ORIGINAL ARTICLE
G H€ ansel Petersson E Ericson S Twetman
Authors’ affiliations: G H€ansel Petersson, Department of Cariology, Faculty of Odontology, Malm€o University, Malm€ o, Sweden E Ericson, Public Dental Service, Region Sk ane, Malm€ o, Sweden S Twetman, Department of Cariology, Endodontics, Pediatric Dentistry and Clinical Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark S Twetman, Maxillofacial Unit, Halland Hospital, Halmstad, Sweden Correspondence to: G. H€ ansel Petersson Faculty of Odontology Malm€ o University SE-205 06 Malm€o Sweden Tel.: +46 - 40 6658529 Fax: +46 - 40 6658577 E-mail: [email protected]
Preventive care delivered within Public Dental Service after caries risk assessment of young adults Abstract: Objectives: To study preventive care provided to young adults in relation to their estimated risk category over a 3-year period. Methods: The amount and type of preventive treatment during 3 years was extracted from the digital dental records of 982 patients attending eight public dental clinics. The baseline caries risk assessment was carried out by the patient’s regular team in four classes according to a predetermined model, and the team was responsible for all treatment decisions. Based on the variables ‘oral health information’, ‘additional fluoride’ and ‘professional tooth cleaning’, a cumulative score was constructed and dichotomized to ‘basic prevention’ and ‘additional prevention’. Results: More additional preventive care was provided to the patients in the ‘low-risk’ and ‘some risk’ categories than to those classified as ‘high’ or ‘very high’ risk (OR = 2.0, 95% CI 1.4–3.0; P < 0.05). Professional tooth cleaning and additional fluorides were most frequently employed in the ‘low-risk’ and ‘some risk’ categories, respectively. Around 15% of the patients in the high-risk categories did not receive additional preventive measures over the 3year period. There was an insignificant tendency that patients with additional prevention developed less caries than those that received basic prevention in all risk categories except for the ‘very high-risk’ group. Conclusion: The caries risk assessment process was not accompanied by a corresponding targeted individual preventive care in a cohort of young adults attending public dental service. Further research is needed how to reach those with the greatest need of primary and secondary prevention. Key words: caries; prediction; prevention; risk classification
Introduction Dates: Accepted 13 January 2015 To cite this article: Int J Dent Hygiene DOI: 10.1111/idh.12135 H€ansel Petersson G, Ericson E, Twetman S. Preventive care delivered within Public Dental Service after caries risk assessment of young adults. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Caries risk assessment (CRA) is the clinical process of establishing the probability for an individual patient to develop caries lesions in the near future and therefore an essential component in the decision-making process for adequate prevention and management of dental caries (1–3). The predictive value of individual risk factors as well as the accuracy of various comprehensive risk assessment models has recently been systematically reviewed (4, 5). Although the evidence was rated as limited, the best accuracy was obtained when employing comprehensive models in preschool children (5). Less is, however, known on what happens after the CRA procedure. Do the patients with high risk really get more primary and/or secondary prevention than those with lower risk in everyday clinical practice? In previous practice-based investigations, only a weak correlation between preventive measures and the patient’s caries risk Int J Dent Hygiene |
1
H€ansel Petersson et al. Risk assessment and prevention
category has been disclosed in 6- to 18-year-olds and in adults (6, 7). We have previously compared and validated a reasoning-based caries risk assessment model used by the Public Dental Service (PDS) with an algorithm-based program (Cariogram) for young adults living in Sweden (8, 9). The result from the study showed that the agreement between the two models was acceptable (78%) for those assessed as low risk, while discrepancies were disclosed among those classified in the higher risk categories. The aim of this study was to examine the amount of preventive measures that actually was provided for the individual patients over a 3-year period in relation to the risk category estimated at baseline. In addition, the main preventive strategies employed in the various risk groups were addressed.
Materials and methods Study group
The study group consisted of 1295 19-year-old subjects representing 10% of their total age group in the Sk ane region in 2006–2007, when the study was implemented. They were invited to take part in a prospective study over 3 years and attended eight different public dental clinics that were selected to represent small and large clinics as well as different geographic and socio-economic areas of the region. All clinics had uniform administrative routines. The selection of the material and the socio-economic characteristics has been further detailed in a previous publication (8). The attrition rate was 24.2% over 3 years, mostly due to relocation, leaving 982 patients for the final analyses (for a flow chart, see (9). All the participants were residents in areas with low natural fluoride content in the drinking water supply but they reported use of fluoridated dentifrice on regular basis.
Preventive measures
Data on the delivered preventive care to each patient over the 3-year study period were extracted from the digital dental records by one of the authors (GHP), and three groups were formed: 1 ‘oral health information’ – any motivational information to the patient about their caries and periodontal situation, diet information and diet counselling and reinforcement of twice daily using fluoride toothpaste 2 ‘extra fluoride therapy’ – in-office fluoride varnish applications as well as additional fluoride supplements for self-care (i.e. fluoride rinses) 3 ‘professional tooth cleaning’ – tooth cleaning performed at the clinic in combination with any oral hygiene instructions. Each preventive group a–c was scored 0–3 depending on its frequency of delivery: Score 0 = no prevention provided; Score 1 = prevention provided only at baseline; Score 2 = prevention provided at baseline and up to 18 months; Score 3 = prevention provided at baseline and up to 36 months. The scores of the different groups were then added to reflect the total preventive care delivered to each patient over the study period with a maximal cumulative preventive score of nine. A cumulative score between 1 and 3 was regarded as ‘basic prevention’ while 4–9 was considered as ‘additional prevention’. Caries scoring
The clinical visual-tactile examination, including bitewing radiographs, was carried out by the regular dentist or dental hygienist according to WHO criteria (10) and expressed as DFS. Caries increment on surface level (ΔDFS) was calculated as the difference between the 3-year follow-up score and baseline of each individual.
Study design and risk assessment
The study had a 3-year observational design and was approved by the Ethical Committee, Lund University, Sweden (H4 44/ 2006). At baseline, the risk category of each individual was assessed by the patient’s dentist or dental hygienist according to the ‘adult guidelines for risk assessment of oral diseases’ issued by the PDS. Based on clinical and radiographic findings, the risk grouping relied on past and present caries, periodontal conditions, general risk and technical risk as described before (9). Four risk categories were used: ‘low risk’, ‘some risk’, ‘high risk’ and ‘very high risk’, and the distribution was 42.7%, 45.4%, 10.4% and 1.5%, respectively. The patient was informed on the outcome of risk assessment, and an individual treatment plan was suggested. The majority (94%) of the participants attended the PDS on a regular basis over the 3-year study period while six per cent (n = 57) turned to a private practitioner. Follow-up data were provided from the private clinics on demand. All decisions on preventive and restorative dental care were solely the responsibility of the patient’s regular dental team during the entire study period. 2
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Statistical methods
All data were processed with the IBM-SPSS software (version 19.0, Chicago, IL, USA). Descriptive statistics and correlations were calculated. Proportions were compared with chi-square test and continuous data with two-sided t-tests (Mann–Whitney). Odds ratios were calculated from two-by-two tables. Pvalues less than 0.05 were considered statistically significant.
Results The overall amount of prevention given to the patients in relation to their risk category at baseline is shown in Fig. 1. Most prevention measures were carried out in the ‘some risk’ group followed by the low-risk group. The odds for having additional prevention in the ‘low-risk’ and ‘some risk’ categories was OR = 2.0 (95% CI 1.4–3.0; P < 0.05) compared with the two high-risk groups. The proportions of additional prevention and basic prevention differed significantly within the ‘low-risk’ and ‘some risk’ categories (P < 0.05). Forty-nine per cent of the
H€ansel Petersson et al. Risk assessment and prevention
Fig. 1. Distribution of the cumulative preventive score over 3 years in relation to the risk group assessed at baseline. Black bars indicate ‘additional prevention’ (score 4–9) and white bars ‘basic prevention’ (score 1–3). The percentage distribution at baseline for the different risk group were 42.7%, 45.4%, 10.4% and 1.5% for the low, some, high and very high risk, respectively.
patients in the two high-risk categories received additional preventive care on top of the basic prevention compared to 66% in the lower risk groups. The distribution of preventive strategies employed in the four risk categories is shown in Table 1. Professional tooth cleaning (score>1) was most common in the low-risk group and significantly more common than in the high-risk group (P < 0.05). Sixteen per cent of all patients in the two high-risk categories did not receive any professional tooth cleaning compared with 7.9% in the ‘low-risk’ and ‘some risk’ categories. The corresponding figures for ‘no oral health information and diet counselling’ (score 0) were 11.0% and 7.9%. Extra fluo-
Table 1. Frequency distribution of the preventive measures provided over 3 years in relation to caries risk assessed at baseline Delivered preventive care
Low risk n = 419
Oral health information Score 0 10 Score 1 40 Score 2 45 Score 3 5 Extra fluoride Score 0 32 Score 1 43 Score 2 23 Score 3 2 Professional tooth cleaning Score 0 10 Score 1 32 Score 2 54 Score 3 4
Some risk n = 446
High risk n = 102
Very high risk n = 15
6 24 40 30
12 35 43 10
6 47 47 0
16 30 30 24
20 46 26 8
13 60 27 0
8 26 41 25
18 45 28 9
6 47 47 0
rides were most frequently provided to the patients in the ‘some risk’ category and very few patients in the high-risk categories were treated regularly with in-office fluorides over the 3-year period. In fact, 19% did not receive any extended fluoride exposure. In Table 2, the 3-year caries incidence in relation to the amount of preventive care given in the various risk categories is presented. Patients classified as high risk and very high risk displayed significantly more new caries lesions and fillings than those with lower risk (P < 0.05). There was a clear tendency that patients with additional prevention developed less caries than those that received basic prevention in all risk categories except in the small ‘very high-risk’ group. The differences were, however, not statistically significant within any risk category.
Discussion The data on preventive care following risk categorization were collected retrospectively and needless to say, the outcome was heavily depending on the quality of the digital dental records. It was originally planned to score the preventive measures in detail which was proven difficult due to lack of specifications. Therefore, the rough and somewhat indistinct grouping in ‘oral health information’, ‘extra fluoride’ and ‘professional tooth cleaning’ was adopted because it could be validated through an intra-examiner analysis. It is, however, important to underline that our data reflect the time period of prevention given rather than the ‘real’ frequency or the actual amount of preventive care. Likewise, we intended to register the actual clinical time spend on the various preventive measures for an estimation of the costs associated with the risk assessment process. This was, however, abandoned because it was not possible to separate the preventive care from the restorative or periodontal care when carried out at the same appointment. The rational to select a cumulative preventive score 0–3 as ‘basic prevention’ was based on the assumption that this preventive care basically was delivered in association with the regular check-ups while a score 4–9 (‘additional prevention’) indicated that the patient was recalled and treated at least
Table 2. Mean caries increments (mean DDFS, SD) over the 3years study period in relation to baseline risk grouping and the amount of preventive care delivered over the 3-year study period Risk group at baseline
Preventive care
DDFS* (SD)
P
Low risk (42.7%)
Additional (n = 237) Basic (n = 182) Additional (n = 332) Basic (n = 114) Additional (n = 50) Basic (n = 52) Additional (n = 7) Basic (n = 8)
1.85 2.04 2.76 2.88 4.23 4.83 4.40 3.00
NS
Some risk (45.4%)
The values in the table denote the percentage within each risk category.
High risk (10.4%) Very high risk (1.5%)
(1.44) (1.27) (1.99) (2.83) (3.26) (3.81) (2.79) (3.21)
NS NS NS
*DFS = Decayed Filled Surfaces. Int J Dent Hygiene |
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H€ansel Petersson et al. Risk assessment and prevention
once between the regular intervals during the study period. It should also be stressed that the baseline risk grouping was based on the patient’s caries situation in 93.2% of all cases (9) which explained the present focus on the anticaries activities implemented by the clinicians. The main finding of the present study was the inverse relationship between the estimated risk group and the delivered preventive care over a 3-year period. Thus, the result was in line with previous studies from children and adults (6, 7, 11, 12). A recent practice-based study from Japan has indicated that only 38% of dentists provided individualized caries prevention to more than 50% of their patients (13). In fact, Sarmadi and co-workers found that 15% of the high-risk patients did not receive any preventive treatment at all (12). In the present material, almost 50% of the high-risk and very highrisk groups received any form of additional prevention at least once over the study period. A confounding factor was that the dropout rate differed in the various risk groups, from 62% in the very high-risk group to 16% in the low-risk group. The baseline caries experience among the dropouts was higher compared to those that remained in the study (DFS 6.7 versus 4.9). The positive predictive value obtained here could, therefore, be underestimated and the negative predictive value somewhat overestimated. It must, however, be pointed out that the sensitivity and specificity values were not influenced by the dropouts. It is important to underline that the negative correlation between caries risk and delivered preventive care neither disqualify the risk assessment procedure as such, nor the organization of the public dental service, or the efforts and work of the clinical staff involved. Although an evidence-based preventive toolbox is available, it is well known, according the ‘inverse care law’ (14), that patients with the greatest risk of disease are those that are least likely to attend preventive care. Moreover, no-shows and late cancellations of appointments are anecdotally more frequent in high-risk groups. It may also be a matter of money because the rate of unemployment is high among young adults in general, and especially among immigrants living in low socio-economic areas. Thus, empowerment and appreciation of oral health, as well as awareness on the value of a healthy lifestyle, must be improved and in this aspect, the dental professionals meeting patients on regular basis have a key role to play. Improved communication skills and a systematic use of the motivational interview technique are the important first steps (15, 16). Another possible explanation for the somewhat extensive preventive care given in the lower risk groups could be that 63% of the patients who remained in the PDS joined an insurance scheme offering regular dental care at a fixed price. This capitation model requires a prepaid fee per month or year according to assessed risk and covering preventive care and counsel. This system might have increased the patients’ awareness and demand for prevention. Future qualitative studies, including dental professionals as well as patients, could be helpful to improve the understanding how to reach the high-risk groups with preventive care. 4
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The content of the preventive care, focusing on oral hygiene instruction, patient education, fluoride recommendations and diet counselling, was mainly in agreement with the findings of Yokoyama et al. (13). It was interesting to note that professional tooth cleaning was so frequently employed in spite of a questionable outcome of this method in caries-active patients (17). One explanation could be that the dental team carried out this treatment as a part of the yearly examination and removal of dental staining, rather than for caries prevention. The dominating ‘extra fluoride’ provided was in-office fluoride varnish applications, which is in line with best clinical practice and current scientific evidence and recommendations (18, 19). For high-risk patients, regular applications up to 2–4 times per year are advocated but unfortunately, this was very seldom accomplished for the patients in the high-risk categories in the present study cohort. Thus, no correlation between baseline risk category and recall frequency was disclosed. Although there is insufficient evidence for the benefit of regular recall visits for adult caries (20, 21), it was obvious that patients in the current two high-risk groups were somewhat ‘under-prevented’. Additional oral hygiene and diet information was given to less than half of all patients irrespective of risk group. It was unfortunately not possible to get any further information on the amount or quality of this counselling from the dental records. Furthermore, the oral health professional’s perceptions on diet and its role in the preventive toolbox remain unknown. The fact that the additional preventive measures were associated with a reduced, albeit not statistically significant, caries incidence over the study period in all risk categories except for the ‘very high’ was comforting but may seriously challenge the concept of targeted dental prevention in favour of population-based schemes (22). A possible limitation of this study was that the calculations were based on the risk classification made at baseline and the changing risk group during the 3-year study period was not taken into account. However, as 70% of the individuals remained in the same risk category during follow-up period and only 15% changed to a lower risk group, we consider the outcome as quite representative. Furthermore, there were no significant differences in the distribution of risk groups or caries increment between those attending public and private clinics of the study period. We recognize that caries risk models are far from perfect (5) but our findings suggest that the subsequent delivery of preventive care is the weakest link of the caries management chain. This must, however, be reconfirmed in future practice-based trials. In conclusion, within the limitations of the present study, the caries risk assessment process was not always accompanied by targeted preventive care in young adults and additional caries-preventive measures were provided more often to those with low and some risk compared to those classified with high risk. The preventive care tended to reduce the caries incidence within all risk categories except in the very high-risk group. The dental professionals must reconsider their communication skills and avenues to reach those with the greatest risk for oral diseases.
H€ansel Petersson et al. Risk assessment and prevention
Clinical relevance Scientific rationale for study – Caries risk assessment is a cornerstone in the daily work of dental hygienists and dentists, but to what extent this leads to targeted preventive action, linked to the patients individual risk category, is not clear. Principal findings – An inverse relationship between the patient’s caries risk category and the amount of delivered preventive care was unveiled; young adults with high caries risk received less professional care and fluoride supplements than those with low caries risk. Practical implications – Future research should focus on strategies to reach patients with the highest need of preventive care and secure compliance.
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8
9
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Acknowledgements The authors would like thank the staff at all participating Public Dental Clinics for their collaboration. The dental assistants Anette Hansson and Birgitta Wallin are acknowledged for their engagement and skilful clinical work, and Anna Karlbrink Sj€ oberg for her assistance with input of data. Dr. Per-Erik Isberg is acknowledged for his statistical support. The study was supported by grants from the Sk ane Region and from the Swedish Patent Revenue Research Fund for Preventive Odontology.
12
Declaration of interest
16
The authors report no conflict of interests. The authors alone are responsible for the content and writing of the paper.
17
13
14 15
References 1 Twetman S, Fontana M. Patient caries risk assessment. Monogr Oral Sci 2009; 21: 91–101. 2 Twetman S, Fontana M, Featherstone JD. Caries risk assessment – can we achieve consensus? Community Dent Oral Epidemiol 2013; 41: 64–70. 3 Hallett KB. The application of caries risk assessment in minimum intervention dentistry. Aust Dent J 2013; 58(Suppl. 1): 26–34. 4 Tellez M, Gomez J, Pretty I, Ellwood R, Ismail A. Evidence on existing caries risk assessment systems: are they predictive of future caries? Community Dent Oral Epidemiol. 2013; 41: 67–78. doi: 10.1111/cdoe.12003. 5 Mejare I, Axelsson S, Dahlen G et al. Caries risk assessment. A systematic review. Acta Odontol Scand 2014; 72: 81–91. 6 Riley JL 3rd, Gordan VV, Rindal DB et al. Preferences for caries prevention agents in adult patients: findings from the dental prac-
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tice-based research network. Community Dent Oral Epidemiol 2010; 38: 360–370. Riley JL 3rd, Qvist V, Fellows JL et al. Dentists’ use of caries risk assessment in children: findings from the Dental Practice-Based Research Network. Gen Dent 2010; 58: 230–234. H€ansel Petersson G, Ericson E, Isberg PE, Twetman S. Caries risk assessment in young adults using Public Dental Service guidelines and the Cariogram-a comparative study. Acta Odontol Scand 2013; 71: 534–540. H€ansel Petersson G, Ericson E, Isberg PE, Twetman S. Caries risk assessment in young adults: a 3-year validation of clinical guidelines used in Public Dental Service. Acta Odontol Scand 2013; 71: 1645–1650. World Health Organization. Oral Health Surveys, Basic Methods, ed 3. Geneva, WHO 1987. Riley JL 3rd, Gordan VV, Ajmo CT et al. Dentists’ use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network. Community Dent Oral Epidemiol 2011; 39: 564–573. Sarmadi R, Gahnberg L, Gabre P. Clinicians’ preventive strategies for children and adolescents identified as at high risk of developing caries. Int J Paediatr Dent 2011; 21: 167–174. Yokoyama Y, Kakudate N, Sumida F, Matsumoto Y, Gilbert GH, Gordan VV. Dentists’ practice patterns regarding caries prevention: results from a dental practice-based research network. BMJ Open 2013; 3: e003227. Hart JT. The inverse care law. Lancet 1971; 1: 405–412. Gao X, Lo ECM, Kot SCC, Chan KCW. Motivational interviewing in improving oral health: a systematic review of randomized controlled trials. J Periodontol 2014; 85: 426–437. Harris R, Gamboa A, Dailey Y, Ashcroft A. One-to-one dietary interventions undertaken in a dental setting to change dietary behaviour. Cochrane Database Syst Rev 2012; 3: CD006540. Tranaeus S, Al-Khateeb S, Bj€orkman S, Twetman S, AngmarM ansson B. Application of quantitative light-induced fluorescence to monitor incipient lesions in caries-active children. A comparative study of remineralisation by fluoride varnish and professional cleaning. Eur J Oral Sci 2001; 109: 71–75. Petersson LG, Twetman S, Dahlgren H et al. Professional fluoride varnish treatment for caries control: a systematic review of clinical trials. Acta Odontol Scand 2004; 62: 170–176. Marinho VC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2013; 7: CD002279. Beirne P, Clarkson JE, Worthington HV. Recall intervals for oral health in primary care patients. Cochrane Database Syst Rev 2007; (4): CD004346. Patel S, Bay RC, Glick M. A systematic review of dental recall intervals and incidence of dental caries. J Am Dent Assoc 2010; 141: 527–539. Milsom KM, Tickle M. Preventing decay in children: dare we risk the “risk assessment” model in practice? Br Dent J 2010; 209: 159– 160.
Int J Dent Hygiene |
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G H€ ansel Petersson E Ericson S Twetman
Authors’ affiliations: G H€ansel Petersson, Department of Cariology, Faculty of Odontology, Malm€o University, Malm€ o, Sweden E Ericson, Public Dental Service, Region Sk ane, Malm€ o, Sweden S Twetman, Department of Cariology, Endodontics, Pediatric Dentistry and Clinical Genetics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark S Twetman, Maxillofacial Unit, Halland Hospital, Halmstad, Sweden Correspondence to: G. H€ ansel Petersson Faculty of Odontology Malm€ o University SE-205 06 Malm€o Sweden Tel.: +46 - 40 6658529 Fax: +46 - 40 6658577 E-mail: [email protected]
Preventive care delivered within Public Dental Service after caries risk assessment of young adults Abstract: Objectives: To study preventive care provided to young adults in relation to their estimated risk category over a 3-year period. Methods: The amount and type of preventive treatment during 3 years was extracted from the digital dental records of 982 patients attending eight public dental clinics. The baseline caries risk assessment was carried out by the patient’s regular team in four classes according to a predetermined model, and the team was responsible for all treatment decisions. Based on the variables ‘oral health information’, ‘additional fluoride’ and ‘professional tooth cleaning’, a cumulative score was constructed and dichotomized to ‘basic prevention’ and ‘additional prevention’. Results: More additional preventive care was provided to the patients in the ‘low-risk’ and ‘some risk’ categories than to those classified as ‘high’ or ‘very high’ risk (OR = 2.0, 95% CI 1.4–3.0; P < 0.05). Professional tooth cleaning and additional fluorides were most frequently employed in the ‘low-risk’ and ‘some risk’ categories, respectively. Around 15% of the patients in the high-risk categories did not receive additional preventive measures over the 3year period. There was an insignificant tendency that patients with additional prevention developed less caries than those that received basic prevention in all risk categories except for the ‘very high-risk’ group. Conclusion: The caries risk assessment process was not accompanied by a corresponding targeted individual preventive care in a cohort of young adults attending public dental service. Further research is needed how to reach those with the greatest need of primary and secondary prevention. Key words: caries; prediction; prevention; risk classification
Introduction Dates: Accepted 13 January 2015 To cite this article: Int J Dent Hygiene DOI: 10.1111/idh.12135 H€ansel Petersson G, Ericson E, Twetman S. Preventive care delivered within Public Dental Service after caries risk assessment of young adults. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Caries risk assessment (CRA) is the clinical process of establishing the probability for an individual patient to develop caries lesions in the near future and therefore an essential component in the decision-making process for adequate prevention and management of dental caries (1–3). The predictive value of individual risk factors as well as the accuracy of various comprehensive risk assessment models has recently been systematically reviewed (4, 5). Although the evidence was rated as limited, the best accuracy was obtained when employing comprehensive models in preschool children (5). Less is, however, known on what happens after the CRA procedure. Do the patients with high risk really get more primary and/or secondary prevention than those with lower risk in everyday clinical practice? In previous practice-based investigations, only a weak correlation between preventive measures and the patient’s caries risk Int J Dent Hygiene |
1
H€ansel Petersson et al. Risk assessment and prevention
category has been disclosed in 6- to 18-year-olds and in adults (6, 7). We have previously compared and validated a reasoning-based caries risk assessment model used by the Public Dental Service (PDS) with an algorithm-based program (Cariogram) for young adults living in Sweden (8, 9). The result from the study showed that the agreement between the two models was acceptable (78%) for those assessed as low risk, while discrepancies were disclosed among those classified in the higher risk categories. The aim of this study was to examine the amount of preventive measures that actually was provided for the individual patients over a 3-year period in relation to the risk category estimated at baseline. In addition, the main preventive strategies employed in the various risk groups were addressed.
Materials and methods Study group
The study group consisted of 1295 19-year-old subjects representing 10% of their total age group in the Sk ane region in 2006–2007, when the study was implemented. They were invited to take part in a prospective study over 3 years and attended eight different public dental clinics that were selected to represent small and large clinics as well as different geographic and socio-economic areas of the region. All clinics had uniform administrative routines. The selection of the material and the socio-economic characteristics has been further detailed in a previous publication (8). The attrition rate was 24.2% over 3 years, mostly due to relocation, leaving 982 patients for the final analyses (for a flow chart, see (9). All the participants were residents in areas with low natural fluoride content in the drinking water supply but they reported use of fluoridated dentifrice on regular basis.
Preventive measures
Data on the delivered preventive care to each patient over the 3-year study period were extracted from the digital dental records by one of the authors (GHP), and three groups were formed: 1 ‘oral health information’ – any motivational information to the patient about their caries and periodontal situation, diet information and diet counselling and reinforcement of twice daily using fluoride toothpaste 2 ‘extra fluoride therapy’ – in-office fluoride varnish applications as well as additional fluoride supplements for self-care (i.e. fluoride rinses) 3 ‘professional tooth cleaning’ – tooth cleaning performed at the clinic in combination with any oral hygiene instructions. Each preventive group a–c was scored 0–3 depending on its frequency of delivery: Score 0 = no prevention provided; Score 1 = prevention provided only at baseline; Score 2 = prevention provided at baseline and up to 18 months; Score 3 = prevention provided at baseline and up to 36 months. The scores of the different groups were then added to reflect the total preventive care delivered to each patient over the study period with a maximal cumulative preventive score of nine. A cumulative score between 1 and 3 was regarded as ‘basic prevention’ while 4–9 was considered as ‘additional prevention’. Caries scoring
The clinical visual-tactile examination, including bitewing radiographs, was carried out by the regular dentist or dental hygienist according to WHO criteria (10) and expressed as DFS. Caries increment on surface level (ΔDFS) was calculated as the difference between the 3-year follow-up score and baseline of each individual.
Study design and risk assessment
The study had a 3-year observational design and was approved by the Ethical Committee, Lund University, Sweden (H4 44/ 2006). At baseline, the risk category of each individual was assessed by the patient’s dentist or dental hygienist according to the ‘adult guidelines for risk assessment of oral diseases’ issued by the PDS. Based on clinical and radiographic findings, the risk grouping relied on past and present caries, periodontal conditions, general risk and technical risk as described before (9). Four risk categories were used: ‘low risk’, ‘some risk’, ‘high risk’ and ‘very high risk’, and the distribution was 42.7%, 45.4%, 10.4% and 1.5%, respectively. The patient was informed on the outcome of risk assessment, and an individual treatment plan was suggested. The majority (94%) of the participants attended the PDS on a regular basis over the 3-year study period while six per cent (n = 57) turned to a private practitioner. Follow-up data were provided from the private clinics on demand. All decisions on preventive and restorative dental care were solely the responsibility of the patient’s regular dental team during the entire study period. 2
| Int J Dent Hygiene
Statistical methods
All data were processed with the IBM-SPSS software (version 19.0, Chicago, IL, USA). Descriptive statistics and correlations were calculated. Proportions were compared with chi-square test and continuous data with two-sided t-tests (Mann–Whitney). Odds ratios were calculated from two-by-two tables. Pvalues less than 0.05 were considered statistically significant.
Results The overall amount of prevention given to the patients in relation to their risk category at baseline is shown in Fig. 1. Most prevention measures were carried out in the ‘some risk’ group followed by the low-risk group. The odds for having additional prevention in the ‘low-risk’ and ‘some risk’ categories was OR = 2.0 (95% CI 1.4–3.0; P < 0.05) compared with the two high-risk groups. The proportions of additional prevention and basic prevention differed significantly within the ‘low-risk’ and ‘some risk’ categories (P < 0.05). Forty-nine per cent of the
H€ansel Petersson et al. Risk assessment and prevention
Fig. 1. Distribution of the cumulative preventive score over 3 years in relation to the risk group assessed at baseline. Black bars indicate ‘additional prevention’ (score 4–9) and white bars ‘basic prevention’ (score 1–3). The percentage distribution at baseline for the different risk group were 42.7%, 45.4%, 10.4% and 1.5% for the low, some, high and very high risk, respectively.
patients in the two high-risk categories received additional preventive care on top of the basic prevention compared to 66% in the lower risk groups. The distribution of preventive strategies employed in the four risk categories is shown in Table 1. Professional tooth cleaning (score>1) was most common in the low-risk group and significantly more common than in the high-risk group (P < 0.05). Sixteen per cent of all patients in the two high-risk categories did not receive any professional tooth cleaning compared with 7.9% in the ‘low-risk’ and ‘some risk’ categories. The corresponding figures for ‘no oral health information and diet counselling’ (score 0) were 11.0% and 7.9%. Extra fluo-
Table 1. Frequency distribution of the preventive measures provided over 3 years in relation to caries risk assessed at baseline Delivered preventive care
Low risk n = 419
Oral health information Score 0 10 Score 1 40 Score 2 45 Score 3 5 Extra fluoride Score 0 32 Score 1 43 Score 2 23 Score 3 2 Professional tooth cleaning Score 0 10 Score 1 32 Score 2 54 Score 3 4
Some risk n = 446
High risk n = 102
Very high risk n = 15
6 24 40 30
12 35 43 10
6 47 47 0
16 30 30 24
20 46 26 8
13 60 27 0
8 26 41 25
18 45 28 9
6 47 47 0
rides were most frequently provided to the patients in the ‘some risk’ category and very few patients in the high-risk categories were treated regularly with in-office fluorides over the 3-year period. In fact, 19% did not receive any extended fluoride exposure. In Table 2, the 3-year caries incidence in relation to the amount of preventive care given in the various risk categories is presented. Patients classified as high risk and very high risk displayed significantly more new caries lesions and fillings than those with lower risk (P < 0.05). There was a clear tendency that patients with additional prevention developed less caries than those that received basic prevention in all risk categories except in the small ‘very high-risk’ group. The differences were, however, not statistically significant within any risk category.
Discussion The data on preventive care following risk categorization were collected retrospectively and needless to say, the outcome was heavily depending on the quality of the digital dental records. It was originally planned to score the preventive measures in detail which was proven difficult due to lack of specifications. Therefore, the rough and somewhat indistinct grouping in ‘oral health information’, ‘extra fluoride’ and ‘professional tooth cleaning’ was adopted because it could be validated through an intra-examiner analysis. It is, however, important to underline that our data reflect the time period of prevention given rather than the ‘real’ frequency or the actual amount of preventive care. Likewise, we intended to register the actual clinical time spend on the various preventive measures for an estimation of the costs associated with the risk assessment process. This was, however, abandoned because it was not possible to separate the preventive care from the restorative or periodontal care when carried out at the same appointment. The rational to select a cumulative preventive score 0–3 as ‘basic prevention’ was based on the assumption that this preventive care basically was delivered in association with the regular check-ups while a score 4–9 (‘additional prevention’) indicated that the patient was recalled and treated at least
Table 2. Mean caries increments (mean DDFS, SD) over the 3years study period in relation to baseline risk grouping and the amount of preventive care delivered over the 3-year study period Risk group at baseline
Preventive care
DDFS* (SD)
P
Low risk (42.7%)
Additional (n = 237) Basic (n = 182) Additional (n = 332) Basic (n = 114) Additional (n = 50) Basic (n = 52) Additional (n = 7) Basic (n = 8)
1.85 2.04 2.76 2.88 4.23 4.83 4.40 3.00
NS
Some risk (45.4%)
The values in the table denote the percentage within each risk category.
High risk (10.4%) Very high risk (1.5%)
(1.44) (1.27) (1.99) (2.83) (3.26) (3.81) (2.79) (3.21)
NS NS NS
*DFS = Decayed Filled Surfaces. Int J Dent Hygiene |
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H€ansel Petersson et al. Risk assessment and prevention
once between the regular intervals during the study period. It should also be stressed that the baseline risk grouping was based on the patient’s caries situation in 93.2% of all cases (9) which explained the present focus on the anticaries activities implemented by the clinicians. The main finding of the present study was the inverse relationship between the estimated risk group and the delivered preventive care over a 3-year period. Thus, the result was in line with previous studies from children and adults (6, 7, 11, 12). A recent practice-based study from Japan has indicated that only 38% of dentists provided individualized caries prevention to more than 50% of their patients (13). In fact, Sarmadi and co-workers found that 15% of the high-risk patients did not receive any preventive treatment at all (12). In the present material, almost 50% of the high-risk and very highrisk groups received any form of additional prevention at least once over the study period. A confounding factor was that the dropout rate differed in the various risk groups, from 62% in the very high-risk group to 16% in the low-risk group. The baseline caries experience among the dropouts was higher compared to those that remained in the study (DFS 6.7 versus 4.9). The positive predictive value obtained here could, therefore, be underestimated and the negative predictive value somewhat overestimated. It must, however, be pointed out that the sensitivity and specificity values were not influenced by the dropouts. It is important to underline that the negative correlation between caries risk and delivered preventive care neither disqualify the risk assessment procedure as such, nor the organization of the public dental service, or the efforts and work of the clinical staff involved. Although an evidence-based preventive toolbox is available, it is well known, according the ‘inverse care law’ (14), that patients with the greatest risk of disease are those that are least likely to attend preventive care. Moreover, no-shows and late cancellations of appointments are anecdotally more frequent in high-risk groups. It may also be a matter of money because the rate of unemployment is high among young adults in general, and especially among immigrants living in low socio-economic areas. Thus, empowerment and appreciation of oral health, as well as awareness on the value of a healthy lifestyle, must be improved and in this aspect, the dental professionals meeting patients on regular basis have a key role to play. Improved communication skills and a systematic use of the motivational interview technique are the important first steps (15, 16). Another possible explanation for the somewhat extensive preventive care given in the lower risk groups could be that 63% of the patients who remained in the PDS joined an insurance scheme offering regular dental care at a fixed price. This capitation model requires a prepaid fee per month or year according to assessed risk and covering preventive care and counsel. This system might have increased the patients’ awareness and demand for prevention. Future qualitative studies, including dental professionals as well as patients, could be helpful to improve the understanding how to reach the high-risk groups with preventive care. 4
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The content of the preventive care, focusing on oral hygiene instruction, patient education, fluoride recommendations and diet counselling, was mainly in agreement with the findings of Yokoyama et al. (13). It was interesting to note that professional tooth cleaning was so frequently employed in spite of a questionable outcome of this method in caries-active patients (17). One explanation could be that the dental team carried out this treatment as a part of the yearly examination and removal of dental staining, rather than for caries prevention. The dominating ‘extra fluoride’ provided was in-office fluoride varnish applications, which is in line with best clinical practice and current scientific evidence and recommendations (18, 19). For high-risk patients, regular applications up to 2–4 times per year are advocated but unfortunately, this was very seldom accomplished for the patients in the high-risk categories in the present study cohort. Thus, no correlation between baseline risk category and recall frequency was disclosed. Although there is insufficient evidence for the benefit of regular recall visits for adult caries (20, 21), it was obvious that patients in the current two high-risk groups were somewhat ‘under-prevented’. Additional oral hygiene and diet information was given to less than half of all patients irrespective of risk group. It was unfortunately not possible to get any further information on the amount or quality of this counselling from the dental records. Furthermore, the oral health professional’s perceptions on diet and its role in the preventive toolbox remain unknown. The fact that the additional preventive measures were associated with a reduced, albeit not statistically significant, caries incidence over the study period in all risk categories except for the ‘very high’ was comforting but may seriously challenge the concept of targeted dental prevention in favour of population-based schemes (22). A possible limitation of this study was that the calculations were based on the risk classification made at baseline and the changing risk group during the 3-year study period was not taken into account. However, as 70% of the individuals remained in the same risk category during follow-up period and only 15% changed to a lower risk group, we consider the outcome as quite representative. Furthermore, there were no significant differences in the distribution of risk groups or caries increment between those attending public and private clinics of the study period. We recognize that caries risk models are far from perfect (5) but our findings suggest that the subsequent delivery of preventive care is the weakest link of the caries management chain. This must, however, be reconfirmed in future practice-based trials. In conclusion, within the limitations of the present study, the caries risk assessment process was not always accompanied by targeted preventive care in young adults and additional caries-preventive measures were provided more often to those with low and some risk compared to those classified with high risk. The preventive care tended to reduce the caries incidence within all risk categories except in the very high-risk group. The dental professionals must reconsider their communication skills and avenues to reach those with the greatest risk for oral diseases.
H€ansel Petersson et al. Risk assessment and prevention
Clinical relevance Scientific rationale for study – Caries risk assessment is a cornerstone in the daily work of dental hygienists and dentists, but to what extent this leads to targeted preventive action, linked to the patients individual risk category, is not clear. Principal findings – An inverse relationship between the patient’s caries risk category and the amount of delivered preventive care was unveiled; young adults with high caries risk received less professional care and fluoride supplements than those with low caries risk. Practical implications – Future research should focus on strategies to reach patients with the highest need of preventive care and secure compliance.
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Acknowledgements The authors would like thank the staff at all participating Public Dental Clinics for their collaboration. The dental assistants Anette Hansson and Birgitta Wallin are acknowledged for their engagement and skilful clinical work, and Anna Karlbrink Sj€ oberg for her assistance with input of data. Dr. Per-Erik Isberg is acknowledged for his statistical support. The study was supported by grants from the Sk ane Region and from the Swedish Patent Revenue Research Fund for Preventive Odontology.
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Declaration of interest
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The authors report no conflict of interests. The authors alone are responsible for the content and writing of the paper.
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