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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Oral Health Prev Dent. Author manuscript; available in PMC Apr 12, 2011.
Published in final edited form as:
PMCID: PMC3074637
NIHMSID: NIHMS172224

Use of Caries Prevention Agents in Children: Findings from the Dental Practice-based Research Network

Joseph L. Riley, III, PhD, Associate Professor, Joshua S. Richman, MD, PhD, Assistant Professor, D. Brad Rindal, DDS, Investigator and Dental Health Provider, Jeffrey L. Fellows, PhD, Investigator, Vibeke Qvist, DDS, PhD, Dr Odont, Associate Professor, Gregg H. Gilbert, DDS, MBA, FAAHD, Professor and Chair, and Valeria V. Gordan, DDS, MS, MS-CI, Professor*, for the Dental PBRN Collaborative Group

Abstract

Purpose

Scientific evidence supports the application of caries preventive agents in children and this knowledge must transfer into the practice of dentistry. There is little multi-region data that allow for comparisons of practice patterns between types of dental practices and geographic regions. The aim of this study was to characterize the use of caries preventive agents in pediatric patients in a large multi-region sample of dental practices.

Methods

This study surveyed Dental Practice-based Research Network dentists who perform restorative dentistry in their practices. The survey asked a range of questions about caries risk assessment and use of prevention techniques in children ages 6-18.

Results

Dental sealants (69%) or in-office fluoride (82%) were the most commonly used of the caries preventive regimens. The recommendation of at-home caries preventive agents ranged from 36%-7%, with non-prescription fluoride rinse the most common. Dentists who practiced in a large group practice model and dentists from the Scandinavian region more frequently use caries risk assessment than regions that were predominately dentists in private practice. Whether or not dentists used caries risk assessment with their pediatric patients was poorly correlated with the likelihood of actually using caries preventive treatments on patients.

Conclusion

Although dentists reported the use of some form of in-office caries prevention, there was considerable variability across practices. These differences could represent a lack of consensus across practicing dentists about the benefits of caries preventive agents or a function of differing financial incentives or patient pools with differing levels of overall caries risk.

Keywords: Caries, Fluoride, Dental Sealant, Prevention, Children

Introduction

Application of specific caries preventive agents in children and adolescents has had increasing support in the dental profession (Brown, 2007; Rozier, 2001). These techniques include professional or at-home application of fluorides (Azarpazhooh et al., 2008; Twetman et al., 2004), dental sealants (Azarpazhooh and Main, 2008), antimicrobials such as chlorhexidine (Baca et al., 2002), and xylitol chewing gum (Burt, 2006) with studies supporting their use. For caries prevention regimens to be as effective as possible, this evidence must transfer into increased use in the practice of clinical dentistry.

The decision about the use of preventive strategies should be made in consideration of the child's risk indicators, in addition to other key factors that include cost/benefit and lesion activity (Rozier, 2001). This assertion is supported by many reviews promoting the adoption of risk-based approaches for the prevention of dental caries (Bader et al., 2001). Recent evidence that the overall prevalence of caries has decreased, in combination with the cost of providing caries prevention to all members of a society at the individual level, are practical arguments for providing caries prevention based on assessed risk (Burt, 1998). The implication is that a caries risk assessment should precede any preventive regimen. Several studies have directly asked dentists whether risk assessment drives decisions about caries prevention (Primosch and Barr, 2001; Trueblood et al., 2008). However, there are little data correlating caries risk assessment in clinical practice and the use of specific caries preventive agents (Bader et al., 2003).

Studies using a wide range of sampling and measurement strategies have reported considerable variability in the use of caries prevention techniques in children across regions or specialties (Primosch and Barr, 2001; Trueblood et al., 2008; Helminen and Vehkalahi, 2003; Tickle et al., 2003; Yoder, 2007; Cherry-Peppers and Gift, 1995; Clark and Berkowitz, 1997; Siegal et al., 1996). Because of differing methodology, it is difficult to draw meaningful conclusions about preferences in the use of preventive treatments across practices. It could be presumed that European regions and particularly the Scandinavian countries would use prevention in greater numbers as a more preventive philosophy has traditionally been acknowledged among theses societies (Wang et al., 1998; Ekstrand and Christiansen, 2005; Pitts, 2001). However, US and Canadian dental schools have recently increased curriculum time that focuses on teaching of caries prevention (Brown, 2007). We are unable to find studies that have examined the use of caries preventive agents, using a standardized method of assessment, across geographic regions or types of dental practices. A greater understanding of regional practice patterns in child and adolescent patients will allow better targeting of continuing education by professional dental associations promoting evidenced-base use of caries preventive modalities.

This study had three key aims: (1) quantify the use of specific caries prevention agents in a large multi-region sample of practicing dentists; (2) test the hypothesis that use of specific caries prevention agents differs across region and other practice characteristics, and (3) test for an association between specific caries prevention treatments and clinician use of individualized caries risk assessment.

Methods

Participants

The “Dental Practice-Based Research Network (DPBRN)” is a consortium of participating practices and dental organizations committed to advancing knowledge of dental practice and ways to improve it. DPBRN comprises five regions: AL/MS: Alabama/Mississippi; FL/GA: Florida/Georgia; MN: dentists employed by HealthPartners and private practitioners in Minnesota; PDA: Permanente Dental Associates in cooperation with Kaiser Permanente Center for Health Research; and SK: Denmark, Norway, and Sweden (Gilbert et al., 2006). Participants of DPBRN were recruited through mass mailing to licensed dentists from the participating regions. As part of enrollment in DPBRN, all practitioner-investigators complete an enrollment questionnaire about their practice characteristics and themselves. The enrollment questionnaire and other details about DPBRN are provided at http://www.DentalPBRN.org. We have demonstrated that DPBRN dentists have much in common with dentists at large (Makhija et al., 2008).

Procedure

The survey was sent to all DPBRN dentist practitioner-investigators who perform restorative dentistry in their practices. The full questionnaire is available at http://www.DentalPBRN.org. At the time of the survey there were 932 network practices that fit this criterion. The study was approved by the respective Institutional Review Board (IRB) of all participating regions. Participants who were not exempt from IRB signed the appropriate informed consent form. Practices were requested to return the questionnaire within three weeks. A reminder letter was sent after the third week to clinicians who had not returned the questionnaire. After a final three-week waiting period, if the dentist had not returned the questionnaire, we assumed that he or she was not interested in participating.

Participation rate

The 534 dentists who returned the survey represent an overall participation rate of 57%. There were no statistically significant differences in participation by gender, area of specialty, years since dental school graduation, or whether the dentist practices full-time or part-time. Fourteen dentists reported they do not perform restorative dentistry procedures on patients between the ages 6 and 18. Eleven dentists from areas outside of the five DPBRN regions also completed this survey, but are not included in the following analyses. We present data from the 509 practitioners (419 male, 90 female) who treat patients ages 6-18 years of age in their practices and returned the survey. For the final sample, 85% work on a full-time basis and the mean numbers of years since graduation was 23.0 (SD=10.6). By specialty, the distribution was general practitioner 93% (n=472), pediatric 5% (n=27), and other 2% (n=8).

Dental practices were distributed by region as follows: AL/MS=298, FL/GA=100, MN=30, PDA=51, SK=30. Demographic descriptors by region are presented in Table 1. All of the prevention questions were answered by 503 of the dentists; consequently, some questions have slightly different sample sizes.

Table 1
Demographics for participating network dentists who responded to the survey

Measures

Practice of caries risk assessment

Dentists were asked about whether they assess for caries risk in any way.

Prevention methods

The following questions were asked of each dentist. Of patients 6 to 18 years old, for what percentage do you: Apply dental sealants on the occlusal surfaces of at least one of their permanent teeth? Administer an in-office fluoride application, such as fluoride gel, fluoride varnish, or fluoride rinse? Recommend a non-prescription (over-the-counter) fluoride rinse? Provide a prescription for some form of fluoride? Recommend an at-home regimen of chlorhexidine rinse? Recommend sugarless chewing gum or xylitol chewing gum? The response choices for these questions were: none or 0% of my patients; 1 to 24%; 25 to 49%; 50 to 74%; 75 to 99%; all or 100%.

Practice Model

Dentists associated with PDA or HealthPartners were categorized as large group practice model. Other practices were assigned by regional coordinators to the categories of private practice or public health clinic. It is acknowledged that some dentists assigned to a private practice model were also members of small (less than 4 dentists) group practices.

Other practice characteristics

Full-time/part-time status was determined by asking dentists if they worked 32 or more hours per week (full-time) or less than 32 hours per week (part-time). Percent of patient seen that are between the ages of 1-18 year of age. The number of days patients wait for a new patient exam.

Statistical methods

Region differences were tested using the General Linear Model within SPSS for the percentages of patients within each practice receiving (or having recommend) the caries prevention techniques. The percentages for each caries prevention methodology were coded to the categories' medians as follows to maintain the interval nature of the data so that parametric statistics could be used: 0%=0%, 1-24%=12.5%, 25-49%=37%, 50-74%=62%, 75-99%=87%, 100%=100%. Gender of the dentist, practice model, years since graduation, full/part time status, percent of children seen, and the examination wait time were also entered in each statistical model to adjust for differences across regions. Covariates were reported where significant. Pair-wise comparisons were performed using a Bonferroni correction. Associations between caries risk assessment and caries prevention were tested using Spearman's correlation.

Results

There were larger percentages of male dentists in the AL/MS, FL/GA, and PDA regions than the SK and MN regions (p < .005) (Table 1). The mean number of years since graduation from dental school differed across the five DPBRN regions (p< .001); dentists in the AL/MS and FL/GA regions had practiced significantly longer than dentists in the PDA region. There were no differences in specialty or whether the practitioner works full vs. part time across the regions.

Practice type by region

To test for potential confounds between region and practice model, we performed multiple t-tests to compare dentists within the MN region (private practice vs. large group practice model) and the Scandinavian region (private practice vs. public health clinic) for all six preventive agents. These two regions had sufficient number of dentists in the second practice model to make the use of inferential statistics meaningful (see Table 1). Within the MN region, dentists in a private practice model qualitatively differed from large group practice dentists on the use of sealants (87%, 64%, p = .09), in-office fluoride (90%, 46%, p = .002), and non-prescription fluoride (43%, 55%, p =.21). Within the SK region, dentists in a private practice model were qualitatively different from public health clinic dentists on the use of sealants (41%, 57%, p = .13). No other tests reached or approached significant at p = .05. Because of empty cells, 2-way ANOVAs were not possible; consequently the practice model variables were used as covariates as appropriate in all other analysis.

Frequency of caries prevention techniques

Figure 1 and Table 2 presents the use of preventive techniques. The in-office treatments (sealants and fluoride) were the interventions used most often. Thirty-six percent (n=193) of dentists indicated they use in-office fluoride on all of their child/adolescent patients, whereas 10% (n=55) would always use a sealant. Only seven dentists indicated they never use either sealants or fluoride treatments. At-home caries prevention regimens were recommended less often. However, at-home fluoride was still recommended by many of the dentists to at least some of their child and adolescent patients. For example, 5% (n=29) recommend some form of at-home fluoride treatment to all of their patients and 29% (n=153) recommended at least one of them to at least 50% of their patients.

Figure 1
Percent use of common caries preventive agents
Table 2
Use of preventive techniques by percentage of patients receiving each treatment

Dental sealants

There were significant differences across region for the percentage of patients within a practice who receive dental sealants (p< .001). Sealants were used most often by dentists from the PDA region (89%), compared to dentists from the FL/GA (73%), MN (67%), AL/MS (66%), and SK (50%) regions. FL/GA and AL/MS dentists also used sealants more often than SK dentists. Sealants were used most often by dentists from a large group practice model (81%), compared to dentists from the private practice model (67%) or public health clinics (64%). Female dentists (74%) were more likely to use dental sealants than male dentists (67%). The percentage of children and adolescents and the examination wait time were positively associated with use of dental sealants.

In-office fluoride

There were significant differences across region for the percentage of patients who receive in-office fluoride (p< .001). In-office fluoride was used more often by dentists from the PDA (94%), AL/MS (86%), and FL/GA (85%) regions, compared to dentists in the MN (52%) and SK (50%) regions. In-office fluoride was used more often by dentists from a private practice model (84%) or large group practice model (78%) than those dentists from a public health model (54%).

Over-the-counter fluoride (OTC)

There were significant differences across region for the frequency of patients within a practice who are recommended OTC fluoride (p< .001). OTC fluoride was more often recommended by dentists from the MN (54%) and PDA (48%) regions, and least by dentists from the AL/MS (26%) and SK (17%) regions. FL/GA (38%) dentists also recommended OTC fluoride more often than SK dentists. Graduation year was also significant (p=.036), with younger dentists recommending OTC fluoride more commonly than older dentists. There was no difference by practice model but the examination wait time was positively associated with the frequency of OTC fluoride recommendation (p = .04).

Prescription fluoride

There were significant differences across region for the percent of patients who are provided with a prescription for fluoride (p< .001). Prescription fluoride was more often recommended by dentists from the PDA region (39%), compared to any of the other regions (FL/GA, 23%; AL/MS 19%; SK, 11%; MN, 10%). FL/GA dentists also recommended non-prescription fluoride more often than SK dentists. There was no difference by practice model but the examination wait time was positively associated with the provision of a prescription fluoride.

Chlorhexidine rinse

There were no significant differences across region for use of chlorhexidine rinse (p= .073). PDA (11%) dentists used chlorhexidine rinse more often than AL/MS (8%) and SK dentists (5%), whereas the FL/GA (8%) and MN (6%) dentists did not differ from the other regions.

Sugarless or xylitol chewing gum

There were no significant group differences for recommending sugarless or xylitol chewing gum. However, sugarless or xylitol chewing gum was recommended by dentists from all regions (PDA, 34%; FL/GA, 38%; AL/MS, 38%; SK, 31%; MN, 20%).

Prevention and caries risk assessment

The caries risk assessment item was not answered by 22 network dentists. Seventy percent of network dentists (n=354) reported they perform a caries risk assessment. Performing caries risk assessment was associated with recommending non-prescription fluoride rinse (r=.14, p=.002) or chewing gum (r=.13, p=.004) to more patients. The in-office fluoride, dental sealant, or chlorhexidine rinse were not associated with caries risk assessment. Significantly more dentists from the PDA (98%), SK (93%), and MN (83%) regions reported the use of caries risk assessment than those from the AL/MS (65%) and FL/GA (57%) regions.

Discussion

We found that the majority of dentists report providing most of their pediatric patients with some form of in-office caries prevention. Fluoride in the form of a fluoride gel, fluoride varnish, or fluoride rinse was the most commonly used. Of the at-home caries prevention modalities, recommendation of a non-prescription fluoride rinse was the most common.

Other studies vary with respect to the prevalence of caries prevention agents administered, depending on whether the data come from self-report by dentists or from population studies. For example, 91% of a sample of Indiana dentists reported they “Always or Usually” administer fluoride treatments to children with active caries, while 60% said they provide fluoride treatments for children without active caries (Yoder, 2007). Primosch and Barr (2001) found that approximately 80% members of the American Academy of Pediatric Dentistry that responded to a survey reported that they sealed caries-free and questionable carious surfaces; only 20% indicated that they sealed incipient carious surfaces and none said that they would seal over caries. A study of Texas Academy of Pediatric Dentists by Trueblood and colleagues (2008) serves to provide a non-network comparison. They found that sealant treatments are provided during 67% of recall visits for pediatric patients. When asked which specific preventive treatments were used in their offices, 92% indicated that they place sealants, 92% apply fluoride and varnishes, and 29% use chlorhexidine rinse. It appears that these pediatric dentists were responding that they use these interventions on at least some patients, so a direct comparison can be made to the 98% of DPBRN dentists who report using sealants and topical fluorides and 54% of dentists who occasionally recommend chlorhexidine.

Studies using chart reviews suggest fewer children received significant caries prevention. For example, Helminen and Wehkalahti (2003) examined dental care data from the Helsinki City Health Department in Finland. They found that repeated caries prevention regimens, consisting of sealant, topical fluoride, and cleaning, were received by 29% of the children 6-15 years of age and 24% of 16-18 year-olds. A review of clinical notes from 50 general dental practitioners in the United Kingdom also found low rates of preventive treatments (Tickle et al., 2003). Fourteen percent of children were prescribed fluoride tablets and 14% had fluoride varnish applied to their teeth. Interestingly, socioeconomic status was not associated with receiving a prescription for fluoride tablets, but children from more affluent backgrounds were significantly more likely to have fluoride varnish applied to their teeth.

National surveys indicate that sealants are underutilized. For example, the Third National Health and Nutrition Examination Survey, conducted from 1988 to 1994, found that among U.S. children ages 5 to 17, only 19% had at least one sealant (Cherry-Peppers and Gift, 1995). Because these data are about 20 years old, they may not represent current practice.

Regional use of prevention

Among the DPBRN regions, PDA dentists consistently recommend and provide caries prevention most often, whereas the SK dentists were the least likely to provide these services. The frequency of caries prevention techniques used by dentists in the FL/GA and AL/MS regions was somewhere in the middle (i.e., neither most- nor least-frequent). Consequently, consistent differences between private practice and large group practice models or public health clinics were not observed. Certainly for fluoride treatment, levels of water fluoridation could account for regional differences. However, many studies have indicated that supplemental fluoride practices of dental offices are poorly correlated with the fluoride content in drinking water (Osso et al., 2008; Narendran et al., 2006).

We had not hypothesized the less-frequent use of nearly all of the caries prevention techniques by the practices in the Scandinavian region. This is surprising, particularly given their generally conservative approach to caries restoration and the practice philosophy to allow early lesions the opportunity to remineralize (Lith et al., 1995; 2002). Although it does not appear that they practice caries risk assessment more often than the large group practices in the US, one possibility is that Scandinavian dentists use differently the information that they collect during caries risk assessment. Scandinavian dentists' relatively higher use of caries risk information may allow the lower overall use of caries prevention treatment through more-customized or more-targeted application to high-risk patients. Among the DPBRN Scandinavian countries, dental care is subsidized or provided free through the school systems for all children. As a consequence, school-age children are seen more regularly and caries prevention or caries management may be more effective, further reducing the need for more sealants and topical application of fluoride. These countries strongly promote the regular use of fluoride toothpaste and public education that emphasizes oral hygiene and improved diet (Burt, 1998), which further reduces caries risk and need for professionally-administered preventive treatment. Other possible explanations include differing financial incentives for sealants or fluoride prescriptions for children and adolescents or differing levels of overall risk observed.

Prevention and risk assessment

We found that most of the dental practices reported they perform a caries risk assessment. However, the number that do not use risk assessment suggests that many practitioners are not heeding the recommendations of current research reviews (Bader et al., 2003). From a regional and practice model perspective, network practices from PDA, SK, and MN regions were more likely to use caries risk assessment than the predominately private practice regions (AL/MS and FL/GA). The current data indicate that performing caries risk assessment is only weakly correlated with dentists' use of some in-office or at-home caries prevention regimens, and suggest that risk assessment does not change decisions about prevention. We did not have individual patient-level data to test whether use of prevention differed by levels of risk. There is a descriptive study of 15 dental offices by Bader et al. (2003) that found that patients determined to be of highest risk had more of some caries preventive treatments included in their treatment plan than patients at low risk. However, it is not clear whether participation in the study influenced clinicians' decisions about prevention.

When assessing practice patterns at the level of the individual practice, Primosch and Barr (2001) found that most pediatric dentists indicated sealants are placed without regard for the child's caries risk. Another study also failed to find an association between sealant use and caries status (Clark and Berkowitz, 1997). Eklund et al (2000) reported that many US dentists do not apply topical fluoride based on caries risk. However, a survey of members of the Texas Academy of Pediatric Dentists found that 56% of the respondents indicated that they implement different treatment programs based on caries risk status (Trueblood et al., 2008). The current survey did not ask this specific question, but if only 57% (FL/GA) and 65% (AL/MS) of the regions with private practice dentists are performing caries risk assessment, it is less likely these dentists actually use these data for most of their treatment decisions.

The time spent by Scandinavian dentists providing caries prevention supports the hypothesis that they make prevention decisions based on need. Helminen and Vehkalahti (2003) found that the average time spent administering basic caries prevention that included sealants and topical fluoride was just under 4 minutes for children in the low caries risk group and just over 8 minutes for children in a high caries risk group. Siegal et al. (1996) found that among US dentists, the level of sealant use was associated with other factors, such as dentists' knowledge about sealants, number of children seen in the practice, and insurance coverage for sealants.

Particularly among dentists in the United States, third-party payment may limit use of preventive treatment because it is not remunerated or not remunerated as well as restorative treatment (Fiset et al., 2000). A study by Dasanayake and colleagues (2001) concluded that low insurance payment/claim ratio could be one of the obstacles to increasing sealant application. The 2000 Surgeon General Report commented that third-party payment systems (e.g., health insurance companies) should acknowledge their responsibility to compensate providers adequately for conservative but effective therapy (USDHHS, 2000). To be effective, risk assessment must be accompanied by an appropriate intervention, prevention and /or surgical treatment and patient education. It is unclear, however, how and if dentists systematically incorporate this information into their treatment decisions (Bader and Shugars, 1997).

Conclusion

The majority of dentists report providing most of their pediatric patients with some form of in-office caries prevention. However, whether or not dentists used caries risk assessment with their pediatric patients was poorly correlated with the likelihood of actually using caries preventive treatments on patients. This suggests that not all practicing dentists use caries preventive agents in the same way. It is not known whether these differences are a function of lack of knowledge of the value of caries prevention, practice philosophies associated with differing financial incentives, or patient pools with differing levels of overall caries risk.

Current best practice suggests the choice of preventive therapy should depend on the individual risk of the child (Rosier 2001; Bader et al., 2001). Our data support the assertion made by Tinahoff and Douglas (2002), that there is often little discrimination in clinical practice between the intensity and choice of preventive therapies that are prescribed to children (Tinahoff and Douglass, 2002). Fluoride is the most scientifically proven method for avoiding the appearance of new lesions and curbing the progression of existing lesions and preventing the appearance of new ones (Puy and Navarro, 2008). Future research must better examine the use of prevention in the context of patient risk at the practice and individual patient levels.

Acknowledgments

This investigation was supported by National Institutes of Health, National Institute of Dental and Craniofacial Research grants U01-DE-16746 and U01-DE-16747. An Internet site devoted to details about DPBRN is located at www.DPBRN.org. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. The informed consent of all human subjects who participated in this investigation was obtained after the nature of the procedures had been explained fully.

Contributor Information

Joseph L. Riley, III, Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, Florida, USA.

Joshua S. Richman, Preventive Medicine and Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA.

D. Brad Rindal, HealthPartners, Minneapolis, Minnesota, USA.

Jeffrey L. Fellows, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA.

Vibeke Qvist, Department of Cariology and Endodontics, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.

Gregg H. Gilbert, Department of Diagnostic Sciences, School of Dentistry, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Valeria V. Gordan, Department of Operative Dentistry, College of Dentistry, University of Florida, Gainesville, Florida, USA.

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