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Correlating dental caries with oral bacteria and the buffering capacity of saliva in children in Madinah, Saudi Arabia

Correlating dental caries with oral bacteria and the buffering capacity of saliva in children in... Introduction: Caries is associated with high counts of mutans streptococci (MS), lactobacillus (LB), and a low saliva buffering capacity (BC). No study using odds ratios (OR) has correlated caries and these factors and no similar study has been done in Saudi Arabia before. Objectives: To determine: The prevalence of caries, the number of colony forming units (CFUs) of MS and LB, the saliva buffering capacity (BC) and the relationship between these factors. Materials and Methods: This was an analytical cross sectional study on children from Madinah. Caries was recorded using dmft/DMFT (decayed, missing, filled teeth). The scores for MS and LB and the BC of saliva was calculated using the Caries Risk Test (CRT) . Results: A total of 316 students were examined; two‑thirds (62%) were female and 25% were caries free. Saliva was collected from 235 participants and the majority had high MS and LB scores (66 and 71%, respectively) while 25% had a low saliva BC. The odds for those who had high LB and MS CFUs, were 9 and 4 times more at risk to developing dental caries and those with a low BC had significantly more caries (P =  0.03). The likelihood for those having severe caries and high counts of LB and MS was 25 (P < 0.01) and 6 (P = 0.042) times greater, respectively, compared to those with no or mild caries. Those with multiple risk factors were more likely to have caries compared to those with single or no risk factors present. Conclusions: The prevalence of caries was relatively high and many respondents had greater than 10 CFUs/ml of MS and LB. Almost all with a low BC had severe caries. There was a strong correlation between high MS, high LB, and low BC and the high prevalence of caries; hence the combination of these factors could be confidently used to predict caries in this population. Key words: Bacteria, buffering capacity, caries the causative factors for this disease is dental plaque INTRODUCTION which is the bacterial deposit that forms continuously Dental caries is one of the most common chronic on the tooth surfaces. The frequency of consumption [1,2] diseases affecting millions of people globally. It of soft drinks and the frequency of intake of sweets as is a major cause of tooth loss, pain and discomfort risk indicators have also been identified previously [3] [4] worldwide; especially amongst children. One of in various caries risk assessment models. It is well‑recognized that these are important and essential Access this article online variables in caries initiation. Thus one may predict a Quick Response Code: child who is likely susceptible to develop caries using Website: these and other innovative risk factors. Factors such www.jispcd.org as bacterial counts of mutans streptococci (MS) and lactobacillus (LB) and the buffering capacity (BC) DOI: of saliva have been shown to be strong risk factors 10.4103/2231-0762.115712 associated with the initiation and progression of dental [5,6] caries. 38 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries To prevent dental caries, the reduction of high counts chair and using a wooden spatula as described by the [8] of bacteria, an improvement in oral hygiene and a high World Health Organization (WHO). There were BC of saliva would be necessary. One way of detecting two calibrated examiners who completed all the bacterial counts and the BC of saliva is by using a caries dental examinations. A calibration exercise was carried out before going to the schools and the inter‑ and risk test (CRT) such as the one developed by Ivoclar Vivadent. intraexaminer variability was 95 and 98%, respectively. [5] It is currently accepted that MS and LB are The bacterial count and pH of saliva was calculated instrumental in the cause and progression of dental using the Caries Risk Test (CRT) kit from Ivoclar [9] Vivadent. A previous study showed that the sensitivity caries. MS plays a decisive role in the onset of caries, while LB contributes to the progression of caries. and specificity of tests using an agar growth was equally Therefore, the presence of these bacteria could predict effective as those using the broth growth and concluded that the results are acceptable for mass screening high risk patients and possible preventive procedures purposes. could be put in place to prevent or reduce dental caries. Studies have also shown that the BC of saliva influences The subjects were asked to chew on a paraffin pellet, [6] the prevalence of dental caries. Those that have a high which was included in the kit, for 30 s and then expectorate the stimulated whole saliva into a disposable BC are more likely to neutralize the pH and hence have cup. A portion of the saliva was then pipetted onto a lower prevalence of dental caries. two agar plates, one for MS and one for LB. The agar plates were incubated for 48 h at 37°C to allow for the The identification of high risk children is essential for planning of oral health treatment and prevention of growth of the organisms. The number of colonies future diseases. It will also help tertiary institutions as measured by colony forming units (CFU) per milliliter of saliva was not actually counted, but a score when planning outreach activities to focus on communities that are most vulnerable to dental caries, was given depending on the visual number of CFUs one of the pillars for the success of a community service present against a reference model chart provided in [7] the instruction manual. The readings were done by program. consensus amongst three investigators using the model However, this study is unique in that it is the first to use chart. The colonies were scored as either “low” (less than 5 5 the Ivoclar CRT buffer and bacteria kits in Saudi Arabia. 10 CFUs/ml) or “high” (greater than 10 CFUs/ml) as It is also the first study carried out in a Saudi Arabian per the manufacturer’s instruction. population to correlate the bacterial counts of MS and The remainder of the saliva was utilized to determine LB and the BC of saliva with the presence of dental caries. the BC of saliva. The saliva was pipetted onto a test strip which was left for 5 min. During this time the strip changed color and the BC category was recorded MATERIALS AND METHODS according to the manufacturer’s instructions. A green This was a cross‑sectional observational study which color was recorded as a “high BC”, a yellow color was carried out on 6 and 12 year‑old school children indicated “medium BC”, and a blue color meant a “low in Madinah. It was conducted between January and BC”. Consensus of three investigators was used to March 2012 in four primary schools which were determine the scores and categories for the variables. randomly selected from a list of registered schools in Madinah. Principals of each school were contacted and For further statistical analyses, the study population introduced to the study. Consent forms were sent to was divided into groups depending on the presence the parents of all the children who were registered in or absence of dental caries. Those without any grades one and six and those who consented, underwent dental caries in both dentitions were classified as a dental examination and saliva samples were collected “healthy” (dmft = 0 and DMFT = 0) and those with one from each of them. or more decayed tooth in either of the dentitions were classified as “diseased” (dmft ≥ 1 or DMFT ≥ 1). Prevalence of caries was recorded using the dmft/ DMFT (decayed, missing, filled teeth) index and To correlate the severity of dental caries, those without examinations were carried out in the classroom under any decay were classified as “healthy” (dmft/DMFT = 0), florescent lighting with subjects sitting on a regular those with a total of between 1 and 7 decayed teeth 39 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries in both dentitions were classified as “mild caries” of 4.85 compared to those with low LB counts who had (dmft +  DMFT between 1 and 7) and those with more a mean dmft of 1.44 (P < 0.01). than 8 decayed teeth were classified as “severe caries” Table 2 shows the correlation between the bacterial (dmft + DMFT ≥ 8). counts and the presence or absence of dental caries. There was a highly significant relationship between Data analysis high counts of LB and MS and the presence of The data was coded and keyed into the Statistical Package dental caries (P <  0.01 and P <  0.01, respectively). for the Social Sciences software version 19 (SPSS Inc, The odds for those who had a high score of LB Chicago, IL) used in Windows 7. Descriptive analysis were four times (P <  0.01) greater to develop dental by inferential statistics was done. Percentages, means, caries compared to those who had a low LB score. and standard deviations (SD) were calculated for Similarly, those who had high MS scores were two qualitative and quantitative data. Chi‑square test ( χ ) and times (P  <  0.01) more likely to have developed Fisher’s exact test were performed to statistically analyze dental caries compared to those who had low qualitative data. A P value of 0.05 was considered to MS scores. control for alpha (type 1) error. There was also a statistical correlation between the Ethical consideration buffering capacity and the presence of caries. Those with low BC were significantly (χ  = 6.9, P = 0.03) more The Research Ethics Committee of the College of likely to have dental caries compared to those with a Dentistry, Taibah University, approved this study. The medium or high BC. consent process was done in two steps; parent consent followed by child assent, any child who refused to To describe the severity of caries, the dmft/DMFT participate in this was excluded. Some parents accepted was divided into three categories; “healthy” (dmft and for including their children in the dental examination DMFT =  0); those with mild caries (dmft +  DMFT but refused the section of saliva collection. All children enrolled in this study were given a full written Table 1: Mean dmft/DMFT scores (N=316) report about their oral condition and dental hygiene. d m f Total 1 D M F Total 2 6 years 4.48 0.17 0.21 4.86±4.17 0.07 0.0 0.0 0.07±0.34 (N=171) RESULTS 12 years 1.06 0.10 0.24 1.41±2.56 0.90 0.05 0.36 1.31±1.20 (N=145) A total of 316 students were screened; almost two‑thirds dmft/DMFT = Decayed, missing, filled teeth were female (N =  197; 62%) and over half (54%) of them were 6‑year‑old. A quarter (25%) of the sample was caries free. The mean dmft/DMFT scores are Table 2: The correlation between dental caries, shown in Table 1. bacterial counts, and the buffering capacity of saliva (N=235) Saliva samples were collected from a total of Variable Category Disease (%) Healthy (%) Total 235 students and statistical correlations were done on LB score High CFUs 139 (84) 27 (16) 166 respondents who had both a dmft/DMFT score and a Low CFUs 37 (54) 32 (46) 69 saliva sample. Of these, the majority had high CFUs Total 176 (75) 59 (25) 235 of MS and LB (66 and 71%, respectively), 51% had a OR=4.45, P<0.01 (CI=2.4‑8.3) medium BC, and 25% had a low BC. MS score High CFUs 126 (81) 30 (19) 156 Low CFUs 50 (63) 29 (37) 79 The vast majority had high CFU scores of MS and LB Total 176 (75) 59 (25) 235 and there was a direct proportional increase in bacterial OR=2.4. P<0.01 (CI=1.3‑4.3) Saliva BC Low BC 25 (93) 2 (7) 27 counts and mean dmft/DMFT scores. Although those Medium BC 92 (76) 29 (24) 121 who had high scores of MS and LB had a higher mean High BC 59 (68) 28 (32) 87 dmft/DMFT compared to those with low counts, there Total 176 (75) 59 (25) 235 were no significant statistical associations. The only χ =6.9 at 2 df; P=0.03 significant association was between 6‑year‑old subjects LB = Lactobacillus, MS = Mutans streptococci, BC = Buffering capacity, with high scores of LB and their mean dmft score. In CFU = Colony forming units, OR = Odds ratio, CI = Confidence interval, this cohort, those with high LB scores had a mean dmft df = Degrees of freedom January-June 2013, Vol. 3, No. 1 Journal of International Society of Preventive and Community Dentistry 40 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries between and including 1 and 7), and those with severe MS counts and low BC were nine times (P <  0.01) caries (dmft  +  DMFT  ≥  8). These categories were more likely to have dental caries compared to the rest then correlated with bacterial scores which showed and those with high MS, high LB, and low BC were a strong correlation between high scores and severe eight times (P =  0.02) more likely to have dental caries caries (P =  0.04 and P <  0.01) for both MS and LB, compared to the rest of the subjects. respectively as shown in Table 3. The likelihood ratio for both MS and LB was extremely high; those who DISCUSSION had severe dental caries were 25 times (P < 0.01) more This study was unique as it used three risk factors singly likely to have high counts of LB compared to those with mild or no caries. Those with severe caries were also and in combination to predict dental caries. No other 6 times (P =  0.04) more likely to have high counts of study of this sort has been done in Saudi Arabia and the MS compared to those with mild or no caries. results could confidently be used to classify children from this community into high or low caries risk To predict the risk of dental caries the variables were subjects. correlated individually and in different combinations to determine those risk factors which would yield the There were more females in the study even though highest risk for developing dental caries. The results are an equal number of boys and girls were asked to displayed in Table 4. The odds ratios (OR) varied from participate. A reason was that many males did not 2 to 9 and those with multiple factors were greater at provide written consent and hence they had to be risk of having dental caries compared to those with no excluded. Another reason for the low number of factors and those with fewer factors. Those with high males was due to them being absent on the days that were allocated for the dental screenings. As a result, there were higher numbers of females compared to Table 3: The correlation between caries severity males. Although 316 students were screened, only and counts of MS and LB 235 provided saliva samples. One of the reasons was Variable Category Severe Mild Healthy Total that some of the participants could not expectorate (%) (%) (%) sufficient amounts of saliva for the saliva tests to be MS scores High CFUs 18 (75) 89 (72) 49 (56) 156 conducted. In addition, some parents refused consent Low CFUs 6 (25) 35 (28) 38 (44) 79 LR=6.3 at 2 df; P=0.04 for saliva testing and did not want their children to LB scores High CFUs 23 (96) 97 (78) 46 (53) 166 provide saliva samples; however they were willing to Low CFUs 1 (4) 27 (22) 41 (47) 69 allow their children to receive a dental examination and LR=25.9 at 2 df; P<0.01 the necessary referral forms in order for their child to Saliva BC Low BC 3 (11) 17 (63) 7 (26) 27 receive any dental treatment that they may require. Medium BC 15 (12) 64 (53) 42 (35) 121 High BC 6 (7) 43 (49) 38 (44) 87 The dmft for the 6‑year‑olds in this sample (4.86) was χ =4.35 at 4 df; P=0.36 considerably lower than other similar studies which LB = Lactobacillus, MS = Mutans streptococci, BC = Buffering capacity, [10‑12] reported dmft scores between 6 and 8. Possible CFU = Colony forming units, OR = Odds ratio, CI = Confidence interval, df = Degrees of freedom reasons could be that these studies were done in the early 2000 and since then there have been changes in the levels of education and awareness in Saudi Arabia. Table 4: Predictability of dental caries using The DMFT for the 12‑year‑olds (1.31) was also slightly combinations of risk factors lower than similar studies conducted in other parts of No. of Odds P value [11] Saudi Arabia. respondents ratio (CI) High MS CFUs 156 2.44 0.05 (1.3‑4.5) The number of caries free children was 25% and this Low LB CFUs 166 4.45 0.00 (2.3‑8.3) was similar to other studies that reported a caries Low BC 27 4.72 0.04 (1.1‑20.6) [10,13,14] High MS CFUs+High 141 3.51 0.00 (1.9‑6.5) free prevalence of between 17 and 25.3%. Some LB CFUs of the reasons for this discrepancy could be the different High MS CFUs+Low BC 23 9.4 0.00 (1.27‑70.7) age groups that were used, the different settings and High LB CFUs+Low BC 22 7.86 0.03 (1.0‑59.8) the fact that two of these studies were done more High MS CFUs+High 21 8.5 0.02 (1.1‑64.2) than 10 years ago. Since then, the levels of knowledge LB CFUs+Low BC regarding oral health have improved and this could High scores ≥10,000 CFUs, LB = Lactobacillus, MS = Mutans streptococci, BC = Buffering capacity, CFU = Colony forming unit, CI = Confidence interval account for the improvement of the caries levels. 41 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries There were many more students that were diagnosed can be prevented from developing dental caries. These with high CFUs compared to low CFUs. This could also results were similar to other studies which showed a be due to poor oral hygiene and a diet rich in fermentable strong correlation between the buffering capacity and the [6,21] carbohydrates and acidic fizzy drinks that other Saudi prevalence of dental caries. [11,14] studies using a similar population have reported. There was a significant relationship between a high dmft When calculating the OR for the correlation between and high counts of LB; confirming results obtained single and multiple combinations of the risk factors [15] by Gábris et al. A possible reason could be that LB is and the presence of dental caries, all tests proved to associated with acid production and the progression be statistically significant. The highest OR was for of dental caries and as the WHO criteria were used combined high MS score and low saliva BC category. to diagnose dental caries, only frank dental caries was This was followed by participants who had all three recorded. MS is associated with the initiation of dental risk factors present (high MS, high LB, and low saliva caries and it is therefore possible that in early lesions BC). This was not unexpected as all of these are risk there may be more MS than LB, but in this sample with factors for dental caries and if a patient presents with cavitated and progressed caries, it was expected to find all three of them, they should be vulnerable to dental [5] high LB counts. Nishikawara et al., showed similar caries. results and concluded that LB could be a useful tool for detecting dental caries while MS could not be confidently Although the ideal way to predict dental caries using used in the prediction of caries. Another reason could be these risk factors would be using a prospective cohort that studies have shown that MS is generally found in study; due to financial, ethical, and time constraints; [16] deep cavities, while LB is found within the oral cavity this was not possible. The alternative was to perform a [17] including the oral mucosa and saliva. Therefore by cross‑sectional study which correlated the risk factors taking saliva it is possible to detect more LB compared to the presence of dental caries. Therefore, the results to MS even though there may be higher numbers of MS from our study could still be used to draw generalized in the oral cavity. Other studies have reported that high conclusions which included the following; those with numbers of LB have been found in the saliva of children high bacteria counts should be detected early and who consume large amounts of simple carbohydrates. prevention programs should be implemented so that [18,19] Numerous studies done in Saudi Arabia have the effects of these bacteria could be reduced. Routine shown that young children in Saudi Arabia tend to bacterial counts should be a part of the annual dental consume large amounts of fizzy drinks and fermentable examination so that patients could be advised as to the carbohydrates and this could explain the high amounts of oral hygiene and diet practices using these bacterial [11,20] LB that was found in this sample. counts as a guide. Lastly, although saliva BC was not as strongly associated with dental caries on its own, saliva There were significant correlations between those with as part of bacterial counts could be a useful predictor of caries and high counts of both MS and LB. The odds dental caries and should not be overlooked. of those with high counts of LB and MS were four and two times higher for developing dental caries compared CONCLUSION to those with low counts, respectively. This has far reaching implications for the planning of services; if Although the prevalence of dental caries amongst the patients with high counts of both LB and MS can be 6‑year‑olds was high, it was considerably lower than detected early, it is possible to prevent dental caries and results obtained from similar studies in Saudi Arabia save the patient and state resources. and this could be attributed to the improvement of knowledge and access to services. There were more Although the majority of the sample had a high or respondents with high CFUs of both bacteria and this medium saliva BC, those who had a low saliva BC could be a cause for the relatively high levels of caries. had statistically more severe caries compared to the The majority of respondents had high or medium saliva rest. These children had on an average 8 or more teeth BC, but amongst the few that had a low BC, almost all of decayed and this form of rampant caries results in pain, them had rampant caries. There was a strong correlation early extractions, and possibly orthodontic treatment between high MS, LB, and low BC and the high in the future. Hence, it is imperative to try and prevent prevalence of dental caries. The presence of high bacteria these complications by early detection and intervention. counts and low saliva BC can be confidently used to Saliva stimulants and fluoride gels could be administered on a regular basis to ensure that these high risk groups predict dental caries in young children in this population. January-June 2013, Vol. 3, No. 1 Journal of International Society of Preventive and Community Dentistry 42 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries 6‑7 year old Saudi girls attending public and armed forces REFERENCES schools in Riyadh, Saudi Arabia. Saudi Dent J 2000;12:33‑6. 13. Chedid NR, Bourgeois D, Kaloustian H, Baba NZ, 1. Edelstein BL. The dental caries pandemic and disparities Pilipili C. 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J Contemp Dent Pract Oral Biol 1999;44:111‑7. 2006;7:46‑54. 11. Stewart BL, Al‑Juhani TS, Al‑Akeel AS, Al‑Brikeet HA, Al‑Buhairan WH, Al‑Bundagji NH, et al. Caries experience How to cite this article: Bhayat A, Ahmad MS, Hifnawy T, Mahrous MS, Al-Shorman H, Abu-Naba'a L et al. Correlating dental caries with in grade 1 and 6 children attending elementary school at oral bacteria and the buffering capacity of saliva in children in Madinah, King Abdul‑aziz Military City, Tabuk, Saudi Arabia. Saudi Saudi Arabia. J Int Soc Prevent Communit Dent 2013;3:38-43. Dent J 2000;12:140‑8. 12. Mansour M, Anwar S, Pine C. Comparison of caries in Source of Support: Nil, Conflict of Interest: None declared. Staying in touch with the journal 1) Table of Contents (TOC) email alert Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to www.jispcd.org/signup.asp. 2) RSS feeds Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal’s website. You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add www.jispcd.org/rssfeed.asp as one of the feeds. 43 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of International Society of Preventive & Community Dentistry Pubmed Central

Correlating dental caries with oral bacteria and the buffering capacity of saliva in children in Madinah, Saudi Arabia

Bhayat, Ahmed; Ahmad, Mohammad Sami; Hifnawy, Tamer; Mahrous, Mohammed Saad; Al-Shorman, Hisham; Abu-Naba’a, Layla; Bakeer, Hala
Journal of International Society of Preventive & Community Dentistry , Volume 3 (1) – Sep 1, 168
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2231-0762
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10.4103/2231-0762.115712
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Abstract

Introduction: Caries is associated with high counts of mutans streptococci (MS), lactobacillus (LB), and a low saliva buffering capacity (BC). No study using odds ratios (OR) has correlated caries and these factors and no similar study has been done in Saudi Arabia before. Objectives: To determine: The prevalence of caries, the number of colony forming units (CFUs) of MS and LB, the saliva buffering capacity (BC) and the relationship between these factors. Materials and Methods: This was an analytical cross sectional study on children from Madinah. Caries was recorded using dmft/DMFT (decayed, missing, filled teeth). The scores for MS and LB and the BC of saliva was calculated using the Caries Risk Test (CRT) . Results: A total of 316 students were examined; two‑thirds (62%) were female and 25% were caries free. Saliva was collected from 235 participants and the majority had high MS and LB scores (66 and 71%, respectively) while 25% had a low saliva BC. The odds for those who had high LB and MS CFUs, were 9 and 4 times more at risk to developing dental caries and those with a low BC had significantly more caries (P =  0.03). The likelihood for those having severe caries and high counts of LB and MS was 25 (P < 0.01) and 6 (P = 0.042) times greater, respectively, compared to those with no or mild caries. Those with multiple risk factors were more likely to have caries compared to those with single or no risk factors present. Conclusions: The prevalence of caries was relatively high and many respondents had greater than 10 CFUs/ml of MS and LB. Almost all with a low BC had severe caries. There was a strong correlation between high MS, high LB, and low BC and the high prevalence of caries; hence the combination of these factors could be confidently used to predict caries in this population. Key words: Bacteria, buffering capacity, caries the causative factors for this disease is dental plaque INTRODUCTION which is the bacterial deposit that forms continuously Dental caries is one of the most common chronic on the tooth surfaces. The frequency of consumption [1,2] diseases affecting millions of people globally. It of soft drinks and the frequency of intake of sweets as is a major cause of tooth loss, pain and discomfort risk indicators have also been identified previously [3] [4] worldwide; especially amongst children. One of in various caries risk assessment models. It is well‑recognized that these are important and essential Access this article online variables in caries initiation. Thus one may predict a Quick Response Code: child who is likely susceptible to develop caries using Website: these and other innovative risk factors. Factors such www.jispcd.org as bacterial counts of mutans streptococci (MS) and lactobacillus (LB) and the buffering capacity (BC) DOI: of saliva have been shown to be strong risk factors 10.4103/2231-0762.115712 associated with the initiation and progression of dental [5,6] caries. 38 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries To prevent dental caries, the reduction of high counts chair and using a wooden spatula as described by the [8] of bacteria, an improvement in oral hygiene and a high World Health Organization (WHO). There were BC of saliva would be necessary. One way of detecting two calibrated examiners who completed all the bacterial counts and the BC of saliva is by using a caries dental examinations. A calibration exercise was carried out before going to the schools and the inter‑ and risk test (CRT) such as the one developed by Ivoclar Vivadent. intraexaminer variability was 95 and 98%, respectively. [5] It is currently accepted that MS and LB are The bacterial count and pH of saliva was calculated instrumental in the cause and progression of dental using the Caries Risk Test (CRT) kit from Ivoclar [9] Vivadent. A previous study showed that the sensitivity caries. MS plays a decisive role in the onset of caries, while LB contributes to the progression of caries. and specificity of tests using an agar growth was equally Therefore, the presence of these bacteria could predict effective as those using the broth growth and concluded that the results are acceptable for mass screening high risk patients and possible preventive procedures purposes. could be put in place to prevent or reduce dental caries. Studies have also shown that the BC of saliva influences The subjects were asked to chew on a paraffin pellet, [6] the prevalence of dental caries. Those that have a high which was included in the kit, for 30 s and then expectorate the stimulated whole saliva into a disposable BC are more likely to neutralize the pH and hence have cup. A portion of the saliva was then pipetted onto a lower prevalence of dental caries. two agar plates, one for MS and one for LB. The agar plates were incubated for 48 h at 37°C to allow for the The identification of high risk children is essential for planning of oral health treatment and prevention of growth of the organisms. The number of colonies future diseases. It will also help tertiary institutions as measured by colony forming units (CFU) per milliliter of saliva was not actually counted, but a score when planning outreach activities to focus on communities that are most vulnerable to dental caries, was given depending on the visual number of CFUs one of the pillars for the success of a community service present against a reference model chart provided in [7] the instruction manual. The readings were done by program. consensus amongst three investigators using the model However, this study is unique in that it is the first to use chart. The colonies were scored as either “low” (less than 5 5 the Ivoclar CRT buffer and bacteria kits in Saudi Arabia. 10 CFUs/ml) or “high” (greater than 10 CFUs/ml) as It is also the first study carried out in a Saudi Arabian per the manufacturer’s instruction. population to correlate the bacterial counts of MS and The remainder of the saliva was utilized to determine LB and the BC of saliva with the presence of dental caries. the BC of saliva. The saliva was pipetted onto a test strip which was left for 5 min. During this time the strip changed color and the BC category was recorded MATERIALS AND METHODS according to the manufacturer’s instructions. A green This was a cross‑sectional observational study which color was recorded as a “high BC”, a yellow color was carried out on 6 and 12 year‑old school children indicated “medium BC”, and a blue color meant a “low in Madinah. It was conducted between January and BC”. Consensus of three investigators was used to March 2012 in four primary schools which were determine the scores and categories for the variables. randomly selected from a list of registered schools in Madinah. Principals of each school were contacted and For further statistical analyses, the study population introduced to the study. Consent forms were sent to was divided into groups depending on the presence the parents of all the children who were registered in or absence of dental caries. Those without any grades one and six and those who consented, underwent dental caries in both dentitions were classified as a dental examination and saliva samples were collected “healthy” (dmft = 0 and DMFT = 0) and those with one from each of them. or more decayed tooth in either of the dentitions were classified as “diseased” (dmft ≥ 1 or DMFT ≥ 1). Prevalence of caries was recorded using the dmft/ DMFT (decayed, missing, filled teeth) index and To correlate the severity of dental caries, those without examinations were carried out in the classroom under any decay were classified as “healthy” (dmft/DMFT = 0), florescent lighting with subjects sitting on a regular those with a total of between 1 and 7 decayed teeth 39 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries in both dentitions were classified as “mild caries” of 4.85 compared to those with low LB counts who had (dmft +  DMFT between 1 and 7) and those with more a mean dmft of 1.44 (P < 0.01). than 8 decayed teeth were classified as “severe caries” Table 2 shows the correlation between the bacterial (dmft + DMFT ≥ 8). counts and the presence or absence of dental caries. There was a highly significant relationship between Data analysis high counts of LB and MS and the presence of The data was coded and keyed into the Statistical Package dental caries (P <  0.01 and P <  0.01, respectively). for the Social Sciences software version 19 (SPSS Inc, The odds for those who had a high score of LB Chicago, IL) used in Windows 7. Descriptive analysis were four times (P <  0.01) greater to develop dental by inferential statistics was done. Percentages, means, caries compared to those who had a low LB score. and standard deviations (SD) were calculated for Similarly, those who had high MS scores were two qualitative and quantitative data. Chi‑square test ( χ ) and times (P  <  0.01) more likely to have developed Fisher’s exact test were performed to statistically analyze dental caries compared to those who had low qualitative data. A P value of 0.05 was considered to MS scores. control for alpha (type 1) error. There was also a statistical correlation between the Ethical consideration buffering capacity and the presence of caries. Those with low BC were significantly (χ  = 6.9, P = 0.03) more The Research Ethics Committee of the College of likely to have dental caries compared to those with a Dentistry, Taibah University, approved this study. The medium or high BC. consent process was done in two steps; parent consent followed by child assent, any child who refused to To describe the severity of caries, the dmft/DMFT participate in this was excluded. Some parents accepted was divided into three categories; “healthy” (dmft and for including their children in the dental examination DMFT =  0); those with mild caries (dmft +  DMFT but refused the section of saliva collection. All children enrolled in this study were given a full written Table 1: Mean dmft/DMFT scores (N=316) report about their oral condition and dental hygiene. d m f Total 1 D M F Total 2 6 years 4.48 0.17 0.21 4.86±4.17 0.07 0.0 0.0 0.07±0.34 (N=171) RESULTS 12 years 1.06 0.10 0.24 1.41±2.56 0.90 0.05 0.36 1.31±1.20 (N=145) A total of 316 students were screened; almost two‑thirds dmft/DMFT = Decayed, missing, filled teeth were female (N =  197; 62%) and over half (54%) of them were 6‑year‑old. A quarter (25%) of the sample was caries free. The mean dmft/DMFT scores are Table 2: The correlation between dental caries, shown in Table 1. bacterial counts, and the buffering capacity of saliva (N=235) Saliva samples were collected from a total of Variable Category Disease (%) Healthy (%) Total 235 students and statistical correlations were done on LB score High CFUs 139 (84) 27 (16) 166 respondents who had both a dmft/DMFT score and a Low CFUs 37 (54) 32 (46) 69 saliva sample. Of these, the majority had high CFUs Total 176 (75) 59 (25) 235 of MS and LB (66 and 71%, respectively), 51% had a OR=4.45, P<0.01 (CI=2.4‑8.3) medium BC, and 25% had a low BC. MS score High CFUs 126 (81) 30 (19) 156 Low CFUs 50 (63) 29 (37) 79 The vast majority had high CFU scores of MS and LB Total 176 (75) 59 (25) 235 and there was a direct proportional increase in bacterial OR=2.4. P<0.01 (CI=1.3‑4.3) Saliva BC Low BC 25 (93) 2 (7) 27 counts and mean dmft/DMFT scores. Although those Medium BC 92 (76) 29 (24) 121 who had high scores of MS and LB had a higher mean High BC 59 (68) 28 (32) 87 dmft/DMFT compared to those with low counts, there Total 176 (75) 59 (25) 235 were no significant statistical associations. The only χ =6.9 at 2 df; P=0.03 significant association was between 6‑year‑old subjects LB = Lactobacillus, MS = Mutans streptococci, BC = Buffering capacity, with high scores of LB and their mean dmft score. In CFU = Colony forming units, OR = Odds ratio, CI = Confidence interval, this cohort, those with high LB scores had a mean dmft df = Degrees of freedom January-June 2013, Vol. 3, No. 1 Journal of International Society of Preventive and Community Dentistry 40 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries between and including 1 and 7), and those with severe MS counts and low BC were nine times (P <  0.01) caries (dmft  +  DMFT  ≥  8). These categories were more likely to have dental caries compared to the rest then correlated with bacterial scores which showed and those with high MS, high LB, and low BC were a strong correlation between high scores and severe eight times (P =  0.02) more likely to have dental caries caries (P =  0.04 and P <  0.01) for both MS and LB, compared to the rest of the subjects. respectively as shown in Table 3. The likelihood ratio for both MS and LB was extremely high; those who DISCUSSION had severe dental caries were 25 times (P < 0.01) more This study was unique as it used three risk factors singly likely to have high counts of LB compared to those with mild or no caries. Those with severe caries were also and in combination to predict dental caries. No other 6 times (P =  0.04) more likely to have high counts of study of this sort has been done in Saudi Arabia and the MS compared to those with mild or no caries. results could confidently be used to classify children from this community into high or low caries risk To predict the risk of dental caries the variables were subjects. correlated individually and in different combinations to determine those risk factors which would yield the There were more females in the study even though highest risk for developing dental caries. The results are an equal number of boys and girls were asked to displayed in Table 4. The odds ratios (OR) varied from participate. A reason was that many males did not 2 to 9 and those with multiple factors were greater at provide written consent and hence they had to be risk of having dental caries compared to those with no excluded. Another reason for the low number of factors and those with fewer factors. Those with high males was due to them being absent on the days that were allocated for the dental screenings. As a result, there were higher numbers of females compared to Table 3: The correlation between caries severity males. Although 316 students were screened, only and counts of MS and LB 235 provided saliva samples. One of the reasons was Variable Category Severe Mild Healthy Total that some of the participants could not expectorate (%) (%) (%) sufficient amounts of saliva for the saliva tests to be MS scores High CFUs 18 (75) 89 (72) 49 (56) 156 conducted. In addition, some parents refused consent Low CFUs 6 (25) 35 (28) 38 (44) 79 LR=6.3 at 2 df; P=0.04 for saliva testing and did not want their children to LB scores High CFUs 23 (96) 97 (78) 46 (53) 166 provide saliva samples; however they were willing to Low CFUs 1 (4) 27 (22) 41 (47) 69 allow their children to receive a dental examination and LR=25.9 at 2 df; P<0.01 the necessary referral forms in order for their child to Saliva BC Low BC 3 (11) 17 (63) 7 (26) 27 receive any dental treatment that they may require. Medium BC 15 (12) 64 (53) 42 (35) 121 High BC 6 (7) 43 (49) 38 (44) 87 The dmft for the 6‑year‑olds in this sample (4.86) was χ =4.35 at 4 df; P=0.36 considerably lower than other similar studies which LB = Lactobacillus, MS = Mutans streptococci, BC = Buffering capacity, [10‑12] reported dmft scores between 6 and 8. Possible CFU = Colony forming units, OR = Odds ratio, CI = Confidence interval, df = Degrees of freedom reasons could be that these studies were done in the early 2000 and since then there have been changes in the levels of education and awareness in Saudi Arabia. Table 4: Predictability of dental caries using The DMFT for the 12‑year‑olds (1.31) was also slightly combinations of risk factors lower than similar studies conducted in other parts of No. of Odds P value [11] Saudi Arabia. respondents ratio (CI) High MS CFUs 156 2.44 0.05 (1.3‑4.5) The number of caries free children was 25% and this Low LB CFUs 166 4.45 0.00 (2.3‑8.3) was similar to other studies that reported a caries Low BC 27 4.72 0.04 (1.1‑20.6) [10,13,14] High MS CFUs+High 141 3.51 0.00 (1.9‑6.5) free prevalence of between 17 and 25.3%. Some LB CFUs of the reasons for this discrepancy could be the different High MS CFUs+Low BC 23 9.4 0.00 (1.27‑70.7) age groups that were used, the different settings and High LB CFUs+Low BC 22 7.86 0.03 (1.0‑59.8) the fact that two of these studies were done more High MS CFUs+High 21 8.5 0.02 (1.1‑64.2) than 10 years ago. Since then, the levels of knowledge LB CFUs+Low BC regarding oral health have improved and this could High scores ≥10,000 CFUs, LB = Lactobacillus, MS = Mutans streptococci, BC = Buffering capacity, CFU = Colony forming unit, CI = Confidence interval account for the improvement of the caries levels. 41 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries There were many more students that were diagnosed can be prevented from developing dental caries. These with high CFUs compared to low CFUs. This could also results were similar to other studies which showed a be due to poor oral hygiene and a diet rich in fermentable strong correlation between the buffering capacity and the [6,21] carbohydrates and acidic fizzy drinks that other Saudi prevalence of dental caries. [11,14] studies using a similar population have reported. There was a significant relationship between a high dmft When calculating the OR for the correlation between and high counts of LB; confirming results obtained single and multiple combinations of the risk factors [15] by Gábris et al. A possible reason could be that LB is and the presence of dental caries, all tests proved to associated with acid production and the progression be statistically significant. The highest OR was for of dental caries and as the WHO criteria were used combined high MS score and low saliva BC category. to diagnose dental caries, only frank dental caries was This was followed by participants who had all three recorded. MS is associated with the initiation of dental risk factors present (high MS, high LB, and low saliva caries and it is therefore possible that in early lesions BC). This was not unexpected as all of these are risk there may be more MS than LB, but in this sample with factors for dental caries and if a patient presents with cavitated and progressed caries, it was expected to find all three of them, they should be vulnerable to dental [5] high LB counts. Nishikawara et al., showed similar caries. results and concluded that LB could be a useful tool for detecting dental caries while MS could not be confidently Although the ideal way to predict dental caries using used in the prediction of caries. Another reason could be these risk factors would be using a prospective cohort that studies have shown that MS is generally found in study; due to financial, ethical, and time constraints; [16] deep cavities, while LB is found within the oral cavity this was not possible. The alternative was to perform a [17] including the oral mucosa and saliva. Therefore by cross‑sectional study which correlated the risk factors taking saliva it is possible to detect more LB compared to the presence of dental caries. Therefore, the results to MS even though there may be higher numbers of MS from our study could still be used to draw generalized in the oral cavity. Other studies have reported that high conclusions which included the following; those with numbers of LB have been found in the saliva of children high bacteria counts should be detected early and who consume large amounts of simple carbohydrates. prevention programs should be implemented so that [18,19] Numerous studies done in Saudi Arabia have the effects of these bacteria could be reduced. Routine shown that young children in Saudi Arabia tend to bacterial counts should be a part of the annual dental consume large amounts of fizzy drinks and fermentable examination so that patients could be advised as to the carbohydrates and this could explain the high amounts of oral hygiene and diet practices using these bacterial [11,20] LB that was found in this sample. counts as a guide. Lastly, although saliva BC was not as strongly associated with dental caries on its own, saliva There were significant correlations between those with as part of bacterial counts could be a useful predictor of caries and high counts of both MS and LB. The odds dental caries and should not be overlooked. of those with high counts of LB and MS were four and two times higher for developing dental caries compared CONCLUSION to those with low counts, respectively. This has far reaching implications for the planning of services; if Although the prevalence of dental caries amongst the patients with high counts of both LB and MS can be 6‑year‑olds was high, it was considerably lower than detected early, it is possible to prevent dental caries and results obtained from similar studies in Saudi Arabia save the patient and state resources. and this could be attributed to the improvement of knowledge and access to services. There were more Although the majority of the sample had a high or respondents with high CFUs of both bacteria and this medium saliva BC, those who had a low saliva BC could be a cause for the relatively high levels of caries. had statistically more severe caries compared to the The majority of respondents had high or medium saliva rest. These children had on an average 8 or more teeth BC, but amongst the few that had a low BC, almost all of decayed and this form of rampant caries results in pain, them had rampant caries. There was a strong correlation early extractions, and possibly orthodontic treatment between high MS, LB, and low BC and the high in the future. Hence, it is imperative to try and prevent prevalence of dental caries. The presence of high bacteria these complications by early detection and intervention. counts and low saliva BC can be confidently used to Saliva stimulants and fluoride gels could be administered on a regular basis to ensure that these high risk groups predict dental caries in young children in this population. January-June 2013, Vol. 3, No. 1 Journal of International Society of Preventive and Community Dentistry 42 Bhayat, et al.: Correlating bacteria, buffering of saliva, and caries 6‑7 year old Saudi girls attending public and armed forces REFERENCES schools in Riyadh, Saudi Arabia. Saudi Dent J 2000;12:33‑6. 13. Chedid NR, Bourgeois D, Kaloustian H, Baba NZ, 1. Edelstein BL. The dental caries pandemic and disparities Pilipili C. 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J Contemp Dent Pract Oral Biol 1999;44:111‑7. 2006;7:46‑54. 11. Stewart BL, Al‑Juhani TS, Al‑Akeel AS, Al‑Brikeet HA, Al‑Buhairan WH, Al‑Bundagji NH, et al. Caries experience How to cite this article: Bhayat A, Ahmad MS, Hifnawy T, Mahrous MS, Al-Shorman H, Abu-Naba'a L et al. Correlating dental caries with in grade 1 and 6 children attending elementary school at oral bacteria and the buffering capacity of saliva in children in Madinah, King Abdul‑aziz Military City, Tabuk, Saudi Arabia. Saudi Saudi Arabia. J Int Soc Prevent Communit Dent 2013;3:38-43. Dent J 2000;12:140‑8. 12. Mansour M, Anwar S, Pine C. Comparison of caries in Source of Support: Nil, Conflict of Interest: None declared. Staying in touch with the journal 1) Table of Contents (TOC) email alert Receive an email alert containing the TOC when a new complete issue of the journal is made available online. To register for TOC alerts go to www.jispcd.org/signup.asp. 2) RSS feeds Really Simple Syndication (RSS) helps you to get alerts on new publication right on your desktop without going to the journal’s website. You need a software (e.g. RSSReader, Feed Demon, FeedReader, My Yahoo!, NewsGator and NewzCrawler) to get advantage of this tool. RSS feeds can also be read through FireFox or Microsoft Outlook 2007. Once any of these small (and mostly free) software is installed, add www.jispcd.org/rssfeed.asp as one of the feeds. 43 Journal of International Society of Preventive and Community Dentistry January-June 2013, Vol. 3, No. 1

Journal

Journal of International Society of Preventive & Community Dentistry – Pubmed Central

Published: Sep 1, 168

References

  • The dental caries pandemic and disparities problem
  • The global burden of oral disease and risks to oral health
  • Prevalence of dental caries among 5-13-year-old children of Manglore city
  • Caries prevalence and treatment needs among children of Dharavi, Bombay, India
  • Correlation of cariogenic bacteria and dental caries in adults
  • Buffering capacity of saliva in patients with active dental caries
  • The impact of service-learning on two groups of South African dental students
  • World Health Organization. Oral Health Surveys: Basic Methods
  • Comparison of two screening tests for Streptococcus mutans and evaluating their sustainability for mass screenings and private practice
  • Prevalence of dental caries, severity, and pattern in age 6 to 7-year-old children in a selected community in Saudi Arabia
  • Caries experience in grade 1 and 6 children attending elementary school at King Abdul-aziz Military City, Tabuk, Saudi Arabia
  • Comparison of caries in 6-7 year old Saudi girls attending public and armed forces schools in Riyadh, Saudi Arabia
  • Caries prevalence and caries risk in a sample of Lebanese preschool children
  • Oral health survey of 5-12-year-old children of National Guard employees in Riyadh, Saudi Arabia
  • Significance of assessing risk factors for caries in their prevention
  • Ecological study of Streptococcus mutans, Streptococcus sobrinus and Lactobacillus spp. at sub-sites from approximal dental plaque from children
  • Distribution of lactobacilli in oral cavities
  • Effects of dietary sucrose levels on the quantity and microbial consumption of human dental plaque
  • Prediction of dental caries in pre-school children
  • Current trends of sugar consumption in developing societies
  • Individual variations of pH, buffer capacity, and concentrations of calcium and phosphate in unstimulated whole saliva