International Journal of Paediatric Dentistry 1992; 2: 8 1-85
Dental health and salivary Streptococcus mutans levels in a group of children with heart defects M. A. POLLARD & M. E. J. C U R Z O N Department of Child Dental Health, University of Lee&
Summary. One-hundred children aged 2- 16 years who were attending the Outpatients Department of the Yorkshire Regional Cardiac Centre were examined for dental caries, gingivitis, plaque and calculus. A control group of 100 children was also examined. A saliva sample was taken from each child in the study group to assessthe level of Streptococcus mutans colonization. Comparing study and control groups, dental caries experience (dmft)was significantly higher only in the primary teeth of 5-9-year-old children in the study group, and there were no significant differencesin gingivitis, plaque or calculus. The S. mutans count was found to be positively correlated to the number of decayed teeth in the study group.
Introduction Children with congenital or acquired heart defects, which affect approximately eight in 1000 live births, run the risk of developing infective endocarditis, which still has a high mortality rate. However, infective endocarditis of dental origin has dropped to between 5-1 5% of cases [ 11. There have been many studies [2-41 concerning bacteraemia associated with various dental procedures, but few on the dental health of these children [ 5 ] , and none on the quality of their dental treatment, despite the fact that dentists encounter these patients on a day-to-day basis [6,7]. Despite these children being 'at risk' from dental disease, many are apparently not given oral hygiene instruction, dietary counselling or advice on the use of fluoride supplements [5]. Some dental practitioners seem unwilling to treat children with heart defects and there is a lack of specially trained personnel to whom they may be referred [8]. The key to protection of susceptible patients is improved dental health education, effective preventive care and sensible treatment planning so that episodes of significant bacteraemia are reCorrespondence and reprint requests to: Dr M. A. Pollard, Department of Child Dental Health, University of Leeds, Clarendon Way, b e d s LS2 9LU, UK.
duced to a minimum. A similar suggestion was made by Pogrel & Welsby [9] who, in a retrospective study of 83 patients who had suffered from endocarditis, found that oral sepsis alone was the cause in 12% of the patients. Although the prevalence of dental caries has declined in the general population, there is no evidence to suggest a similar reduction in this 'at risk' group. This lack of data makes the identification 'at risk' children difficult and prevents targeting of resources to deal with them. The purpose of the present study was to investigate the dental health of a group of children with cardiac defects and to determine the efficacy of a salivary S. mutans test in assessing their caries risk status.
Methods All children between the ages of 2 and 16 years with some form of heart defect who attended the Yorkshire Regional Cardiac Centre between 3rd February and 30th June 1989 were included in the study, subject to the consent of their parents. The child's name, date of birth, address and sex were recorded and the type of heart defect was obtained from the hospital records. Social class was determined after having recorded the occupa81
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M. A. Pollard & M. E. J. Curzon
tion of the head of the household in which the child lived. This was done by reference to the Registrar General's classifications of occupation [ lo]. The control group was formed by children of similar age, sex, race and socio-economic class who attended schools in the West Yorkshire area. The study group children were examined in an office adjacent to the paediatric cardiologist's consulting room. They were seated and illumination was provided by an anglepoise lamp. The control group children were examined under identical conditions in a school classroom. The criteria for caries diagnosis were those described by Palmer et al. [ 1 I]. Decayed, missing and filled surfaces were recorded for all teeth present. Gingivitis, plaque and calculus were assessed using the criteria set down by Todd & Dodd [ 121. Three mouth segments in each arch were assessed one anterior (canine to canine) and two buccal. The presence or absence of gingivitis, plaque or calculus in each segment was recorded. The caries risk of each child with a heart defect was assessed using a caries prediction test based upon that of Kohler & Bratthall [ 131 to estimate the level of S. mutans in saliva. Incubation on a selective streptococcus medium, known as bacto mitis salivarius agar (Difco Laboratories) which has a high concentration of sucrose and 0.2 unitdm1 bacitracin (Sigma Chemical Company Ltd) to suppress the growth of most non-S. mutans colonies [ 141. Sampling of the saliva from the oral cavity was performed with a 1.8 cm wide wooden spatula. Both sides of the spatula were pressed onto the tongue, wiping off any excess saliva against closed lips on removal of the spatula from the mouth. Each side of the spatula was then pressed against the slightly convex surface of the MSB agar in disposable Petri dishes (Falcon Rodac Plates, Belton Dickinson Labware). The agar plates were then incubated at 37°C for 48 hours in a sealed plastic bag containing expired air.
was used to investigate differences between the groups in the proportions of teeth that were decayed, missing or filled. Fisher's exact probability test was used for M/DMFT. The relationship between S.mutans counts and decayed, filled and missing primary and permanent teeth were determined using Spearman rank correlation test.
Results There were 100 children in the study group, and 100 in the control group. The age of the subjectsin the study group ranged from 2 years 1 month to 16 years 4 months; the age of the control group subjects ranged from 2 years five and one-half months to 16 years exactly. Each group was then divided into three age ranges: 2-4"/,2, 5-9V12, and 10-1611/12(Table 1).
Table 1. The number and the ages of the children in the study and control groups ~~~
~
Age group (years)
n
Study group mean age*SD
n
2-4 5-9 10-16
32 31 37
3.57i0.86 7.16k1.38 12.78k1.98
32 31 37
The Mann-Whitney U test was employed to assess the significance of differences between the two groups in dt, dmft, DT and DMFT and in the number of segments having no gingivitis, plaque or calculus. Chi-squared test with Yates correction
3.7420-71 7.19&1*43 12*40rtl*90
The results of examinationsfor dental canes are summarized in Tables 2 and 3. The only significant difference between the groups was in dmft of the 5-9 year-olds.
Table 2. Dental caries experience in the primary dentition of children in the study and control groups (mean dr, dmji SD)
*
Age group (years)
Statistical analysis
Control group mean age*SD
2-4 5-9
Study group mean SD
*
dt dmji dt dmji
0.8121.89 1.81 4-07 2.10*2.15 4.32+2-97.
*
Control group mean SD
*
dt dmfi dt dmft
0-97*1.86 1.63 3.28 1-3922.22 2.77 3.48*
*
*
*Difference between study and control groups significant,
P
Dental health and salivary Streptococcus mutans levels in a group of children with heart defects M. A. POLLARD & M. E. J. C U R Z O N Department of Child Dental Health, University of Lee&
Summary. One-hundred children aged 2- 16 years who were attending the Outpatients Department of the Yorkshire Regional Cardiac Centre were examined for dental caries, gingivitis, plaque and calculus. A control group of 100 children was also examined. A saliva sample was taken from each child in the study group to assessthe level of Streptococcus mutans colonization. Comparing study and control groups, dental caries experience (dmft)was significantly higher only in the primary teeth of 5-9-year-old children in the study group, and there were no significant differencesin gingivitis, plaque or calculus. The S. mutans count was found to be positively correlated to the number of decayed teeth in the study group.
Introduction Children with congenital or acquired heart defects, which affect approximately eight in 1000 live births, run the risk of developing infective endocarditis, which still has a high mortality rate. However, infective endocarditis of dental origin has dropped to between 5-1 5% of cases [ 11. There have been many studies [2-41 concerning bacteraemia associated with various dental procedures, but few on the dental health of these children [ 5 ] , and none on the quality of their dental treatment, despite the fact that dentists encounter these patients on a day-to-day basis [6,7]. Despite these children being 'at risk' from dental disease, many are apparently not given oral hygiene instruction, dietary counselling or advice on the use of fluoride supplements [5]. Some dental practitioners seem unwilling to treat children with heart defects and there is a lack of specially trained personnel to whom they may be referred [8]. The key to protection of susceptible patients is improved dental health education, effective preventive care and sensible treatment planning so that episodes of significant bacteraemia are reCorrespondence and reprint requests to: Dr M. A. Pollard, Department of Child Dental Health, University of Leeds, Clarendon Way, b e d s LS2 9LU, UK.
duced to a minimum. A similar suggestion was made by Pogrel & Welsby [9] who, in a retrospective study of 83 patients who had suffered from endocarditis, found that oral sepsis alone was the cause in 12% of the patients. Although the prevalence of dental caries has declined in the general population, there is no evidence to suggest a similar reduction in this 'at risk' group. This lack of data makes the identification 'at risk' children difficult and prevents targeting of resources to deal with them. The purpose of the present study was to investigate the dental health of a group of children with cardiac defects and to determine the efficacy of a salivary S. mutans test in assessing their caries risk status.
Methods All children between the ages of 2 and 16 years with some form of heart defect who attended the Yorkshire Regional Cardiac Centre between 3rd February and 30th June 1989 were included in the study, subject to the consent of their parents. The child's name, date of birth, address and sex were recorded and the type of heart defect was obtained from the hospital records. Social class was determined after having recorded the occupa81
82
M. A. Pollard & M. E. J. Curzon
tion of the head of the household in which the child lived. This was done by reference to the Registrar General's classifications of occupation [ lo]. The control group was formed by children of similar age, sex, race and socio-economic class who attended schools in the West Yorkshire area. The study group children were examined in an office adjacent to the paediatric cardiologist's consulting room. They were seated and illumination was provided by an anglepoise lamp. The control group children were examined under identical conditions in a school classroom. The criteria for caries diagnosis were those described by Palmer et al. [ 1 I]. Decayed, missing and filled surfaces were recorded for all teeth present. Gingivitis, plaque and calculus were assessed using the criteria set down by Todd & Dodd [ 121. Three mouth segments in each arch were assessed one anterior (canine to canine) and two buccal. The presence or absence of gingivitis, plaque or calculus in each segment was recorded. The caries risk of each child with a heart defect was assessed using a caries prediction test based upon that of Kohler & Bratthall [ 131 to estimate the level of S. mutans in saliva. Incubation on a selective streptococcus medium, known as bacto mitis salivarius agar (Difco Laboratories) which has a high concentration of sucrose and 0.2 unitdm1 bacitracin (Sigma Chemical Company Ltd) to suppress the growth of most non-S. mutans colonies [ 141. Sampling of the saliva from the oral cavity was performed with a 1.8 cm wide wooden spatula. Both sides of the spatula were pressed onto the tongue, wiping off any excess saliva against closed lips on removal of the spatula from the mouth. Each side of the spatula was then pressed against the slightly convex surface of the MSB agar in disposable Petri dishes (Falcon Rodac Plates, Belton Dickinson Labware). The agar plates were then incubated at 37°C for 48 hours in a sealed plastic bag containing expired air.
was used to investigate differences between the groups in the proportions of teeth that were decayed, missing or filled. Fisher's exact probability test was used for M/DMFT. The relationship between S.mutans counts and decayed, filled and missing primary and permanent teeth were determined using Spearman rank correlation test.
Results There were 100 children in the study group, and 100 in the control group. The age of the subjectsin the study group ranged from 2 years 1 month to 16 years 4 months; the age of the control group subjects ranged from 2 years five and one-half months to 16 years exactly. Each group was then divided into three age ranges: 2-4"/,2, 5-9V12, and 10-1611/12(Table 1).
Table 1. The number and the ages of the children in the study and control groups ~~~
~
Age group (years)
n
Study group mean age*SD
n
2-4 5-9 10-16
32 31 37
3.57i0.86 7.16k1.38 12.78k1.98
32 31 37
The Mann-Whitney U test was employed to assess the significance of differences between the two groups in dt, dmft, DT and DMFT and in the number of segments having no gingivitis, plaque or calculus. Chi-squared test with Yates correction
3.7420-71 7.19&1*43 12*40rtl*90
The results of examinationsfor dental canes are summarized in Tables 2 and 3. The only significant difference between the groups was in dmft of the 5-9 year-olds.
Table 2. Dental caries experience in the primary dentition of children in the study and control groups (mean dr, dmji SD)
*
Age group (years)
Statistical analysis
Control group mean age*SD
2-4 5-9
Study group mean SD
*
dt dmji dt dmji
0.8121.89 1.81 4-07 2.10*2.15 4.32+2-97.
*
Control group mean SD
*
dt dmfi dt dmft
0-97*1.86 1.63 3.28 1-3922.22 2.77 3.48*
*
*
*Difference between study and control groups significant,
P
