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Journal of Dental Research

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Risk Factors of Caries Progression in a Hispanic School-aged Population


M. Fontana, E. Santiago, G.J. Eckert and A.G. Ferreira-Zandona
J DENT RES 2011 90: 1189 originally published online 15 July 2011
DOI: 10.1177/0022034511413927

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RESEARCH REPORTS
Clinical

M. Fontana1*, E. Santiago2,G.J. Eckert3,


and A.G. Ferreira-Zandona4
Risk Factors of Caries Progression
1
Department of Cariology, Restorative Sciences and
in a Hispanic School-aged
Endodontics, University of Michigan School of Dentistry,
1011 North University, Room 2029B, Ann Arbor, MI 48109, Population
USA; 2Research Center, University of Puerto Rico School of
Dentistry, San Juan; 3Department of Medicine, Indiana
University School of Medicine, Indianapolis; and 4Department
of Preventive and Community Dentistry, Indiana University
School of Dentistry, Indianapolis; *corresponding author,
mfontan@umich.edu

J Dent Res 90(10):1189-1196, 2011

Abstract Introduction
The purpose of this Institutional Review Board-
approved study was to identify risk factors of car-
ies lesion progression in children enrolled in rural
R isk-based prevention and management have been recognized as the cor-
nerstones of modern caries management (Zero et al., 2001; Featherstone,
2003; Fontana and Zero, 2006; Twetman and Fontana, 2009). The fact that the
schools in Puerto Rico. A convenience sample of
presence of recent restorations is one of the greatest indicators of future caries
408 children (5-13 yrs old) was examined at base-
risk (Zero et al., 2001) only proves that the act of surgically treating the lesion
line and at 12 and 24 mos with the International
does little to reduce caries risk. Caries risk assessment involves an analysis of
Caries Detection and Assessment System (ICDAS).
the probability that there will be a change in the number (incidence), sever-
A total of 395 caregivers completed a 25-item
ity, and/or activity of caries lesions (Fontana and Zero, 2006). Because of the
questionnaire including socio-demographic,
multifactorial nature of the caries process, and the fact that the disease is very
dietary, protective factors, disease experience, and
dynamic (e.g., lesions can progress and/or regress), studies on risk assessment
access to care. Caries progression was significant
tend to be complex, with a multitude of variables challenging the prediction at
(89% and 91% at 12 and 24 mos, respectively).
different times during life (Twetman and Fontana, 2009). In addition, risk fac-
Multiple-variable models for predicting children
tors may vary based on race, culture, and ethnicity (Huntington et al., 2002;
with lesion progression and numbers of lesions
Shiboski et al., 2003; Eckert et al., 2010; Fontana et al., 2010). For a clini-
progressing were calculated for 2 outcome vari-
cian, the concepts of risk assessment and prognosis are an essential part of
ables (any-progression vs. progression-toward-
clinical decision-making. In fact, the dentist’s overall subjective impression
cavitation). Models developed had areas under the
of the patient might have good caries-predictive power (Disney et al., 1992),
receiver operating characteristic (ROC) curve
but it is unclear how this information is incorporated into everyday practice.
ranging between 0.70 and 0.79 and were very
A recent survey of US practices suggests that a significant proportion of den-
similar regardless of the outcome (progression
tists had yet to adopt treatments based on assessment of caries risk (Riley
criteria), prediction time (12-24 mos), or inclusion
et al., 2010), even when multiple expert-opinion tools are available for chil-
(or not) of previous caries experience. Significant
dren [e.g., Caries Assessment Tool-CAT of the American Academy of Pediatric
predictors of disease progression collected through
Dentistry, developed for use in multiple settings (2007); the American Dental
a parent-completed questionnaire included ques-
Association’s Caries Risk Tool (2008); the Caries Management by Risk
tions related to caries experience in the child or
Assessment tool (Ramos-Gomez et al., 2007)]. Therefore, a more objective,
caregiver, and the caregiver’s rating of the child’s
easy-to-implement, and validated risk tool is highly desirable, particularly for
oral health.
use in non-dental settings (e.g., schools, medical offices), to help target lim-
ited human/economic resources toward disease prevention.
KEY WORDS: longitudinal study, Hispanic, The objective of this study was to identify risk factors of caries lesion
dental caries, risk assessment, lesion progression, progression and numbers of lesions progressing in children enrolled in rural
number of lesions. schools in the Commonwealth of Puerto Rico. This project is part of a larger
prospective longitudinal study to establish the feasibility of using early non-
DOI: 10.1177/0022034511413927
cavitated lesions as a surrogate for cavitated lesions, by studying the natural
Received December 23, 2010; Last revision May 20, 2011; history of dental caries over 4 yrs (Ferreira-Zandona et al., 2010).
Accepted May 20, 2011

A supplemental appendix to this article is published elec- Materials & Methods


tronically only at http://jdr.sagepub.com/supplemental.
This longitudinal study was approved by Indiana University and the University
© International & American Associations for Dental Research of Puerto Rico. Children (N = 529) in 3 public schools in the area of Aguas

1189
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© 2011 International & American Associations for Dental Research


1190  Fontana et al. J Dent Res 90(10) 2011

Buenas were recruited. For inclusion, parental consent was Baseline ICDAS scores were examined for significance in 2
obtained, and children had to be 5 to 13 yrs of age, provide assent ways. For models that could be used in non-dental settings, it
if older than 7 yrs, be available for all examination visits, have at would be important to assess predictors collected through a
least one permanent molar with at least one unrestored surface, questionnaire first, without using the results of a caries examina-
have no medical problem for participation (i.e., need of premedi- tion. Thus, caries experience was not used until the prediction
cation, epilepsy), and allow examination of the oral cavity. model had been developed, and then was added to see if it
We examined a convenience sample of 408 children at baseline improved the prediction. For models that could be used in a
and 12 and 24 mos to monitor caries development/progression in dental setting, we started with previous caries experience (dmfs/
primary and permanent teeth, using the International Caries DMFS at baseline, using ICDAS ≥ 3 as caries), since this
Detection and Assessment System (ICDAS) applied by a single would be the easiest variable to obtain, and included additional
calibrated dentist (Ismail et al., 2007). Ten percent of the chil- questionnaire-based predictors as explained previously. A simi-
dren were re-examined after each visit to determine intra- and lar process was utilized for the Poisson regression analyses of
inter-examiner (examiner and back-up examiner) reliability. At the numbers of lesions with progression.
each visit, teeth were cleaned with a toothbrush, air-dried, and
assessed under light, without magnification. Bitewing radio-
Results
graphs were taken at baseline and annually thereafter. Risk
questionnaires were sent home to all caregivers at the 12- and Most caregivers were mothers, but also included 19 fathers, 12
24-mo examinations. ‘Caregiver’ was defined as the individual grandmothers, and 5 others. The children (49% females, 51%
consistently responsible for the child’s housing, health, and males) were 5 to 13 yrs old at baseline (9.7 ± 2.2 yrs, mean ±
safety. standard deviation). The ethnic/racial distribution of the children
A total of 395 caregivers completed and returned the 25-item was self-reported (rounded%): Hispanic (all races), 91%; African-
questionnaire (English version in the Appendix) at both time American-Non-Hispanic, < 1%; Other-Non-Hispanic, < 1%; and
intervals, which included socio-demographic, dietary, protective unknown, 8%. Children were covered by health insurance (86%)
factors, disease experience by the child and caregiver, and through the 1993 Puerto Rico Health Reform, while 48% of care-
access to care. The questionnaire was adapted from a previously givers had completed high school, and 51% had technical/college
published one used in preschool children (Fontana et al., 2010). degree. Children had a dmfs/DMFS (ICDAS ≥ 1) = 15.7 ± 12.4
At every examination, caregivers were informed of conditions (mean ± standard deviation) and dmfs/DMFS (ICDAS ≥ 3) = 8.2
requiring treatment, and the child was referred for care. Data ± 8.6 at baseline. By the 12-mo examination, 348 (89%) children
were analyzed for identification of children with lesion progres- had at least one surface with Any-Progression and 239 (61%) with
sion and numbers of lesions progressing using 2 types of pri- a Progression-Toward-Cavitation [dmfs/DMFS (ICDAS ≥ 1) =
mary outcomes for predictive modeling: 17.9 ± 13.8; dmfs/DMFS (ICDAS ≥ 3) = 8.3 ± 8.5]. By the 24-mo
(1)  Any-Progression (caries if ICDAS ≥ 1): Presence of at examination, 358 (91%) children had at least one surface with
least one new lesion ICDAS ≥ 1 (i.e., any lesion), one new fill- Any-Progression and 268 (68%) with a Progression-Toward-
ing, and/or progression of a lesion from a score of 1-2 (first Cavitation [dmfs/DMFS (ICDAS ≥ 1) = 16.8 ± 12.4; dmfs/DMFS
initial signs of caries lesion) to 3 or higher (established caries), (ICDAS ≥ 3) = 8.4 ± 8.1]. There were few lesion reversals
or from a score of 3-4 (established caries) to 5 or higher (severe (for ICDAS ≥ 1 = 1.9 ± 2.4 at 12 mos and 2.1 ± 2.8 at 24 mos; for
caries) between the 2 examinations. ICDAS ≥ 3 = 0.2 ± 0.5 at 12 and 24 mos). Repeatability of the
(2)  Progression-Toward-Cavitation (caries if ICDAS ≥ 3): ICDAS severity scores at all examinations (mean weighted kappa
Presence of at least one new lesion ICDAS ≥ 3, one new filling, = 0.72) was acceptable. Radiographic data were not included in
and/or progression of a lesion from a score of 1-2 to 3 or higher, the analysis of the present study.
or lesions progressing from a score of 3-4 to 5 or higher between There were very few missing responses for each question-
the 2 examinations. naire item (2.2 ± 1.8%; range = 0-8.1%). For models developed
Predictors included baseline questionnaire responses and for use in non-dental settings, predictors of the primary outcome
ICDAS examination results. Questionnaire items were catego- were first examined individually. Significance of individual
rized as: demographics/access to care, medical history, dental predictors for identification of a child is shown in the Fig., with
history, dental habits, dietary habits, and protective factors. lesion progression at 24 mos according to the 2 outcome criteria.
Repeatability of the ICDAS scores was assessed with 2-way The final multiple-variable models for predicting children at
contingency tables and kappa statistics. risk based on lesion progression at 12 and 24 mos are shown in
Logistic regressions were performed for progression at 12 Table 1. The AUC and identified predictors were in general very
and 24 mos using each predictor individually. Parsimonious similar and ranged from 0.70 to 0.79 regardless of progression
multiple-variable models were developed with a backward- criteria and time of follow-up. In general, high sensitivities
elimination procedure to retain predictors with p < 0.05 in the could be reached, but at the expense of specificity. Although the
final model. The area under the receiver operating characteristic addition of previous caries experience (dmfs/DMFS at baseline,
(ROC) curve (AUC) was calculated to assess the overall predic- using ICDAS ≥ 3) does add to the models developed, it does not
tive ability of the final models. The use of the AUC is one way greatly affect the prediction ability of the model. For models that
of measuring the accuracy of caries risk assessment and is a could be used in a dental setting, predictors and predictive abil-
common way to measure the prognostic ability of risk factors. ity of the developed models were in general very similar to the

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J Dent Res 90(10) 2011 Caries Risk Factors in Hispanics  1191

Figure. Odds ratios with 95% confidence intervals for questionnaire items for Progression-1 (caries if ICDAS ≥ 1) and Progression-2 (caries if
ICDAS ≥ 3) at 24 mos. CG = Primary caregiver. HCP = Health-care provider.

ones developed for non-dental settings, but included fewer ques- morbidity, suboptimal health status, underuse of health services,
tions. The numbers of caries lesion progression counts per and impaired access to care. For example, Puerto Rican children
questionnaire item for each outcome variable (Table 2) were have the highest prevalence of active asthma (14.1%), exceeding
very similar among questions, and much higher for Any- by far the prevalence for African-American-Non-Hispanics
Progression. The final multiple-variable models for predicting (10.2%) and Caucasian-Non-Hispanics (7.6%) (CDC, 2010). In
numbers of lesions progressing at 12 and 24 mos are shown in our study, disease progression in this rural population was sig-
Table 3 (i.e., numbers of lesions are additive across all variables nificant over the 24-mo follow-up period (89% and 91% at 12
in a model). These models included predictors similar to those and 24 mos, respectively), which is in agreement with high caries
developed to identify children with lesions progressing, with the rates found in other studies of Hispanic population subgroups
addition of the use of additional fluoride products at home. (Flores et al., 2002).
Objective caries risk assessment is greatly needed and can
facilitate the process of early identification of children at high
Discussion
risk and assist in decision-making to tailor appropriate preven-
There are many disparities in dental caries experience in the US, tive interventions and the periodicity of these services.
with the disease being particularly prevalent in children from Unfortunately, “past caries experience” is one of the most pow-
minority (racial and ethnic) and low socio-economic (SES) erful predictors of future caries development (Zero et al., 2001).
groups (Beltrán-Aguilar et al., 2005; Dye et al., 2007). Hispanics However, from a disease management perspective, this is a less
are the largest racial/ethnic minority group of US children and than desirable outcome, since the disease is manifested before
are in general underserved and high-risk populations because it can be accurately predicted, and the ultimate goal of caries
they experience a disproportionate burden of health risk factors, management is to prevent disease. It is also an impractical

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1192  Fontana et al. J Dent Res 90(10) 2011

Table 1. Multivariate Caries Risk Models for Identification of At-risk Individuals with Lesions Progressing at 12 and 24 Months According to 2
Outcome Criteria

Model (start with dmfs/DMFS then


Model (No dmfs/DMFS) Model (add dmfs/DMFS at end) add other variables)

Examination
Period Predictors p-value Odds Ratio (95% CI) p-value Odds Ratio (95% CI) p-value Odds Ratio (95% CI)

12 months Child had a tooth extracted 0.0002 2.56 ( 1.56, 4.17) 0.0111 1.97 (1.17, 3.32) 0.0177 1.96 (1.12, 3.44)
(ICDAS ≥ 3) Child had a tooth restored 0.0029 2.08 (1.28, 3.33) 0.0323 1.74 (1.05, 2.89) 0.0125 1.97 (1.16, 3.36)
  Time elapsed since last dental 0.0063 2.22 (1.19, 4.17) for 0.0129 2.04 (1.08, 3.85) 0.0190 2.10 (1.06, 4.17)
visit < 3 months vs. ≥ 6
months
  0.76 (0.45, 1.30) for 0.74 (0.43, 1.26) 0.74 (0.42, 1.32)
3, 6 months vs. ≥ 6
months
  CG does not consider child’s 0.0001 2.68 (1.67, 4.32) 0.0005 2.37 (1.46, 3.86) 0.0014 2.33 (1.39, 3.90)
oral health to be ’very good’
  CG received a referral for the 0.0218 1.80 (1.09, 2.98)
child
  Child drinks soda between meals 0.0496 1.75 (1.00, 3.08)
  dmfs/DMFS 0.0065 1.17 (1.05, 1.31) 0.0260 1.14 (1.02, 1.29)
  AUC 0.75, 80% sensitivity, AUC 0.77, 81% sensitivity, 58% AUC 0.79, 81% sensitivity,
58% specificity specificity 57% specificity
12 months Child had a tooth extracted 0.0006 3.97 (1.45, 10.9) 0.0067 4.05 (1.47, 11.1) 0.0067 4.05 (1.47, 11.1)
(ICDAS ≥ 1) CG does not consider child’s 0.0338 5.43 ( 2.07, 14.3) 0.0217 2.27 (1.13, 4.59) 0.0217 2.27 (1.13, 4.59)
oral health to be ’very good’
  dmfs/DMFS 0.0835 1.19 (0.98, 1.44) 0.0835 1.19 (0.98, 1.44)
  AUC 0.74, 77% sensitivity, AUC 0.77, 79% sensitivity, AUC 0.77, 79% sensitivity,
63% specificity 58% specificity 58% specificity
24 months Child had a tooth restored 0.0004 2.38 (1.47, 3.85) 0.0215 1.81 (1.09, 3.00) 0.0162 1.83 (1.12, 2.99)
(ICDAS ≥ 3) Time elapsed since last dental 0.0270 1.93 (1.02, 3.68) for 0.0602 1.67 (0.85, 3.23)
visit < 3 months vs. ≥ 6
months
  0.76 (0.45, 1.30) for 0.72 (0.42, 1.23)  
3, 6 months vs. ≥ 6
months
  CG does not consider child’s 0.0001 2.80 (1.74, 4.48) 0.0010 2.28 (1.40, 3.73) 0.0029 2.05 (1.28, 3.28)
oral health to be ’very good’
  dmfs/DMFS 0.0012 1.21 (1.08, 1.36) 0.0007 1.21 (1.08, 1.35)
  AUC 0.70, 73% sensitivity, AUC 0.73, 73% sensitivity, AUC 0.70, 73% sensitivity,
61% specificity 61% specificity 61% specificity
24 months CG has current caries 0.0160 2.62 (1.20, 5.71) 0.0299 2.40 (1.09, 5.32) 0.0097 2.77 (1.28, 5.99)
(ICDAS ≥ 1) Child had a tooth restored 0.0321 2.31 (1.07, 4.98) 0.1659 1.80 (0.78, 4.12)
  CG received a referral for the 0.0289 2.43 (1.10, 5.38) 0.0411 2.30 (1.03, 5.13) 0.0157 2.61 (1.20, 5.68)
child
  CG does not consider child’s 0.0363 2.33 (1.06, 5.15) 0.0793 2.04 (0.92, 4.55)  
oral health to be ’very good’
  dmfs/DMFS 0.1318 1.18 (0.95, 1.47) 0.0118 1.33 (1.07, 1.66)
  AUC 0.75, 82% sensitivity, AUC 0.76, 84% sensitivity, AUC 0.77, 75% sensitivity,
59% specificity 59% specificity 61% specificity

assessment indicator, especially for at-risk populations with dif- Multiple factors have been proposed in caries risk assess-
ficulties accessing dental care (e.g., those from racial or ethnic ment, varying sometimes based on the age group at which they
minorities and low SES, or rural communities such as the one in are targeted. Prediction models which include a variety of fac-
this study). In fact, dental care is one of the most difficult health tors seem to increase the accuracy of the prediction in young
care services for low-income people to obtain, due to a lack of children (Fontana et al., 2010b). A recent study in Singapore
dental insurance, limited dental benefits available through pub- showed that caries prediction based on a questionnaire reached
lic insurance programs, and a paucity of dentists available to a sensitivity/specificity of 0.82/0.81 in 3- to 6-year-olds (Gao
serve these patients (Felland et al., 2008). Strategies to address et al., 2010). However, additional risk factors (e.g., plaque, bac-
these problems include promoting risk-based individualized terial tests, salivary factors, exposure to fluoride) do not seem to
preventive regimens in a variety of settings (e.g., dental and markedly improve the prediction in older schoolchildren, ado-
medical offices, schools) (USDHHS, 2000). lescents, and adults (Disney et al., 1992; Vanobbergen et al.,

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J Dent Res 90(10) 2011 Caries Risk Factors in Hispanics  1193

Table 2.  Number of Caries Lesion Progression Counts per Survey Question Analyzed Individually

12-month 12-month 24-month 24-month


(ICDAS ≥ 1) (ICDAS ≥ 3) (ICDAS ≥ 1) (ICDAS ≥ 3)  

Question Count (95% CI) p-value Count (95% CI) p-value Count (95% CI) p-value Count (95% CI) p-value

CG has current caries No 6.80 (5.83, 7.93) 0.0195 2.19 (1.75, 2.75) 0.0525 7.88 (6.81, 9.11) 0.0478 2.96 (2.4, 3.65) 0.0261
  Yes 8.47 (7.62, 9.41) 2.85 (2.45, 3.32) 9.41 (8.5, 10.42) 3.91 (3.41, 4.5)  
CG supervises child’s Regularly 8.24 (7.15, 9.5) 0.6827 3.11 (2.57, 3.76) 0.0651 9.54 (8.34, 10.92) 0.2003 4.16 (3.48, 4.97) 0.0501
toothbrushing Occasionally 7.66 (6.79, 8.65) 2.42 (2.02, 2.89) 8.72 (7.77, 9.8) 3.37 (2.86, 3.97)
  No 7.45 (5.75, 9.64) 2.00 (1.32, 3.02) 7.36 (5.65, 9.59) 2.60 (1.76, 3.83)  
CG education High school 8.51 (7.53, 9.62) 0.0614 2.97 (2.5, 3.52) 0.0149 9.92 (8.85, 11.13) 0.0068 3.96 (3.37, 4.65) 0.0825
  Post-high school 7.29 (6.24, 8.51) 1.92 (1.49, 2.46) 7.66 (6.58, 8.93) 2.93 (2.36, 3.65)  
  College degree 6.33 (4.95, 8.09) 2.61 (1.9, 3.57) 7.30 (5.79, 9.19) 3.31 (2.44, 4.49)  
CG received referral No 7.11 (6.18, 8.18) 0.0513 2.48 (2.04, 3.03) 0.4232 7.82 (6.83, 8.96) 0.0112 3.24 (2.69, 3.91) 0.1723
for child Yes 8.48 (7.60, 9.48) 2.76 (2.35, 3.24) 9.75 (8.78, 10.82) 3.83 (3.3, 4.44)
CG followed up on No 7.19 (6.24, 8.28) 0.1208 2.15 (1.73, 2.66) 0.0174 7.83 (6.82, 8.98) 0.0231 2.93 (2.4, 3.57) 0.0074
referral Yes 8.29 (7.41, 9.27) 2.95 (2.53, 3.45) 9.56 (8.6, 10.62) 4.07 (3.53, 4.69)
CG took child to the No 7.84 (7.04, 8.75) 0.8317 2.5 (2.13, 2.93) 0.3174 8.51 (7.65, 9.46) 0.1446 3.38 (2.91, 3.92) 0.1708
dentist after referral Yes 8.01 (6.85, 9.36) 2.87 (2.31, 3.56) 9.73 (8.43, 11.24) 4.02 (3.3, 4.9)
Child had teeth No 7.22 (6.4, 8.14) 0.0461 2.20 (1.84, 2.63) 0.0040 7.90 (7.03, 8.87) 0.0037 3.15 (2.68, 3.7) 0.0191
extracted Yes 8.63 (7.60, 9.80) 3.17 (2.66, 3.77) 10.11 (8.97, 11.39) 4.15 (3.52, 4.89)
Child had teeth filled No 6.51 (5.54, 7.64) 0.0044 1.74 (1.35, 2.25) 0.0001 7.42 (6.37, 8.64) 0.0039 2.43 (1.93, 3.06) 0.0000
  Yes 8.55 (7.70, 9.50) 3.10 (2.68, 3.57) 9.66 (8.74, 10.67) 4.18 (3.66, 4.77)  
Child brushes twice No 7.87 (6.69, 9.25) 0.9406 2.53 (2.00, 3.21) 0.7860 8.74 (7.47, 10.23) 0.8517 3.42 (2.75, 4.27) 0.6415
a day Yes 7.81 (7.04, 8.66) 2.63 (2.27, 3.05) 8.90 (8.06, 9.83) 3.64 (3.18, 4.17)
Amount of toothpaste Length of brush 7.67 (6.94, 8.48) 0.4745 2.66 (2.30, 3.07) 0.6436 8.40 (7.62, 9.26) 0.0635 3.44 (3.01, 3.94) 0.4532
child uses Pea-size 8.28 (6.90, 9.93) 2.47 (1.86, 3.27) 10.12 (8.56, 11.97) 3.83 (3.01, 4.88)
Child has been to the Last 3 months 9.57 (8.13, 11.26) 0.0256 4.22 (3.46, 5.14) 0.0000 10.71 (9.17, 12.52) 0.0240 5.53 (4.59, 6.66) 0.0000
dentist 3-6 months 7.18 (6.06, 8.50) 2.29 (1.80, 2.92) 7.90 (6.71, 9.30) 3.11 (2.48, 3.88)
  6+ months 7.38 (6.47, 8.41) 1.97 (1.60, 2.41) 8.64 (7.64, 9.77) 2.90 (2.42, 3.48)  
Professional fluoride Regularly 7.83 (6.95, 8.83) 0.4847 2.61 (2.20, 3.10) 0.9904 9.21 (8.23, 10.30) 0.4356 3.79 (3.25, 4.43) 0.2340
  Occasionally 7.43 (6.34, 8.69) 2.64 (2.12, 3.29) 8.18 (7.02, 9.53) 3.06 (2.46, 3.82)  
  No 8.78 (7.05, 10.94) 2.56 (1.83, 3.60) 9.24 (7.42, 11.49) 3.91 (2.91, 5.25)  
Child uses additional No 8.46 (7.56, 9.47) 0.0333 2.81 (2.38, 3.31) 0.1762 9.42 (8.45, 10.51) 0.0475 3.76 (3.22, 4.38) 0.2968
fluoride products Yes 6.97 (6.06, 8.01) 2.35 (1.92, 2.87) 7.92 (6.94, 9.05) 3.31 (2.75, 3.98)
at home
Child drinks water No 8.83 (7.27, 10.72) 0.2552 2.46 (1.81, 3.35) 0.6070 8.83 (7.24, 10.76) 0.9205 3.30 (2.48, 4.40) 0.5006
between meals Yes 7.77 (7.04, 8.57) 2.69 (2.34, 3.09) 8.93 (8.13, 9.80) 3.68 (3.23, 4.18)
Type of water child Well water 8.35 (7.01, 9.96) 0.5726 2.41 (1.83, 3.18) 0.8499 9.50 (8.00, 11.27) 0.5863 3.75 (2.95, 4.77) 0.8144
drinks Bottled water 7.31 (6.15, 8.70) 2.61 (2.04, 3.34) 8.38 (7.08, 9.92) 3.37 (2.66, 4.26)
  Tap water 7.81 (6.85, 8.89) 2.65 (2.19, 3.20) 8.78 (7.73, 9.98) 3.61 (3.03, 4.30)  
Child drinks soda No 7.54 (6.30, 9.02) 0.6643 1.86 (1.38, 2.52) 0.0073 8.48 (7.12, 10.1) 0.5767 3.13 (2.42, 4.04) 0.2322
between meals Yes 7.89 (7.13, 8.72) 2.87 (2.50, 3.30) 8.98 (8.15, 9.90) 3.72 (3.25, 4.26)
Child drinks juices No 9.79 (7.15, 13.4) 0.1686 2.67 (1.61, 4.41) 0.9503 9.17 (6.58, 12.76) 0.8109 3.25 (1.99, 5.31) 0.6976
between meals Yes 7.72 (7.06, 8.46) 2.62 (2.30, 2.99) 8.79 (8.06, 9.58) 3.59 (3.18, 4.04)
Child has sweet drinks Never 7.55 (6.43, 8.85) 0.7944 2.74 (2.20, 3.42) 0.8632 8.64 (7.42, 10.05) 0.6391 3.5 (2.84, 4.33) 0.3446
between meals 1x/day 8.69 (6.88, 10.98) 2.80 (1.98, 3.95) 10.10 (8.10, 12.60) 4.57 (3.42, 6.11)
  2x/day 7.62 (6.08, 9.54) 2.37 (1.69, 3.32) 8.42 (6.76, 10.47) 3.22 (2.35, 4.40)  
  >2x/day 7.9 (6.89, 9.06) 2.54 (2.08, 3.11) 8.69 (7.61, 9.92) 3.39 (2.81, 4.10)  
Child snacks between Never 7.97 (6.65, 9.54) 0.3273 2.29 (1.73, 3.04) 0.2970 7.85 (6.52, 9.46) 0.4352 2.99 (2.29, 3.90) 0.3078
meals 1x/day 8.86 (7.19, 10.94) 3.27 (2.45, 4.37) 9.86 (8.05, 12.09) 4.31 (3.28, 5.65)
  2x/day 7.02 (5.98, 8.25) 2.43 (1.93, 3.05) 8.91 (7.7, 10.31) 3.67 (3.00, 4.49)  
  >2x/day 8.19 (7.00, 9.60) 2.77 (2.21, 3.48) 8.96 (7.67, 10.45) 3.54 (2.85, 4.40)  
Child snacks between No 9.18 (7.24, 11.63) 0.1716 2.38 (1.61, 3.51) 0.5921 10.84 (8.67, 13.56) 0.0830 4.6 (3.40, 6.22) 0.1068
meals Yes 7.65 (6.95, 8.42) 2.66 (2.32, 3.05) 8.71 (7.94, 9.55) 3.48 (3.06, 3.96)
Child chews gum Never 7.61 (6.83, 8.48) 0.7831 2.60 (2.23, 3.03) 0.9985 8.47 (7.63, 9.39) 0.4559 3.5 (3.03, 4.03) 0.5517
  1x/day 7.96 (6.17, 10.26) 2.57 (1.77, 3.72) 9.39 (7.40, 11.92) 3.09 (2.14, 4.44)  
  2x/day 7.84 (5.26, 11.69) 2.68 (1.52, 4.73) 10.79 (7.64, 15.25) 4.53 (2.83, 7.23)  
  >2x/day 8.72 (6.91, 11.01) 2.66 (1.87, 3.78) 9.60 (7.66, 12.03) 3.98 (2.93, 5.41)  
Child chews sugar- No 7.80 (6.77, 8.98) 0.8463 2.76 (2.25, 3.37) 0.8698 8.72 (7.60, 10.02) 0.7061 3.57 (2.96, 4.32) 0.6346
containing gum Yes 7.94 (7.00, 9.01) 2.69 (2.24, 3.24) 9.04 (7.99, 10.22) 3.8 (3.22, 4.49)
CG believes child has No 9.25 (8.37, 10.22) 0.0000 3.05 (2.62, 3.54) 0.0007 10.06 (9.11, 11.11) 0.0000 4.15 (3.62, 4.76) 0.0003
’very good’ dental Yes 5.47 (4.65, 6.43) 1.91 (1.51, 2.42) 6.85 (5.90, 7.97) 2.63 (2.12, 3.26)
health
CG believes child has No 7.46 (6.74, 8.25) 0.0426 2.58 (2.24, 2.99) 0.6810 8.56 (7.77, 9.43) 0.1219 3.39 (2.96, 3.88) 0.1021
’very good’ general Yes 9.23 (7.75, 11.00) 2.76 (2.11, 3.61) 10.02 (8.44, 11.9) 4.26 (3.38, 5.36)
health
CG has difficulty No 7.81 (7.14, 8.55) 0.6948 2.65 (2.33, 3.01) 0.5743 8.77 (8.04, 9.57) 0.4409 3.55 (3.15, 4.01) 0.5388
understanding Yes 8.43 (5.86, 12.11) 2.24 (1.24, 4.03) 10.1 (7.19, 14.18) 4.14 (2.6, 6.59)
information from
HCP

(continued)

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1194  Fontana et al. J Dent Res 90(10) 2011

Table 2. (continued)

12-month 12-month 24-month 24-month


(ICDAS ≥ 1) (ICDAS ≥ 3) (ICDAS ≥ 1) (ICDAS ≥ 3)  

Question Count (95% CI) p-value Count (95% CI) p-value Count (95% CI) p-value Count (95% CI) p-value

CG has difficulty No 7.65 (6.98, 8.38) 0.0354 2.59 (2.27, 2.96) 0.5625 8.72 (7.99, 9.52) 0.2195 3.55 (3.14, 4.00) 0.4350
communicating Yes 10.8 (8.06, 14.48) 3.00 (1.88, 4.78) 10.68 (7.9, 14.45) 4.24 (2.78, 6.46)
with HCP
Child is covered under No 7.32 (5.77, 9.29) 0.6128 2.71 (1.96, 3.75) 0.7146 8.86 (7.10, 11.05) 0.9290 3.36 (2.46, 4.58) 0.7465
health care reform Yes 7.82 (7.11, 8.60) 2.54 (2.21, 2.92) 8.76 (8.00, 9.6) 3.55 (3.13, 4.02)  
Race Black 8.53 (5.84, 12.44) 0.2194 2.95 (1.73, 5.04) 0.2992 9.47 (6.59, 13.63) 0.0265 5.00 (3.23, 7.73) 0.0003
  Other 9.50 (7.71, 11.70) 3.32 (2.48, 4.46) 11.66 (9.63, 14.11) 5.55 (4.37, 7.07)  
  Unknown 8.22 (6.11, 11.06) 2.13 (1.31, 3.45) 8.53 (6.35, 11.46) 2.34 (1.44, 3.83)  
  White 7.42 (6.69, 8.23) 2.49 (2.15, 2.90) 8.29 (7.50, 9.16) 3.21 (2.79, 3.69)  
Gender Female 7.62 (6.73, 8.62) 0.5337 2.70 (2.27, 3.20) 0.5779 8.34 (7.39, 9.41) 0.1766 3.56 (3.03, 4.19) 0.9926
  Male 8.05 (7.13, 9.09) 2.51 (2.09, 3.01) 9.35 (8.34, 10.49) 3.56 (3.02, 4.19)  
Number of counts 1.01 (0.97, 1.05) 0.6146 0.92 (0.87, 0.98) 0.0068 0.99 (0.95, 1.03) 0.4783 0.98 (0.93, 1.04) 0.4827
increases as age
increases (per yr)

2001; Stenlund et al., 2002; Twetman and Fontana, 2009). This underestimated some interproximal lesions, if not visible clini-
may be explained in part by the fact that caries experience cally. However, during mixed dentition, interproximal surfaces
reflects relatively well both past and current interplay between are more easily visible, and their prevalence in 5- to 13-year-old
and among the various etiologic factors. In our study, risk fac- children is a very minor component of the overall caries experi-
tors related to diet and caries-protective factors and habits (e.g., ence (Ismail et al., 1988; Macek et al., 2003). (4) Lesion rever-
fluoride exposure, brushing, use of sugarless chewing gum) did sals were not included in the analyses, since the focus was on the
not significantly improve the prediction of children at risk in a identification of patients, not surfaces, at risk. Even if some
high-caries-risk population. Interestingly, exposure to additional lesions regressed, the patient was considered to be at risk as long
sources of fluoride was related to the numbers of lesions that as there was some progression within the mouth. (5) We asked
progressed. This may be a reflection of treatment recommenda- about the caregiver’s presence of cavities in the past 2 yrs only.
tions previously given to these children. Our study identified However, several reports have stressed the importance of care-
factors associated with caries progression in the child and sever- giver’s health on the child’s caries risk (Shearer et al., 2011;
ity of progression (i.e., numbers of lesions that progressed) that Weintraub et al., 2011).
could be measured from a parent-completed questionnaire. Not In conclusion, factors related to disease experience or rating
surprisingly, most of these factors were related to disease experi- of oral health collected through a parent-completed question-
ence or rating of oral health, such as whether the child had a naire were associated with child’s risk of caries lesion develop-
tooth extracted or restored, time elapsed since last dental visit, ment/progression and numbers of lesions progressing, and could
and if the caregiver does not consider the child’s oral health to be used to screen at-risk children in this rural population. In
be ’very good’. These questions could be used in non-dental agreement with the literature, prediction models were fair in
settings without the need for an oral examination. This has great their ability to predict caries in this high-caries-risk school-age
public health implications for caries management from a Hispanic population. Identified factors were similar regardless
resource (financial/personnel) and location (school, medical of progression criteria and time interval. Addition of caries
office, etc.) perspective. experience as measured from a dental examination did not
In addition, it has been suggested that the chance to correctly greatly affect the prediction.
identify non-risk preschoolers and adolescents is greater than a
correct identification of individuals with high risk (Twetman
Acknowledgments
and Fontana, 2009). Based on the range of AUC values identi-
fied for the developed prediction models in our study (0.70-0.79), This study was supported by grant #RO1DE017890-05 from the
the accuracy of the prediction, regardless of whether caries National Institute of Dental and Craniofacial Research.
experience is or is not included in the models, was fair. Preliminary data from this study were presented at the 2010
This study is limited in its conclusions: (1) It is localized in IADR General Session in Barcelona, Spain. The authors declare
Puerto Rico, with a relatively uniform Hispanic population, and no potential conflicts of interest with respect to the authorship
thus results may not be extrapolated to other Hispanic popula- and/or publication of this article. We thank Sharon Gwinn,
tion subgroups. (2) Since we wanted to identify factors that Myrna Hernandez, Melissa Mau, Mildred Riviera, Jennifer
could be collected through a questionnaire, we did not measure Tran, Evaristo Delgado, Hafsteinn Eggertsson, Pedro Hernandez,
other clinical variables that could be associated with caries risk. and OHRI and University of Puerto Rico’s staff for their
(3) the lack of radiographic data, it is possible that we may have assistance.

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J Dent Res 90(10) 2011 Caries Risk Factors in Hispanics  1195

Table 3. Multivariate Caries Risk Models for Identification of Numbers of Lesions Progressing at 12 and 24 Months According to 2 Outcome
Criteria

Model (no dmfs/ Model (add dmfs/ Model (start with dmfs/DMFS then
DMFS) DMFS at end) add other variables)

Examination
  Predictors Period Count (95% CI) p-value Count (95% CI) p-value Count (95% CI) p-value

12-month Child had teeth filled No 1.52 (1.15, 2.01) 0.0003 1.58 (1.20, 2.09) 0.0021 1.63 (1.23, 2.14) 0.0042
(ICDAS ≥ 3) Yes 2.57 (2.12, 3.10) 2.48 (2.05, 3.00) 2.46 (2.04, 2.98)
  Child has been to the dentist: Last 3 months 3.10 (2.42, 3.98) 0.0000 2.97 (2.32, 3.82) 0.0000 3.01 (2.35, 3.86) 0.0000
  3-6 months 1.70 (1.29, 2.25) 1.73 (1.31, 2.28) 1.75 (1.33, 2.30)  
  6+ months 1.46 (1.13, 1.87) 1.51 (1.18, 1.94) 1.52 (1.19, 1.95)  
  Child drinks soda between No 1.60 (1.17, 2.19) 0.0090 1.62 (1.19, 2.20) 0.0119 1.63 (1.20, 2.22) 0.0104
meals Yes 2.44 (2.06, 2.89) 2.43 (2.05, 2.87) 2.46 (2.08, 2.90)
  CG believes child has ’very No 2.41 (1.96, 2.96) 0.0036 2.31 (1.87, 2.84) 0.0277 2.33 (1.89, 2.87) 0.0287
good’ dental health Yes 1.62 (1.25, 2.09) 1.70 (1.32, 2.19) 1.72 (1.34, 2.21)
  Age 0.93 (0.87, 0.98) 0.0103 0.95 (0.89, 1.00) 0.0717  
  For baseline dmfs/DMFS 1.02 (1.01, 1.03) 0.0026 1.02 (1.01, 1.04) 0.0004
(ICDAS ≥ 3)
12-month Child had teeth filled No 6.16 (5.22, 7.27) 0.0227 6.35 (5.39, 7.48) 0.0991  
(ICDAS ≥ 1) Yes 7.70 (6.84, 8.65) 7.47 (6.64, 8.41)
  Child has been to the dentist: Last 3 months 8.42 (7.08, 10.00) 0.0122 8.15 (6.86, 9.69) 0.0422 8.51 (7.23, 10.02) 0.0367
  3-6 months 6.11 (5.11, 7.30) 6.15 (5.15, 7.34) 6.56 (5.55, 7.75)  
  6+ months 6.35 (5.50, 7.34) 6.52 (5.65, 7.52) 6.64 (5.80, 7.61)  
  Child uses additional fluoride No 7.54 (6.62, 8.58) 0.0496 7.53 (6.63, 8.56) 0.0486  
products at home Yes 6.29 (5.42, 7.30) 6.30 (5.43, 7.30)
  CG believes child has ’very No 8.72 (7.74, 9.83) 0.0000 8.46 (7.50, 9.54) 0.0000 9.15 (8.22, 10.18) 0.0000
good’ dental health Yes 5.43 (4.60, 6.42) 5.61 (4.75, 6.62) 5.64 (4.80, 6.63)
  For baseline dmfs/DMFS 1.02 (1.01, 1.03) 0.0021 1.02 (1.01, 1.03) 0.0009
(ICDAS ≥ 3)
24-month CG supervises child’s Regularly 3.51 (2.78, 4.43) 0.0437 3.47 (2.75, 4.38) 0.0657 3.68 (2.94, 4.61) 0.0380
(ICDAS ≥ 3) toothbrushing Occasionally 3.06 (2.43, 3.84) 3.11 (2.47, 3.90) 3.42 (2.77, 4.23)
  No 2.07 (1.33, 3.21) 2.11 (1.37, 3.27) 2.19 (1.44, 3.32)  
  CG received referral for child No 3.45 (2.56, 4.66) 0.0473 3.56 (2.64, 4.80) 0.0295  
  Yes 2.29 (1.70, 3.09) 2.26 (1.67, 3.05)  
  CG followed up on referral No 2.14 (1.56, 2.92) 0.0101 2.15 (1.58, 2.93) 0.0096  
  Yes 3.70 (2.75, 4.97) 3.74 (2.79, 5.02)  
  Child had teeth filled No 2.32 (1.74, 3.09) 0.0036 2.40 (1.80, 3.19) 0.0109 2.50 (1.91, 3.28) 0.0031
  Yes 3.40 (2.70, 4.29) 3.35 (2.66, 4.23) 3.65 (2.93, 4.55)  
  Child has been to the dentist: Last 3 months 4.23 (3.26, 5.50) 0.0000 4.15 (3.20, 5.38) 0.0000 4.34 (3.38, 5.59) 0.0000
  3-6 months 2.43 (1.82, 3.23) 2.48 (1.86, 3.29) 2.67 (2.03, 3.51)  
  6+ months 2.16 (1.63, 2.87) 2.22 (1.67, 2.94) 2.38 (1.82, 3.10)  
  CG believes child has ’very No 3.51 (2.77, 4.44) 0.0004 3.42 (2.70, 4.32) 0.0039  
good’ dental health Yes 2.25 (1.70, 2.97) 2.35 (1.78, 3.11)
  Race Black 3.08 (1.90, 5.00) 0.0203 3.01 (1.86, 4.87) 0.0163 3.16 (1.95, 5.11) 0.0032
  Other 3.90 (2.94, 5.18) 4.01 (3.02, 5.31) 4.45 (3.42, 5.78)  
  Unknown 1.99 (1.23, 3.21) 2.06 (1.28, 3.32) 2.17 (1.36, 3.47)  
  White 2.60 (2.14, 3.16) 2.60 (2.14, 3.16) 2.73 (2.28, 3.28)  
  For baseline dmfs/DMFS 1.02 (1.00, 1.03) 0.0205 1.02 (1.01, 1.03) 0.0006
(ICDAS ≥ 3)
24-month CG followed up on referral No 7.15 (6.16, 8.31) 0.0420 7.27 (6.27, 8.44) 0.0818  
(ICDAS ≥ 1) Yes 8.61 (7.62, 9.72) 8.52 (7.55, 9.62)
  Child had teeth filled No 6.98 (5.95, 8.19) 0.0140 7.19 (6.13, 8.43) 0.0572  
  Yes 8.82 (7.86, 9.89) 8.63 (7.69, 9.68)  
  Child has been to the dentist: Last 3 months 9.48 (8.00, 11.24) 0.0117 9.25 (7.80, 10.95) 0.0325  
  3-6 months 6.73 (5.66, 8.01) 6.82 (5.74, 8.10)  
  6+ months 7.56 (6.60, 8.67) 7.74 (6.76, 8.86)  
  Child uses additional fluoride No 8.61 (7.59, 9.76) 0.0376 8.63 (7.62, 9.77) 0.0382  
products at home Yes 7.15 (6.20, 8.26) 7.19 (6.23, 8.28)
  CG believes child has ’very No 9.11 (8.07, 10.30) 0.0015 8.90 (7.87, 10.06) 0.0105 9.62 (8.69, 10.65) 0.0011
good’ dental health Yes 6.76 (5.79, 7.88) 6.97 (5.98, 8.12) 7.13 (6.15, 8.27)
  For baseline dmfs/DMFS 1.01 (1.00, 1.02) 0.0061 1.02 (1.01, 1.03) 0.0001
(ICDAS ≥ 3)

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1196  Fontana et al. J Dent Res 90(10) 2011

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