Root caries incidence and associated risk factors in middle-aged and older adults

Data from population-based longitudinal studies required to assess the incidence of root caries and associated risk factors are sparse in the literature. To this end, a group of 130 middle-aged and older adults were examined for root caries at baseline and at a follow-up visit between nine and 24 months (median: 16 months). Dental examinations were conducted by one examiner at a Tufts dental clinic using NIDR defined diagnostic criteria. Fifty percent of subjects in this study population developed one or more new root caries lesions over the follow-up period. Also, an annualised increment of 0.60 (SD: 0.72) decayed and filled surfaces per person was observed for the 45–59 year old group while the 70+ group showed an annualised increment of 1.38 (SD: 1.97) DFS in this study. Multivariate logistic regression analysis identified past root caries experience, high plaque score, and high number of teeth (>= 22) to be positively associated with new root caries (p < 0.05).     

Epidemiology of Root Caries1

Over a dozen studies have been conducted on the prevalence of and factors associated with root caries, yet our knowledge of this disease process remains limited. This is due, in large part, to a lack of consistency of reporting among the studies undertaken and the wide spectrum of population groups investigated. Nevertheless, the occurrence of root caries is between 20 and 40 percent in healthy, urban adults. Certain population groups such as the institutionalized elderly and patients with periodontal disease tend to exhibit much larger prevalence rates. New root caries develops slowly and tends to be concentrated in a few individuals, usually on the buccal and proximal surfaces of teeth. It is generally accepted that only roots with gingival recession are susceptible to root caries and that age, sex, oral hygiene, diet, saliva, systemic fluoride and previous carious experience have been shown to be associated factors. The next wave of investigations of root canes should focus on testing hypotheses relating to causation so that efficacious preventive and treatment procedures can be developed.     

Trends in Oral Disease and Health1

Geriatric dentistry researchers are building a basic knowledge basic pertaining to the oral health status of older adults. Important findings on the prevalence of disease that run counter to “conventional wisdom” surrounding the oral health of older adults are that edentulism is decreasing, that both coronal and root caries are prevalent, that serious periodontal disease is not as prevalent as thought, that chronological age is not strongly associated with disease in older adults, and that oral lesions, especially those related to dentures, are prevalent. An important finding has been that the majority of disease seems to occur in a minority of the population. While the prevalence of oral diseases have been shown to be associated with water fluoridation, systemic diseases, use of medications, social and behavioral factors, and a variety of other oral conditions, there is only preliminary information on the incidence of disease and actual risk factors. The data available on the incidence of disease come from a study of community-dwelling older adults in Iowa, and these data generally confirm the prevalence results. Coronal and root caries are active in this older population with caries being the best predictor of tooth loss. Furthermore, most disease occurs in a high risk group. Multivariate models predicting people at highest risk for root and coronal caries implicate stress and anxiety, use of tobacco, and recent onset of illness as risk factors. In addition, preliminary results indicate that some dental conditions may be predictive of general health status.     

The Epidemiology of Dental Diseases in the Elderly1

This paper summarizes and evaluates epidemiologic evidence on adult dental conditions with a focus on older adults. Information is presented on coronal caries; root caries; loss of teeth, attrition, abrasion, and erosion; periodontal diseases; and oral cancer. The author concludes that the oral health status of the elderly in the United States is essentially unknown. There are no recent, representative population base studies of oral conditions in the elderly. Studies of prevalence or incidence of oral diseases typically include few elderly persons or describe a select group of elderly who are at high risk. Furthermore, it is not really known whether the incidence and prevalence of coronal caries or root caries is actually increasing or is part of a cohort effect. While oral cancers have been shown to increase with age, there is no information as to whether their incidence rates are increasing. While, clinically, there are indications that attrition, abrasion and erosion are characteristics that are more likely to be seen in older adults, there is no information about their distribution in the population. There is evidence that loss of teeth is decreasing but nothing is known about the patterning of that loss. As for periodontal diseases, much work is needed to identify various syndromes that may be distinguished by their distribution in the population as well as determining whether periodontitis is a condition responsible for a majority of tooth loss or just the majority of tooth loss in a small high risk group. In addition, some suggestions are presented for future directions of research in this area.     

Dental Caries in the Elderly

Studies in the United States and other countries have shown that there is continued caries activity with advancing age. These studies, however, do not elaborate on the nature of the dental caries nor its anatomical location on the tooth. It has been assumed that dental caries occur on the coronal portion of retained teeth and that recurrent decay around existing restorations represents the major form of the disease. In addition to continued coronal caries activity in adults, the problem of carious lesions occurring on the exposed roots of teeth has been identified in a number of recent surveys. The exposure of the root surface to the oral cavity is a consequence of the apical migration of the periodontal attachment through periodontal disease and dental treatment which renders this part of the tooth at risk of the dental caries process. However, there are several distinct differences between coronal and root caries. The continued occurrence of coronal caries in adults and the projected increase m the prevalence of root caries suggests an expanded role for the restorative and preventive services for the older adult patient. Although the techniques relating to coronal caries are well-established, those relating to root caries are just beginning to be explored and developed. Many of the principles, materials and philosophies which have proved to be effective for coronal caries are not equally efficacious when the tooth root is involved. This area represents a fertile field for research and development in the older adult patient.     

Diabetes enhances dental caries and apical periodontitis in caries-susceptible WBN/KobSlc rats

Many epidemiologic studies have suggested that diabetes may be an important risk factor for periodontal disease. To determine whether diabetes induces or enhances periodontal disease or dental caries, dental tissue from diabetic male and nondiabetic female WBN/KobSlc rats and male and female age-matched nondiabetic F344 rats was analyzed morphologically and morphometrically for these 2 types of lesions. Soft X-ray examination revealed that the incidence and severity of both molar caries and alveolar bone resorption were much higher in male WBN/KobSlc rats with chronic diabetes than in nondiabetic female rats of the same strain. Histopathologic examination showed that dental caries progressed from acute to subacute inflammation due to bacterial infections and necrosis in the pulp when the caries penetrated the dentin. In the most advanced stage of dental caries, inflammatory changes caused root abscess and subsequent apical periodontitis, with the formation of granulation tissue around the dental root. Inflammatory changes resulted in resorption of alveolar bone and correlated well with the severity of molar caries. Our results suggest that diabetic conditions enhance dental caries in WBN/KobSlc rats and that periodontal lesions may result from the apical periodontitis that is secondary to dental caries.     

Caries experience in existing and new nursing home residents in Adelaide,Australia

Objectives: The Adelaide Dental Study of Nursing Homes was instigated to provide comprehensive information concerning oral disease experience, incidence and increments in a random sample of those older South Australians residing in Adelaide nursing homes. Methods: This paper presents caries experience results for existing and new nursing home residents, and caries incidence and increments for existing residents, from dental inspections conducted at the baseline and one‐year data collections. Results: The residents in this study were very functionally dependent, medically compromised, cognitively impaired and behaviourally difficult older adults, the great majority of whom had moderate to severe cognitive impairment. Residents gave their carers many complex and challenging behavioural problems during oral hygiene care provision. Existing and new residents had similar dental history, oral hygiene, and socio‐detnographic characteristics, and similar cognitive, medical, functional, and nutritional status. Oral disease experience was high in both existing and new residents. There were no significant differences between existing and new residents for their dentate status, tooth status, coronal caries experience, or root caries experience, with the exceptions that new residents had significantly greater mean number of teeth, more filled coronal and root surfaces, and also new residents had significantly fewer decayed retained roots. Large numbers of tooth surfaces were covered in plaque and debris that negated more precise assessment of caries. The existing residents had caries increments on both coronal (2.5 surfaces) and root surfaces (1.0 surfaces) over the one‐year period. Coronal caries incidence was 64% and root caries incidence was 49% of existing residents. Conclusions: Oral disease experience was high in both existing and new residents. There were few significant differences between existing and new residents’ oral health status. New residents were being admitted to nursing homes with a compromised oral health status. Coronal and root caries increments and incidence were high for existing residents over the one‐year period.     

The prevalence of root surface caries amongst Irish adults

In a national survey of adult dental health conducted in the Republic of Ireland in 1989/90 a total of 1,527 subjects aged 25 and older were examined for root surface caries. It was found that the prevalence of root surface caries was highest in older age groups and also amongst males, residents of non-fluoridated communities and those earning low incomes. Tooth loss masked the potential prevalence of root surface caries. With more persons retaining their natural teeth into middle and old age the prevalence of root surface caries is likely to increase in the future.     

Relationship between root caries and cardiac dysrhythmia

doi: 10.1111/j.1741‐2358.2010.00367.x
Relationship between root caries and cardiac dysrythmia Background: Cardiac dysrhythmia are frequently found in the elderly population because of conduction system disease and ageing. Recent reports have suggested that dental caries and periodontal disease are predictors of coronary heart events. However, this hypothesis remains largely unproven. Objective: This study investigated the relationship between root caries and cardiac dysrhythmia in an elderly population. Subjects and methods: Among 600 subjects, 233 who were dentate at baseline underwent a baseline examination and subsequent annual investigations, including an oral examination and a 12‐lead electrocardiogram, for a 4‐year period. Analysis of covariance (ancova) was used to assess the number of sites with root caries between subjects with mean C‐reactive protein (CRP) serum level of <3.0 mg/l and those with the mean CRP serum level ≥3.0 mg/l. Logistic regression analysis was performed to assess relationship between root caries and cardiac dysrhythmia. Results: A high mean CRP serum level group had a significantly higher number of sites with root caries than a low CRP group (p < 0.001). Number of sites with root caries events was significantly associated with cardiac dysrhythmia among non‐smokers (odds ratio, 5.84; p = 0.040). These results suggest that root caries is related to the incidence of dysrhythmias in non‐smokers. Conclusions: We conclude that non‐smoking elders with root caries lesions are at an elevated risk for dysrhythmias.     

The reasons for tooth loss in geriatric patients attending two surgical clinics in Jerusalem,Israel.

Abstract Objectives Numerous studies around the world have been conducted in order to understand the reasons for tooth extractions in various age groups. Most studies have dealt with the general adult population but little attention has been paid to the elderly population. In Israel, as in most of the western countries, the elderly population is growing rapidly and thus demands for its dental needs are also increasing. In order to meet the dental requirements of the geriatric population, data on the main reasons of tooth mortality have been collected. Design Retrospective analysis of reasons for extraction divided into three categories: caries, periodontal disease and “other’’. Subjects The files of 302 consecutive elderly patients aged 65-95 years attending for extraction. The cause for tooth extraction was gathered from the written diagnosis described by the operator as well as from radiographs. Setting Two surgical clinics in Jerusalem serving low income residents. Results Results indicated that 30% of the extractions were due to caries, 65% were due to periodontal disease and only 6.4% related to “other’’ reasons. In both, males and females, periodontal disease was the major cause for tooth loss yet, females exhibited more extractions due to caries than males (35%vs 23% respectively). A relatively high incidence of tooth loss was documented for the 85+ age group. Of the teeth that were extracted, incisors and molars were equally the most frequent (29%) followed by premolars (26%) and canines (17%). Premolars were the teeth most frequently extracted out of the teeth removed due to caries (32%) whereas incisors were the most frequently removed within the group of teeth extracted due to periodontal disease (31%). Conclusions The results of this study point to the importance of prevention and treatment of dental diseases, particularly periodontal disease, in adults aged 0 years and above in order to prevent tooth loss in their later years.     

The Diagnosis of Root Caries – A Review

Interest in root caries has grown among dental caries research workers over the past 20 years. However, many studies, either in the fields of microbiology, pathology, epidemiology or clinical trials, have used differing definitions in their diagnosis of root caries. These differences mean that comparison between studies is difficult, if not impossible. Most of the criteria currently in use are neither sufficiently specific to allow the identification of the initial root caries lesion, not detailed enough to assess the progression of lesions. Furthermore, most definitions provide no information on treatment need within the populations studied. In this paper, the criteria which have been used to diagnose root caries, and their individual components – texture, cavitation, position, size, colour and radiolucency – are reviewed. It is concluded that there is a need to standardise terminology and definitions used for the diagnosis of root caries.     

Partial dentures as an independent indicator of root caries risk in a group of older adults.

Objectives: To estimate the independent association between the wearing of removable partial dentures (RPD) and the presence of root caries in a population of older adults. Design: Multivariate logistic regression modeling of root caries prevalence using different measures of root caries as dependent variables. The model included measures of disease history as indicators of historical risk. Setting: Data collected in the field from three areas of England. Subjects: Random sample of adults aged 60 years and over, drawn from lists of patients registered with general medical practitioners. Intervension: Field measurements of a range of oral health variables including oral disease, disease history, oral status and various social and demographic measures. Main outcome measures: The presence of root caries, unsound and sound root restorations. Results: Of the five different models of root caries prevalence which were used, RPDs featured as an independent risk indicator for root surface cades in the three which were related to the presence of untreated disease. The odds ratios for the contribution made by RPDs were all over 1.6, and when considered alone was in excess of 2 in one model. These models were generally well fitting. RPDs did not feature as a risk indicator in the two models which related only to the presence of root surface restorations. Conclusions: In this study, where RPDs were present, the odds of untreated disease being present increased substantially     

Caries activity and associated risk factors in elderly hospitalised population--15-months follow-up in French institutions

Only a few studies have been published concerning hospitalised elderly disabled people. Objectives: 1) to investigate the oral health status of elderly French patients hospitalised in the two main geriatric hospitals of Paris. 2) to describe the respective influences of general parameters (type of hospitalisation, pathologies and medication) on oral environment parameters. 3) to analyse the influences of these oral parameters on caries activity in Long-Term Care (LTCF) and in rehabilitation facilities (RF) patients and to study the incidence and the time-course of caries in these specific population. Subjects: 117 subjects (mean age=83.0 years, SD=7.8, range=64 to 102 years) were examined at baseline and 32 of the 50 LTCF subjects were reexamined 15-months later. Methods: The general parameters recorded were age, gender, type of hospitalisation, period of stay, removable prosthesis, general diseases, number of diagnoses, medications with hyposalivary side-effects. The oral environment parameters recorded were flow rate, buffer capacity, mutans streptococci and lactobacilli counts, measured at baseline by tests on stimulated saliva, and plaque index. Crown and root surfaces were recorded according to a modified caries activity index. Results: Among the polypathological subjects (85.5% of the population), the number of diseases ranged from 2 to 8. The LTCF patients had a significantly higher mean number of diagnoses (3.5; SD=1.5) than the RF patients (2.8; SD=1.4). 76.9% of patients were taking medications with hyposalivary side-effects. The stimulated flow rate ranged from 0.02 ml/min to 5 ml/min. Its mean was significantly lower for LTCF patients (0.67 ml/min; SD=0.51) than for RF patients (1.12 ml/min; SD=0.89). The plaque index was significantly higher in LTCF subjects and in patients with mental diseases. At baseline, 17,442 crown and root surfaces were examined. Flow rate was related to crown caries and buffer capacity to root caries. During the 15-months follow-up, the mean number of active root surfaces was significantly increased: from 0.148 (SD=0.116) at baseline vs. 0.250 (SD=0.174) at the second examination. Conclusions: The strongest relationship in the present study between oral parameters and caries activity was the negative relationship between buffer capacity and active root caries. This study confirms an association between the type of hospitalisation and both salivary parameters flow rate and plaque index. This investigation illustrates the critical need for hygiene and oral care, in this elderly disabled population.     

Microbial Etiology of Root Surface Caries

Available knowledge relating to the microbiology of root surface caries was reviewed. This included direct information from microbiological observations on human and animal material as well as subsidiary information derived from pertinent dietary studies and histological examination of cemental lesions. Early investigations on root surface caries in experimental animals have provided valuable insight into some of the dietobacterial interactions involved. However, these ideas have not been completely validated at the human level. It was concluded that interactions between oral bacteria and other factors involved in the development of root surface dental caries may be broader in scope and more difficult to interpret than the bacterial activities which result in coronal caries.     

Caries incidence in patients with dementia

One in ten persons over the age of 65 and as many as half the population aged 85 and over have Alzbeimer's disease. Review of the literature reveals substantial decrements in oral health in persons with dementia as measured by denture hygiene, coronal decayed, missing and filled teeth, filled teeth (cervical), percentage of the population with caries. Oral Hygiene Index-simplified, and of sites with plaque, gingival bleeding and calculus. A study of caries incidence is described in 23 male veterans with moderate and advanced dementia of the Alzheimer's type, using a comparison group of male veterans from the Department of Veterans Affairs Dental Longitudinal Study, matching 2 :1 for age, number of teeth and education. Baseline findings indicate significant differences in the numbers of coronal surfaces with decay, root decayed and/or filled teeth and root decayed and/or filled surfaces. Mean annual increments of coronal caries in the dementia group were 2.29±4.29 per 100 surfaces at risk, over twice that in the comparison group (0.88±1.14). For root caries, mean annual increments in the dementia group were 2.38±5.57 per 100 available surfaces, versus 0.31± 0.69 in the comparison group. Despite these large mean differences, the marked variability in these small samples statistical significance in caries increments between the two groups. The article concludes by suggesting some potential modifications to clinical trials of caries preventive agents and some overall research issues in populations with dementia.     

Observations of dental diseases among prehistoric populations of Hungary

The incidence of dental disease among people in developing countries today raises questions about the variation in the oral health of prehistoric populations. Considering these questions, we offer observations describing several types of dental disease which occurred among certain prehistoric populations of Hungary. The dental remains of 162 individuals recovered from seven sites of the Neolithic, Copper, and Bronze Age periods were examined for evidence of caries, hypoplasia, and periodontal disease. Appropriate methods were used to describe and record these dental lesions. The incidence of dental caries was low by comparison to other prehistoric agriculturists except for two forms of root caries: cervical and cemental. These types accounted for 68% of all the carious teeth recorded. Enamel hypoplasia was also lower than expected, occurring on only 4% of the total number of teeth. Periodontal abscesses were rare but other milder forms of periodontal lesions were frequent. Alveolar bone resorption occurred in varying degrees and followed the expected age distribution. The few exceptions were children or adolescents whose crania had other lesions suggesting a mineral metabolic disturbance. The lower incidence of enamel caries is likely due to high fluoride ingestion which also may have influenced the expression of enamel hypoplasia. No clear population trends were seen in dental disease incidence except for cemental caries which were found among Copper and Bronze Age remains.     

The Clinical Identification of Root Caries

This paper discusses a variety of considerations associated with the clinical identification of root caries. While focusing upon this clinical identification process from the perspective of the clinical researcher, the differing diagnostic needs between the clinical researcher and the dental practitioner are frequently addressed. The topic of the identification of untreated root caries lesions includes a presentation of both existing definitions and a proposed set of diagnostic criteria. The presentation of the topic on the identification of arrested and treated root caries lesions emphasizes the diagnostic challenge that will occur due to the newly introduced chemotherapeutic treatments that have been proposed for the control of root caries. The influence of varying examination conditions, techniques and instruments on the reliability and validity of the clinical identification of root caries are also considered. Finally, a preliminary set of clinical research diagnostic conventions, which would both aid the researcher in “grey zone decisions” and enhance comparability of findings across studies, are proposed.     

Prevention of Root Caries1

Primary prevention of root caries should focus on preventing periodontitis and the concomitant loss of gingival attachment. This requires a regimen of plaque control consisting of scrupulous oral hygiene, supplemented, if necessary, by antimicrobial agents. Once gingival recession has occurred, available data from human and animal studies indicate that to prevent root caries, patients should limit their dietary sucrose intake both in amount and frequency. The cornerstone of any preventive regimen for patients at high risk for caries is some mode of topical fluoride therapy. No controlled clinical data exist that show one agent (sodium fluoride versus stannous fluoride) or one vehicle (gel versus rinse) as more effective than another. When used daily at home, these topical fluoride agents reduce caries in patients with xerostomia. Some reports claiming efficacy are anecdotal, but ethical considerations preclude the use of an untreated control group. As no studies exist documenting an effect of topical fluoride in controlling root caries per se, current recommendations are based on extrapolation from studies of these xerostomic patients. Limited studies, both in humans and animals, indicate that drinking fluoridated water helps in reducing root caries. Progression of early root caries lesions can be arrested by a combination of mechanical/chemical therapy, recontouring and smoothing the roots, and applying topical fluoride to these surfaces.     

Future directions for root caries research

Interest among researchers in the diagnosis, aetiology, prevention, and treatment of root caries has increased substantially over the past two decades. However, there are some fundamental problems impeding the advancement of the field which remain to be addressed and resolved. A universally acceptable definition of root caries is not yet available. The relationship of root caries to coronal caries has not been established. The underlying disease process is still not clearly understood. The optimal utilisation of preventive/therapeutic agents for the treatment or prevention of root caries has not been determined. New treatment materials and preventive agents have not yet been tested in controlled clinical trials. These are a few of the issues and problems which we address in this paper.     

Caries incidence and increments in community-living older adults with and without dementia

Objectives: The Oral Health of Older Adults with Dementia was instigated in the late 1990s to quantify and compare coronal and root caries incidence and increments in community‐living older Australians with and without dementia. Methods: A longitudinal design was used to conduct dental inspections at baseline and one‐year, for two groups of randomly selected community‐living older adults ‐ one group of 116 people with dementia and a comparison group of 116 people without dementia. Results: At one‐year there were 103 dementia and 113(112 dentate) non‐dementia participants. Coronal and root surface caries incidence was higher for dementia participants (p<0.05). Dementia participants had higher coronal and root caries adjusted caries increments (ADJCI) (p<0.01). Both coronal and root ADJCI were evident in half of dementia participants, compared with one‐quarter of non‐dementia participants. Dementia participants with higher coronal ADJCI were those who had visited the dentist since baseline, who were taking neuroleptics with high anticholinergic adverse effects, and whose carer had high carer burden score (p<0.01). Dementia participants with higher root ADJCI were those needing assistance with oral hygiene care and whose carers had difficulties with oral hygiene care (p<0.05). Baseline characteristics predictive in linear regression for: (1) coronal caries increments among all participants were ‐ dementia participants, those with cognitive testing scores indicative of moderate‐severe dementia, those with private health insurance; (2) root caries increments among all participants were ‐ dementia participants, and those who had 1 decayed/filled root surface at baseline. Among dementia participants, being male was the baseline characteristic predictive in logistic regression for coronal caries increments, and having 1 decayed coronal surface was the baseline characteristic predictive for root caries increments. Conclusions: Coronal and root caries incidence and increments were significantly higher in the community‐living older adults with dementia over the one‐year follow‐up period. Dementia participants had high levels of coronal and root caries increments; characteristics related to high caries increments included sex (males), dementia severity (moderate‐severe), high carer burden, oral hygiene care difficulties, use of neuroleptic medication (with high anticholinergic adverse effects) and previous experience of caries.