Caries risk in formerly sealed teeth.

BACKGROUND: The authors examined the risk of caries development in teeth with partially or fully lost sealant (formerly sealed [FS] teeth) relative to the risk in teeth that never have received sealants (never-sealed [NS] teeth). METHODS: The authors searched the population of studies used in five reviews of sealant effectiveness as established in split-mouth design studies involving resin-based sealants with no reapplication of lost sealant. They required included studies to contain sufficient data to estimate the risk of caries in FS teeth relative to that in NS teeth (relative risk [RR] = % FS development caries% NS development caries) and its 95 percent confidence interval (CI). To estimate the mean RR by year since sealant placement, they used a weighted bivariate model and tested for heterogeneity using the quantity I(2). RESULTS: The weighted mean RR was 0.998 (95 percent CI, 0.817-1.220) one year after placement (four studies, 345 tooth pairs) and 0.936 (95 percent CI, 0.896-0.978) at four years (five studies, 1,423 tooth pairs). CONCLUSIONS: Teeth with fully or partially lost sealant were not at a higher risk of developing caries than were teeth that had never been sealed. CLINICAL IMPLICATIONS: Inability to provide a retention-check examination to all children participating in school sealant programs because of loss to follow-up should not disqualify a child from receiving sealants.

Development and status of the National Oral Health Surveillance System.

During the last 2 decades of the 20th century, few national, state, or local oral health programs were able to conduct public health surveillance in a timely fashion. Under the leadership of the Association of State and Territorial Dental Directors and with substantial support from the Division of Oral Health at the Centers for Disease Control and Prevention, the National Oral Health Surveillance System was established as a first step in helping oral health programs routinely document population needs and program impact with standard, feasible methods. In 1999, the Council of State and Territorial Epidemiologists approved 7 oral health indicators for public health surveillance: 3 for adults (most recent dental visit, most recent dental cleaning, total tooth loss) using data from the Behavioral Risk Factor Surveillance System; 3 for third-grade students (presence of treated or untreated dental caries, untreated tooth decay, dental sealants) collected by states using a standard screening protocol; and the percentage of the population served by public water systems that receives optimally fluoridated water, tracked through the Water Fluoridation Reporting System. The Web site that describes the National Oral Health Surveillance System (http://www.cdc.gov/nohss/) and provides access to current indicators was launched in 2001 with adult and water fluoridation data for all states; child indicators were added later. Data are now available electronically for 35 to 51 states (including the District of Columbia), depending on the indicator, indicating progress toward state-specific monitoring of these oral health indicators.

A comparison of the effects of toothbrushing and handpiece prophylaxis on retention of sealants.

BACKGROUND: Tooth surface cleaning before acid etching is considered to be an important step in the retention of resin-based pit-and-fissure sealants. METHODS: The authors reviewed and summarized instructions for cleaning tooth surfaces from five manufacturers of 10 unfilled resin-based sealants marketed in the United States. The authors also searched electronic databases for studies that directly compared the effects of different surface-cleaning methods on sealant retention and for systematic reviews of the effectiveness of sealants. They explored the association between surface-cleaning methods and sealant retention in the studies included in the systematic reviews. They calculated the summary weighted retention rates for studies that used either a handpiece or toothbrush prophylaxis. RESULTS: All of the sealant manufacturers' instructions for use (IFU) recommended cleaning the tooth before acid etching. None of the IFU directly stated that a handpiece was required to perform the cleaning, but five IFU implied the use of handpiece prophylaxis. None of the IFU recommended surface-altering procedures in caries-free teeth. Direct evidence from two clinical trials showed no difference in complete sealant retention between surfaces cleaned mechanically with pumice or prophylaxis paste and those cleaned with air-water syringe or dry toothbrushing. Indirect evidence from 10 studies found that weighted summary retention by year after sealant placement in studies that used toothbrush prophylaxis was greater than or equivalent to values for studies that used handpiece prophylaxis. CONCLUSIONS: Levels of sealant retention after surface cleaning with toothbrush prophylaxis were at least as high as those associated with hand-piece prophylaxis. CLINICAL IMPLICATIONS: This finding may translate into lower resource costs for sealant placement.

Exploring four-handed delivery and retention of resin-based sealants.

BACKGROUND: To date, no trials have been published that examine whether four-handed delivery of dental sealants increases their retention and effectiveness. In the absence of comparative studies, the authors used available data to explore the likelihood that four-handed delivery increased sealant retention. METHODS: The authors examined data regarding the retention of autopolymerized resin-based sealants from studies included in systematic reviews of sealant effectiveness. The explanatory variable of primary interest was the presence of a second operator. To examine the unique contribution of four-handed delivery to sealant retention, the authors used linear regression models. RESULTS: Eleven of the 36 studies from systematic reviews met explicit criteria and were included in this analysis. The high level of heterogeneity among studies suggested that multivariate analysis was the correct approach. According to the regression model, the presence of a second operator increased retention by 9 percentage points. CONCLUSIONS: For this group of studies, four-handed delivery of autopolymerized sealants was associated with increased sealant retention. CLINICAL IMPLICATIONS: Using four-handed delivery to place resin-based sealants may increase retention.

The role of evidence in formulating public health programs to prevent oral disease and promote oral health in the United States.

A major goal of federal, state, and local health agencies is to reduce the burden of disease in populations. To obtain sufficient resources to achieve this goal, they must document the importance of the health problems addressed and the impact and efficiency of programs. CDC supports core activities within state and local health departments to promote health and prevent disease. This presentation will focus on the need for evidence to document the effectiveness of these activities that include routine monitoring of oral health, risk behaviors, and other factors; implementing effective population-based interventions; and evaluating programs to ensure successful translation of interventions. CDC supports research to build the evidence for innovative strategies to promote oral health in communities. This presentation should increase awareness of evidence-based tools and activities that are supported by CDC to strengthen public health practice within states.

Blood lead concentrations in children and method of water fluoridation in the United States, 1988-1994.

Some have hypothesized that community water containing sodium silicofluoride and hydrofluosilicic acid may increase blood lead (PbB) concentrations in children by leaching of lead from water conduits and by increasing absorption of lead from water. Our analysis aimed to evaluate the relation between water fluoridation method and PbB concentrations in children. We used PbB concentration data (n=9,477) from the Third National Health and Nutrition Examination Survey (1988-1994) for children 1-16 years of age, merged with water fluoridation data from the 1992 Fluoridation Census. The main outcome measure was geometric mean PbB concentration, and covariates included age, sex, race/ethnicity, poverty status, urbanicity, and length of time living in residence. Geometric mean PbB concentrations for each water fluoridation method were 2.40 microg/dL (sodium silicofluoride), 2.34 microg/dL (hydrofluosilicic acid), 1.78 microg/dL (sodium fluoride), 2.24 microg/dL (natural fluoride and no fluoride), and 2.14 microg/dL (unknown/mixed status). In multiple linear and logistic regression, there was a statistical interaction between water fluoridation method and year in which dwelling was built. Controlling for covariates, water fluoridation method was significant only in the models that included dwellings built before 1946 and dwellings of unknown age. Across stratum-specific models for dwellings of known age, neither hydrofluosilicic acid nor sodium silicofluoride were associated with higher geometric mean PbB concentrations or prevalence values. Given these findings, our analyses, though not definitive, do not support concerns that silicofluorides in community water systems cause higher PbB concentrations in children. Current evidence does not provide a basis for changing water fluoridation practices, which have a clear public health benefit.

Promoting the oral health of older adults through the chronic disease model: CDC's perspective on what we still need to know.

The Centers for Disease Control and Prevention (CDC) has adopted a multicomponent approach to health promotion: the Chronic Disease Model. Among its underlying public health principles are 1) recognition of the universal preference for primary prevention of disease, 2) awareness that prevention often takes place outside of clinical settings and is influenced by behaviors that can be affected by social circumstances and institutional policies, 3) the need to base program efforts on the best available science, 4) the special responsibility of public health for at-risk populations, and 5) the need for population-based approaches. Such approaches require public health agencies to build programs that engage broad networks of partners; monitor diseases, risk factors, and behaviors; implement proven prevention strategies; and evaluate programs rigorously. If CDC is to implement comprehensive programs to promote the oral health of elderly people, more information is needed. In this short report we comment on gaps in knowledge concerning the components of programs, measurement of oral diseases and risk factors, and the effectiveness of preventive interventions at the self-care, clinical, and community levels for dental caries and oral and pharyngeal cancers.

Dental care use among pregnant women in the United States reported in 1999 and 2002.

INTRODUCTION: The purpose of this study was to determine national and state-specific estimates of dental care use among adult pregnant women in the United States using data from two 12-month periods. The study also determined person-level characteristics that may predict a lack of dental care use within this subgroup. METHODS: Responses were analyzed from 4619 pregnant women aged 18 to 44 years who participated in the 1999 and 2002 state-based Behavioral Risk Factor Surveillance System. Dental care use was defined as having a dental visit or a dental cleaning in the 12 months preceding the interview. State-specific estimates were adjusted to the 2000 U.S. population distribution. Multivariable regression analysis was used to evaluate person-level characteristics that may predict not obtaining dental care during this period. RESULTS: Overall, 70% of pregnant women in 1999 and 2002 had received dental care in the previous 12 months. Age-adjusted estimates ranged from 36% (Nevada) to 89% (Vermont) to 91% (Puerto Rico). In 19 states, 75% or more of pregnant women had obtained dental care in the previous 12 months (age-adjusted figure). Most pregnant women with dental care were non-Hispanic white and married, and they had a greater than high school education. Income and smoking status were significant predictors for not using dental care. CONCLUSION: In several states, more than 70% of pregnant women reported a dental visit or dental cleaning during the previous 12 months. Relative to the general population, pregnant women are as likely to receive dental care, but certain subgroups need to do much better. However, these estimates may be biased toward a population with a higher socioeconomic status and may not represent dental care use among pregnant women in the general U.S. population.

Estimating prevalence and severity of caries in the mixed dentition: a comparison of two screening protocols.

OBJECTIVE: Most oral health surveys examine and record data on individual teeth or surfaces (STD), providing valid estimates of caries prevalence and severity. Simplified screening protocols based on assessments at the person level (Stop-After-First-Encounter--SAFE) have been validated for assessment of prevalence. We developed an alternative protocol (SENTINEL), which examined the 12 teeth at highest risk for caries and compared how it performed to SAFE and STD for surveillance and evaluation. METHODS: We used data from the Third National Health Nutrition and Examination Survey for children aged 8 to 12 years to analyze the feasibility of assigning STD estimates of severity to children designated by SAFE as having caries. SENTINEL was tested for accuracy of estimating prevalence and severity against STD. In addition, we used subsampling to test the frequency with which SAFE and SENTINEL agreed with STD in identifying the highest risk population. Finally, we compared the mean number of teeth and the recorded data elements for each protocol. RESULTS: Assigning national estimates of severity to SAFE provided inaccurate estimates. SENTINEL agreed with STD in identifying the survey group with the highest severity more frequently than did SAFE (96 percent vs 74 percent). SAFE on average examined nine more teeth than SENTINEL. CONCLUSIONS: Both SAFE and SENTINEL could serve as surveillance tools, depending on the system's purpose/objectives. However, it is unlikely that SAFE would provide adequate information to evaluate sealant programs.

Guidelines for infection control in dental health care settings--2003.

BACKGROUND: The Centers for Disease Control and Prevention, or CDC, is the lead federal agency for disease prevention in the United States. It has been 10 years since CDC infection control guidelines for dental health care settings were last published. During those 10 years, new technologies and issues have emerged, and other CDC infection control guidelines for health care settings have been updated. RESULTS: In light of these developments, CDC collaborated with experts in infection control to revise its infection control recommendations for dental health care settings. Existing guidelines and published research pertinent to dental infection control principles and practices were reviewed. This article provides background information, describes the process used to create these guidelines, and lists the new recommendations. CLINICAL IMPLICATIONS: CDC believes that dental offices that follow these new recommendations will strengthen an already admirable record of safe dental practice. Patients and providers alike can be assured that oral health care can be delivered and received in a safe manner.

Guidelines for infection control in dental health-care settings--2003.

This report consolidates previous recommendations and adds new ones for infection control in dental settings. Recommendations are provided regarding 1) educating and protecting dental health-care personnel; 2) preventing transmission of bloodborne pathogens; 3) hand hygiene; 4) personal protective equipment; 5) contact dermatitis and latex hypersensitivity; 6) sterilization and disinfection of patient-care items; 7) environmental infection control; 8) dental unit waterlines, biofilm, and water quality; and 9) special considerations (e.g., dental handpieces and other devices, radiology, parenteral medications, oral surgical procedures, and dental laboratories). These recommendations were developed in collaboration with and after review by authorities on infection control from CDC and other public agencies, academia, and private and professional organizations.

Oral health surveillance: past, present, and future challenges.

We reviewed and summarized the efforts in the United States to collect data on oral diseases, conditions, and behaviors implemented at the national and state level. The main characteristics of these efforts were: (1) systematic collection of data from representative samples, mostly at the national level; (2) one-time or sporadic experiences when data are collected at state and local levels; (3) use of visual-tactile protocols implemented at the tooth-surface or tooth-site level for data collection; (4) focus mainly on dental caries and periodontal diseases; and (5) leap-time from data collection to publication of results. Using the definition of surveillance in public health (the ongoing and systematic collection, analysis, and interpretation of outcome-specific data for use in planning, implementing, and evaluating public health practice), we show there is an impending need to develop new techniques to build up surveillance systems for oral diseases, conditions, and behaviors at the national, state, and local levels. In the second part of this review, we presented a number of alternative techniques developed in the last 10 years to collect timely data for oral health. The main characteristics of these efforts include: (1) focusing on data collection at state and local level; (2) integration into existing and ongoing surveillance systems; (3) using visual-only protocols to collect data on oral disease status; (4) focusing on a variety of diseases, conditions, and behaviors; and (5) analyzing the data in a timely matter. Many of these efforts have been integrated into the National Oral Health Surveillance System, which has developed eight indicators in response to national health objectives. Finally, we envision the future of visual-tactile protocols in data collection of representative samples to monitor oral health status at the national level and as a research tool. At the state and local level, however, we envision an integrated system of data collection as a constantly evolving process as new techniques are developed in response to new demands.

Updated comparison of the caries susceptibility of various morphological types of permanent teeth.

UNLABELLED: In 1941, Klein and Palmer published a landmark study that ranked the relative susceptibility to dental caries of various morphological tooth types. Specifically, Klein and Palmer used a four-step approach, which included derivation of: (1) an eruption schedule; (2) posteruptive tooth age; (3) cumulative number of decayed, missing, and filled teeth and cumulative posteruptive tooth age; and (4) relative susceptibility values. Their study was conducted when dental caries prevalence and severity were generally high in the United States, prior to the introduction of preventive measures such as fluoride and dental sealants. This investigation used more recent data to assess whether declines in dental caries prevalence over time have been accompanied by changes in the relative susceptibility of permanent tooth types. METHODS: The data source for this investigation was the oral examination component of the Third National Health and Nutrition Examination Survey. This investigation used analytical methods to derive the relative susceptibility values that were identical with those used during the Klein and Palmer study. Full sample weights were used with SUDAAN so that the descriptive estimates would be representative of the US population. Analysis was limited to children aged 4 through 20 years. RESULTS: The investigation found six categories of susceptibility, with molars being more susceptible than incisors, canines, or premolars. In general, susceptibility values declined since the Klein and Palmer study, providing additional evidence for a caries decline in the United States. First and second molar susceptibility values from the NHANES III data, however, intersected with those of Klein and Palmer, suggesting that factors specific to the molars, such as the selective use of dental sealants on these teeth, might be playing an additional role. CONCLUSIONS: Future research should explore factors that might explain the changes in relative susceptibility values over time.