Correlates of root caries experience in middle-aged and older adults in the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry

research network Donald L. Chi, Joel H. Berg, Amy S. Kim and JoAnna Scott JADA 2013;144(5):507-516 The following resources related to this article are available online at jada.ada.org (this information is current as of December 14, 2013):
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RESEARCH

Correlates of root caries experience in middle-aged and older adults in the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry research network
Donald L. Chi, DDS, PhD; Joel H. Berg, DDS, MS; Amy S. Kim, DDS; JoAnna Scott, PhD; for the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry

.S. adults are retaining their teeth longer.1 Longitudinal data from multiple countries have indicated similar increases in tooth retention.2-4 Although these trends are promising and may lead to overall improvements in oral healthrelated quality of life,5 tooth retention is associated with an increased risk of developing root caries,6 which is a debilitating disease.7 The overall prevalence of root caries in the United States decreased between 1988-1999 and 1999-2004.8 However, data from the 1999-2004 National Health and Nutrition Ex amination Survey indicate that root caries is a problem for adults. For instance, 21.6 percent of adults aged 50 to 64 years, 31.7 percent of adults aged 65 to 74 years, and 42.3 percent of adults 75 years and older had unrestored or restored root caries.8 Furthermore, between 2000 and 2010, there were large increases in the numbers of adults in the U.S. population (a 31.5 percent increase in adults aged 45-64 years and a 15.1 percent increase in adults 65 years and older),9 making adults
Dr. Chi is an assistant professor, Department of Oral Health Sciences, School of Dentistry, University of Washington, Box 357475, Seattle, Wash. 98195, e-mail dchi@uw.edu. Address reprint requests to Dr. Chi. Dr. Berg is a professor and the dean, Department of Pediatric Dentistry, School of Dentistry, University of Washington, Seattle. Dr. Kim is a clinical assistant professor, Department of Pediatric Dentistry, School of Dentistry, University of Washington, Seattle. Dr. Scott is a clinical assistant professor, Department of Pediatric Dentistry, School of Dentistry, University of Washington, Seattle.

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AB STRACT

Background. The authors examined the correlates of root caries experience for middle-aged adults (aged 45-64 years) and older adults (65 years and older) to test the hypothesis that the factors related to root caries are different for middle-aged adults than they are for older adults. Methods. The authors conducted an observational crosssectional study that focused on adult patients aged 45 to 97 years recruited from the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry research network (N = 775). The outcome variable was any root caries experience (no/yes). The authors hypothesized that sociodemographic, intraoral and behavioral factors were root caries correlates. The au thors used Poisson regression models to generate overall and age-stratied prevalence ratios (PRs) of root caries, and they used generalized estimating equations to account for practicelevel clustering of participants. Results. A total of 19.6 percent of adults had any root caries. A dentists assessment that the patient was at high risk of developing any caries was associated with greater prevalence of root caries experience in both middle-aged adults (PR, 2.70; 95 percent condence interval [CI], 1.63-4.46) and older adults (PR, 1.87; 95 percent CI, 1.19-2.95). The following factors were associated signicantly with increased root caries prevalence but only for middle-aged adults: male sex (P = .02), self-reported dry mouth (P < .001), exposed roots (P = .03) and increased frequency of eating or drinking between meals (P = .03). No other covariates were related to root caries experience for older adults. Conclusions. Within a practice-based research network, the factors associated with root caries experience were different for middle-aged adults than they were for older adults. Research is needed to identify relevant root caries correlates for adults 65 years and older. Practical Implications. Interventions aimed at preventing root caries are likely to be different for middle-aged adults than for older adults. Dentists should use root caries prevention programs that address appropriate aged-based risk factors. Key Words. Root caries; dental caries susceptibility; older adults; aged; risk factors. JADA 2013;144(5):507-516.
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RESEARCH

45 years and older the fastest growing U.S. population subgroup. Collectively, these data suggest that increasing numbers of adult patients with root caries will visit dental offices. These trends have generated an interest in understanding the factors related to root caries so that appropriate preventive interventions can be developed. Root caries is a complex and multifactorial disease. In a 2010 systematic review, investigators examined risk models10 and identified the following factors as important correlates of root caries and organized them into four domains: sociodemographic (for example, age, sex, race/ ethnicity), systemic health (for example, dementia), intraoral (for example, number of teeth, plaque levels, bacterial species, caries, periodontal attachment loss, gingival recession, salivary flow) and behavioral (for example, dental care use, toothbrushing, smoking). Investigators in subsequent studies confirmed the findings of that systematic review11-13 and identified additional factors related to root caries: poor self-reported oral health,14 not being married,15 limitations in basic daily life activities,16 rural residence17 and genetic susceptibility.18 Although age is an unequivocal risk factor for root caries in adults,12 to date, few investigators have examined root caries risk factors for middle-aged adults and older adults separately. Another limitation is limited generalizability of the results of existing studies to patients in private dental practices, a population that may differ from those in clinical trials and small studies, as well as those residing in long-term care facilities. To address these limitations, we tested the hypothesis that the correlates of root caries would be different for middle-aged adults (aged 45-64 years) and older adults (65 years and older). We conducted this study within the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry (PRECEDENT) research network, and it is the first step in identifying the factors related to root caries in middle-aged and older adult populations in a practice-based patient population.
METHODS

Conceptual model. We based our study on a conceptual model in which we adapted elements from a systematic review of root caries risk models.10 We focused on individual-level predictor variables as hypothesized correlates of root caries. Study design, location and procedures. We conducted a retrospective cross-sectional
508JADA 144(5)http://jada.ada.orgMay 2013

analysis of baseline data for adult patients enrolled in a longitudinal caries risk study within the Northwest PRECEDENT research network in Idaho, Montana, Oregon, Utah and Washington. Northwest PRECEDENT was one of the three dental practicebased research networks funded by the National Institutes of Health, National Institute of Dental and Craniofacial Research, and details about the establishment and characteristics of the Northwest PRECEDENT have been published.19,20 All Northwest PRECEDENT dentists were eligible to participate. Dentists at the study sites were responsible for reviewing information about the study; completing training modules; and recruiting, receiving consent from, enrolling and collecting data about participants. We provided each office with a manual of procedures that detailed the study procedures. Before we began the study, dentists and staff members at all study sites participated in a training session with the Northwest PRECEDENT regional coordinator to review the manual of procedures. The University of Washington (Seattle) institutional review board approved the study. Participants. We focused our study on adults 45 years and older who were patients in Northwest PRECEDENT research network dental practices. To be eligible, adults were required to have at least four natural permanent teeth at the time of enrollment. Within each practice, dentists randomly selected adults from the daily patient roster so that no more than one to two patients per practice were recruited on any given day. Dentists recruited patients during the period from 2008 to 2011. Patients who agreed to participate provided written informed consent, and the dentists enrolled them in the study. Our study focused on 775 adults from 56 practices. Data sources. There were three data sources. The first data source was a patient survey we used to collect sociodemographic (age, sex, race, education, annual household income), intraoral (dry mouth) and behavioral (smoking, alcohol use, number of times patient eats or drinks between meals) data. The second data source was a saliva test we used to measure patients stimulated salivary pH after they chewed on a piece of paraffin wax. We required that patients refrain from smoking, eating, drinking, toothbrushing or using mouthwash for at least one hour before the saliva test. The
ABBREVIATION KEY. DMFT: Decayed, missing or filled teeth. PRECEDENT: Practice-based REsearch Collaborative in Evidence-based DENTistry.

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RESEARCH

third data source was a clinical dental examination conducted by a Northwest PRECEDENT dentist who was masked as to survey and saliva test data (henceforth referred to as the dentist). Before the dentists implemented the salivary diagnostic procedures, they conducted prestudy reliability tests and found them to be excellent for stimulated salivary pH (intraclass correlation coefficient, 0.80).21 The dentists collected data about visible plaque, as well as the total number of decayed, missing or filled teeth (DMFT); exposed root surfaces; and root caries lesions. At the end of the examination, the dentists assessed the participants caries risk by indicating whether they believed the patient would develop any caries (coronal or root) in the next 24 months. All clinical measures were subjective and based on how the dentists would assess these outcomes in the course of normal practice. There was no calibration of clinical measures across dentists because this would have interfered with how they practiced and reduced dentists participation. All dentists used the same data collection forms. Data management. We captured all data by using the Web-based system at Axio Research (Seattle). We deidentified and encrypted all data during transmission to Axio. Northwest PRECEDENT regional coordinators conducted data audits on all of the data collection forms for 15 percent of participating dentists to ensure accuracy. Northwest PRECEDENT executive committee members also monitored the data. Study variables. Outcome variable. The outcome variable was whether the patient had any decayed or restored root caries (no/yes). (We defined decayed as any cavitation.) The dentists assessed root caries experience, and we defined root caries experience as any lesion on the root surface of the tooth (restored or decayed). Predictor variables. We organized the hypothesized predictor variables into three domains: socioeconomic, intraoral and behavioral. The variables in the sociodemographic domain were age22-26 (45-64 years, 65 years), sex (female, male),26-30 race14,26,29,31,32 (white, other), education26 (< high school, high school, >high school) and annual household income33 (<$25,000, $25,000 to $49,999, $50,000 to $99,999, $100,000). The variables in the intraoral domain were patient-reported dry mouth34 (yes, no), stimulated salivary pH35 ( 7.0, > 7.0), any exposed root surfaces24,32,36-39 (yes, no), total number of DMFT29,37,38 and visible heavy plaque22,40 (yes, no). We also included an exploratory variable

(caries risk) in our model that was operationalized as the dentists assessment of whether the patient would develop any caries (coronal or root) in the next 24 months (yes, no). Caries risk is a global measure of risk that accounts for factors beyond DMFT and visible plaque. The variables in the behavioral domain were smoking41,42 (never smoked, ever smoked), alcohol use (none, any) and diet43,44 (number of times the patient eats or drinks between meals each day; 0-2, 3). Statistical analysis. After generating descriptive statistics of the study population, we used Poisson regression models to examine bivariate associations between each predictor variable and root caries experience (no, yes) and adjusted for within-practice correlation using generalized estimating equations ( = .05). Next, we used multiple variable Poisson regression models for the study population and separately for middle-aged adults (aged 45-64 years) and older adults ( 65 years) to generate covariate adjusted prevalence ratios (PRs). We used generalized estimating equations with robust standard error estimates to account for clustering of participants within practices (for example, some practices may be more likely to have patients with certain characteristics). We used statistical software (STATA 12.0, StataCorp, College Station, Texas) to conduct all analyses.
RESULTS

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Descriptive statistics. A total of 52.5 percent of participants were aged 45 through 64 years and 47.5 percent were 65 years and older (Table 1). The mean (standard deviation [SD]) age of all participants was 63.2 (11.1) years (range, 4597 years). A total of 94.9 percent of participants was white, and 89.2 percent completed at least high school. Most (56.5 percent) had an annual household income of $50,000 or greater. A total of 62.2 percent of adults did not report having dry mouth, and 86.7 percent had stimulated salivary pH greater than 7.0. More than 78.2 percent had exposed root surfaces, and 16.9 percent had visible heavy plaque. The mean (SD) DMFT was 9.2 (4.8). Dentists classified 25.5 percent of adults as being likely to develop any caries (coronal or root) in the next 24 months. A total of 57.3 percent of participants never smoked, 30.8 percent did not use alcohol, and 69.8 percent ate or drank between meals less than three times per day. Bivariate statistics. The results of the unadjusted Poisson regression models indicated that there was a significant relationship between root caries experience and the following
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RESEARCH TABLE 1

Descriptive statistics for study participants (N = 775) stratified according to age group.
VARIABLE ROOT CARIES IN PARTICIPANTS AGED 45-64 YEARS (n = 407) No (n = 348) Sociodemographic Factor Sex, no. (%) Female Male Race, no. (%) White Other Education, no. (%) < High school High school > High school Missing Annual household income ($), no. (%) < 25,000 25,000-49,999 50,000-99,999 100,000 Missing Yes (n = 59)

P VALUE*

ROOT CARIES IN PARTICIPANTS 65 YEARS AND OLDER (n = 368) No (n = 275) Yes (n = 93)

P ROOT CARIES IN P VALUE* ALL PARTICIPANTS VALUE* (N = 775)

No (n = 623) Yes (n = 152)

135 (38.8) 213 (61.2) 328 (94.2) 20 (5.8) 15 (4.3) 117 (33.6) 216 (62.1) 0

32 (54.2) 27 (45.8) 54 (91.5) 5 (8.5) 4 (6.8) 17 (28.8) 38 (64.4) 0

.03

127 (46.2) 148 (53.8) 265 (96.4) 10 (3.6) 23 (8.4) 93 (33.8) 156 (56.7) 3 (1.1)

37 (39.8) 56 (60.2) 89 (95.7) 4 (4.3) 9 34 49 1 (9.7) (36.5) (52.7) (1.1)

.39

262 (42.0) 361 (58.0)

69 (45.4) 83 (54.6)

.55

.31

.80

593 (95.2) 143 (94.1) 30 (4.8) 9 (5.9) 38 (6.1) 210 (33.7) 372 (59.7) 3 (0.5) 13 (8.5) 51 (33.6) 87 (57.2) 1 (0.7)

.59

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.63

.77

.47

15 (4.3) 56 (16.1) 158 (45.4) 91 (26.2) 28 (8.0)

3 (5.1) 11 (18.6) 34 (57.6) 7 (11.9) 4 (6.8)

.13

26 (9.4) 78 (28.4) 103 (37.4) 15 (5.5) 53 (19.3)

15 25 23 6 24

(16.1) (26.9) (24.7) (6.5) (25.8)

.18

41 (6.6) 134 (21.5) 261 (41.9) 106 (17.0) 81 (13.0)

18 (11.8) 36 (23.7) 57 (37.5) 13 (8.6) 28 (18.4)

.01

* P values from Poisson regression models adjusted for within-practice clustering by using generalized estimating equations (unadjusted for model covariates).

covariates: age (P < .001), annual household income (P = .005), self-reported dry mouth (P<.001), stimulated salivary pH (P =.01), exposed root surfaces (P = .002), DMFT (P =.017), visible heavy plaque (P < .001) and eating or drinking between meals (P = .009) (data not shown). Multiple variable regression models. In the results of the covariate-adjusted Poisson regression model for all study participants (45 years and older), we found that four model covariates were associated significantly with root caries experience (Table 2, pages 512 and 513). Adults assessed as being at risk of developing caries by a dentist had a root caries PR that was 2.24 times as high as that of adults assessed as not being at risk of developing caries (95 percent confidence interval [CI], 1.55-3.25). In addition, we noted significantly higher root caries PRs in adults with exposed roots (PR, 2.69; 95 percent CI, 1.18-6.09), with self-reported dry mouth (PR, 1.66; 95 percent CI, 1.21-2.29) and who ate or drank between meals three or more times each day (PR, 1.44, 95 percent CI, 1.14-1.82). In the age-stratified models for adults 65 years and older, the only factor significantly associated with root caries experience was caries risk (PR, 1.87; 95 percent CI, 1.19-2.95; P = .01).
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For adults aged 45 through 64 years, in addition to caries risk, there were four factors related to root caries: male sex (P = .02), exposed roots (P = .03), dry mouth (P < .001), and eating or drinking between meals (P = .03).
DISCUSSION

To our knowledge, this is the first study conducted within a practice-based research network in which the investigators examined the factors related to root caries experience in adults. We tested the hypothesis that the correlates of root caries would be different for middle-aged adults than they would be for older adults. The results of our study support this hypothesis. We have two main sets of findings. Our first main finding was that there was only one factor associated with root caries experience in both middle-aged and older adults: dentist-assessed caries risk. Middle-aged adults classified as being at risk of developing any caries (coronal or root) in the next 24 months had a root caries prevalence that was 2.70 times as high as that for middle-aged adults not at risk of developing caries (P < .001). The PR for older adults was 1.87 (P = .01). The other two factors in our models that are traditional markers for high caries risk (DMFT and plaque) failed to

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RESEARCH

TABLE 1 (CONTINUED)

VARIABLE

ROOT CARIES IN PARTICIPANTS AGED 45-64 YEARS (n = 407) No (n = 348) Yes (n = 59)

P VALUE*

ROOT CARIES IN PARTICIPANTS 65 YEARS AND OLDER (n = 368) No (n = 275) Yes (n = 93)

P ROOT CARIES IN P VALUE* ALL PARTICIPANTS VALUE* (N = 775)

No (n = 623) Yes (n = 152)

Intraoral Factor Dry mouth, no. (%) Yes No Missing Stimulated salivary pH, no. (%) 7.0 > 7.0 Missing Any exposed roots, no. (%) Yes No Missing Decayed, missing or filled teeth, mean (standard deviation) Visible heavy plaque, no. (%) Yes No Missing Whether the patient would develop any caries (coronal or root) in the next 24 months, no. (%) Yes No Missing Behavioral Factor Smoking, no. (%) Never smoked Ever smoked Missing Alcohol use, no. (%) None Any Number of times eat or drink between meals per day, no. (%) 0-2 3

112 (32.2) 236 (67.8) 0

34 (57.6) 25 (42.4) 0

< .001

102 (37.1) 173 (62.9) 0

44 (47.3) 48 (51.6) 1 (1.1)

.02

214 (34.4) 409 (65.6) 0

78 (51.3) 73 (48.0) 1 (0.7)

< .001

46 (13.2) 302 (86.8) 0 250 (71.8) 98 (28.2) 0 8.9 (4.2)

11 (18.6) 48 (81.4) 0 53 (89.8) 6 (10.2) 0 10.7 (4.1)

.25

27 (9.8) 247 (89.8) 1 (0.4) 220 (80.0) 55 (20.0) 0 9.0 (5.0)

17 (18.3) 74 (80.6) 1 (1.1) 83 (89.3) 9 (9.7) 0 10.0 (5.9)

.01

73 (11.7) 28 (18.4) 549 (88.1) 123 (80.9) 1 (0.2) 1 (0.7) 470 (75.4) 136 (89.4) 153 (24.6) 15 (9.9) 0 1 (0.7) 8.9 (4.6) 10.3 (5.3)

.01

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.01

.07

.002

.001

.22

.02

44 (12.6) 303 (87.1) 1 (0.3)

11 (18.6) 48 (81.4) 0

.23

47 (17.1) 227 (82.5) 1 (0.4)

29 (31.2) 64 (68.8) 0

.01

91 (14.6) 40 (26.3) 530 (85.1) 112 (73.7) 2 (0.3) 0

.001

60 (17.2) 280 (80.5) 8 (2.3)

29 (49.1) 27 (45.8) 3 (5.1)

< .001

61 (22.2) 204 (74.2) 10 (3.6)

45 (48.4) 41 (44.1) 7 (7.5)

< .001

121 (19.4) 484 (77.7) 18 (2.9)

74 (48.7) 68 (44.7) 10 (6.6)

< .001

223 (64.1) 122 (35.0) 3 (0.9) 94 (27.0) 254 (73.0)

28 (47.5) 31 (52.5) 0 14 (23.7) 45 (76.3)

.02

142 (51.6) 131 (47.7) 2 (0.7) 88 (32.0) 187 (68.0)

51 (54.8) 42 (45.2) 0 43 (46.2) 50 (53.8)

.69

365 (58.6) 253 (40.6) 5 (0.8) 182 (29.2) 441 (70.8)

79 (52.0) 73 (48.0) 0 57 (37.5) 95 (62.5)

.17

.52

.01

.08

239 (68.7) 109 (31.3)

33 (55.9) 26 (44.1)

.02

208 (75.6) 67 (24.4)

61 (65.6) 32 (34.4)

.07

447 (71.7) 176 (39.3)

94 (61.8) 58 (38.2)

.01

achieve statistical significance, which suggests that a global assessment of caries risk may be an important factor in predicting whether a patient develops root caries. There are no studies available for us to make direct comparisons. Although there is the potential for reverse causality (the presence of root caries is linked causally to an assessment of higher caries risk), our findings regarding dentist-assessed caries risk suggest that dentists in the Northwest PRECEDENT research network might be making clinical decisions regarding caries risk on the

basis of factors from formal caries risk assessment tools (for example, Caries Management by Risk Assessment45 and the American Academy of Pediatric Dentistry Caries-risk Assessment Tool46). We do not know what specific elements from formal risk factor tools dentists in the Northwest PRECEDENT research network used to assess caries risk. Widespread dissemination of formal caries risk assessment tools is unlikely47 but necessary to enable detailed tracking of specific changes in caries risk factors across time. There is a need for additional research regarding
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RESEARCH TABLE 2

Multiple variable Poisson regression models for age strata and all participants with corresponding covariate-adjusted prevalence ratios (N = 631).
VARIABLE AGED 45-64 YEARS (n = 360) Prevalence Ratio* Sociodemographic Factor Sex Female Male Race White Other Education < High school High school > High school Annual household income ($) < 25,000 25,000-49,999 50,000-99,999 100,000 95% CI 65 YEARS AND OLDER (n = 271) Prevalence Ratio* 95% CI ALL PARTICIPANTS (N = 631) Prevalence Ratio* 95% CI

P Value

P Value

P Value

0.53 Reference 0.82 Reference Reference 1.19 1.46

0.32-0.88 Reference 0.40-1.69 Reference Reference 0.52-2.73 0.70-3.05

.02

0.99 Reference 1.97 Reference Reference 0.88 0.87

0.53-1.82 Reference 0.31-12.67 Reference Reference 0.42-1.82 0.40-1.92

.97

0.77 Reference 1.13 Reference Reference 0.86 0.91

0.51-1.18 Reference 0.55-2.36 Reference Reference 0.53-1.40 0.58-1.44

.24

.60

.48

.73

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.53

.94

.84

Reference 1.52 1.72 0.76

Reference 0.63-3.67 0.76-3.92 0.30-1.87

.18

Reference 0.99 0.91 1.25

Reference 0.51-1.95 0.39-2.13 0.53-2.97

.87

Reference 0.99 0.95 0.59

Reference 0.59-1.67 0.56-1.60 0.31-1.15

.34

* Adjusted for model covariates and clustering within dental practices by using generalized estimating equations. CI: Confidence interval.

factors dentists use to determine general caries risk, as well as a need to identify the barriers to dentists adoption of standardized caries risk assessment systems. Longitudinal studies involving dentists whose techniques are calibrated on the use of caries risk assessment tools are needed to stand ardize the caries risk assessment process and evaluate whether such tools can be used to manage and prevent dental disease reliably. Our second main finding was that there were four factors related to root caries experience that were significant for middle-aged adults but not for older adults: sex, dry mouth, exposed roots, and frequency of eating and drinking between meals. Middle-aged men had a greater prevalence of root caries than did middle-aged women, which is consistent with the findings in two studies29,30 but is inconsistent with the findings of two other studies.26,28 The most recent U.S. data from 19992004 indicate that slightly larger proportions of men aged 20 to 64 years than of women aged 20 to 64 years had caries or restored root caries (15.8 percent and 12.7 percent, respectively).8 One possible reason is that men may be less likely to practice preventive oral health behaviors such as toothbrushing and visiting the dentist.48-50 Interventions aimed at middle-aged adults need to reinforce preventive oral health behaviors, with an emphasis on additional strategies targeted at middle-aged men. Although the U.S. data indicate
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even more pronounced sex-based differences in root caries among older adults (40.9 percent for men and 33.0 percent for women),8 sex was not a significant risk factor for older adults in our study. In addition, race, education level and annual household income were not related to root caries prevalence in any of our models. Although these latter indicators of socioeconomic status do not measure a persons access to financial resources, our findings are consistent with those from a recent study in which investigators found no relationship between financial hardship and selfreported oral health in adults 50 years and older.51 The results of Chi and Tucker-Seeleys51 study provided evidence of sex-based differences in the relationship between financial hardship and oral health, which is a potential topic for future research on adult root caries. Future studies should continue to examine the roles of sex and socioeconomic factors in root caries prevalence. Self-reported dry mouth, exposed roots, and increased frequency of eating and drinking between meals were all significantly associated with root caries experience in middle-aged adults but not in older adults. The reasons for these age-related differences are not clear and need to be elucidated further. One potential explanation for the dry mouth finding is that patients with xerostomia are likely to be taking medications, including those used to treat cardiac arrhythmia.

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RESEARCH TABLE 2 (CONTINUED)

VARIABLE

AGED 45-64 YEARS (n = 360) Prevalence Ratio* 95% CI

65 YEARS AND OLDER (n = 271) Prevalence Ratio* 95% CI

ALL PARTICIPANTS (N = 631) Prevalence Ratio* 95% CI

P Value

P Value

P Value

Intraoral Factor Dry mouth Yes No Stimulated salivary pH 7.0 > 7.0 Any exposed roots Yes No Decayed, missing or filled teeth Visible heavy plaque Yes No Whether the patient would develop any caries (coronal or root) in the next 24 months Yes No Behavioral Factor Smoking Never smoked Ever smoked Alcohol use None Any Number of times eat or drink between meals per day 0-2 3

2.30 Reference

1.46-3.64 Reference

< .001

1.33 Reference

0.88-2.00 Reference

.18

1.66 Reference

1.21-2.29 Reference

.002

Reference 0.84 3.27 Reference 1.03

Reference 0.47-1.50 1.11-9.63 Reference 0.96-1.09

.55

Reference 0.65 1.88 Reference 1.02

Reference 0.41-1.04 0.75-4.70 Reference 0.98-1.06

.07

Reference 0.72 2.69 Reference 1.02

Reference 0.49-1.06 1.18-6.09 Reference 0.99-1.05

.09

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.03 .42 .54

.18 .34 .47

.02 .25 .91

0.81 Reference

0.41-1.59 Reference

1.20 Reference

0.73-1.99 Reference

1.02 Reference

0.66-1.57 Reference

< .001 2.70 Reference 1.63-4.46 Reference 1.87 Reference 1.19-2.95 Reference

.01 2.24 Reference 1.55-3.25 Reference

.01

Reference 1.13 Reference 1.46

Reference 0.69-1.84 Reference 0.75-2.82

.63

Reference 0.99 Reference 0.72

Reference 0.63-1.54 Reference 0.47-1.12

.96

Reference 1.00 Reference 0.95

Reference 0.70-1.43 Reference 0.63-1.45

.99

.26

.14

.79

Reference 1.57

Reference 1.05-2.35

.03

Reference 1.39

Reference 0.89-2.16

.15

Reference 1.44

Reference 1.14-1.82

.002

Investigators have found associations between cardiac arrhythmia and root caries.52,53 In our study, a larger proportion of adults in the middleaged group may have been taking such medications than were adults in the older age group in whom use of arrhythmia medications may not be as prevalent because people who were taking this medication when they were middle-aged may have died before they reached old age. Another possible explanation is the residual confounding factors (for example, mutans streptococci level, hyposalivation, dental insurance, employment, stress, food insecurity, financial hardship, social capital or knowledge regarding how to manage adverse effects from medications) that made middle-aged and older adults in our population different. To address problems with residual confounding, future studies should identify the

medical, social and behavioral factors related to root caries in adults and examine whether these factors operate differently in middle-aged adults than in older adults. Broadly, the results of our study suggest that intraoral and behavioral factors were more important determinants of root caries experience than were sociodemographic factors. In terms of addressing the intraoral factors related to root caries, our findings reinforce the critical role that dentists have in managing and preventing dental disease. Results from a single clinical trial indicated that chlorhexidine-thymol varnish (Cervitec Plus, Ivoclar Vivadent, Amherst, N.Y.) prevents root caries in elderly people in longterm care settings.54 However, investigators in another study found that the use of a 0.12 percent chlorhexidine mouthrinse did not signifiJADA 144(5) http://jada.ada.org May 2013513

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RESEARCH

cantly reduce the development of root caries in people aged 60 to 75 years.55 Other chemotherapeutic approaches that potentially could reduce root caries include diammine silver fluoride, chlorhexidine varnish, sodium fluoride containing varnish and dentin-bonding agents.56-58 In terms of addressing the behavioral factors related to root caries, dentists should encourage patients to engage in regular toothbrushing with a fluoride-containing dentifrice and to reduce their frequencies of carbohydrate intake, particularly between meals. The use of toothpastes containing high levels of fluoride (for example, those with 5,000 parts per million fluoride) and fluoride-containing varnishes has reduced root caries.59-61 There are mixed results in regard to the preventive benefit of fluoridecontaining mouthrinses among older adults.62,63 Study results indicate that older adults benefit from water fluoridation,22,64,65 which reinforces the importance of dental care professionals being prepared to speak to patients about the oral health benefits associated with community water fluoridation.66 Our study had a number of strengths. To our knowledge, ours is the first dental practice based study to focus on the correlates of root caries experience in adults. We recruited patients from Northwest PRECEDENT research network practices throughout a large geograph ic area. Our statistical models accounted for differences in root caries prevalence between middle-aged adults and older adults. Our study also had three main limitations. The first was that we did not adopt a standard measure of root caries (for example, the Root Caries Index67). There was no differentiation between restored and decayed root caries, nor were there standardized procedures for distinguishing root caries from abrasion, which could have led to overidentification of root caries.68 The second was that we did not include microbiological measures of mutans streptococci or lactobacilli in our models,69 and we did not include other potentially important social and behavioral measures such as fluoride exposure, insurance status, employment, financial resources and social capital. This limitation increases the likelihood that our models are incomplete and may be susceptible to residual confounding. The third is limited external generalizability. In our study, we focused on dental care users in private practice settings. Most study participants were white and from households with higher incomes. Thus, our findings cannot be generalized to vulnerable adults or those living in long-term care facilities. How514JADA 144(5)http://jada.ada.orgMay 2013

ever, root caries prevalence rates for patients in both age groups in our study were similar to rates from the most recent U.S. National Health and Nutrition Examination Survey from 1999-2004.8 Limitations aside, our study was a first step in understanding the factors related to root caries in U.S. adults who obtain dental care in private practice settings and how these factors might differ between middle-aged adults and older adults.
CONCLUSION

Caries risk was the main factor related to root caries prevalence in a population of middleaged adults and older adults recruited from dental practices in the Northwest PRECEDENT research network. The correlates of root caries experience were different for middle-aged adults than they were for older adults. Investigators in future studies should continue to develop comprehensive adult root caries risk models that account for relevant sociodemographic, intraoral, behavioral and social factors. This knowledge then can be used to develop chairside interventions and strategies to help dental professionals manage and prevent root caries in patients. n
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