development of a hypothesis that mesiodentes may be resorbed and disappear over time. The aim of this study was to radiographically investigate the frequency of resorptions and pathologies in relation to mesiodentes left in situ. METHODS: The study population consisted of 44 individuals, with 49 mesiodentes left in situ at an early age. The individuals were 18-38 years old when re-examined. The inclusion criteria were that the mesiodentes had been diagnosed in childhood and left in situ, and that each individual was over 18 years of age at the time of re-examination. Either digital or analogue intraoral radiographs were used at the re-examination and compared with earlier analogue radiographs. RESULTS: Forty-one per cent of the impacted mesiodentes showed resorptions-from limited to nearly complete resorption. No pathologies in connection to the mesiodentes were found. CONCLUSION: About half of the mesiodentes examined displayed resorption. No pathologies caused by the mesiodentes were recorded.

Detection of approximal caries by clinical and radiographic examination in 9-year-old Swedish children.

The aims were to determine caries prevalence in 9-year-olds belonging to a low-caries prevalence population and to assess how accurately some commonly used risk factors/risk markers (predictors) can identify additional approximal caries as judged from bitewing examination (BW). One calibrated dentist examined 117 consecutive 9-year-olds from the inner city of Stockholm. The predictors were the number of clinically detected dfs and DFS, visible plaque, salivary mutans streptococci, tooth brushing habits, consumption of sugary products, parents' education, and (before BW) an overall clinical judgement by the examiner. Analyses of the data included sensitivity and specificity and a multiple logistic regression model. When BW was included, the mean DFS was 0.27 and the mean dfs 1.74. For approximal enamel and dentin lesions, the average gain from BW was 0.20 lesions for permanent first molars and 1.23 lesions for primary molars. Altogether, 48% of the children benefited from BW. The best predictors of additional approximal caries from BW were presence of caries (cavitation/dentin level) on occlusal surfaces of permanent first molars and the dentist's judgement based on clinical findings, both with a combined sensitivity and specificity of 134%. The only statistically significant variables in a logistic regression model were the dentist's judgement and the child's statement about regular tooth brushing. It is concluded that a sizeable proportion of 9-year-olds, representing a low-caries prevalence population, benefited from BW. However, the ability to identify these children from the predictors was limited.

A survey of specialist paediatric dental services in Sweden: results from 2003, and trends since 1983.

UNLABELLED: The child population in Sweden has changed dramatically during the last 20 years. Changes have also occurred within the Public Dental Service (PDS), regarding the provision of dental care to children and adolescents. All these changes may affect the referral pattern and provision of specialist dental care for children and adolescents. OBJECTIVES: The primary aim of this study was to survey the services provided by specialists in paediatric dentistry in Sweden during 2003. A secondary aim was to compare the results with previous surveys. METHODS: A Web-based survey was sent to all 34 specialist paediatric dentistry clinics and was answered by all clinics. Data were compared with results from the surveys performed in 1983, 1989, and 1996. RESULTS: The number of paediatric dentists had been relatively constant over the last 20 years, whereas the number of children referred to paediatric dentists had increased by 28% since 1983. It was estimated that 1.3% of all children in Sweden are treated at a specialist paediatric dental clinic in 2003. Dental treatment need in combination with behaviour management problems (BMP) was the main reason for referral and occurred in 37% of all referrals. The proportion of medically compromised children/children with disabilities had increased from 6% in 1983 to 22% in 2003. The number of patients treated using sedation and general anaesthesia had increased since 1983, and particularly since 1996. CONCLUSIONS: Despite improvements in dental health among children and adolescents in Sweden during the last 20 years, an increasing number of children are referred for specialist paediatric dental treatment. There is an urgent need to increase the number of specialist paediatric dentists in Sweden in order to ensure the continuation of high quality of dental care for children and adolescents.

Hypomineralized molars and incisors of unknown origin: treatment outcome at age 18 years.

OBJECTIVE: To assess the outcome of treatment of hypomineralized molars and incisors of unknown aetiology (MIH) in 18-year-olds. DESIGN: A follow-up study including clinical examination, panoramic radiography and intraoral photos. SAMPLE AND METHOD: Seventy-six individuals treated at the Eastman Dental Institute in Stockholm during 1978-2001 with the diagnosis MIH. Severity of enamel defects in molars and incisors, prevalence and distribution of extracted molars, type, quality and median duration of restorations, periradicular condition of affected molars, dental occlusion and space closure in cases of extraction, as well as the individual's satisfaction with the treatment, were assessed. RESULTS: Severe defects with enamel surface breakdown in all four molars occurred in 42% of the individuals and 29% had at least one incisor with yellow/brown opacity in the enamel. At follow up, 42% of the individuals had at least one molar extracted; 18% had all four molars extracted. The median duration of the molar restorations (n = 153) was 5 years. Of the individuals with restored molars, 48% had at least one unacceptable restoration. Periradicular pathology was observed in three molars. The sagittal relations did not differ between individuals with and without extraction of molars. Space closure was acceptable in 87% of the individuals with extracted molars. Eighty percent were satisfied with the treatment. CONCLUSIONS: Extraction of molars with severe enamel defects gave good or acceptable results in a majority of the patients while conservative restorative treatment resulted in a need for additional treatment in approximately half of the patients.

Social inequality in oral health and use of dental care in Sweden.

OBJECTIVE: To describe oral health and use of dental care in relation to socio-economic determinants over time in Sweden. METHODS: Cross-sectional study based on interview data on two randomly sampled sequential populations consisting of 7,610 Swedish adult (25-64 years) residents and 4,315 children (3-15 years) in their households from the Survey of Living Conditions 1996-97, and 7,649 adult Swedish residents (25-64 years) from the survey of 1988-89. RESULTS: Low educational level, having no cash margin and being born outside of Sweden was associated with higher odds of problems with chewing, wearing a prosthesis and not having been treated by a dentist during the 24 months preceding the interview, in a logistic regression analysis of data from the 1996-97 survey in the adult study population (adjusted odds ratios 1.6-2.9). The same socio-economic determinants were associated with caries in children (adjusted odds ratios 1.2-1.5). The socio-economic differences in dental treatment and problems with chewing were greater in the age group 45-64 years compared to 25-44-year-olds. The prevalence of problems with chewing increased from 7.1% (95% CI 6.5-8.1) in the 1988-89 survey to 9.1% (8.4-9.8) in the 1996-97 survey. A similar increase, from 2.4% (2.2-2.6) to 4.4% (3.9-4.9) was observed for individuals not having been in dental treatment during the last 24 months. The socio-economic distribution of oral health and use of dental care in the adult population was similar in the two surveys. CONCLUSION: This study demonstrates that socio-economic differences in oral health and use of dental care are most marked in older (45-64 years) adults in Sweden, but are significant in young adults and, in terms of oral health, in children as well. A steep increase in user charges during the 1990s has been paralleled by a moderate increase in problems with chewing and the proportion of the population that has no regular dental care, which suggests a link that needs to be evaluated in further studies.

Dental health and access to dental care for ethnic minorities in Sweden.

OBJECTIVE: To describe access to dental care in a population-based sample of foreign-born Swedish residents in relation to dental health. DESIGN: The study was based on data from the Immigrant Survey of Living Conditions in four minority study groups consisting of a total of 1,898 Swedish residents born in Poland, Chile, Turkey and Iran aged 27-60. An age-matched study group of 2,477 Swedish-born residents from the Survey of Living Conditions of 1996 was added as a comparison group. The study also included 2,228 children aged 3-15 years in the minority households and 2,892 children in the households of the Swedish-born study group. RESULTS: The risk of poor dental health was higher in all four minority study groups than for the Swedish-born study group after adjusting for socio-economic variables. In the adult minority study groups the adjusted odds ratios (ORs) for having prostheses and problems with chewing was 6.3 (4.3-9.1) and 2.7 (1.8-4.3), respectively, for the Polish-born, 4.8 (3.3-7.1) and 3.2 (2.1-4.9) for the Chilean-born, 4.6 (3.1-6.9) and 4.8 (3.6-7.2) for the Turkish-born, and 2.7 (1.5-4.8) and 6.5 (4.1-10.3) for the Iranian-born compared with the Swedish-born. In the child study group all four minority groups had an increased risk of caries ranging from OR 1.6 (1.3-2.1) in the Chilean group to 2.5 (2.0-3.0) in the Turkish group compared with the children with Swedish-born parents. The adults in all four minority study groups more often lacked regular treatment by a dentist than Swedish-born residents. The OR for not having been treated by a dentist during the 2 years preceding the interview ranged from 1.9 (1.4-2.6) in the Polish-born study group to 3.0 (2.3-4.0) in the Chilean-born study group after adjustment for socio-economic factors and general health. CONCLUSION: This study demonstrates that adults in minority populations in Sweden use less dental care despite having greater needs of dental treatment than the majority population. This inequity calls for action in health policy and preventive dental health programmes.

Mutans streptococci suppression by chlorhexidine gel in toddlers.

PURPOSE: The effect of daily toothbrushing with a chlorhexidine gel on the levels of oral mutants streptococci was evaluated in a group of 37 healthy 1 1/2-year-old children. MATERIALS AND METHODS: The microbial samplings were performed with a modified Strip mutans chair-side technique: a sterile cotton pellet on a wooden pin was rolled along the surfaces of the upper primary incisors and then rolled again on a specially prepared plastic strip. The strips were thereafter incubated and cultivated in a selective media. After baseline registrations, the parents were instructed and trained to brush the teeth of their children with a 1% chlorhexidine gel (Corsodyl), twice daily during 14-days. Follow-up samplings were obtained 1 and 3 months after termination of gel treatment. RESULTS: The results revealed a statistically significant (P < 0.01) reduction of mutans streptococci colonization after 1 month compared with baseline. After 3 months, a certain reduction was still evident although not statistically significant from baseline.

Stepwise prediction of dental caries in children up to 3.5 years of age.

The present study is a part of a prospective, longitudinal investigation of caries development in children (n = 692) living in the southern suburbs of Stockholm. The aim was to evaluate, longitudinally, the caries-predictive ability of variables describing social and immigrant background, dietary habits, microbial and oral hygiene factors, and fluoride exposure in children at 1 and 2.5 years of age with respect to caries development before the age of 3.5. The predictors for caries development in children before 2.5 years of age were mutans streptococci (p < 0.01), immigrant background (p < 0.01), and consumption of candy (p < 0.01). The predictors for developing manifest caries between 2.5 and 3.5 years of age were mutans streptococci (p < 0.001), mother's education (p < 0.001), immigrant background (p < 0.01), and consumption of candy (p < 0.05) and sugar-containing beverages (p < 0.05). The caries incidence at 2.5 years of age as well as the caries increment between 2.5 and 3.5 years of age were significantly higher in children with immigrant background compared to non-immigrants. This study indicates that the possibility of identifying children at risk for caries development increases longitudinally from 1 to 3.5 years of age and there was a synergistic effect between age and each predictor.

Prediction of dental caries development in 1-year-old children.

Dietary habits, oral hygiene, fluoride exposure and occurrence of mutans streptococci were studied in 1-year-old children (n = 786) as well as the socio-economic and immigrant background of their parents. The purpose was to evaluate the predictive ability of variables studied in 1-year-old children that could be used to identify children at risk for early caries development. In a multivariate logistic regression analysis, the variables significantly associated with caries at 3.5 years of age were immigrant background (p < 0.001), mother's education (p < 0.001), consumption of sugar-containing beverages (p < 0.001), mutans streptococci (p < 0.05) and candy (p < 0.05). The probability of caries development was 87% when all the variables associated with caries were present at 1 year of age. The relative risk (odds ratio) of those children to develop manifest caries at 3.5 years of age was estimated to be 32 times higher than in the children where corresponding risk factors were not present. The results indicate that prediction at 1 year of age, built on risk factors associated with dental caries, can provide an indication of possible preventive interventions.

Caries development in children from 2.5 to 3.5 years of age: a longitudinal study.

The development of dental caries from the age of 2.5 to 3.5 years was studied longitudinally in 692 children living in the southern suburbs of Stockholm. The parents answered a structured questionnaire concerning the family's social and immigrant background as well as the dietary habits, oral hygiene and fluoride exposure of their children. Furthermore, the occurrence of mutans streptococci and lactobacilli was determined in samples taken from the tongue of the children, and the buffer capacity of the saliva was measured. At baseline examination, 11.3% of the children exhibited dental caries. At follow-up, 1 year later, decayed and/or filled surfaces were registered in 36.7% of the subjects. The majority of the new lesions were located on the occlusal surfaces of the second molar. Ninety-two percent of the children with caries at baseline developed new carious lesions during the 1-year period, compared to 29% of the children who were caries-free at baseline (p < 0.001). Of the lesions diagnosed at baseline as initial caries, 64% progressed to manifest lesions during the 1-year period. The study indicates that children with early caries development exhibit high caries progression as well as a high risk for further development of an extensive number of new carious lesions.

Caries prevalence in 2.5-year-old children.

The prevalence of caries and gingivitis was determined clinically in 2.5-year-old children (n = 832) living in the southern suburbs of Stockholm. The occurrence of mutants streptococci and lactobacilli was determined in samples taken from the tongue and the buffer capacity of the saliva was measured. The parents answered a structured questionnaire concerning their children's dietary habits, oral hygiene, fluoride exposure and their social and ethnic background. Initial or manifest caries was diagnosed in 11.7 and 6.4% of the subjects, respectively. Seventy-two percent of the total number of caries lesions were localized to the maxillary incisors. Caries prevalence in children with an immigrant background was significantly higher (p < 0.001) than in children without. In the multivariate analysis, the variables significantly associated with caries were: colonization with mutans streptococci (p < 0.001), lactobacilli (p < 0.01) and children with immigrant background (p < 0.01). The study demonstrates an association between early colonization of cariogenic microflora and an increased risk of developing dental caries in very young children.

Prevalence of mutans streptococci in one-year-old children.

Colonization with mutans streptococci was studied in 1095 1-year-old children living in suburban Stockholm. During a scheduled vaccination appointment at a child health centre, a bacterial sample was obtained from the child's tongue and a structured questionnaire was completed by the accompanying parent. Six percent of the subjects were colonized with mutans streptococci. The variables most strongly correlated with presence of mutans streptococci were: non-Swedish background, consumption of sugar-containing beverages at night and total consumption of sugar-containing beverages. The results indicate that, by the age of 1 year, maternally influenced behaviour patterns such as dietary habits that may predispose to early colonization of mutans streptococci are already established. Such early colonization with mutans streptococci may predict high caries risk in the primary dentition.