Fluoride, beverages and dental caries in the primary dentition.

Knowledge concerning risk factors for primary dentition caries in young children is incomplete. Models are presented for caries development using longitudinally gathered fluoride exposure and dietary intake data in the Iowa Fluoride Study. Primary tooth caries examinations were conducted at age 5. Dietary (beverage) and fluoride exposure data were gathered longitudinally from age 6 weeks through 4 years (n = 291); 23% had decayed or filled surfaces. Logistic regression revealed that beverage components and toothbrushing made unique contributions to caries experience. Water consumption (36-48 months), milk consumption (24-36 months), and fluoridated toothpaste brushings (36-48 months) were negatively associated with caries; sugared beverages and milk (6 weeks to 12 months) were positively associated. Although fluoride exposure is important, sugared beverages contribute substantially to caries risk, while water and milk consumption and frequent toothbrushing early can have protective effects.

Prevalence of dental fluorosis in the primary dentition.

OBJECTIVES: This paper presents data on the prevalence of primary tooth fluorosis among children residing in Iowa, and the relationships between fluorosis prevalence and selected measures of fluoride exposures. METHODS: Children in the study cohort were followed prospectively during the first year of life. This study assessed their home water fluoride concentrations and use of fluoride dentifrice or dietary fluoride supplements. A total of 637 children (320 females and 317 males) were examined for fluorosis using a modification of the TSIF index at age 4 1/2 to 5 years, with 90.4 percent having intact primary dentitions. RESULTS: 74 children (11.6%) had fluorosis present on one or more of their primary teeth, and 71 children (11.1%) had two or more teeth affected. Nearly all fluorosis was mild, with the primary second molar teeth most commonly affected. Fluorosis was significantly associated with higher water fluoride concentration, but not with the use of dentifrice or fluoride supplements. CONCLUSIONS: The results of this study show that primary tooth fluorosis is relatively uncommon, but is most frequently seen on the posterior teeth, particularly the primary second molars, which form at later stages of development. This finding suggests that primary tooth fluorosis is mostly a postnatal phenomenon, and is associated with higher water fluoride levels.

Patterns of fluoride intake from birth to 36 months.

OBJECTIVES: Dental fluorosis prevalence has increased in the United States, Canada, and other nations due to the widespread availability of fluoride in many forms, with fluoride ingestion during the first three years of life appearing most critical in fluorosis etiology. With few contemporary studies of fluoride ingestion in this age group, the purpose of this paper is to describe patterns of estimated fluoride ingestion from birth to 36 months of age from water, dentifrice, and dietary fluoride supplements and combined. METHODS: Repeated responses to separate series of questions about water intake, use of fluoride dentifrice, and use of fluoride supplements were collected by questionnaire as part of the longitudinal Iowa Fluoride Study and used to estimate fluoride intake. Estimated intake is reported by source and combined at different ages. Effects of subject age and other covariates on fluoride intake were assessed using regression methods appropriate for the analysis of correlated data. RESULTS: For most children, water fluoride intake was the predominant source, especially through age 12 months. Combined daily fluoride intake increased through 9 months, was lower at 12 and 16 months, and increased again thereafter. Mean intake per unit body weight (bw) was about 0.075 mg F/kg bw through 3 months of age, 0.06 mg F/kg bw at 6 and 9 months, 0.035 mg F/kg bw at 12 and 16 months, and 0.043 mg F/kg bw from 20-36 months. Depending on the threshold chosen (e.g., 0.05 or 0.07 mg F/kg bw), variable percentages of the children exceeded the levels, with percentages greatest during the first 9 months. Regression analyses showed fluoride intake (mg F/kg bw) from 1.5-9 months to decrease with increasing child's age, mother's age, and mother's education, with a complex three-way interaction among these factors. From 12-20 months, fluoride intake increased with increasing child age and decreased with increasing mother's age. No statistically significant relationships were found for fluoride intake from 24-36 months. CONCLUSIONS: There is considerable variation in fluoride intake across ages and among individuals. Longitudinal studies may be necessary to fully understand the relationships between fluoride ingestion over time and development of fluorosis.

Prevalence of enamel hypoplasia and isolated opacities in the primary dentition.

PURPOSE: Enamel hypoplasia is of interest to both the clinician and the basic scientist because it may indicate an increased risk for caries and can contribute to the understanding of enamel development. The purpose of this paper is to report the prevalence of enamel hypoplasia and isolated enamel opacities in a cohort of healthy, well-nourished children in Iowa. METHODS: The study sample consisted of 698 children examined at 4-5 years of age. Individual tooth surfaces were scored for the presence of enamel hypoplasia (EH) and isolated enamel opacities. Prevalence of EH and isolated opacities were determined by tooth type and by gender. RESULTS: Six percent of the children examined had at least one tooth with EH; 27% had at least one tooth with isolated enamel opacities. There was no difference in the prevalence of EH between boys and girls, but significantly more boys than girls had enamel opacities. CONCLUSIONS: The prevalence of enamel defects in this study group is comparable to that seen in other studies of normally developed children except that in this study, the primary tooth types most commonly affected with enamel hypoplasia or isolated opacities were mandibular second molars and maxillary second molars, respectively.

Are general dentists' practice patterns and attitudes about treating Medicaid-enrolled preschool age children related to dental school training?

PURPOSE: The purpose of this study were to investigate the willingness of general practitioners to provide dental care for preschool-aged children, and to explore the relationship between dental school experiences and practitioners' attitudes about treating Medicaid-enrolled children 3 years of age and younger. METHODS: A survey was mailed to 3,559 randomly selected general dentists in Texas. Respondents were asked to answer questions about their willingness to provide specified dental procedures for children of different ages, their dental school experiences with pediatric dentistry and whether these experiences were hands-on, lecture or no training, and their attitudes concerning treating Medicaid-enrolled children 3 years of age or younger. Associations between attitudes about treating Medicaid-enrolled children and dental school experiences were determined. RESULTS: The response rate was 26%. Almost all respondents were willing to provide routine procedures such as an examination (95%) and prophylaxis (94%) for children 5 years or younger. However, as children became younger and procedures more difficult, the number of general dentists willing to provide treatment decreased. The level of dental school training was significantly associated with the attitudes of general dentists about providing dental care for Medicaid-enrolled preschool-aged children (P < or = 0.05). CONCLUSION: Identification of factors associated with general dentists' willingness to see young children may improve access by increasing the number who will provide care for preschool-aged children.

Caries risk assessment and prevention: strategies for Head Start, Early Head Start, and WIC.

OBJECTIVES: This review updates the evidence regarding caries risk assessment for infants, toddlers, and preschool children and formulates recommendations for preventive strategies for WIC, Head Start, and Early Head Start. METHODS: Literature on caries risk assessment and preventive strategies for infants, toddlers, and preschool children were reviewed and synthesized. Recommendations for WIC, Head Start, and Early Head Start were made based on the review. RESULTS: Individual caries risk for children in WIC, Head Start, and Early Head Start should be based on: (1) previous caries experience, (2) precavity lesions, (3) visible plaque, and (4) perceived risk by examiners. Recommended preventive strategies for WIC and Head Start populations include: (1) daily toothbrushing in Head Start centers using fluoridated toothpaste; (2) fluoride varnish application to children enrolled in WIC, Head Start, and Early Head Start; (3) use of chlorhexidine gels and varnishes (following FDA approval); and (4) increased use of sealants on children with precavity pit and fissure lesions. CONCLUSIONS: Early screening, risk assessment, and preventive programs in WIC, Head Start, and Early Head Start populations hold a great deal of promise for preventing dental decay in high-risk children.

Appointment-keeping behavior of Medicaid-enrolled pediatric dental patients in eastern Iowa.

PURPOSE: The purpose of this prospective study was to assess the appointment-keeping behavior of Medicaid-enrolled pediatric dental patients in three Eastern Iowa practices. METHODS: During the month of October 1998, a tally was kept of all patient appointments at a private pediatric dental office, a public health dental clinic, and a university-based pediatric dentistry clinic. Patients were categorized as either Medicaid or non-Medicaid. Appointment behavior categories were defined as: On time; Failure; Late-notice Cancellation (less than 24 hours notice); and Tardy (greater than 10 minutes). The data was entered in SPSS and analyzed using the chi square statistic. Statistical significance was P < 0.05. RESULTS: A total of 1,406 appointments were recorded for all three sites. Overall, patients on Iowa Medicaid had higher appointment failure, late-notice cancellation, and tardiness rates than non-Medicaid patients at all three clinics. However, these differences were only statistically significant for the private office and the university-based clinic. Failed appointment rates for Medicaid patients were much higher at the private office (38%) than at the other two sites. CONCLUSION: Consistent with anecdotal reports from dentists, Medicaid patients had higher rates of broken appointments than did non-Medicaid patients, particularly in a private practice setting.

Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia.

OBJECTIVE: This paper examines the cost to the Iowa Medicaid program of hospitalizing young children for restorative dental care under general anesthesia, and describes the dental services received in this setting. METHODS: Medicaid dental claims for young children receiving restorative dental care under general anesthesia during fiscal year 1994 were matched with corresponding hospital and anesthesia claims. RESULTS: The total cost to the Medicaid program of treating a child in the hospital under general anesthesia was $2,009 per case. Less than 2 percent of Medicaid-enrolled children under 6 years of age who received any dental service accounted for 25 percent of all dollars spent on dental services for this age group, including hospital and anesthesia care. The most frequent type of procedure was stainless steel crowns (SSCs), with an average of almost six per case. CONCLUSIONS: Early identification, prevention, and intervention are critically important to prevent the costly treatment of children with ECC in hospital operating rooms.

A comparison of sealant placement techniques and 12-month retention rates.

OBJECTIVE: This study compared time required and 12-month retention for two methods of sealant placement: traditional acid-etch technique and air-abrasion technique without acid etch. METHODS: Sealants were placed on the permanent first molars of 84 children in grades 1-4 who were randomly assigned to treatment groups. All sealants were placed in a school setting by the same clinician. Chair time required for sealant placement was recorded, and retention rates were determined for each technique 12 months after placement. RESULTS: Mean chair time for placement of sealants on four first molars using the air-abrasion technique was significantly less than for the acid-etch technique (7:36 minutes vs 10:56 minutes). Fifty-eight children were available at 12-month follow-up; an examiner not involved in sealant placement and masked as to the technique used determined retention. Rates of complete retention for occlusal surfaces were not significantly different for the two techniques, although the rate for acid etch was higher than that for air abrasion (95% vs 87%). The complete retention rates for the acid-etch technique were significantly higher than air abrasion for buccal and distolingual surfaces. These rates were 65 percent and 58 percent, respectively, for acid etch and 6 percent and 28 percent, respectively, for air abrasion. CONCLUSION: Although more research is needed to improve air-abrasion applications, it does not appear that air abrasion without acid etching offers a significant advantage over traditional sealant placement methods and, in fact, appears to be inferior to the acid-etch technique for use in public health settings.

Effect of a fluoride varnish on demineralization adjacent to orthodontic brackets.

Home fluoride regimens have long been used to reduce the amount of demineralization adjacent to orthodontic appliances. In the absence of patient compliance, another method of applying the fluoride must be used. The purpose of this study was to evaluate, in vitro, the ability of a fluoride varnish, Duraflor, to directly inhibit demineralization of enamel surrounding orthodontic brackets. Brackets were bonded to 36 extracted human canines and premolars with a traditional composite resin and randomly assigned to three equal groups of twelve. Group 1 served as the control with no topical application after bonding. Group 2 was treated with a single application of a nonfluoridated placebo varnish. Group 3 was treated with a single application of Duraflor. All groups were cycled in an artificial caries challenge for 1 hour two times daily for 37 days and were brushed with a medium bristled toothbrush to simulate mechanical wear of the varnish. Demineralization of enamel was evaluated in longitudinal buccolingual tooth sections using polarized light microscopy. Both average depth and area of demineralization were measured with a sonic digitizer. ANOVA (P

Effects of four anticaries agents on lesion depth progression in an in vitro caries model.

PURPOSE: This study compares four chemotherapeutic regimens used for inhibiting carious lesion progression: silver nitrate (AgNO3); silver fluoride/stannous fluoride (AgF/SnF2); silver diammine fluoride (SDF); and chlorhexidine (CHX). METHODS: For this study, a bacterial model system containing Mutans streptococci (MS) and Lactobacilli casei (L) was used to generate carious lesions on 85 extracted sound permanent third molars which were randomly assigned to four test groups and one control group. At week two, the four treatment regimens were applied to the lesions (one treatment per test group). RESULTS: Six weeks later, lesions treated with a single AgF/SnF2 or AgNO3 application demonstrated 29% and 19% less lesion progression, respectively, than did the control group (P < 0.05). SDF and CHX did not differ significantly from the control. CONCLUSION: AgF/SnF2 and AgNO3 may be useful in slowing down carious lesion depth progression.

Fluorosis of the primary dentition: what does it mean for permanent teeth?

BACKGROUND: The prevalence of fluorosis of the permanent teeth has increased during the past few decades in the United States and Canada. However, primary-tooth fluorosis has been largely overlooked, because it is often difficult to recognize. This article describes primary-tooth fluorosis, both as characterized in the literature and as seen clinically. METHODS: The authors review and summarize previous studies of primary-tooth fluorosis and discuss its etiology. In addition, the authors describe the condition, based on findings from the literature, and their own experiences in characterizing it as part of a longitudinal investigation of fluoride exposures, dental fluorosis and dental caries. RESULTS: Several studies indicate that primary-tooth fluorosis can be prevalent and severe in areas of very high water fluoride concentrations. In these areas, primary-tooth fluorosis is likely the result of both pre- and postnatal exposures. Studies have documented that primary-tooth fluorosis does occur in areas with optimal or suboptimal water fluoride concentrations, and that in these settings primary-tooth fluorosis is most likely caused by postnatal exposures and is seen most commonly in the primary molars. Primary-tooth fluorosis, however, is often more difficult to identify than fluorosis in permanent teeth, and clinicians may be unfamiliar with its characteristics and may not recognize its somewhat subtle appearance. CONCLUSIONS: Primary-tooth fluorosis may be related to occurrence of fluorosis in the permanent dentition, so that its recognition by the clinician should raise awareness of possible increased risk for the permanent dentition. CLINICAL IMPLICATIONS: The detection of primary-tooth fluorosis in a young child should prompt the clinician to carefully review the child's past fluoride exposures and current fluoride practices, as well as those of any younger siblings.

Practices and attitudes concerning oral health in pediatric cardiology clinics to prevent infective endocarditis.

A survey of 121 pediatric cardiology clinics investigated the current practices and attitudes toward oral health education and oral screenings in pediatric cardiology clinics for patients susceptible to infective endocarditis. Most pediatric cardiology clinics do not provide oral health education and oral screenings, but believe it would be beneficial.

The impact of WIC dental screenings and referrals on utilization of dental services among low-income children.

PURPOSE: This cross-sectional study examined whether referrals from nondental health professionals impacted utilization of dental services by low-income populations. METHODS: A sample of 309 mothers enrolled in the Women, Infant, and Children (WIC) clinic in Jackson County, Missouri, completed a self-administered, 32-item questionnaire to assess the mother and child's oral health behavior and past use of dental services. Dental utilization, the primary dependent variable, was defined as whether or not the child had ever been to a dentist. RESULTS: Findings showed 27% of the children in the sample had been referred for dental care. Bivariate analysis indicated that a dental referral, age of the child, age of the mother, mother's perceived dental need for the child, household size, number of children in the household, and dental insurance for the child were associated with a child having a dental visit. Logistic regression, however, indicated that only age was significantly related to utilization. CONCLUSION: The results showed a strong effect of increasing age being related to dental utilization, while additional research is needed to clarify the importance of WIC referrals.

Utilization of dental services by Iowa Medicaid-enrolled children younger than 6 years old.

All Medicaid-enrolled children are eligible to receive dental care through the Early and Periodic Screening, Diagnostic and Treatment Program (EPSDT). As part of an evaluation of the effectiveness of the EPSDT program in Iowa, Medicaid enrollment and claims files from fiscal year (FY) 1994 were used to evaluate the utilization of dental services by Medicaid-enrolled children younger than age 6 during FY 1994. During FY 1994, 23% of Medicaid-enrolled children younger than age 6 received at least one dental service while enrolled in the Medicaid program. The total Medicaid-allowed charges for all dental services provided to this population while enrolled in Medicaid during FY 1994 was $1.53 million (the amount Medicaid would pay for the service, prior to calculating any copayments or other insurance charges). Although the EPSDT program in Iowa requires a referral of all Medicaid-enrolled children to a dentist at 1 year of age, fewer than 4% of enrolled children in this age group received any dental services. The percent of enrolled children receiving a dental exam during FY 1994, by age, was as follows: younger than 1 year, 0.2%; age 1, 3%; age 2, 10%; age 3, 27%; age 4, 46%; age 5, 54%. Utilization rates of dental services by Medicaid-enrolled children in Iowa fall far short of federal regulations, which currently require that 80% of enrollees receive EPSDT screenings, referrals, and treatment by age 3.

Comparison of air abrasion versus acid etch sealant techniques: six-month retention.

This study compared two techniques for placing sealant in an elementary school setting. Eighty-five children in grades 1 to 4 in two schools were assigned randomly to two sealant treatment groups: 1) acid etch technique (AE), and 2) air abrasion with no acid etch (KCP-1000). Noncarious, nonfilled occlusal, distolingual and buccal pit surfaces of first permanent molars were sealed. A total of 300 teeth received sealants, and 230 were evaluated at 6 months. Rates of complete sealant retention at 6 months were: occlusal surfaces, 97% for AE and 96% for KCP-1000; distolingual surfaces, 82% for AE and 49% for KCP-1000; and buccal surfaces, 77% for AE and 7% for KCP-1000. Differences in complete retention at 6 months between AE and KCP-1000 were not significant for occlusal surfaces (P = 0.14) but were significant for buccal and distolingual surfaces (P < 0.0001). Results suggest that sealants placed with air abrasion have retention rates for occlusal surfaces similar to AE. More research is needed to identify factors contributing to low retention rates on other surfaces for KCP-1000.

Changes in maternal attitudes toward baby bottle tooth decay.

Several studies have shown that a significant number of parents whose children have baby bottle tooth decay (BBTD) admit prior knowledge regarding the harmful effects of putting their children to bed with a bottle. The Elaboration Likelihood Model of Persuasion (ELM) offers a theoretical framework for better understanding why knowledge and attitude are often not predictive of behavior. The goal of this study was to use the ELM to analyze the manner in which information about BBTD is evaluated. One hundred twenty low-income women (either pregnant or with a child younger than 7 months of age) at a WIC clinic were randomly assigned to three groups: 1) 5-min audiotaped persuasive message about BBTD; 2) same audiotaped message with overheard audience response affirming the message; and 3) no intervention control group. Knowledge and attitudes about BBTD were measured before and after the experimental intervention. Participants hearing the audiotaped message also were asked to rate the expertise of the messenger and the quality of the message. Both groups hearing a taped message about BBTD showed a significant positive change in attitude and knowledge when compared with the control group (P < 0.05). No significant difference was found between the attitude and knowledge of those who heard an audiotaped message accompanied by an audience response compared with those who heard the audiotaped message alone. No significant difference between the ratings of message quality or messenger expertise by group was found. It was concluded that the participants in this study processed the BBTD message primarily through the central route, that is, by careful evaluation of the issue-relevant information contained in the persuasive message.