Accepted Manuscript Title: Association between developmental defects of enamel and dental caries: a systematic review and meta-analysis Author: F. Vargas-Ferreira M.M.S Salas G.G Nascimento Tarquinio S.B.C. C.M. Faggion M.A Peres W.M Thomson F.F Demarco PII: DOI: Reference:
S0300-5712(15)00079-2 http://dx.doi.org/doi:10.1016/j.jdent.2015.03.011 JJOD 2445
To appear in:
Journal of Dentistry
Received date: Revised date: Accepted date:
11-10-2014 23-3-2015 27-3-2015
Please cite this article as: Vargas-Ferreira F, Salas MMS, Nascimento GG, S.B.C. T, Faggion CM, Peres MA, Thomson WM, Demarco FF, Association between developmental defects of enamel and dental caries: a systematic review and metaanalysis, Journal of Dentistry (2015), http://dx.doi.org/10.1016/j.jdent.2015.03.011 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Title: Association between developmental defects of enamel and dental caries: a
2
systematic review and meta-analysis
3 4
Authors. F. Vargas-Ferreiraa, M.M.S Salasb, G.G Nascimentob, Tarquinio S.B.C.b,
5
C.M. Faggionc, M.A Peresd, W.M Thomsone, F.F Demarcoa,b
7
a
8
[[email protected]].
9
b
ip t
6
cr
Post-Graduate Program in Epidemiology, Federal University of Pelotas, Brazil. Post-Graduate Program in Dentistry, Federal University of Pelotas, Brazil.
[[email protected] / [email protected] / [email protected]].
11
c
12
Germany [[email protected]].
13
d
14
Australia. [[email protected]].
15
e
16
[[email protected]].
Australian Research Centre for Population Oral Health, University of Adelaide,
22 23
d
te
Short Title: Developmental defects of enamel and dental caries Key words: epidemiology, dental caries, developmental defects of enamel, child
Ac ce p
21
M
Sir John Walsh Research Institute, University of Otago, Dunedin, New Zealand.
18 20
an
Department of Periodontology, Faculty of Dentistry, University of Münster, Münster,
17 19
us
10
24
Author for correspondence:
25
Flávio Fernando Demarco
26
Federal University of Pelotas (UFPEL), School of Dentistry
27
457 Gonçalves Chaves Street, Zip Code 96015-560, Pelotas, RS, Brazil
28
Tel 55 53 3222 6690 / Fax 55 53 3222 6690
29
e-mail:[email protected]
30 31 32 33 1
Page 1 of 22
33
Title: Association between developmental defects of enamel and dental caries: a
34
systematic review and meta-analysis
35 36 37 Abstract
39
Background: Dental caries is the main problem oral health and it is not well established
40
in the literature if the enamel defects are a risk factor for its development. Objective:
41
Studies have reported a potential association between developmental defects enamel
42
(DDE) and dental caries occurrence. We investigated the association between DDE and
43
caries in permanent dentition of children and teenagers. Data Sources: A systematic
44
review was carried out using four databases (Pubmed, Web of Science, Embase,
45
Science Direct), which were searched from their earliest records until December 31
46
2014. Study selection: Population-based studies assessing differences in dental caries
47
experience according to the presence of enamel defects (and their types) were included.
48
PRISMA guidelines for reporting systematic reviews was followed. Meta-analysis was
49
performed to assess the pooled effect, and meta-regression was carried out to identify
50
heterogeneity sources. From the 2,558 initially identified papers, nine studies fulfilled
51
all inclusion criteria after checking the titles, abstracts, references, and complete
52
reading. Seven of them were included in the meta-analysis with random model.
53
Results: A positive association between enamel defects and dental caries was
54
identified; meta-analysis showed that individuals with DDE had higher pooled odds of
55
having dental caries experience [OR 2.21 (95%CI 1.3; 3.54)]. Meta-regression analysis
56
demonstrated that adjustment for sociodemographic factors, countries’ socioeconomic
57
status and bias (quality of studies) explained the high heterogeneity observed.
58
Conclusion: A higher chance of dental caries should be expected among individuals
59
with enamel defects.
Ac ce p
te
d
M
an
us
cr
ip t
38
2
Page 2 of 22
60
Introduction Dental caries is a chronic disease, being considered the oral health problem
62
worldwide.1 Caries is also the cause of dental pain and could lead to tooth loss,
63
affecting oral health related quality of life.
64
etiology, where demographic, socioeconomic, behavioral and biological risk factors
65
could be enrolled. 5-7 Generally, children whose mothers are poorly educated have more
66
dental caries experience 6, as well as individuals from low socioeconomic position
67
and/or in disadvantaged conditions.5,7-8 In addition, epidemiological data have revealed
68
a polarization of caries experience, a concept defined as the occurrence of a large
69
number of disease–free individuals and the majority of the disease burden concentrated
70
in a relatively small proportion of individuals, reflecting social inequalities in oral
71
health conditions. 7 In such a context, identifying potential factors that could contribute
72
to caries occurrence is relevant. When considering the biological influences on dental
73
caries, there has been greater attention given to the role of developmental defects
74
enamel (DDE).
This condition has a multifactorial
d
M
an
us
cr
2-4
ip t
61
Enamel defects are related to disturbances during enamel formation and could be
76
seen as enamel hypoplasia or opacities. Enamel hypoplasia is a quantitative defect
77
involving reduced thickness of enamel (formed during the secretory stage of
78
amelogenesis).
79
intact surface, but there is a discrete area (or areas) of different enamel translucency,
80
being classified as diffuse or demarcated opacities. 10
Ac ce p
81
te
75
9
Opacities are characterized by enamel with normal thickness and an
Several studies have highlighted the possibility of enamel defects being an 11-13
82
important biological influence on dental caries development in deciduous
83
permanent dentitions
84
important to consider that most of these studies have not accounted for important factors
85
such as fluoride exposure 12 and/or sociodemographic characteristics. Thus, generalizing
86
their findings should be done carefully. 16
87 88 89
14-16
and in
11,17
, whereas others have failed to find this association.
It is
Enamel hypoplasia has been frequently associated with dental caries experience 14-15
, mainly due to the higher acid solubility of the affected enamel
accumulation
19-20
18
, plaque
and a higher degree of colonization by Streptococcus mutans and 3
Page 3 of 22
90
Lactobacilli. 21 Nevertheless, cross-sectional studies have demonstrated that demarcated
91
opacities were significantly associated with dental caries experience in permanent
92
incisors and molars. 22-23 Even with a possible relationship between DDE and dental caries, this
94
association remains unclear in the literature. Therefore, the aim of the present study was
95
to systematically review the literature in order to evaluate the association between
96
development defects of enamel and dental caries experience in the permanent dentition.
ip t
93
99 100
Material and Methods
This systematic review was reported according to the PRISMA [Preferred
us
98
cr
97
Reporting Items for Systematic reviews and Meta-Analyses) protocol. 24
an
101 Search strategy and bibliographic sources
103
This literature review used the following four electronic bibliographic data
104
sources: PubMed, Web of Science, Science Direct and EMBASE. In PubMed, the terms
105
used were: topic terms (enamel defects OR developmental defects of enamel OR Dental
106
Enamel Hypoplasia[Mesh]) OR dental hypoplasia OR enamel hypoplasia OR opacities)
107
AND (dental caries[Mesh]OR caries OR dental decay). The same terms were used in
108
the Science Direct and EMBASE databases. In the Web of Science database, we needed
109
to include ‘TS=’ before the parentheses for each subset of terms.
d
te
The use of independent keywords allows a broader search because it rules out
Ac ce p
110
M
102
111
potential mistyping and other errors when using MeSH Terms (Medical Subject
112
Headings) in different databases.
113 114 115 116 117
The search was carried out on January 2015 and included all of the papers
published until December 31 2014, with no date limits.
Criteria for inclusion / exclusion of papers To be included in the review, a paper should have met the following criteria: (a)
118
be an epidemiologic study, without any restriction of design (such as cross-sectional,
119
case-control and longitudinal studies) with assessment of likely association between
120
DDE and dental caries; (b) determine the presence of DDE in the permanent dentition;
121
(c) include participants aged 8 to 19 years old; (d) and use a population-based sample
122
rather than a clinical convenience sample. 4
Page 4 of 22
The exclusion criteria were: studies where dental caries was not the outcome;
124
articles without the evaluation of enamel defects; studies evaluating the deciduous
125
dentition; studies evaluating the mixed dentition without separate information about the
126
permanent dentition; case-reports; literature reviews; manuscripts evaluating specific
127
sub-populations (such as congenital cardiac disease patients); guidelines; and papers not
128
using the FDI criteria [FDI,1992] to assess enamel defects.
129
ip t
123
Stages of reference selection
131
All references were imported into reference management software (EndNote X3;
132
Thomson Reuters Inc. Philadelphia, PA, USA). Two authors (FVF, MMSS)
133
independently performed the assessments, with the reading of the titles and the abstracts
134
of the selected manuscripts in order to exclude papers not meeting the inclusion criteria.
135
The same authors also performed the complete reading of the papers and when
136
disagreements occurred, discussion was made to obtain consensus, without the need for
137
a third evaluator. 24 In addition, the reference lists of the selected articles were checked
138
in order to find any investigation not found in the database previously consulted by the
139
authors. 24
d
140
M
an
us
cr
130
Data collection
142
A data extraction spreadsheet was developed and the two researchers (FVF,
143
MMSS) collected the information independently. For each selected manuscript, the
144
following information was collected: year of publication (dichotomized in 1994-2005
145
and 2006-2014), first author institutional affiliation, country (dichotomized in high-
146
income countries and medium- and low-income countries), study design (cross-
147
sectional, case-control, cohort, or other), language, age, sample size (up to 1,000; more
148
than 1,000), presence of enamel defects (hypoplasia and other types), other exposure
149
variables assessed (such as fluoride status, socioeconomic and behavioral aspects),
150
diagnostic criteria for DDE and dental caries, intra-oral examinations (conditions and
151
teeth analyzed), and the outcome of the defects-caries analysis. We analyzed the
152
presence of controlling for confounding such as sociodemographic in each study and
153
discussed its influence on findings (dichotomized in crude results and those adjusted for
154
socioeconomic factors). Additionally, crude and adjusted Odds Ratios (ORs) with
Ac ce p
te
141
5
Page 5 of 22
155
respective 95% Confidence Intervals were collected. In two papers, the ORs and 95%CI
156
were calculated based on data presented. 22,25
157 158 Quality assessment
160
In order to evaluate the quality of studies that fulfill the inclusion criteria, an
161
ip t
159
adapted version of Downs and Black checklist 26 was used. 27
From the original 27 items regarding interventional studies, only 17 were
163
employed. The items assessed, mainly, methodology section (sample size, statistical
164
analysis, participants selection) and each item scored only one point, except one that
165
could score at most two. Consequently, the total score could range from 0 to 18 points,
166
being classified according to the obtained score as follows: high risk of bias (0-5
167
points); moderate risk of bias (6-11 points) and low risk of bias (more than 12 points).
168
Articles were evaluated independently by two reviewers, and disagreements were
169
discussed until a consensus was achieved. More details are in elsewhere. 27
M
an
us
cr
162
170 Meta-analysis
172
The pooled effect of DDE on dental caries experience was calculated using a
173
fixed and a random model (pooled OR and 95%CI). When heterogeneity was
174
statistically significant (P0.05); children with enamel hypoplasia had more chance of dental caries than their counterparts [OR 11.01 95% CI 1.51;225.57] and also with demarcated opacity [OR 2.32 95% CI 1.18;4.59]. Teeth with hypoplasia [75.9% had caries] and with opacity [55.8% showed dental caries]. Children with enamel defects had a higher chance of dental caries than those without DDE. Crude analysis [OR 3.0 95% CI 1.99;4.51]
17
Page 17 of 22
ip t cr
Dental caries in deciduous teeth Maternal schooling
All teeth Natural light
Gender Family size Current occupation Socioecon omic level Tooth brushing frequency Plaque
Ellwood and Mullane English
2002
9
1994
1,640
Crosssectional
ed
Mexico
ce pt
Ekanayake and Van der Hoek English
2005
Sri Lanka
14
Ac
Casanova et al English
M an
us
Without description
North Wales
12
486
3,538
Crosssectional
Crosssectional
FDI
FDI
FDI
WHO
WHO
WHO
Index teeth(14,13,14 ,12,11,21,22,2 3,24,36,46) Natural light Gauze to remove debris Index teeth(14,13,14 ,12,11,21,22,2 3,24,36,46) Wet teeth Natural light
Gender Water fluoridated
-
and in adjusted [4.03 95% CI 2.03;7.99].
The presence of enamel defects [OR=4.17; 95% CI=2.36;7.39] was also positively associated with caries.
No difference between gender and enamel defects/dental caries. Caries prevalence and the mean caries experience were significantly higher in children with diffuse opacities than in those without in the group consuming water containing > 0.70 mg/l of fluoride [p
S0300-5712(15)00079-2 http://dx.doi.org/doi:10.1016/j.jdent.2015.03.011 JJOD 2445
To appear in:
Journal of Dentistry
Received date: Revised date: Accepted date:
11-10-2014 23-3-2015 27-3-2015
Please cite this article as: Vargas-Ferreira F, Salas MMS, Nascimento GG, S.B.C. T, Faggion CM, Peres MA, Thomson WM, Demarco FF, Association between developmental defects of enamel and dental caries: a systematic review and metaanalysis, Journal of Dentistry (2015), http://dx.doi.org/10.1016/j.jdent.2015.03.011 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Title: Association between developmental defects of enamel and dental caries: a
2
systematic review and meta-analysis
3 4
Authors. F. Vargas-Ferreiraa, M.M.S Salasb, G.G Nascimentob, Tarquinio S.B.C.b,
5
C.M. Faggionc, M.A Peresd, W.M Thomsone, F.F Demarcoa,b
7
a
8
[[email protected]].
9
b
ip t
6
cr
Post-Graduate Program in Epidemiology, Federal University of Pelotas, Brazil. Post-Graduate Program in Dentistry, Federal University of Pelotas, Brazil.
[[email protected] / [email protected] / [email protected]].
11
c
12
Germany [[email protected]].
13
d
14
Australia. [[email protected]].
15
e
16
[[email protected]].
Australian Research Centre for Population Oral Health, University of Adelaide,
22 23
d
te
Short Title: Developmental defects of enamel and dental caries Key words: epidemiology, dental caries, developmental defects of enamel, child
Ac ce p
21
M
Sir John Walsh Research Institute, University of Otago, Dunedin, New Zealand.
18 20
an
Department of Periodontology, Faculty of Dentistry, University of Münster, Münster,
17 19
us
10
24
Author for correspondence:
25
Flávio Fernando Demarco
26
Federal University of Pelotas (UFPEL), School of Dentistry
27
457 Gonçalves Chaves Street, Zip Code 96015-560, Pelotas, RS, Brazil
28
Tel 55 53 3222 6690 / Fax 55 53 3222 6690
29
e-mail:[email protected]
30 31 32 33 1
Page 1 of 22
33
Title: Association between developmental defects of enamel and dental caries: a
34
systematic review and meta-analysis
35 36 37 Abstract
39
Background: Dental caries is the main problem oral health and it is not well established
40
in the literature if the enamel defects are a risk factor for its development. Objective:
41
Studies have reported a potential association between developmental defects enamel
42
(DDE) and dental caries occurrence. We investigated the association between DDE and
43
caries in permanent dentition of children and teenagers. Data Sources: A systematic
44
review was carried out using four databases (Pubmed, Web of Science, Embase,
45
Science Direct), which were searched from their earliest records until December 31
46
2014. Study selection: Population-based studies assessing differences in dental caries
47
experience according to the presence of enamel defects (and their types) were included.
48
PRISMA guidelines for reporting systematic reviews was followed. Meta-analysis was
49
performed to assess the pooled effect, and meta-regression was carried out to identify
50
heterogeneity sources. From the 2,558 initially identified papers, nine studies fulfilled
51
all inclusion criteria after checking the titles, abstracts, references, and complete
52
reading. Seven of them were included in the meta-analysis with random model.
53
Results: A positive association between enamel defects and dental caries was
54
identified; meta-analysis showed that individuals with DDE had higher pooled odds of
55
having dental caries experience [OR 2.21 (95%CI 1.3; 3.54)]. Meta-regression analysis
56
demonstrated that adjustment for sociodemographic factors, countries’ socioeconomic
57
status and bias (quality of studies) explained the high heterogeneity observed.
58
Conclusion: A higher chance of dental caries should be expected among individuals
59
with enamel defects.
Ac ce p
te
d
M
an
us
cr
ip t
38
2
Page 2 of 22
60
Introduction Dental caries is a chronic disease, being considered the oral health problem
62
worldwide.1 Caries is also the cause of dental pain and could lead to tooth loss,
63
affecting oral health related quality of life.
64
etiology, where demographic, socioeconomic, behavioral and biological risk factors
65
could be enrolled. 5-7 Generally, children whose mothers are poorly educated have more
66
dental caries experience 6, as well as individuals from low socioeconomic position
67
and/or in disadvantaged conditions.5,7-8 In addition, epidemiological data have revealed
68
a polarization of caries experience, a concept defined as the occurrence of a large
69
number of disease–free individuals and the majority of the disease burden concentrated
70
in a relatively small proportion of individuals, reflecting social inequalities in oral
71
health conditions. 7 In such a context, identifying potential factors that could contribute
72
to caries occurrence is relevant. When considering the biological influences on dental
73
caries, there has been greater attention given to the role of developmental defects
74
enamel (DDE).
This condition has a multifactorial
d
M
an
us
cr
2-4
ip t
61
Enamel defects are related to disturbances during enamel formation and could be
76
seen as enamel hypoplasia or opacities. Enamel hypoplasia is a quantitative defect
77
involving reduced thickness of enamel (formed during the secretory stage of
78
amelogenesis).
79
intact surface, but there is a discrete area (or areas) of different enamel translucency,
80
being classified as diffuse or demarcated opacities. 10
Ac ce p
81
te
75
9
Opacities are characterized by enamel with normal thickness and an
Several studies have highlighted the possibility of enamel defects being an 11-13
82
important biological influence on dental caries development in deciduous
83
permanent dentitions
84
important to consider that most of these studies have not accounted for important factors
85
such as fluoride exposure 12 and/or sociodemographic characteristics. Thus, generalizing
86
their findings should be done carefully. 16
87 88 89
14-16
and in
11,17
, whereas others have failed to find this association.
It is
Enamel hypoplasia has been frequently associated with dental caries experience 14-15
, mainly due to the higher acid solubility of the affected enamel
accumulation
19-20
18
, plaque
and a higher degree of colonization by Streptococcus mutans and 3
Page 3 of 22
90
Lactobacilli. 21 Nevertheless, cross-sectional studies have demonstrated that demarcated
91
opacities were significantly associated with dental caries experience in permanent
92
incisors and molars. 22-23 Even with a possible relationship between DDE and dental caries, this
94
association remains unclear in the literature. Therefore, the aim of the present study was
95
to systematically review the literature in order to evaluate the association between
96
development defects of enamel and dental caries experience in the permanent dentition.
ip t
93
99 100
Material and Methods
This systematic review was reported according to the PRISMA [Preferred
us
98
cr
97
Reporting Items for Systematic reviews and Meta-Analyses) protocol. 24
an
101 Search strategy and bibliographic sources
103
This literature review used the following four electronic bibliographic data
104
sources: PubMed, Web of Science, Science Direct and EMBASE. In PubMed, the terms
105
used were: topic terms (enamel defects OR developmental defects of enamel OR Dental
106
Enamel Hypoplasia[Mesh]) OR dental hypoplasia OR enamel hypoplasia OR opacities)
107
AND (dental caries[Mesh]OR caries OR dental decay). The same terms were used in
108
the Science Direct and EMBASE databases. In the Web of Science database, we needed
109
to include ‘TS=’ before the parentheses for each subset of terms.
d
te
The use of independent keywords allows a broader search because it rules out
Ac ce p
110
M
102
111
potential mistyping and other errors when using MeSH Terms (Medical Subject
112
Headings) in different databases.
113 114 115 116 117
The search was carried out on January 2015 and included all of the papers
published until December 31 2014, with no date limits.
Criteria for inclusion / exclusion of papers To be included in the review, a paper should have met the following criteria: (a)
118
be an epidemiologic study, without any restriction of design (such as cross-sectional,
119
case-control and longitudinal studies) with assessment of likely association between
120
DDE and dental caries; (b) determine the presence of DDE in the permanent dentition;
121
(c) include participants aged 8 to 19 years old; (d) and use a population-based sample
122
rather than a clinical convenience sample. 4
Page 4 of 22
The exclusion criteria were: studies where dental caries was not the outcome;
124
articles without the evaluation of enamel defects; studies evaluating the deciduous
125
dentition; studies evaluating the mixed dentition without separate information about the
126
permanent dentition; case-reports; literature reviews; manuscripts evaluating specific
127
sub-populations (such as congenital cardiac disease patients); guidelines; and papers not
128
using the FDI criteria [FDI,1992] to assess enamel defects.
129
ip t
123
Stages of reference selection
131
All references were imported into reference management software (EndNote X3;
132
Thomson Reuters Inc. Philadelphia, PA, USA). Two authors (FVF, MMSS)
133
independently performed the assessments, with the reading of the titles and the abstracts
134
of the selected manuscripts in order to exclude papers not meeting the inclusion criteria.
135
The same authors also performed the complete reading of the papers and when
136
disagreements occurred, discussion was made to obtain consensus, without the need for
137
a third evaluator. 24 In addition, the reference lists of the selected articles were checked
138
in order to find any investigation not found in the database previously consulted by the
139
authors. 24
d
140
M
an
us
cr
130
Data collection
142
A data extraction spreadsheet was developed and the two researchers (FVF,
143
MMSS) collected the information independently. For each selected manuscript, the
144
following information was collected: year of publication (dichotomized in 1994-2005
145
and 2006-2014), first author institutional affiliation, country (dichotomized in high-
146
income countries and medium- and low-income countries), study design (cross-
147
sectional, case-control, cohort, or other), language, age, sample size (up to 1,000; more
148
than 1,000), presence of enamel defects (hypoplasia and other types), other exposure
149
variables assessed (such as fluoride status, socioeconomic and behavioral aspects),
150
diagnostic criteria for DDE and dental caries, intra-oral examinations (conditions and
151
teeth analyzed), and the outcome of the defects-caries analysis. We analyzed the
152
presence of controlling for confounding such as sociodemographic in each study and
153
discussed its influence on findings (dichotomized in crude results and those adjusted for
154
socioeconomic factors). Additionally, crude and adjusted Odds Ratios (ORs) with
Ac ce p
te
141
5
Page 5 of 22
155
respective 95% Confidence Intervals were collected. In two papers, the ORs and 95%CI
156
were calculated based on data presented. 22,25
157 158 Quality assessment
160
In order to evaluate the quality of studies that fulfill the inclusion criteria, an
161
ip t
159
adapted version of Downs and Black checklist 26 was used. 27
From the original 27 items regarding interventional studies, only 17 were
163
employed. The items assessed, mainly, methodology section (sample size, statistical
164
analysis, participants selection) and each item scored only one point, except one that
165
could score at most two. Consequently, the total score could range from 0 to 18 points,
166
being classified according to the obtained score as follows: high risk of bias (0-5
167
points); moderate risk of bias (6-11 points) and low risk of bias (more than 12 points).
168
Articles were evaluated independently by two reviewers, and disagreements were
169
discussed until a consensus was achieved. More details are in elsewhere. 27
M
an
us
cr
162
170 Meta-analysis
172
The pooled effect of DDE on dental caries experience was calculated using a
173
fixed and a random model (pooled OR and 95%CI). When heterogeneity was
174
statistically significant (P0.05); children with enamel hypoplasia had more chance of dental caries than their counterparts [OR 11.01 95% CI 1.51;225.57] and also with demarcated opacity [OR 2.32 95% CI 1.18;4.59]. Teeth with hypoplasia [75.9% had caries] and with opacity [55.8% showed dental caries]. Children with enamel defects had a higher chance of dental caries than those without DDE. Crude analysis [OR 3.0 95% CI 1.99;4.51]
17
Page 17 of 22
ip t cr
Dental caries in deciduous teeth Maternal schooling
All teeth Natural light
Gender Family size Current occupation Socioecon omic level Tooth brushing frequency Plaque
Ellwood and Mullane English
2002
9
1994
1,640
Crosssectional
ed
Mexico
ce pt
Ekanayake and Van der Hoek English
2005
Sri Lanka
14
Ac
Casanova et al English
M an
us
Without description
North Wales
12
486
3,538
Crosssectional
Crosssectional
FDI
FDI
FDI
WHO
WHO
WHO
Index teeth(14,13,14 ,12,11,21,22,2 3,24,36,46) Natural light Gauze to remove debris Index teeth(14,13,14 ,12,11,21,22,2 3,24,36,46) Wet teeth Natural light
Gender Water fluoridated
-
and in adjusted [4.03 95% CI 2.03;7.99].
The presence of enamel defects [OR=4.17; 95% CI=2.36;7.39] was also positively associated with caries.
No difference between gender and enamel defects/dental caries. Caries prevalence and the mean caries experience were significantly higher in children with diffuse opacities than in those without in the group consuming water containing > 0.70 mg/l of fluoride [p
