Using a Caries Activity Test to Predict Caries Risk in Early Childhood Michiko Nishimura, Takashi Oda, Naoyuki Kariya,

Seishi Matsumura and Tsutomu Shimono J Am Dent Assoc 2008;139;63-71

The following resources related to this article are available online at jada.ada.org ( this information is current as of November 10, 2010 ):
Updated information and services including high-resolution figures, can be found in the online version of this article at:
http://jada.ada.org/cgi/content/full/139/1/63

Downloaded from jada.ada.org on November 10, 2010

Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at:
http://www.ada.org/prof/resources/pubs/jada/permissions.asp

2010 American Dental Association. The sponsor and its products are not endorsed by the ADA.

Using a caries activity test to predict caries risk in early childhood

Michiko Nishimura, DDS, PhD; Takashi Oda, DDS; Naoyuki Kariya, DDS, PhD; Seishi Matsumura, DDS, PhD; Tsutomu Shimono, DDS, PhD

ecause caries is preventable, the diagnosis of caries as a tooth lesion is not sufficient for a treatment plan. The clinician must devise a need-related treatment plan on the basis of certain scientific diagnosis. In doing so, he or she should assess a patients caries risk status, because it provides an estimate of future caries activity.1 Therefore, an accurate caries risk assessment in early childhood is a necessary prerequisite to effectively formulating a total health strategy.2 It is difficult to identify cariessusceptible children on the basis of a visual and tactile oral examination. Many bacteriological caries activity tests have been developed to avert this difficulty. They are classified into two types: count methods3-5 and evaluation of bacterial virulence.6-8 Borgstrm and colleagues9 reported that the most common method used to identify caries-susceptible people is estimating the number of cariogenic bacteria such as lactobacilli and mutans streptococci in saliva or plaque samples taken from the patient. However, the power of bacterial counts to explain and predict a persons risk of developing caries has not been sufficient. Borgstrm and colleagues recommendation was to evaluate one virulence factor, such as acidogenicity of these bacteria, in attempting to identify a caries-susceptible person. The Cariostat (Dentsply-Sankin, Tokyo) caries activity test is a col-

ABSTRACT

CON
T

IO N

Background. The authors conducted a two-year longitudinal study to show the predictive abilities of a N caries activity test (Cariostat, Dentsply-Sankin, Tokyo), C A UING EDU 4 and to include the predicted screening indexes that RT ICLE were based on previous caries activity test results and lifestyle factors that influence caries activity. Methods. The subjects were 1,206 children born in 2000. These children participated in health examinations at 18 months, 2 years and 312 years of age at Kurashiki-City Public Health Center in Kurashiki-City, Japan. Two of the authors performed caries activity tests at 18-month and 2-year examinations. Questionnaires regarding the patients lifestyle were mailed to each participants parents or guardians. The authors analyzed these questionnaires to evaluate lifestyle factors that made participants susceptible to caries. Results. A caries activity test score at 18 months of age not only reflected caries incidence but also predicted caries incidence and screening results in 2- and 312-year-old children. A caries activity test score at 2 years of age both reflected and predicted childrens caries incidence and screening results at 312 years of age. Breast-feeding and use of the bottle to intake liquids other than water produced significant caries susceptibility in 18-month-old children. Additionally, increased frequency and total time of sucrose intake put 2-year-old children at high risk of developing caries and failure of parental brushing produced a high risk in 312-year-old children. Conclusions. A caries activity test could predict 312-year-old childrens caries risk based on 18-month and 2-year-old test results. Early weaning, less sucrose intake and toothbrushing by parents were effective in reducing a childs caries risk. Clinical Implications. The caries activity test is more useful than oral examination because it can indicate the need for caries-preventive treatment before a carious lesion actually is manifest. Key Words. Dental caries; dental caries activity tests; dental caries susceptibility; incidence. JADA 2008;139(1):63-71.
T

Downloaded from jada.ada.org on November 10, 2010

Dr. Nishimura is an assistant professor, Behavioral Pediatric Dentistry, Okayama University, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8525, Japan, e-mail naruto10@md. okayama-u.ac.jp. Address reprint requests to Dr. Nishimura. Dr. Oda is a clinical fellow, Behavioral Pediatric Dentistry, Okayama University, Japan. Dr. Kariya is an assistant professor, Behavioral Pediatric Dentistry, Okayama University, Japan. Dr. Matsumura is an associate professor, Behavioral Pediatric Dentistry, Okayama University, Okayama, Japan. Dr. Shimono is a professor, Behavioral Pediatric Dentistry, Okayama University, Japan.

JADA, Vol. 139 http://jada.ada.org Copyright 2008 American Dental Association. All rights reserved.

January 2008

63

R E S E A R C H

0 3.7 18-Month-Old Children n = 1,206 0 9.1 1.0 29.9 1.5 19.0 2.0 28.1

3.0 3.2 2.5 7.0

0 1.4 2-Year-Old Children n = 1,206 0

3.0 3.8

Not Significant

0.5 8.2

1.0 29.2

1.5 27.2

2.0 23.3

2.5 6.9 100

Downloaded from jada.ada.org on November 10, 2010

Figure 1. The differences between the distributions with caries activity test results at the 18-month and 2-year time points (the Wilcoxon signed rank test was used).

orimetric test developed by Shimono and Sobue in there are no studies to show current and pre1974.10 The test medium contains sucrose and two dicted screening indexes for each score of caries kinds of pH indicators to display the continuous activity tests. A predictive and precise caries risk pH decrease of the test medium caused by microassessment is absolutely necessary to enable the organisms gathered in the patients plaque clinician to evaluate a patients caries risk and sample. The microorganisms in the dental plaque develop a treatment plan that focuses on metabolize sucrose and produce acids that react to prevention. these pH indicators, thus leading to SUBJECTS AND METHODS colorimetric change. Some A correct diagnosis of researchers have reported strong Subjects. The subjects were 1,208 caries depends on the children born in 2000. These chilcorrelations between pH and the caries activity test score.11-13 dren underwent health examiacquisition of data Nishimura and colleagues14 including information nations at 18 months, 2 years and reported positive correlations 312 years of age at Kurashiki-City on caries activity, between caries activity test score Public Health Center, Kurashikilifestyle and oral and the counts of mutans streptoCity, Japan. We excluded two of the hygiene habits. cocci and lactobacilli. Dental caries 1,208 children because they did not is well-known as having a number of causes.1 Therefore, a correct diagnosis depends on the acquisition of additional data including information on caries activity, lifestyle and oral hygiene habits. We determined to conduct a two-year longitudinal study to show the caries-reflective and -predictive abilities of the Cariostat test, and to include the predicted screening indexes based on previous caries activity test results and lifestyle factors that influence caries activity. Some researchers have already reported the caries activity tests predictive value.11,15,16 However,
64 JADA, Vol. 139

receive the caries activity test at 18 months of age. We had already excluded from this study children taking any kind of medication during any of their two caries activity test sampling periods. Methods. Oral examination. The 18-month, 2-year and 312-year-old childrens examinations ABBREVIATION KEY. dft: Decayed and filled teeth. dt: Decayed teeth. NPV: Negative predictive value. PPV: Positive predictive value. ROC: Receiver operating characteristic. SP: Specificity. SRCC: Spearman rank correlation coefficient. ST: Sensitivity.

http://jada.ada.org January 2008 Copyright 2008 American Dental Association. All rights reserved.

R E S E A R C H

TABLE 1 included an oral examination, a caries activity Screening indexes of each caries activity test score test and counseling by at every age, based on test results for 18-month-old Kurashiki-City public and 2-year-old children. dental hygienists that was based both on responses to AGE (YEARS) CARIES ACTIVITY TEST SCORE questionnaires regarding 0.5 1.0 1.5 2.0 2.5 patients lifestyles and on 18-Month-Old Caries Activity previous caries activity test Test Score as a Cutoff Point results. Each examiner was 18-month-old children 0.87 0.66 0.40 0.33 0.87 ST* blinded as to previous 0.44 0.62 0.90 0.97 0.13 SP 1.34 1.28 1.30 1.30 1.00 Validity (ST+SP) caries activity test results. 1.90 1.90 4.80 12.80 1.24 PPV Initial caries (white-spot 99.60 99.20 99.20 99.10 98.70 NPV lesions) was not counted as 2-year-old children a caries lesion. The caries 0.72 06.20 0.23 0.11 0.92 ST 0.45 0.64 0.91 0.98 0.13 SP activity test was not 1.17 1.26 1.14 1.09 1.05 Validity (ST+SP) performed at the 312-year11.10 14.00 19.40 30.00 9.20 PPV 94.40 94.60 92.50 92.00 94.80 NPV old childrens oral examination. 3 -year-old children 0.66 0.49 0.18 0.08 0.94 The health examinations ST 0.44 0.67 0.94 0.99 0.16 SP of 18-month- and 312-year1.10 1.16 1.12 1.07 1.10 Validity 37.70 41.30 58.10 79.50 34.80 PPV old children are routine 74.50 73.10 70.50 68.80 83.80 NPV and are sanctioned by the 2-Year-Old Caries Activity Japanese government, Test Score as a Cutoff Point while the examinations of 2-year-old children 0.78 0.59 0.32 0.16 0.96 ST 2-year-old children are 0.40 0.69 0.91 0.96 0.10 SP additional ones carried 1.18 1.28 1.23 1.12 1.06 Validity 16.00 15.00 24.80 30.90 9.30 PPV out at Kurashiki-City. The 95.00 94.50 93.40 92.70 96.60 NPV routine government3 -year-old children sanctioned examinations 0.69 0.46 0.28 0.08 0.95 ST began in 197717; Kurashiki0.42 0.72 0.93 0.97 0.17 SP 1.11 1.18 1.21 1.05 1.12 Validity Citys 2-year oral exami36.70 44.00 50.40 58.20 33.90 PPV nations began in 1988. 74.60 73.50 69.90 68.80 81.90 NPV Each examiner assessed * ST: Sensitivity. dental caries according to SP: Specificity. PPV: Positive predictive value. the criteria of the Japanese NPV: Negative predictive value. Ministry of Health and Welfares Health Policy Bureau, so this was an integrated study of difat Okayama University at the time the study was ferent systems. The same dentists, members of conducted; the examinations were performed the Dental Society of Kurashiki-City, carried out under the auspices of the government and the examinations in 18-month- and 312-year-old Kurashiki-Citys health program. Furthermore, children; the 2-year-old children were examined Kurashiki-City completely sealed subjects priby pediatric dentists (M.N. and T.O.) of Okayama vate information and then released the data to us University (Japan). Calibration of the oral examiin coded form. nations was impossible because of the different The caries activity test. The examiners collected systems. However, the authors nevertheless conplaque samples from the maxillary buccal cervical sidered this study to be important in predicting surfaces using sterile cotton swabs. The examindividual caries risk on the basis of current iners ran the swab along the tooth surface five caries activity test results. The same pediatric times in a swiping motion before placing it in an dentists gathered plaque samples for the caries ampule containing 2 milliters of the Cariostat test activity test from the 18-month and 2-year-old medium. Dental hygienists incubated this children. There was no institutional review board medium at 37C for 48 hours. They assigned a
1 2 1 2

Downloaded from jada.ada.org on November 10, 2010

JADA, Vol. 139 http://jada.ada.org Copyright 2008 American Dental Association. All rights reserved.

January 2008

65

R E S E A R C H

1.0 1.0

SPECIFICITY

0 0

18-Month-Old Childrens ROC

2-Year-Old Childrens Predicted ROC Based on 18-Month-Old Childrens

SENSITIVITY

Caries Activity Test Results

3.5-Year-Old Childrens Predicted ROC Based on 18-Month-Old Childrens Caries Activity Test Results

Downloaded from jada.ada.org on November 10, 2010

2-Year-Old Childrens ROC

Meaningless Area

3.5-Year-Old Childrens Predicted ROC Based on 2-Year-Old Childrens Caries Activity Test Results

0 0 1.0

1.0

Figure 2. Receiver operating characteristic (ROC) curves of 18-month-old and 2-year-old children and predicted curves based on the caries activity test results at both ages.

caries activity test score with reference to four standard colors. The same hygienists evaluated each of these scores as follows: score 0 (pH 5.87.2), 1.0 (pH 5.4 0.3), 2.0 (pH 4.8 0.3) and 3.0 (pH < 4.4). In this study, we used a modified scale in which the intervals between 0-1.0, 1.0-2.0 and 2.0-3.0 were divided into halves. The same dental hygienist evaluated all caries activity test results. We sent the test results to the subjects by mail. Questionnaires. We administered questionnaires to the subjects parents or guardians to evaluate which factors regarding the patients lifestyles made them susceptible to caries. We mailed these questionnaires to subjects along with a notification of their examination date. The subjects parents or guardians completed the questionnaire and brought it to the Kurashiki-City Public Health Center on the day of the childs scheduled examination. The questions were as follows: dDo you check and brush your childs teeth? dHow many times a day does your child ingest sucrose-containing foods? dDo you determine the total time of your childs sucrose-containing food intake?
66 JADA, Vol. 139

dDoes your child continue to breast-feed or drink liquids other than water through a bottle? Predicted screening indexes. The 18-month caries activity test results of children aged 2 and 312 years were predictive of the childrens either being caries-free or experiencing caries. We calculated predicted screening indexes on the basis of 18-month-old caries activity test results by using discriminate analysis for screening indexes. We calculated 312-year-old childrens predicted screening indexes on the basis of 2-yearolds caries activity test results in a similar manner. Statistical methods. We analyzed the data released by the Kurashiki-City Public Health Center. We used Spearman rank correlation to evaluate the relationship between the caries activity test of the subjects oral condition at 18 months and 2 years of age, as well as the predictive ability of the caries activity test. We used the Wilcoxon signed rank test to analyze the differences between caries activity test result distributions at 18 months and 2 years. Furthermore, we used the Mann-Whitney U test to analyze the caries activity test result distributions between

http://jada.ada.org January 2008 Copyright 2008 American Dental Association. All rights reserved.

R E S E A R C H

TABLE 2

Relationship between caries activity test results and actual mean number of carious teeth and caries prevalence at each test.
SUBJECTS CARIES ACTIVITY, BY AGE AT CARIES ACTIVITY TEST 18 Months Mean dt (SD) Caries prevalence (%) No. of children 2 Years Mean dt (SD) Caries prevalence (%) No. of children * CARIES ACTIVITY TEST SCORE 0 0.5 1.0 1.5 2.0 2.5 3.0 < .05 0 (0) 0 45 0.24 (0.66) 11.8 17 0.02 (0.13) 1.8 110 0.04 (0.24) 2.0 99 0 (0) 0 367 0.13 (0.66) 5.1 354 0.05 (0.41) 1.8 221 0.13 (0.57) 6.0 331 0.02 (0.25) 0.88 339 0.28 (0.91) 10.0 269 0.05 (0.43) 1.1 85 0.51 (1.32) 20.5 83 0.38 (1.04) 12.8 39 < .01 0.92 (1.72) 30.9 55 0.176 8.7 0.07 1.2 SRCC*

P VALUE

Downloaded from jada.ada.org on November 10, 2010

SRCC: Spearman rank correlation coefficient. dt: Decayed teeth. SD: Standard deviation. Mean caries prevalence. No children had filled teeth. Mean caries prevalence was 32.4 percent when patients were 312 years old. There were significant correlations between caries activity test scores and mean number of current dt.

caries-experienced and caries-free groups at both based on the 2-year-old caries activity test ages. We used discriminate analysis to create results. Validity beyond 1.0 was accepted and screening indexes for the results of the caries used for the screening test. The validity of caries activity test. Screening indexes include sensiactivity test score 0.5 was only 1.0, so we did not tivity (ST), specificity (SP), validity (ST plus SP), use this score as a cutoff point for dividing chilpositive predictive value (PPV) and negative predren into different caries-risk groups. Receiver dictive value (NPV). ST is the probability that a operating characteristic (ROC) curves showed the true high-risk child is predicted to be at high risk. results of screening indexes except for PPV and SP is the probability that a true lowNPV. None of the curves for ST risk child is predicted to be at low and SP was drawn in the meanrisk. PPV is the probability that a ingful area. (The meaningful area There were positive child is truly at high risk when he or is beyond a diagonal line and the correlations between she is predicted to be at high risk. meaningless area is below a diagcaries activity test NPV is the probability that a child is onal line. A diagonal line shows results and mean truly at low risk when he or she is the validity of 1.0, so this line is number of carious predicted to be at low risk. We used included in the meaningless area.) teeth at 18 months the 2 test to investigate which facThe 2-year-olds current and pretors regarding the subjects lifestyle dicted curves based on the 18and 2 years of age. made him or her susceptible to month-old caries activity test caries. We considered a P value of results were not the same. Howless than .05 to be significant. ever, both curves were located beyond the diagonal line. Both predicted curves RESULTS for the 312 year-olds based on their caries activity There were no significant differences in the distest results at the other ages were drawn close to tributions between caries activity test results each other (Figure 2). when the children were 18 months old and 2 There were positive correlations between caries years old (Figure 1). Table 1 shows the screening activity test results and mean number of carious indexes of 18-month-old children and the 2- and teeth at 18 months and 2 years of age. The 2-year 312-year-old childrens predicted indexes based on caries activity test results showed a stronger corthe 18-month-old caries activity test results. relation with the mean number of decayed teeth Table 1 also shows the screening indexes of than did the 18-month results (Table 2). None of 2- and 312-year-old childrens predicted indexes the children had filled teeth at either of those
JADA, Vol. 139 http://jada.ada.org Copyright 2008 American Dental Association. All rights reserved. January 2008 67

R E S E A R C H

TABLE 3

Relationship between caries activity test results and predicted mean number of decayed and filled teeth and caries prevalence.
SUBJECTS CARIES STATUS 0 2-Year-Old Childrens Caries Status Based on 18-Month-Old Childrens Caries Activity Test Results dft (SD) Caries prevalence (%) 3 12-Year-Old Childrens Caries Status Based on 18-Month-Old Childrens Caries Activity Test Results dt (SD) Caries prevalence (%) No. of children 3 12-Year-Old Childrens Caries Status Based On 2-Year-Old Childrens Caries Activity Test Results dft (SD) Caries prevalence (%) No. of children 0.5 CARIES ACTIVITY TEST SCORE 1.0 1.5 2.0 2.5 3.0 N/A SRCC*

P VALUE

0.11 (0.53) 0.13 (0.56) 0.13 (0.65) 0.10 (0.45) 0.29 (0.92) 0.42 (1.15) 1.15 (2.01) 4.4 1.8 5.7 5.0 12.1 14.1 30.0

0.147

Downloaded from jada.ada.org on November 10, 2010

0.29 (0.76) 0.64 (2.05) 1.02 (2.16) 0.97 (2.03) 1.58 (3.10) 2.45 (3.45) 4.46 (4.53) 15.6 15.5 29.2 32.6 35.2 45.9 86.9 45 110 367 221 339 85 39

0.202

< .001

0.29 (0.69) 0.56 (1.39) 0.88 (2.08) 1.01 (2.27) 1.62 (2.88) 2.77 (4.28) 3.91 (4.07) 17.6 15.1 28.0 28.4 39.0 48.2 68.5 17 99 354 331 269 83 55

0.223

< .01

* SRCC: Spearman rank correlation coefficient. There were significant correlations between the caries activity test results and predicted mean number of decayed and filled teeth (dft). SD: Standard deviation. dt: Decayed teeth. N/A: Not applicable.

ages. Table 2 shows the caries prevalence at each caries activity test point. Caries prevalence was higher at 18 months than at any other caries activity test point. The 2-year-olds caries prevalence increased according to the caries activity test results. Table 3 shows the mean number of 2- and 312-year-olds decayed and filled teeth (dft) at every caries activity test point in comparison with previous test results. Previous caries activity test results significantly predicted future caries incidence. The 18-month-old caries activity test results predicted 2- and 312-year caries incidences more strongly than the 2-year caries activity test results predicted the 312-year test results. Table 3 also shows the future caries prevalence based on previous caries activity test results. In 2-year-old children, the actual and predicted caries prevalences were similar from caries activity test score 0.5 to scores 2.0 and 3.0, but
68 JADA, Vol. 139

the actual caries prevalence was higher than the predicted one at caries activity test scores 0 and 2.5. The 312-year-olds predicted caries prevalence based on the 18-month and 2-year caries activity test scores were well-matched except for the 18month caries activity test score of 3.0. A child who had a caries activity test score of 3.0 when he or she was 18 months old would have a higher probability of carious teeth at 312 years of age than would a 2-year-old child who had a 3.0 caries activity test score. We analyzed the responses to the lifestyle questions for behaviors that would put children at risk of developing caries. We observed a significant difference between the children who reportedly continued breast-feeding or received anything other than water through a bottle through the age of 18 months. Additionally, we observed a significant difference regarding the frequency of

http://jada.ada.org January 2008 Copyright 2008 American Dental Association. All rights reserved.

R E S E A R C H

TABLE 4

The distribution of caries activity test results and answers to questions regarding oral habits and lifestyle of caries-experienced and caries-free children.*
SUBJECTS 18-Month-Old Children (n = 1,206): Caries-Experienced (High-Risk) Children (n = 9); Caries-Free (LowRisk) Children (n = 1,197) QUESTIONS 1: Do you check and brush your childs teeth? 2: How many times a day does your child ingest sucrose-containing foods? 3: Do you determine the total time of your childs sucrose-containing food intake? 4: Does your child continue to breast-feed or drink liquids other than water through a bottle? 1: Do you check and brush your childs teeth? 2: How many times a day does your child ingest sucrose-containing foods? 3: Do you determine the total time of your childs sucrose-containing food intake? 4: Does your child continue to breast-feed or drink liquids other than water through a bottle? 1: Do you check and brush your childs teeth? 2: How many times a day does your child ingest sucrose-containing foods? 3: Do you determine the total time of your childs sucrose-containing food intake? 4: (not included in 312 year-old childrens questionnaires)

P VALUE
.536, NS .372, NS .235, NS < .05 No data < .05 < .05

2-Year-Old Children (n = 1,206): HighRisk (n = 105); Low-Risk (n = 1,101)

Downloaded from jada.ada.org on November 10, 2010

< .05 < .05 < .05 < .05 No data

3 12-Year-Old Children (n = 1,206): High-Risk (n = 391); Low-Risk (n = 815)

* The distributions of caries activity test results of caries-experienced and caries-free children were analyzed by means of the Mann-Whitney U test. There were significant differences of P < .01 (U value, 5,453) and P < .001 (U value, 37,742) at 18 months of age and 2 years of age, respectively. The distribution of answers to questions regarding oral habits and lifestyle and their relationship with caries experience was analyzed by means of the 2 test. NS: Not significant.

sucrose intake and total time of sucrose intake through 2 years of age. There were no data regarding the act of parents brushing of the childrens teeth at 2 years of age. However, there was a significantly high rate of caries in children whose parents brushed the childrens teeth and who had a high sucrose intake at 312 years of age (Table 4).
DISCUSSION

Other researchers have investigated the reflective and predictive abilities of the caries activity test. Matsumura and colleagues17 reported that the caries activity test could screen high caries activity in children aged 1 year to 15 years, and they found a significant correlation between the caries activity test scores and number of decayed teeth for each age. Sutadi and colleagues11 and Tsubouchi and colleagues15 reported that the caries activity test had high screening indexes through their longitudinal studies in groups with high caries prevalence (more than 70 percent). Koroluk and colleagues16 reported the screening indexes of caries activity test, and their results were almost the same as ours. They used the

same screening test but produced different screening indexes. The caries prevalence of the subjects in the study by Koroluk and colleagues was 33.3 percent; in our study, it was 32.4 percent. The subjects caries prevalence influenced the screening indexes. The greatest difference between our study and other studies is that ours shows the screening indexes regarding each score. It is important to establish the screening indexes of each score for clinicians and researchers because they then can fix a cutoff point for patients on the basis of the shown screening indexes. High ST and low SP mean that there is a high probability of true positives and false negatives. Low ST and high SP means that there is a high probability of false positives and true negatives. Therefore, the practitioners can determine a cutoff point for their patients under the following circumstances: if patients caries prevalence is high, ST is more than SP; if patients caries prevalence is low, SP is more than ST. However, the test score that has the highest validity generally is considered to be the cutoff point. Caries is a complex chronic disease,18 and the
January 2008 69

JADA, Vol. 139 http://jada.ada.org Copyright 2008 American Dental Association. All rights reserved.

R E S E A R C H

constantly alternating process of demineralization and remineralization19 on the tooth surfaces is the most clinically important process. Therefore, a caries activity test is considered better in screening for caries potential than for caries experience. It is important that the clinician screen for caries potential, especially before finding caries on the tooth. Therefore, the test validity beyond 1.0 is a prerequisite condition, because the basic goal in dentistry and medicine is to prevent the initiation of disease and its further development. In this study, a caries activity test score at 18 months of age not only reflected the 18-month-old caries status but also predicted the childs caries status at 2 and 312 years of age. We saw the same results with the 2-year-old caries activity test scores. Furthermore, 2- and 312-year-old screening indexes were predicted on the basis of the 18month-old caries activity test scores, and 312-yearold screening indexes were predicted on the basis of the 2-year-old caries activity test scores. The 312-year-olds predicted screening indexes based on the 18-month-olds and 2-year-olds caries activity test scores were similar because the two predicted ROC curves were similar. This means that there were no significant differences in the distributions of the 18-month-olds, 2-year-olds and 312-year-olds caries activity test scores. ROC curves generally are used to compare screening tests targeted at the same disease. An ROC curve is drawn by connecting the coordinates on an ROC curve plane with a normal curve. However, in this study we used a straight line instead of a normal curve to clarify the relationship of the curves ups and downs. Researchers and clinicians must adopt a cutoff point that is based on exact scientific evidence. To our knowledge, this study is the first study to show the screening indexes at each caries activity test point. A researcher or clinician can use the caries activity test to diagnose caries susceptibility on the basis of exact scientific evidence. An ultimate decrease in the prevalence of caries makes it imperative that the 18-month-old caries activity test result be improved. Investigation of 312-yearolds lifestyles may be useful for caries prevention in the future. Oral examinations of six-month-old infants, especially involving instruction of parents regarding appropriate oral hygiene practices, is considered to be effective in caries prevention. Tooth eruption and change of feeding method (from breast or bottle to weaning) occur in many children at this age. Pediatric dentists and dental
70 JADA, Vol. 139

hygienists can give parents or guardians information regarding childrens oral hygiene, diet and lifestyle factors that lead to higher caries rates. Parental awareness can prevent children from developing caries.20-22 Intake of fermentable carbohydrates, particularly sucrose, is well-known as a caries risk factor. The American Academy of Pediatric Dentistrys recommendations include parental oral hygiene such as parents brushing of childrens teeth,21 and some researchers have reported that intake of liquid other than water is not acceptable.20,22,23 Therefore, the questions in this study were important, and the information concerning early childhood caries found in the results of our study can be effective in improving 18-month-olds caries activity test results.
CONCLUSIONS

Downloaded from jada.ada.org on November 10, 2010

The caries activity test succeeded in predicting 312-year-old childrens caries risk assessment based on 18-month and 2-year test results. Early weaning, less sucrose intake and toothbrushing by parents lowered a childs caries risk. It also may be useful to show screening indexes of not only each score of the caries activity test but also of other caries activity tests so that clinicians and researchers can determine a cutoff point.
The authors are greatly indebted to Joel H. Berg, MS, for his kind suggestions and sophisticated English instruction. 1. Reich E, Lussi A, Newbrun E. Caries-risk assessment. Int Dent J 1999;49(1):15-26. 2. Koch G. Importance of early determination of caries risk. Int Dent J 1988;38(4):203-10. 3. Larmas M. A new dip-slide method for counting of salivary lactobacilli. Proc Finn Dent Soc 1975;71(2):31-5. 4. Matsukubo T, Ohta K, Maki Y, Takeuchi M, Takazoe I. A semiquantitative determination of Streptococcus mutans using its adherent ability in a selective medium. Caries Res 1981;15(1):40-5. 5. Jordan HV, Laraway R, Snirch R, Marmel M. A simplified diagnostic system for cultural detection and enumeration of Streptococcus mutans. J Dent Res 1987;66(1):57-61. 6. Snyder ML. A simple colorimetric method for the diagnosis of caries activity. JADA 1941;28:44-9. 7. Alban A. An improved Snyder test. J Dent Res 1970;49(3):641. 8. Maki Y, Yamamoto H, Matsukubo T, Takazoe I, Sibuya M, Asama K. Prevalence and caries activity test scored Resazurin disk method. J Dent Health 1984;34(2):18-26. 9. Borgstrm MK, Sullivan A, Granath L, Nilsson G. On the pHlowering potential of lactobacilli and mutans streptococci from dental plaque related to the prevalence of caries. Community Dent Oral Epidemiol 1997;25(2):165-9. 10. Shimono T, Sobue S. A new colorimetric method for caries diagnosis. Dent Outlook 1974;43(6):829-35. 11. Sutadi H, Huey JC, Nishimura M, Matsumura S, Shimono T. The determination of the predictive value of caries activity test and its suitability for mass screening in Indonesia. Pediatr Dent J 1992;2(1):73-81. 12. Huey JC, Nishimura M, Matsumura S, Shimono T. Comparison of mutans streptococci count methods and Cariostat test for caries risk assessment. Pediatr Dent J 1995;5(1):31-42. 13. Rodivic OD. A longitudinal study of approximal caries in primary molars: predictive value of Cariostat. Pediatr Dent J 1996;6(1):125-34. 14. Nishimura M, Bhuiyan MM, Matsumura S, Shimono T. Assessment of the caries activity test (Cariostat) based on the infection levels of mutans streptococci and lactobacilli in 2- to 13-year-old childrens

http://jada.ada.org January 2008 Copyright 2008 American Dental Association. All rights reserved.

R E S E A R C H

dental plaque. ASDCJ Dent Child 1998;65(4):248-51, 229. 15. Tsubouchi J, Yamamoto S, Shimono T, Domoto PK. A longitudinal assessment of predictive value of a caries activity test in young children. ASDC J Dent Child 1995;62(1):34-7. 16. Koroluk L, Hoover JN, Komiyama K. The sensitivity and specificity of a colorimetric microbiological caries activity test (Cariostat) in preschool children. Pediatr Dent 1994;16(4):276-81. 17. Matsumura S, Shimono T, Morisaki I, Shimono T, Sobue S. Dental caries experience and dental caries activity by new caries susceptibility test (CARIOSTAT) by the children in Okinawa prefecture (Tarama Island of Miyako). Jpn J Ped Dent 1980;18:612-7. 18. Hunter PB. Risk factors in dental caries. Int Dent J 1988;38(4):211-7.

19. Silverstone LM. Remineralization phenomena. Caries Res 1977;11(supplement 1):59-84. 20. Johnsen DC, Gerstenmaier JH, Schwartz E, Michal BC, Parrish S. Background comparisons of pre-312-year-old children with nursing caries in four practice settings. Pediatr Dent 1984;6(1):50-4. 21. Febres G, Echeverri EA, Keene HJ. Parental awareness, habits, and social factors and their relationship to baby bottle tooth decay. Pediatr Dent 1997;19(1):22-7. 22. American Academy of Pediatric Dentistry. Clinical guideline on infant oral health care. Pediatr Dent 2004;26(7):67-70. 23. Tinanoff N, OSullivan DM. Early childhood caries: overview and recent findings. Pediatr Dent 1997;19(1):12-6.

Downloaded from jada.ada.org on November 10, 2010

JADA, Vol. 139 http://jada.ada.org Copyright 2008 American Dental Association. All rights reserved.

January 2008

71