research-article2016
JCTXXX10.1177/2380084416648932JDR Clinical & Translational ResearchCaries Risk Assessment Item Importance
Caries Risk Assessment Item Importance
Vol. 1 • Issue 2
Original Report: Epidemiologic Research
Caries Risk Assessment Item Importance: Risk Designation and Caries Status in Children under Age 6 B.W. Chaffee1, J.D.B. Featherstone1, S.A. Gansky1, J. Cheng1, and L. Zhan2
Abstract: Caries risk assessment (CRA) is widely recommended for dental caries management. Little is known regarding how practitioners use individual CRA items to determine risk and which individual items independently predict clinical outcomes in children younger than 6 y. The objective of this study was to assess the relative importance of pediatric CRA items in dental providers’ decision making regarding patient risk and in association with clinically evident caries, crosssectionally and longitudinally. CRA information was abstracted retrospectively from electronic patient records of children initially aged 6 to 72 mo at a university pediatric dentistry clinic (n = 3,810 baseline; n = 1,315 with follow-up). The 17-item CRA form included caries risk indicators, caries protective items, and clinical indicators. Conditional random forests classification trees
were implemented to identify and assign variable importance to CRA items independently associated with baseline high-risk designation, baseline evident tooth decay, and follow-up evident decay. Thirteen individual CRA items, including all clinical indicators and all but 1 risk indicator, were independently and statistically significantly associated with student/resident providers’ caries risk designation. Provider-assigned baseline risk category was strongly associated with follow-up decay, which increased from low (20.4%) to moderate (30.6%) to high/extreme risk patients (68.7%). Of baseline CRA items, before adjustment, 12 were associated with baseline decay and 7 with decay at follow-up; however, in the conditional random forests models, only the clinical indicators (evident decay, dental plaque, and recent restoration placement) and 1 risk indicator (frequent snacking)
were independently and statistically significantly associated with future disease, for which baseline evident decay was the strongest predictor. In this predominantly high-risk population under caries-preventive care, more individual CRA items were independently associated with providers’ risk determination than with future caries status. These university dental providers considered many items in decision making regarding patient risk, suggesting that, in turn, these comprehensive CRA forms could also aid individualized care, linking risk assessment to disease management. Knowledge Transfer Statement: Caries risk assessment (CRA) is widely recommended for patienttailored, prevention-focused caries management. Studies show mixed predictive performance of pediatric CRA instruments, but little is known
DOI: 10.1177/2380084416648932. 1Department of Preventive and Restorative Dental Sciences, University of California San Francisco, San Francisco, CA, USA; 2 Department of Orofacial Sciences, University of California San Francisco, San Francisco, CA, USA. Corresponding author: B.W. Chaffee, Department of Preventive and Restorative Dental Sciences, University of California San Francisco, 3333 California St., Suite 495, Box 1361, San Francisco, CA 94143, USA. Email: benjamin.chaffee@ ucsf.edu © International & American Associations for Dental Research 2016 131
July 2016
JDR Clinical & Translational Research
regarding how information captured in CRA forms guides clinical decision making. This study, in highcaries prevalence 6- to 72-mo-olds, demonstrates the following: 1) most items in a CRA instrument were independently associated with practitioners’ risk designations, 2) practitioners’ risk designations were significantly associated with future disease, and 3) of baseline measures associated with future caries, evident decay was the strongest independent indicator of future caries status. Although current disease (resulting from existing pathological and protective factor imbalance) may sufficiently predict future caries status in populations, other CRA items incorporated during risk categorization could aid practitioners to develop individualized intervention strategies against identified risk factors. Keywords: preschool child, dental caries, epidemiology, child dentistry, decision making, risk factors Introduction Recent decades have seen calls for risk-based medical management of dental caries, favoring preventionfocused, minimally invasive treatments, implemented as individualized, continuous patient care (Krasse 1985; Powell 1998; Fontana et al. 2009; Brocklehurst et al. 2011). Dental education leaders have long promoted risk-based caries management in predoctoral and pediatric specialty training programs (Brown 1995; Adair 2003). Risk-based management demands that practitioners identify patient-specific caries risk factors and direct more intensive interventions toward patients at greater risk for disease. Thus, the goal of caries risk assessment (CRA) is to enable practitioners to bring patients into a favorable balance between caries predisposing and preventive factors (Featherstone 2003). Multiple CRA forms (Ramos-Gomez et al. 2007; American Dental Association
132
2009–2011; Ramos-Gomez et al. 2012; American Academy of Pediatric Dentistry [AAPD] 2013) and algorithm-based programs (Bratthall and Hansel Petersson 2005; Gao et al. 2010) are available to aid practitioners in determining caries risk for children younger than 6 y. These CRA systems are based on a combination of scientific evidence and expert opinion and serve to guide practitioners in assigning risk status based on a variety of clinical and social factors. Caries Management by Risk Assessment (CAMBRA) is one approach that couples risk assessment with tailored preventive care and risk monitoring (Ramos-Gomez et al. 2007; Ramos-Gomez et al. 2012). Prospective studies have reported a range of sensitivity and specificity values across CRA instruments for predicting future decay among young children in Europe and Asia (Gao et al. 2013; Tellez et al. 2013). However, limited information is available regarding how practitioners use CRA instruments to determine patient risk status and how individual CRA items relate to patient outcomes, particularly for children younger than 6 y. In the present study, we evaluated the relative importance of CAMBRA CRA items in dental providers’ risk determination and in disease prediction for children aged 6 to 72 mo visiting a university pediatric dentistry specialtytraining program. We applied a conditional random forests tree-based regression method to describe individual variable importance. Random forests classification models can account for confounding between multiple risk factors and handle nonlinear associations and interactions (Breiman 2001; Strobl et al. 2007). The objectives of this study were to quantify the relative importance of items included in the CAMBRA pediatric CRA form as they related to 3 outcomes: 1) dental providers’ decision to designate a patient as high caries risk, 2) clinically evident dental caries at the time of the CRA, and 3) clinically evident dental caries at the following recall visit. We also calculated unadjusted associations between baseline CRA items and
clinically evident dental caries at baseline and at the following recall visit, along with the association between provider risk designation and caries status at recall. Methods This was an observational retrospective cohort study based on patient electronic dental records at the University of California San Francisco (UCSF) Pediatric Dentistry clinic. This clinic serves a primarily low-income, urban population and provides pediatric dentistry training to predoctoral dental students and postgraduate dental residents. Most patients are from the local geographic area; however, some patients travel significant distances, particularly for care under general anesthesia or management of complex dental or medical conditions. The UCSF Committee on Human Research (institutional review board) reviewed and approved the use of retrospective patient data. Study reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline for cohort studies (von Elm et al. 2007). Eligibility criteria were: 1) a completed oral examination with CRA between January 1, 2009 (introduction of electronic CRA forms), and April 30, 2015, and 2) age ≥6 mo and
JCTXXX10.1177/2380084416648932JDR Clinical & Translational ResearchCaries Risk Assessment Item Importance
Caries Risk Assessment Item Importance
Vol. 1 • Issue 2
Original Report: Epidemiologic Research
Caries Risk Assessment Item Importance: Risk Designation and Caries Status in Children under Age 6 B.W. Chaffee1, J.D.B. Featherstone1, S.A. Gansky1, J. Cheng1, and L. Zhan2
Abstract: Caries risk assessment (CRA) is widely recommended for dental caries management. Little is known regarding how practitioners use individual CRA items to determine risk and which individual items independently predict clinical outcomes in children younger than 6 y. The objective of this study was to assess the relative importance of pediatric CRA items in dental providers’ decision making regarding patient risk and in association with clinically evident caries, crosssectionally and longitudinally. CRA information was abstracted retrospectively from electronic patient records of children initially aged 6 to 72 mo at a university pediatric dentistry clinic (n = 3,810 baseline; n = 1,315 with follow-up). The 17-item CRA form included caries risk indicators, caries protective items, and clinical indicators. Conditional random forests classification trees
were implemented to identify and assign variable importance to CRA items independently associated with baseline high-risk designation, baseline evident tooth decay, and follow-up evident decay. Thirteen individual CRA items, including all clinical indicators and all but 1 risk indicator, were independently and statistically significantly associated with student/resident providers’ caries risk designation. Provider-assigned baseline risk category was strongly associated with follow-up decay, which increased from low (20.4%) to moderate (30.6%) to high/extreme risk patients (68.7%). Of baseline CRA items, before adjustment, 12 were associated with baseline decay and 7 with decay at follow-up; however, in the conditional random forests models, only the clinical indicators (evident decay, dental plaque, and recent restoration placement) and 1 risk indicator (frequent snacking)
were independently and statistically significantly associated with future disease, for which baseline evident decay was the strongest predictor. In this predominantly high-risk population under caries-preventive care, more individual CRA items were independently associated with providers’ risk determination than with future caries status. These university dental providers considered many items in decision making regarding patient risk, suggesting that, in turn, these comprehensive CRA forms could also aid individualized care, linking risk assessment to disease management. Knowledge Transfer Statement: Caries risk assessment (CRA) is widely recommended for patienttailored, prevention-focused caries management. Studies show mixed predictive performance of pediatric CRA instruments, but little is known
DOI: 10.1177/2380084416648932. 1Department of Preventive and Restorative Dental Sciences, University of California San Francisco, San Francisco, CA, USA; 2 Department of Orofacial Sciences, University of California San Francisco, San Francisco, CA, USA. Corresponding author: B.W. Chaffee, Department of Preventive and Restorative Dental Sciences, University of California San Francisco, 3333 California St., Suite 495, Box 1361, San Francisco, CA 94143, USA. Email: benjamin.chaffee@ ucsf.edu © International & American Associations for Dental Research 2016 131
July 2016
JDR Clinical & Translational Research
regarding how information captured in CRA forms guides clinical decision making. This study, in highcaries prevalence 6- to 72-mo-olds, demonstrates the following: 1) most items in a CRA instrument were independently associated with practitioners’ risk designations, 2) practitioners’ risk designations were significantly associated with future disease, and 3) of baseline measures associated with future caries, evident decay was the strongest independent indicator of future caries status. Although current disease (resulting from existing pathological and protective factor imbalance) may sufficiently predict future caries status in populations, other CRA items incorporated during risk categorization could aid practitioners to develop individualized intervention strategies against identified risk factors. Keywords: preschool child, dental caries, epidemiology, child dentistry, decision making, risk factors Introduction Recent decades have seen calls for risk-based medical management of dental caries, favoring preventionfocused, minimally invasive treatments, implemented as individualized, continuous patient care (Krasse 1985; Powell 1998; Fontana et al. 2009; Brocklehurst et al. 2011). Dental education leaders have long promoted risk-based caries management in predoctoral and pediatric specialty training programs (Brown 1995; Adair 2003). Risk-based management demands that practitioners identify patient-specific caries risk factors and direct more intensive interventions toward patients at greater risk for disease. Thus, the goal of caries risk assessment (CRA) is to enable practitioners to bring patients into a favorable balance between caries predisposing and preventive factors (Featherstone 2003). Multiple CRA forms (Ramos-Gomez et al. 2007; American Dental Association
132
2009–2011; Ramos-Gomez et al. 2012; American Academy of Pediatric Dentistry [AAPD] 2013) and algorithm-based programs (Bratthall and Hansel Petersson 2005; Gao et al. 2010) are available to aid practitioners in determining caries risk for children younger than 6 y. These CRA systems are based on a combination of scientific evidence and expert opinion and serve to guide practitioners in assigning risk status based on a variety of clinical and social factors. Caries Management by Risk Assessment (CAMBRA) is one approach that couples risk assessment with tailored preventive care and risk monitoring (Ramos-Gomez et al. 2007; Ramos-Gomez et al. 2012). Prospective studies have reported a range of sensitivity and specificity values across CRA instruments for predicting future decay among young children in Europe and Asia (Gao et al. 2013; Tellez et al. 2013). However, limited information is available regarding how practitioners use CRA instruments to determine patient risk status and how individual CRA items relate to patient outcomes, particularly for children younger than 6 y. In the present study, we evaluated the relative importance of CAMBRA CRA items in dental providers’ risk determination and in disease prediction for children aged 6 to 72 mo visiting a university pediatric dentistry specialtytraining program. We applied a conditional random forests tree-based regression method to describe individual variable importance. Random forests classification models can account for confounding between multiple risk factors and handle nonlinear associations and interactions (Breiman 2001; Strobl et al. 2007). The objectives of this study were to quantify the relative importance of items included in the CAMBRA pediatric CRA form as they related to 3 outcomes: 1) dental providers’ decision to designate a patient as high caries risk, 2) clinically evident dental caries at the time of the CRA, and 3) clinically evident dental caries at the following recall visit. We also calculated unadjusted associations between baseline CRA items and
clinically evident dental caries at baseline and at the following recall visit, along with the association between provider risk designation and caries status at recall. Methods This was an observational retrospective cohort study based on patient electronic dental records at the University of California San Francisco (UCSF) Pediatric Dentistry clinic. This clinic serves a primarily low-income, urban population and provides pediatric dentistry training to predoctoral dental students and postgraduate dental residents. Most patients are from the local geographic area; however, some patients travel significant distances, particularly for care under general anesthesia or management of complex dental or medical conditions. The UCSF Committee on Human Research (institutional review board) reviewed and approved the use of retrospective patient data. Study reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline for cohort studies (von Elm et al. 2007). Eligibility criteria were: 1) a completed oral examination with CRA between January 1, 2009 (introduction of electronic CRA forms), and April 30, 2015, and 2) age ≥6 mo and
