Microbial Testing for Caries Risk Assessment

Hypotheses and Specific Aims

Hypotheses CG Saliva-Check Mutans will test positive in children with clinical caries.

Specific Aims

- Assess CG Saliva-Check Mutans saliva testing for identification of high caries risk
patients

Background and Significance

Early Childhood Caries

Suboptimal oral health is an existing and growing concern for the pediatric patient, with
dental decay considered the most common chronic disease of childhood in the United States.
About 1 in 5 children (20%) aged 5 to 11 years old have at least one untreated decayed tooth,
with childhood caries being 4 times more common than early childhood obesity, 5 times more
common than asthma, and 20 times more common than diabetes. Early childhood caries (ECC) is
diagnosed when one or more primary teeth are affected by the caries process before six years
of age, and severe early childhood caries (S-ECC) is defined as any smooth-surface caries in
a child under the age of three. ECC is a multifactorial process and is not exclusively
associated with poor feeding habits such as ad libitum bottle or breast-feeding. Factors
include susceptible tooth surfaces, frequent consumption of a cariogenic diet, and an
elevated colonization of cariogenic bacteria. Mutans Streptococci (MS) are pathognomonic for
ECC and S-ECC in all age groups. The rise of ECC and S-ECC has increased the number of
children needing dental treatment at an early age, often requiring treatment in advanced care
settings such as under sedation, general anesthesia, or the emergency department. Over 51
million school hours are lost each year due to dental problems or urgent dental needs.
Furthermore, 44 % of children in the U.S. will suffer from pediatric dental disease before
kindergarten and approximately 22% of people across all age groups have existing untreated
dental decay. As health care providers, it is imperative for both dentists and pediatricians
to promote optimal oral health through the utilization of prevention strategies, such as the
caries risk assessment.

Caries Risk Assessment (CAMBRA)

The multiple factors that contribute to dental caries development should be evaluated to
determine an individual patient's risk status. An evidence-based model termed Caries
Management Risk Assessment (CAMBRA) was developed to provide dentists with a protocol for
caries diagnosis, prevention and treatment. CAMBRA helps identify children at risk of caries
development and provides age-specific recommendations for caries prevention across all
demographics. The goal of the assessment is that by identifying a patient at high risk of
caries development, the dental provider can make patient specific recommendations in attempt
to lower risk and mitigate disease progression. The risk assessment for all patients
determines biological, protective, and clinical factors that may contribute to the caries
disease process. Examples of high risk factors for pediatric patients include frequent
between meal sugar-containing foods and sugar sweetened beverages (SSB), nighttime bottle
feeding, previous caries experience, and elevated MS levels. Protective factors against
caries progression include optimal oral hygiene, topical fluoride, and sugar substitutes.

Concepts of a Healthy Mouth

A healthy mouth has a symbiotic environment of cariogenic and non-cariogenic bacteria and is
characterized as being free of and at low risk for developing disease. A low plaque score (or
low plaque growth) has a strong correlation with a healthier mouth for both dental and
periodontal health. When the symbiotic relationship becomes unbalanced, the resulting acidic
environment leads to demineralization of tooth structure. High levels of cariogenic bacteria
such as Mutans Streptococci (MS) and Lactobacilli acidophilus (LB) lower environmental pH
levels, which selects for progressive dissolution of mineral into saliva and causes an
increased risk of caries development. Saliva is an important intrinsic host factor protecting
against caries formation, as it provides a reservoir of calcium, phosphate and fluoride to
remineralize affected enamel and acts as a buffer to reestablish a healthy oral pH. By
educating parents of the pediatric patient about concepts of a healthy mouth and
demonstrating good oral hygiene practices, a child can be at lower risk for dental decay.

Etiology of Caries

Dental caries is a multifactorial disease process that is driven primarily by a diet high in
fermentable carbohydrates and simple sugars, cariogenic bacteria, and suboptimal oral
hygiene. The prevailing microorganisms that contribute to the development of dental caries
are MS and LB, which metabolize fermentable carbohydrates to produce acid (acidogenic) and
thrive in low pH environments (aciduric). Frequent consumption of fermentable carbohydrates
and SSBs leads to maintained levels of low salivary pH, resulting in the dissolution of
calcium and phosphate from enamel surfaces over time. This demineralization of tooth
structure presents initially as a white spot lesion, which can be reversed or remineralized
by decreasing exposure to fermentable carbohydrates and practicing optimal oral hygiene.
However, if the local oral environment is not improved to promote remineralization at these
affected sites, mineral loss will continue until a physical breakdown or cavitation of the
enamel's crystal lattice structure occurs, requiring surgical intervention to restore.

Prevention Measures and Adjective Therapies (Prevident5000)

Fluoride applications represent a non-surgical approach to enamel remineralization. High
concentrations of fluoride, such as those found in toothpastes and varnishes, creates an
altered layer of calcium (fluorapatite) on the tooth surface. Therefore, fluoride aides to
increase the pH for acid resistance and decrease the adhesion of bacteria to smooth surfaces
by directly affecting the metabolism activity of cariogenic bacteria. High fluoride
containing toothpastes such as PreviDent5000 Plus (1.1 % NaF; 5,000ppm F) has been shown to
be effective at increasing enamel remineralization and reducing dental caries in both the
primary and permanent dentition. When used as an at home regimen, PreviDent5000 decreased
lesion depths up to 24%, supporting the finding that dentifrices with 5,000ppm fluoride are
more effective at remineralizing carious lesions compared to standard over the counter
dentifrices containing 1,100 - 1,500ppm fluoride. However, it remains unclear if
PreviDent5000 Plus has been effective in decreasing caries causing bacteria.

Background on Salivary Testing Various salivary tests have been used for years in clinical
practice to determine a patient's oral bacterial load. Culturing MS from saliva in children
has proven safe and valuable as part of a caries risk assessment due to the correlation
between high bacterial levels and caries development. Saliva testing is relatively simple
with a previous study completed at the Children's Hospital Colorado Pediatric Dentistry
Clinic supporting the efficacy of several different methods for saliva collection, including
directly pipetting saliva, swabbing the buccal surfaces of teeth, and stimulating saliva
production with a paraffin pellet. Saliva is obtained and cultured for bacteria that are
causative in caries initiation and progression, such as MS and LB. Children with a high load
of MS have been shown to be 6 times more likely to develop caries and experience caries
progress over a five-year period. GC Saliva-Check Mutans has been used in dental practices as
a useful and simple microbial testing tool to aide providers in caries risk detection.
Bacterial (MS) samples resulting in 5x10 to the 5th power colony-forming units per milliliter
of saliva (CFU/mL) indicates a low caries risk. In contrast, less than 5x10 to the 5th power
CFU/mL of MS in a saliva sample correlates to a moderate or high caries risk. This study is
designed to use saliva sampling to determine a non-surgical adjunctive therapy to help lower
cavity causing bacteria. The value of saliva testing is that it can serve as both a
non-invasive diagnostic tool in determining a patient's caries risk status and a visual aide
for educating parents and young patients.

Inclusion Criteria:

- Subjects must be a patient of record at Children's Hospital Colorado Dental Center

- Child must fall between 24 and 96 months of age

- Child must present with full primary dentition

Exclusion Criteria:

- Patients with a complex medical history classified as being greater than ASA II

- Patients with recent dose of antibiotics within the previous two weeks or who present
with a low caries risk set forth by the AAPD