Examiner agreement on caries detection and plaque accumulation during dental surveys of elders

Indices used to evaluate plaque accumulation and coronal caries have been widely accepted in epidemiological studies, yet their reliability cannot be guaranteed. The aim of this study was to evaluate the reliability of clinical criteria used in coronal and root caries diagnosis and oral hygiene evaluation as applied in elders. Nineteen elderly subjects, 73 years old on average, were examined at a first appointment by two independent examiners. They were re-examined two weeks later. Plaque accumulation was evaluated using the Plaque Index (PI) and coronal and root caries were detected according to the WHO criteria and Fejerskov et al (1991), respectively. Recurrent caries was recorded as recommended by WHO and by probing at the interface tooth-restoration. Inter- and intra-examiner agreement was evaluated using kappa statistics. The PI score showed good reliability except for examiner b, for whom a simplification of the 4-point scale in 3-point scale improved significantly the reliability. The prevalence of coronal caries was very low and intra- and inter-examiner agreement was poor. Most of the root caries lesions were covered by plaque and the kappa values indicated only poor agreement. Recurrent caries were found with good agreement using WHO criteria but the detection with the probe was not reliable. In conclusion, it seems that examiners should be trained carefully to maximise their reliability and that plaque should be removed to obtain reliable diagnoses of caries. Retraining and calibration may be necessary for surveys continuing over a long period.     

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.     

Epidemiology of root caries

Many epidemiological studies have been conducted on a variety of populations. Unfortunately, comparison of the prevalence data, and to a lesser degree of the incidence data, between the various studies is of little use due to the lack of standardised diagnostic criteria, reporting methods and population diversity. In the few incidence studies which have been conducted around 30–40% of people developed root caries, although many adults in the population appear to have been affected by root caries. Many risk factors associated with the occurrence of root caries have been identified and these include oral, medical, mental, behavioural and psychosocial conditions.     

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.     

Indicators for root caries in Danish persons with recently diagnosed Alzheimer's disease

doi: 10.1111/j.1741‐2358.2011.00560.x
Indicators for root caries in Danish persons with recently diagnosed Alzheimer’s disease Objective: To identify indicators of root caries among persons with newly diagnosed Alzheimer’s disease (AD). Background: Few studies have investigated dental caries in older adults with AD. Previously we found that persons with AD had significantly more root caries compared to persons with dementia other than AD. Methods: Participants were recruited from two university hospital clinics in Copenhagen, Denmark. A team of neurologists/geriatricians carried out the diagnostic screening. The study included an interview, oral examination and medical records. Results: We evaluated potential indicators of root decay across subjects with 3+ decayed surfaces vs. <3 decayed surfaces. Variables associated with increased odds of root caries were age over 80 years, 2+ decayed coronal surfaces and 5+ filled root surfaces. Among the social variables, living with someone was associated with a nearly 70% reduction in the odds of having 3+ surfaces of untreated caries. Discussion: Root caries is highly prevalent among individuals with new AD and there is still a strong need for active assessment of and attention to oral problems in persons with AD. Our findings document that recently diagnosed AD cases with multiple coronal caries lesions are at elevated risk of having more root caries. Also persons 81+ years and those with multiple root fillings are more likely to have numerous untreated root lesions.     

Demographic Trends of Aging — Application to Gerodontology1

Aging of the global world population both in developed and developing countries, an unbalanced male-female ratio within this elderly population, increasing populations – including elderly – within urban areas, all will have a marked effect on the practice of dentistry. Furthermore, major epidemiological changes occurring in the dental field, including an increasing dentition life expectancy, increasing root caries prevalence, decreasing coronal caries rates in children, and the relative increase in the prevalence of periodontal problems will have further impact on the dental care system. Major changes need to be anticipated both at the level of the care provider, including the dentist, the hygienist and the dental assistant, and at the level of the potential patient, especially among the geriatric population, if the profession is to be prepared to adequately address these issues.     

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.     

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.     

Plant growth modelling without integrating mechanisms

The integration of root and shoot activity for resource acquisition and allocation is a central problem both in experimental physiology and in mathematical growth modelling. A key feature in all proposed solutions is the mechanism by which roots and shoot communicate their resource status, their needs or their demands. In experimental studies, chemical messengers (hormones or nutrients) have been central. In mathematical models, partitioning or productivity functions of one form or another have been incorporated to fill a similar role. In this paper, the central hypothesis is that growth and resource allocation can be based solely on local, internal, non-structural resource concentrations and local kinetic rules, without the need for additional mechanisms to integrate activities at the organis-mal level. The specific objective was to develop a formal model using the classical two-compartment, two-resource framework which did not include direct intercompartmental coordinating or communicating mechanisms or resource partitioning functions. The formalization effort was successful based on two criteria. First, the ‘plants’ grow at steady and balanced rates when ‘growth conditions’ are constant; and second, challenged with experimental manipulations such as pruning or limitations in resource acquisition, their growth responses mimic those of real plants. Analysis of the results indicates that the complex integrated growth patterns of the modelled plants are emergent properties – having no direct or indirect mechanistic basis – of the simple system. They imply that similar ‘mechanism-less’ integration is possible in real plants as an emergent property of strictly local, cellular-level activities.     

The 2008 EORTC/MSG consensus definitions: What’s new? What’s next?

The definitions of invasive fungal diseases are intended to guide the appropriate use of clinical, radiologic, and various laboratory findings to increase diagnostic certainty in clinical research. The need for standardized definitions was the result of highly variable criteria used to diagnose invasive fungal diseases in epidemiologic and therapeutic studies. We review the original definitions published in 2002, and the need for revision. We also summarize the key changes in the revised 2008 definitions, discuss limitations and pitfalls, and comment on the potential impact of these changes.     

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.     

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.     

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).     

Prosthetic crowns and other clinical risk indicators of caries among old-old Swedish adults: findings from the KEOHS Project. Kungsholmen Elders Oral Health Study

Objectives: The Kungsholmen Elders Oral Health Study (KEOHS) evaluated the oral health status of generally healthy, community‐dwelling persons over the age of 80 living in Kungsholmen, Sweden. This paper explored possible clinical risk indicators of coronal and root caries among the KEOHS subjects. Design: In this cross‐sectional study, dentate KEOHS subjects received a caries assessment using defined visual, tactile criteria. Setting: Examinations were carried out in two local clinics by standardized examiners. Subjects: One hundred twenty‐nine dentate persons were examined. Main Outcome Measures: The examination identified decayed and filled surfaces, prosthetic crowns, and missing teeth. Results: More root than coronal surfaces had untreated decay, and secondary root caries contributed the greatest number of decayed surfaces. Ninety percent of the examined dentate subjects had at least one prosthetic crown. Root surfaces exposed to crown margins were more likely to have caries than root surfaces not so exposed, particularly among women. The presence of untreated coronal caries (yes/no) was positively associated with having untreated root caries and an intermediate number (14–20) of teeth, but inversely associated with having 4+ prosthetic crowns. Active root caries (yes/no) was positively associated with having untreated coronal caries, 14–20 teeth, and 4+ prosthetic crowns. Nearly 20% of identified root lesions were present at or below the gingival margin, and most (88%) were secondary caries associated with crown margins (65%) or other restorations (23%). Conclusions: Our findings suggest that some dental characteristics, including the presence of prosthetic crowns, are risk indicators for the presence of untreated coronal and root caries.     

Interobserver reliability of methods for paleopathological diagnosis of dental caries

There is disagreement as to whether clinical methods of caries diagnosis will produce reliable results in skeletal material, and studies vary greatly in the extent to which such methods are employed. The purpose of this study is, therefore, to evaluate the interobserver reliability of visual, tactile, and radiographic methods of scoring dental caries in ancient populations. Thirty-three individuals from a Mogollon skeletal sample were scored on three occasions by pairs of examiners. The first exam employed visual criteria alone. In the second exam, visual methods were supplemented with the dental explorer. For the third exam, mesial and distal surfaces were scored from “intraoral” radiographs. Examiners worked independently, but did calibrate on material from clinical populations prior to the second and third exams. Exams were conducted on a “blind” basis, and analysis was delayed until all exams were completed. Caries scores were expressed as a percentage of total surfaces present per individual. Repeat-measures ANOVA and intraclass correlation coefficients (ICC) were used to estimate interobserver reliabilities. For visual scores, ICC = 0.97, and there is no significant difference between examiners (P = 0.897). For visual plus explorer scores, ICC drops to 0.90, and there is a significant difference between examiners (P = 0.003). For the radiographs, ICC = 0.86, and there is no significant difference between observers (P = 0.117). These results suggest that clinical methods are less reliable in skeletal populations. Probable sources of error include postmortem dehydration of carious dentin, confusing radiolucencies engendered by worn or fractured enamel, and inadequate radiologic standards for root caries. These problems can be avoided through reliance on visual criteria.     

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.     

Does Biology Need an Organism Concept?

Among biologists, there is no general agreement on exactly what entities qualify as ‘organisms’. Instead, there are multiple competing organism concepts and definitions. While some authors think this is a problem that should be corrected, others have suggested that biology does not actually need an organism concept. We argue that the organism concept is central to biology and should not be abandoned. Both organism concepts and operational definitions are useful. We review criteria used for recognizing organisms and conclude that they are not categorical but rather continuously variable. Different organism concepts are useful for addressing different questions, and it is important to be explicit about which is being used. Finally, we examine the origins of the derived state of organismality, and suggest that it may result from positive feedback between natural selection and functional integration in biological entities.     

Clinical and behavioural risk indicators for root caries in older people

Objective: To investigate the clinical and behavioural factors indicating root caries risk among older people. Desing: Cross sectional clinical and interview data from the National Diet and Nutrition Survey (aged 65 years and over) in Great Britain. Logistic regression models of the prevalence of root caries and linear regression models of the extent of root caries were constructed to quantify the role of a range of clinical and behavioural risk indicators, including sugars intake. Setting: A national sample of older British adults, free‐living and institutionalised. Participants: 462 dentate adults aged 65 years or over. Results: Nine or more intakes of sugars per day more than doubled the odds of root caries being present (OR 2.2–2.4). Other clinical and behavioural factors affecting root caries included wearing a partial denture in the presence of heavy plaque deposits (OR 2.1–2.6) and infrequent tooth brushing (OR 2.8 – 4.1). Linear regression models showed that, amongst those that had root caries, sucking sweets in the presence of a dry mouth, poor hygiene, partial dentures and living in an institution contributed to the extent of root caries, as measured by the RCI(d). Conclusions: Of the factors open to possible clinical or behavioural intervention, frequent sugars intake, poor hygiene and partial dentures were all associated with large increases in risk.     

Assessing root death and root system dynamics in a study of grape canopy pruning

Defining root death in studies of root dynamics is problematic because cell death occurs gradually and the resulting effects on root function are not well understood. In this study, metabolic activity of grape roots of different ages was assessed by excised root respiration and tetrazolium chloride reduction. We investigated changes in metabolic activity and patterns of cell death occurring with root age and changes in root pigmentation. Tetrazolium chloride reduction of roots of different ages was strongly correlated to respiration ( R ² = 0.786). As roots aged, respiration and tetrazolium chloride reduction declined similarly, with minimum metabolic activity reached at six weeks. Tetrazolium chloride reduction indicated that the onset of root browning corresponded to a 77% reduction in metabolic activity ( P < 0.001). Anatomical examination of roots at each pigmentation stage showed that even though some cells in brown roots were still alive, these roots were functionally dead. The effect of using different definitions of root death in relation to root survivorship was determined in a study of 'Concord' grapes with two pruning treatments, using three criteria for root death: browning, blackening or shriveling, and disappearance. There was no effect of vine pruning on root life span when life span was defined as the time from first appearance to the onset of browning. However, if death was judged as the point when roots either became black or shriveled or disappeared, vine pruning decreased root life span by 34% and 40%, respectively ( P < 0.001), and also increased the decay constant for root decomposition by about 45% ( P < 0.001). We conclude that the discrepancy among determinations of root life span assessed with different definitions of death might be partly caused by the latter evaluations of root life span incorporating a portion of root decomposition in definitions of root death.     

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.