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Predicting Caries in Permanent Teeth from Caries in Primary Teeth: An Eight-

year Cohort Study

Article  in  Journal of Dental Research · August 2002

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 RESEARCH REPORTS
Clinical
Y. Li1* and W. Wang2
1Department of Basic Science and Craniofacial Biology,
New York University College of Dentistry, 345 E. 24th
Street, New York, NY 10010-4086, USA; and 2Department
of Community and Preventive Dentistry, Peking University
School of Stomatology, Beijing, China; *corresponding
author, yihong.li@nyu.edu
J Dent Res 81(8):561-566, 2002
ABSTRACT
Several cross-sectional studies report that caries in
primary teeth is correlated with caries in
permanent teeth. This eight-year cohort study
sought to determine if caries in the primary
dentition can predict caries in the permanent
dentition of the same individuals and, if so, with
what degree of prediction accuracy. A total of 362
Chinese children, from 3 to 5 years old at the time
of the 1992 baseline study, were re-examined in
2000. The study found statistically significant
associations between caries prevalence in primary
and permanent dentitions (p < 0.01). Children
having caries in their primary teeth were three
times more likely to develop caries in their
permanent teeth (relative ratio = 2.6, 95% CI =
1.4-4.7; p < 0.001). Caries on primary molars had
the highest predictive value (85.4%). This study
demonstrates that caries status in the primary teeth
can be used as a risk indicator for predicting caries
in the permanent teeth.
KEY WORDS: dental caries, primary and
permanent teeth, Chinese children.
Received October 31, 2001; Last revision June 7, 2002;
Accepted June 13, 2002
Predicting Caries in Permanent
Teeth from Caries in Primary
Teeth: An Eight-year Cohort Study
INTRODUCTION
D ental caries is the most prevalent of all chronic diseases among US
children (USDHHS, 2000). It affects 18% of all children ages 2-4, 52%
of children ages 6-8, and 80% of adolescents age 17 (Kaste et al., 1996). In
China, caries prevalence ranges from 67% to 86% among pre-school
children (3 to 6 yrs old) and 32% to 48% among adolescents (12 yrs old)
(PRCMPH, 1987, 1999; Petersen and Guang, 1994; Wang et al., 1994;
Douglass et al., 1995; Peng et al., 1997; Wong et al., 1997, 2001; Petersen
and Esheng, 1998). High caries prevalence still endures as one of the major
oral health issues in children.
Because dental caries is a disease that is both preventable and costly to
treat, previous studies have focused on identifying caries risk predictors,
including developmental tooth defects, mutans streptococci infection
(time, source, and level), lactobacilli counts, salivary buffer capacity and
flow rate, sucrose intake frequency, and past caries experience (Seppä et
al., 1989; Alaluusua et al., 1990; Helfenstein et al., 1991; Disney et al.,
1992; Steiner et al., 1992; Vehkalahti et al., 1996; van Palenstein
Helderman et al., 2001). Most of these studies, however, consisted of a
single or several cross-sectional surveys. Information validating the
correlation between caries in primary and permanent dentitions of the
same individuals is needed.
The present eight-year cohort study addresses the following questions:
Does the caries status of the primary teeth correlate with that of the
permanent teeth in the same individual? If so, which teeth contribute most
strength to the correlation? Finally, can caries in the permanent teeth be
predicted from caries status in the primary teeth of the same individual?
Here, we examined the specificity, sensitivity, predictive value, and
efficiency of various risk predictors that might be used to predict future
caries in this prospective study.
MATERIALS & METHODS
Study Cohort
The study was approved by the University of Alabama at Birmingham
Institutional Review Board for Human Use with English Informed Consent
and Chinese translation. Parents’ consent was obtained prior to the study. The
baseline dental examination for caries status in the primary dentition was
conducted from July to October, 1992 (Li et al., 1996). A total of 504
children, 256 boys and 248 girls, participated in this eight-year cohort study.
They were randomly selected from 11 villages and 4 kindergartens of two
representative communities, outside the Beijing metropolitan area. The
children were then 3 to 4 yrs old (mean = 3.5). Gender, age, and socio-
economic status (SES) were equally distributed. Forty-nine percent of the
families had annual incomes less than ¥3000 RMB ($370 US dollars) and
were categorized as the low-SES group. The average fluoride concentration
was below 0.26 ppm in the drinking water.
561
562 Li & Wang J Dent Res 81(8) 2002

Eight years later, in December of 2000, the same group of RESULTS

children (N = 362, 46% boys and 54% girls) was re-examined for
caries status in their permanent dentition. Fifty-seven of the
children had passed their 13th birthday when the oral examination
was conducted. Therefore, the average age of the children examined
was 11.7 yrs, ranging from 11 to 13 yrs. The rate of loss to follow-
up was 28%, in part the result of two entire villages relocating for
regional irrigation projects. More than half (56%) of the families
remained at annual income levels below the regional average.
Dental Examination
Both baseline and follow-up dental examinations were conducted
under the same conditions, in classroom settings with natural light and
standard mouth mirrors and explorers. Two calibrated dentists, trained
at the WHO Collaborative Training Center in Beijing, performed the
dental examinations according to WHO caries diagnostic criteria
(WHO, 1987). Caries status, decayed (cavitated), missing, and filled
primary (dmf) or permanent (DMF) teeth or tooth surfaces were
assessed. Children’s teeth were not air-dried or cleaned prior to the
examinations. No radiographs were taken. Prior to the baseline study, a
caries diagnostic standardization was performed between the
examiners. The agreement in applying the diagnostic criteria was 92%.
The intra-examiner reproducibility for applying the diagnosis criteria
was 95%. The Kappa coefficients were 0.86 and 0.88, respectively.
Statistical Analysis
The data analyses were performed with SPSS software 10.0 (SPSS
Inc., Chicago, IL, USA). Caries outcome in permanent teeth was
defined as the dependent variable. Both descriptive and categoric
statistics were applied for the prevalence and the mean of dental caries
experience. Binary logistic regression analyses, as well as Spearman’s
correlation coefficient, logistic regression analysis, predictive value,
and relative risk (RR) analysis, were also computed for caries risk
estimations and for comparative analyses between caries in primary
teeth and permanent teeth.
Caries Status
Caries prevalence and the mean values are summarized in Table
1. Caries prevalence in the primary dentition was 83%; the mean
dmft (dmfs) was 6.1 ± 4.7 (12.5 ± 12.4). The caries prevalence
associated with increase in age was significant (p < 0.01). No
significant difference was observed between genders. Caries
prevalence in the permanent dentition among Chinese adolescents
was 41%, and the means of both DMFT and DMFS were low.
When caries status was compared with SES, higher caries
prevalence was found among children with lower SES (86% vs.
81%, p < 0.05; dmft 6.7 vs. 5.7, p < 0.01) in primary dentitions. In
the permanent dentition, however, a reverse correlation was
observed (35% vs. 47%, p < 0.05). Adolescents in the high-SES
group also experienced more caries than adolescents in the low-
SES group (Independent t test, p < 0.05).
Caries Correlation and Relative Risk
Results from this study illustrated a significant correlation
between caries experience in the primary and that in the
permanent teeth (r = 0.38, p < 0.001). A greater correlation
coefficient was found between caries in primary maxillary
anterior teeth and caries in permanent molars (r = 0.49, p <
0.001). Of the children who developed dental caries in
permanent teeth, 94% of them experienced caries in their
primary teeth (Pearson ␹2 = 13.7; p < 0.001). Of the children
who did not have any caries in their primary teeth, 83%
remained caries-free by the age of 12. A relative risk value of
2.6 (95% CI of 1.4 to 4.7, p < 0.001) indicated that children
who manifested caries in their primary teeth were three times
more likely to develop caries in their permanent teeth than were
those children previously free of caries. The study also revealed
that the mean decay in the permanent teeth significantly
correlated with the mean decay in the primary teeth (p <

”
Table 1. Comparison of Dental Caries Status in the Primary and Permanent Dentitions of the Children

„„„„„ Baseline Examination, 1992 ÌÌ ÌÌ ÌÌ Follow-up Examinations, 2000

Primary Dentition Permanent Dentition

Prevalence dmft dmfs Prevalence DMFT DMFS
(%) (mean ± SD) (mean ± SD) (%) (mean ± SD) (mean ± SD)

Total (N = 504) 83.3 6.1 ± 4.7 12.5 ± 12.4 Total (N = 362) 40.6 0.9 ± 1.3 1.1 ± 1.8
By age
3 yrs (n = 252) 78.2a 5.5 ± 4.5b 10.5 ± 10.8b 11 yrs (n = 154) 40.4 0.8 ± 1.2 1.0 ± 1.6
4 yrs (n = 252) 88.5 6.7 ± 4.8 14.5 ± 13.5 12 yrs (n = 151) 38.4 0.8 ± 1.4 1.0 ± 1.8
13 yrs (n = 57) 47.4 1.1 ± 1.5 1.5 ± 2.5
By gender
Boys (n = 256) 83.2 6.2 ± 4.8 12.9 ± 13.1 Boys (n = 196) 39.8 0.8 ± 1.2 1.0 ± 1.7
Girls (n = 248) 83.5 6.8 ± 4.6 12.0 ± 11.5 Girls (n = 166) 41.6 1.0 ± 1.5 1.3 ± 2.0
By SES
Low (n = 247) 85.8c 6.6 ± 4.5 13.4 ± 12.0 Low (n = 201) 35.3c 0.7 ± 1.2d 0.9 ± 1.7d
High (n = 257) 80.9 5.7 ± 4.8 11.5 ± 12.6 High (n = 161) 47.2 1.0 ± 1.4 1.4 ± 2.1

a Pearson chi-square test for prevalence comparison; p < 0.01.

b Independent t test; p < 0.01.
c Pearson chi-square test for prevalence comparison; p < 0.05.
d Independent t test; p < 0.05.
J Dent Res 81(8) 2002 Dental Caries in Primary and Permanent Dentitions 563

0.001). The linear regression analysis Table 2. Relative Risk (RR) of Developing Caries in the Permanent Teeth as Predicted by Different
demonstrated a trend in which the number Caries Experiences in the Primary Teeth or Tooth Surfaces
of permanent teeth with caries rose during
the study period in response to an increase Caries in Primary Teeth Caries in Permanent Teeth
of the mean caries score of the primary Score N (%) RR 95% CI ␹2 p valuea
teeth (FDMFT = 0.39 + 0.08*dmft; r = 0.27;
p < 0.001). In addition, a steady increase Caries-free 52 (14.4)
in the relative risk (RR) and predictive dmfs
value for caries was observed as the ≤5 74 (20.4) 1.95 1.0-3.8 4.2 0.04
number of decayed tooth surfaces 6-12 80 (22.1) 1.95 1.0-3.8 4.3 0.04
increased (Table 2). 13-20 79 (21.8) 2.99 1.6-5.6 15.9 < 0.001
Caries Prediction > 20 77 (21.3) 3.38 1.8-6.3 21.6 < 0.001
dmft
When the caries experience in the primary
≤3 70 (19.3) 1.57 0.8-3.2 1.6 0.28
teeth was used to predict future caries of
4-6 71 (19.6) 2.11 1.1-4.1 5.5 0.19
the same individual, the study found an
7-9 83 (22.9) 2.91 1.5-5.4 14.1 < 0.0001
overall sensitivity of 93.9%, an overall
≥ 10 86 (23.8) 3.49 1.9-6.5 24.5 < 0.0001
specificity of 20.0%, and an overall
positive predictive value of 85.4%. To a Pearson chi-square test computed by a series of 2x2 crosstab comparisons of caries-active
answer the question as to which teeth vs. caries-free primary teeth to estimate caries risk in permanent teeth. An increase in the
contribute the most to the positive RR and significance levels was evidenced in the Table as the numbers of decayed teeth or
predictive value, we repeated the tooth surfaces increased.
statistical analyses on subsets of teeth, by
dividing the primary teeth with caries into
different groups: maxillary incisors (4 teeth), maxillary anterior caries on any of the primary molars with the highest predictive
teeth (6 teeth), maxillary first and second molars (4 teeth), value (85.4%), and the highest specificity (91.6%) was
mandibular first and second molars (4 teeth), and all primary observed in caries on all of the primary molars. An almost-
molars (8 teeth). The sensitivity, specificity, predictive value, perfect specificity, 97.7% for caries, on all maxillary anterior
and efficiency were determined for different tooth teeth was paired with a low sensitivity. The highest efficiency
combinations according to two categories: caries present in any (65.8%) was for caries on all mandibular primary molars. The
one of these teeth, or caries present in all of the teeth. Table 3 positive predictive value decreased when the prevalence was
shows that the highest sensitivity (93.9%) was observed in low, even for high values of sensitivity or specificity.

Table 3. Positive Predictive Value (PPV) of Caries in the Primary Teeth for Caries in the Permanent Teeth

Caries in Primary Teeth Prediction of Caries in Permanent Teeth

Tooth Typea Prevalence (%) Sensitivity (%) Specificity (%) Efficiency (%) PPV (%)

Maxillary incisors
(52, 51, 61, 62)
Any one of them 56.4 61.2 47.0 56.4 59.9
All of them 48.9 53.1 54.0 52.8 52.5
Maxillary anterior teeth
(53, 52, 51, 61, 62, 63)
Any one of them 60.5 66.7 43.7 53.6 64.5
All of them 3.9 6.1 97.7 60.5 9.7
Maxillary 1st & 2nd molars
(55, 54, 64, 65)
Any one of them 69.9 83.7 39.5 57.5 76.3
All of them 20.7 32.0 87.0 64.6 39.1
Mandibular 1st & 2nd molars
(85, 84, 74, 75)
Any one of them 77.3 89.8 31.2 55.0 81.6
All of them 32.3 47.6 78.1 65.8 50.9
All molars
(55, 54, 64, 65, 74, 75, 85, 84)
Any of the molars 82.3 93.9 25.6 53.3 85.4
All of the molars 14.4 23.2 91.6 63.8 31.7

a Since only 6.4 of the children had caries on any of the mandibular incisors, statistical analyses on predictive values for this group were excluded.
564 Li & Wang
Figure. The overall relative risk (RR) for caries development in the
permanent dentition was 2.6 (Pearson chi-square test, p < 0.001),
indicating that children who had caries in their primary teeth were
nearly three times more likely to develop caries in their permanent
teeth than the children who were previously free of caries. This Fig.
shows the specific value of RR for caries development in the permanent
dentition, depending upon caries presence on different types of
primary teeth. Caries on primary maxillary (Max) incisors alone did
not have significant predictable value. Caries on mandibular (Man)
molars had the highest RR value (1.89) with the highest predictive
efficiency (65.8%).
Another way to determine the predictive value was to
compare relative risk values according to caries status of
different tooth segments in the primary dentition. As shown in
the Fig., caries presence on all upper incisors (4 teeth) did not
have significant predictive value for caries development in the
permanent dentition (RR = 1.1; 95% CI = 0.85-1.47; p = 0.43).
Caries presence on all upper anterior teeth (6 teeth) had
marginally significant predictive value for caries development
in the permanent dentition (RR = 1.6; 95% CI = 1.07-2.45; p =
0.07). Caries presence either on all upper primary molars or on
lower primary molars had similar predictive values (p < 0.001).
A relative risk value for caries presence on all first and second
primary molars was 1.8 (95% CI = 1.40-2.30, p < 0.001). The
relative risk value was even greater for caries presence on any
of the first and second primary molars (RR = 3.4; 95% CI =
1.8-6.1, p < 0.001), with the positive prediction value 94%.
DISCUSSION
When caries experience in primary teeth is used as a risk
indicator to predict caries in permanent teeth, the commonly
used and most pragmatic characteristics of tests are
sensitivity, specificity, and predictive value. Previous studies
reported ranges of sensitivities from 28% to 76%, specificities
from 63% to 93%, and predictive values from 61% to 77% for
overall positive prediction (Abernathy et al., 1987; Seppä et
al., 1989; Wilson and Ashley, 1989; Helfenstein et al., 1991;
Disney et al., 1992). Results of this longitudinal study
demonstrated that the best indicator of sensitivity (94%) was
caries on any of the primary molars. The best indicator of
specificity (98%) was caries on all maxillary anterior teeth.
J Dent Res 81(8) 2002
There was no single indicator with both high sensitivity and
specificity for the identification of individuals at high risk
before they develop caries. In addition to the sensitivity,
specificity, and positive predictive values, the study also
systematically examined the prediction efficiency, calculated
from true caries-active and caries-free status, for each of the
tooth groups over the grand total. The predictive value of
85.4% suggests that nine out of ten children who had caries in
their primary molars will develop caries in their permanent
teeth. Accordingly, a combination of caries present on
primary molars (the highest sensitivity) and caries-free
primary maxillary anterior teeth (the highest specificity)
would be the best predictor for distinguishing children as
high- or low-risk for caries.
Analysis of the baseline data showed that 78% of children
at age 3 and 88.5% at age 4 had at least one decayed tooth.
According to the new definition of early childhood caries
(ECC) (Drury et al., 1999), 90% of this cohort manifested
ECC. But not all of them developed caries in his/her
permanent teeth. Since the caries scores ranged from 1 to 20
for dmft and from 1 to 60 for dmfs, a wide spread in positive
predictive values was also observed. Based on caries
prediction analyses as a function of different caries scores, the
study discovered that caries on primary maxillary incisors
alone or fewer decayed teeth (dmft ≤ 6) might not necessarily
be a sufficient predictive risk indicator for future caries.
Children with severe ECC (24%) who had dmft scores equal to
or greater than 10 were 3.5 times at greater risk for developing
caries in their permanent dentition. Therefore, the current
definition for ECC or severe ECC may lack specific and
sufficient power to distinguish between those individuals at
high risk and those at low risk for caries.
Since 1990, several cross-sectional epidemiological
studies on caries in Chinese children have been reported
(PRCMPH, 1987, 1999; Petersen and Guang, 1994; Wang et
al., 1994; Douglass et al., 1995; Peng et al., 1997; Wong et
al., 1997, 2001; Petersen and Esheng, 1998). The caries
prevalence in primary dentitions was 76% to 83%, with an
average of 4.3 to 4.8 decayed teeth. Caries prevalence in
permanent dentitions was 32% to 45%; the average ranged
from 0.7 to 1.0. This study found similar results. Interestingly,
high caries prevalence and more decayed teeth were observed
in the primary dentition of children with lower SES. Eight
years later, the caries prevalence in the same cohort was higher
among children with higher SES. This discordance of caries
status between the primary and the permanent dentitions in
Chinese children is remarkable compared with that in
populations in developed countries (Kaste et al., 1996). One
hypothesis was that the primary teeth, compared with the
permanent teeth, are more susceptible to developmental
defects (Li et al., 1995), such as enamel hypoplasia, as the
result of maternal chronic nutritional deficiency, low birth
weight, and prenatal infectious diseases. The second
hypothesis was that enamel hypoplastic lesions could foster
earlier colonization of cariogenic bacteria, mainly mutans
streptococci, in the oral cavity−colonization that could
accelerate caries development and progression (Li et al., 1994,
1996). As expected, the socio-economic status may not
indicate a direct etiologic risk factor for dental caries, but it
can significantly undermine tooth susceptibility, especially in
the primary teeth, for caries.
J Dent Res 81(8) 2002 Dental Caries in Primary and Permanent Dentitions
Since dental caries is a dietary carbohydrate-modified
bacterial infectious disease (van Houte, 1994), one would
expect a similar caries development pattern in both the primary
and the permanent dentitions in the same individual. However,
the study observed reversed caries prevalence in the permanent
dentition for high-SES children. One explanation could be that
the permanent teeth have a longer developmental and
maturational period than the primary teeth. They are less
affected by prenatal disturbances. The impact of developmental
defects on tooth susceptibility to caries might be diminished in
children with low SES. Second, there was a substantial
difference in the levels of consumption of sugar-containing
beverages and sweetness between children of low SES (rural
area) and those of high SES (urban area), as a result of overall
economic improvement in China (ISO, 2001). An increase in
caries prevalence has been reported among high-SES children
(Lo et al., 1999; PRCMPH, 1999). In comparison, in children
of low SES with well-developed permanent teeth and a more
traditional diet, the caries prevalence remained relatively low.
Although the study presents several strengths–such as a
very homogeneous study cohort with known traditional dietary
habits, limited exposure to dental restorative treatments,
fluoride, and antibiotics–the main drawback was that caries
diagnostic criteria in the study were based on exclusion of non-
cavitation (enamel caries lesion) for caries risk prediction. The
caries status in primary teeth, the predisposing variable, could
have been underestimated. It might have affected the
measurement of association between the predisposing variable
and the outcome variable, the caries status in permanent teeth,
and contribute to the low prediction efficiency observed in the
study. Clearly, more sensitive caries diagnostic and detecting
techniques are needed for the future study of caries prediction.
Overall, this eight-year cohort study demonstrated a
significant positive association between caries in primary and
caries in permanent dentitions. Future caries development could
be predicted based on the overall risk estimation and caries
status of specific groups of primary teeth. As evident in this
study, assessment of caries status in primary teeth constitutes a
valuable prognostic tool with a high level of confidence in
predicting future caries, making it possible for preventive
regimens to be initiated in anticipation of future caries.
ACKNOWLEDGMENTS
We express our grateful appreciation to Dr. Page W. Caufield
for his critical comments on this manuscript. We also thank
Drs. Xiang-Yong Pan and Hua Wu and Ms. Shu-Yuan Wang
for their technical assistance, and Dr. Howard Sage for his
English editing. This study was supported, in part, by the John
J. Sparkman Center for International Public Health Education
(SCIPHE) of the University of Alabama at Birmingham and by
NIH/NIDCR Grant DERR10595.
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 LETTERS TO THE EDITOR

TO THE EDITOR: high risk are extremely low, it is possible to save money and

Fprimary
resources by identifying children at high risk and offering them
rom an eight-year longitudinal study, Li and Wang (2002)
efficacious individual protection (Rose, 1992). However, for a
analyzed the relationship between baseline caries on
high-risk strategy to be justifiable, the fraction of children
teeth at the age of 3 to 5 years and follow-up caries
classified at high risk should not exceed 30% (Hausen, 1997).
on permanent teeth in a cohort of 362 children. They found
With the high caries prevalence in primary teeth reported by
these variables to be statistically associated and the presence
the authors of the paper, more than 80% of children would be
of caries in primary teeth to be predictive of caries in
classified as high risk and would receive intensive preventive
permanent teeth.
care, whereas the remaining 20% would not. In this case, the
Since the numbers of true-positive, false-positive, true-
time and the resources required to apply the test would be
negative, and false-negative subjects were not directly
greater than those saved by leaving such a small fraction of
available from the text, I have extrapolated them to build a 2 x
children without preventive care.
2 table and re-calculate the caries-predictive power of caries on
My opinion is that the paper by Li and Wang demonstrates
primary teeth. The data I have used were caries prevalence on
that caries status of primary teeth is not predictive of caries on
permanent teeth (40.6%), proportion of children with baseline
permanent teeth in their cohort. Study populations with a high
dmf = 0 (14.4%), proportion of children with baseline dmf > 0
proportion of subjects classified to be at high risk require
and DMF > 0 (94%), and the proportion of children with
population-based programs.
baseline dmf = 0 and DMF = 0 (83%) (Table).
To be sure that my extrapolations were exact, I re-calculated
—Stefano Petti
the Relative Risk (RR = 2.57; 95% Confidence Interval, 1.40 -
Department of Public Health Sciences “G. Sanarelli”
4.72). Finally, I re-calculated Sensitivity, Specificity, Positive,
University “La Sapienza”
and Negative Predictive Values to be 0.939, 0.200, 0.445, and
P. le Aldo Moro 5
0.827, respectively. While the RR, Sensitivity, and Specificity I
00185 Rome, Italy
calculated were equal to the values reported by Li and Wang,
the PPV that I found was lower.
If the “true” overall PPV was 44% and not 85%, I suspect REFERENCES
that the other PPVs of baseline caries on subsets of primary Hausen H (1997). Caries prediction-state of the art. Community Dent
teeth reported by the authors were also not correct. The Oral Epidemiol 25:87-96.
numbers of tp, fp, fn, and tn subjects for all the possible Li Y, Wang W (2002). Predicting caries in permanent teeth from
combinations tested must be reported and analyzed. If not, the caries in primary teeth: an eight-year cohort study. J Dent Res
authors' error leads to inverse conclusions. 81:561-566.
Even if the reported PPVs were exact, there are other Rose G (1992). The strategy of preventive medicine. Oxford: Oxford
aspects that are not agreeable. First, the predictive power University Press.
cannot be estimated by the correlation coefficient,
RR, or by the PPV without the NPV, as in the Table. 2 x 2 contingency table, indicating Relative Risk (RR) and Predictive Power of
paper of Li and Wang. There are many methods caries on primary teeth using the data reported by Li and Wang (2002).
to assess predictive power, including the value of
Sensitivity plus Specificity (Hausen, 1997). The DMF > 0 DMF = 0
highest value for this measure deducible from the dmf > 0 true positive (tp) false positive (fp) (classified as high risk)
paper was 119.5, far from the minimum required 138 172 310
for an effective test (i.e., 160, with both dmf = 0 false negative (fn) true negative (tn) (classified as low risk)
parameters > 80%). 9 43 52
There is a final important methodological (true high risk) (true low risk) 362
limitation in the paper. Caries prediction is 147 215
modeled as a high-risk preventive strategy. When
caries incidence and the fraction of children at Relative Risk
RR = tp/(tp + fp)x(fn + tn)/fn = (138/310) x (52/9) = 2.57; lnRR = 0.9447
Standard Error (ln RR ) = = [1/tp] - [1/(tp + fp)] + [1/fn] - [1/(fn + tn)] =
=[1/138]- [1/(138 + 172)] + [1/9] - [1/(9 + 43)] = 0.3097
95% Confidence Interval RR = 1.40 - 4.72
t-ratio = (lnRR)/SE(lnRR) = 0.9447/0.3097 = 3.05; p < 0.005
Predictive Power
Sensitivity = tp/(tp +f n) =138/147 = 0.939; Specificity = tn/(fp + tn) = 43/215 = 0.200
Positive Predictive Value (PPV) = tp/(tp + fp) = 138/310 = 0.445
Negative Predictive Value (NPV) = tn/(fn + tn) = 43/52 = 0.827
Sensitivity+Specificity = 93.9 + 20.0 =113.9

804
J Dent Res 81(12) 2002 Letters to the Editor
THE AUTHORS REPLY:
O ur study found that the caries status of primary teeth,
especially the primary molars, can be used as a risk
indicator for caries development in the permanent dentition of
Chinese children. This conclusion was made based not upon
the positive predictive value which depends on the prevalence
of the disease, but, rather, upon the following findings from the
study: (1) a significant correlation between caries in the
primary and permanent teeth; (2) a high sensitivity (93.9%) in
predicting caries in permanent teeth for children with caries in
the primary teeth; (3) a significant relative risk associated with
caries in permanent teeth for children who manifested caries
compared with children caries-free in the primary teeth; and (4)
an increasing pattern of the relative risk associated with caries
in permanent teeth as the mean dmfs and mean dmft scores in
the primary teeth increase. In fact, our findings were consistent
with the work performed by Heller et al. (2000), who used a
different research approach. Based on insurance claims data,
they reported that primary posterior teeth treatment was
significantly associated with future caries treatment in first
permanent molars. Their study, in addition to others (Powell,
1998), has suggested that caries experiences in primary teeth
should be considered as a risk predictor for future caries. We
appreciate Dr. Petti's thoughtful reading of the article and agree
that the overall positive predictive value should be lower than
that given in the original article, based on the fact that high
caries prevalence occurred in the primary teeth and low caries
prevalence in the permanent teeth. It should be clarified that the
85.4% was calculated from the subgroup children (23.4% of the
total) who had a mean dmft score greater or equal to 7 and who
developed caries in their permanent molars.
Dr. Petti's second point relates to the relatively low value
(119.5) of sensitivity plus specificity used in the caries-risk
screening examination. Precisely, the highest combination
value was 125.7 in Table 3. By using the combination to eval-
uate a diagnostic test, one would normally assume that the two
values were equally important to a test outcome, which is true
for many diseases. Dental caries, however, has unique charac-
teristics. It is infectious but not life-threatening, no single
causality has been reported for the disease, a considerable
amount of time is required for caries to develop, and preventive
measures are available at reasonable cost. Considering these
unique characteristics, we strongly believe that a risk-screening
test with a high sensitivity is more important than one of high
specificity. Thus, we intentionally decided not to use the
combination approach, but rather to examine the sensitivity and
specificity separately. To date, studies have failed to show the
ability of a simple clinical diagnostic test to predict future
caries activity accurately in individuals (Powell, 1998). With a
multitude of variables and complex statistical models, in which
bacterial levels, dietary behavior, salivary factors, and other
social variables were included, a combined sensitivity and
specificity score could be as high as 173 (Steiner et al., 1992).
In our study, we examined only past caries experience;
therefore, a low combination value of sensitivity plus
specificity was expected.
Dr. Petti also raises an important point regarding caries
prediction and caries-preventive strategy. We believe that
children having one decayed tooth or caries on only 4
805
maxillary incisors should not be simply classified as “high-risk
individuals”. If more than 80% of the children already affected
by dental caries in their primary teeth were classified as a
high-risk group, it would be pointless to develop and
implement a cost-effective preventive measure to prevent
dental caries in the permanent dentition, especially in China,
which has a severe shortage of dental professionals at all
levels (PRCMPH, 1999). Since caries distribution was skewed
in this study cohort and in many other populations (Hausen,
1997), various methods have been used to delineate low- and
high-risk individuals. For example, Kaste et al. (1992) found
that Native American children with a dmft of 5 or more were
more likely develop caries in their permanent teeth (RR = 2.4,
95% CI = 1.4-4.3). Heller et al. (2000) demonstrated that
primary posterior tooth treatment at ages 4-8 was significantly
associated with future caries treatment (RR = 2.5, 95% CI =
2.3-2.7). Bratthall (2000) introduced the Significant Caries
Index using DMFT > 3 as a cut-off for the evaluation of caries
risk in the permanent dentition.
In our study, we proposed to divide the decayed primary
teeth in different risk groups. The main objectives were to
make caries prediction more accurate and to introduce a
different means of detecting those individuals most in need
of enhanced caries prevention. A less significant correlation
was found between caries in the primary anterior teeth and
that in the permanent teeth. Statistical analyses for the
different combinations of caries in the primary molars
demonstrated that: (1) the positive predictive values ranged
from 47.3% (caries on any of the mandibular molars) to
65.4% (caries on all primary molars); (2) the relative risk
values were 1.8 (95% CI = 1.4-2.3) to 3.4 (95% CI = 1.8-
6.2); and (3) all of the results were highly significant.
Statistical analyses were also performed for children with
high risk (dmft > 7, 46.7%) and very high risk (dmft > 10,
23.8%) (Table 2). If we focused our analyses on those
children who had a dmft score greater or equal to 7 and had
pit and fissure caries in their permanent molars, the positive
predictive values would be as high as 94.6%. Those
children were truly high-risk individuals. Because positive
predictive value fluctuated according to disease prevalence,
which is one of the drawbacks, and because of its
uncertainty as a predictive indicator (Galen and Gambino,
1975), the study conclusion was not based merely on the
positive predictive value; rather, it was strongly supported
by other analytical results.
As Dr. Petti pointed out, a population-based caries-
prevention program would be cost-effective in controlling
the high caries prevalence in young Chinese children.
Community-based water fluoridation, for example, has been
a very successful caries-preventive approach in the United
States and is listed as one of the top ten public health
achievements in the United States in the 20th century (CDC,
1999). However, it will have to be carefully reconsidered to
benefit Chinese children, for several reasons: Chinese food
culture and dietary practices are very different from those of
the United States, and the optimal level of fluoride that
needs to be added to the water supply is yet to be
determined (Guo, 2000). One-sixth of the nation
(242,885,400 of the entire population) live in areas where
excess fluoride has been found in the drinking water, soil,
and air (Chen, 1997; Chen, 2000). Lack of infrastructure and
 806 Letters to the Editor
professional manpower prevents the implementation of
community-based water fluoridation programs. Since China
has established an outstanding nationwide primary health-
care system and network, we believe that dental public
health strategies should utilize the existing system and focus
on improving maternal oral health conditions and awareness
plus intervention to reduce primary teeth susceptibility to
caries and caries incidence in permanent teeth. Further
studies of those strategies are critically important.
—Yihong Li1 and Weijian Wang2
1 Department of Basic Science and Craniofacial Biology, New York
University College of Dentistry, New York, NY 10010, USA;
yihong.li@nyu.edu. 2Department of Community and Preventive Dentistry,
Peking University School of Stomatology, Beijing, China 10081;
ncoh@public.bta.net.cn
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