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The purpose of this analysis is to compare three different statistical models for predicting children likely to be at risk of developing dental caries over a 3-yr period. Data are based on 4117 children who participated in the University of North Carolina Caries Risk Assessment Study, a longitudinal study conducted in the Aiken, South Carolina, and Portland, Maine areas. The three models differed with respect to either the types of variables included or the definition of disease outcome. The two "Prediction" models included both risk factor variables thought to cause dental caries and indicator variables that are associated with dental caries, but are not thought to be causal for the disease. The "Etiologic" model included only etiologic factors as variables. A dichotomous outcome measure--none or any 3-yr increment, was used in the "Any Risk Etiologic model" and the "Any Risk Prediction Model". Another outcome, based on a gradient measure of disease, was used in the "High Risk Prediction Model". The variables that are significant in these models vary across grades and sites, but are more consistent among the Etiologic model than the Predictor models. However, among the three sets of models, the Any Risk Prediction Models have the highest sensitivity and positive predictive values, whereas the High Risk Prediction Models have the highest specificity and negative predictive values. Considerations in determining model preference are discussed.

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Central to the development of a model for identifying children at high risk to caries is a clinical evaluation to assess dental status and other conditions potentially useful in caries prediction. Traditionally, this evaluation has been based on a relatively lengthy visual/tactile examination conducted by a dentist. Replacing the dentist examination with a dental auxiliary conducted screening evaluation could lead to reduced time and costs. The 4-yr University of North Carolina Caries Risk Assessment Study involved approximately 5000 schoolchildren initially in Grades 1 and 5 living near Aiken, South Carolina, and Portland, Maine. The effectiveness of caries prediction models using visual/tactile examination data were compared with the same models using simplified screening evaluation data. Results showed sensitivity ranged from 0.57 to 0.61 for the visual/tactile and screening models by site and grade cohort. Specificity for the models ranged from 0.80 to 0.83. None of these differences in sensitivity and specificity between visual/tactile (dentist) and screening (hygienist) models was statistically significant. Findings show that for the prediction of children at high risk to dental caries the clinical evaluation may be conducted with no reduction of precision by using dental hygienist performed screening evaluations rather than dentist conducted visual/tactile examinations. While no cost data were collected, these results imply that costs to future prediction programs could be reduced by using screening evaluations.

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The University of North Carolina caries risk assessment was conducted between 1986 and 1989 with 5000 children initially in grades 1 and 5 from low fluoride sites in South Carolina and Maine. Clinical, microbiologic, behavioral, and demographic factors served as independent variables used in logistic multiple regression models to determine the predicted caries risk classification of each child. The 3-yr DMFS increment of each child was the dependent variable, and the 20-25% of those in each cohort with the highest increment were considered the high risk group. Sensitivity and specificity values averaged 0.60 and 0.83 respectively, indicating the misclassification of substantial numbers of children. This paper reports analysis of the DMFS increments of the misclassified children. The majority of children had DMFS increments within one or two surfaces of the classification cut points. Many false negative children had increments composed entirely of filled surfaces, often of minimal extent and without evidence of previous decay. Many false positive children had increments composed of decayed surfaces and would have benefitted from being identified as high risk and assigned to a preventive program. Other false positive children had sealants placed after the baseline examination that undoubtedly reduced their true increment. It is concluded that the consequences of misclassification are not serious for most children in this study.

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Over 4000 first and fifth grade children from the areas surrounding Aiken, South Carolina, and Portland, Maine, participated in a 4-yr study to develop caries risk assessment models. The predictors used at baseline included detailed clinical examinations, salivary microbiological tests, and sociodemographic and dental behavior data. Mean 3-yr caries increments in South Carolina were twice those in Maine. For the four risk assessment models (two grade cohorts at two sites) specificity values averaged 0.83 and sensitivity values averaged 0.60. Clinical predictors such as prior DMFS, pit and fissure morphology, and predicted caries risk status were the major contributors to the models.

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This paper seeks to achieve four goals, each of which forms the basis for a section in the presentation. First, the rationale of risk assessment is fully described. In this section, some of the necessary conditions are identified that make disease prediction worth pursuing. The second section discusses some essential background to the understanding of risk assessment in dentistry. In this segment, attention is focused on population-based and individual-based perspectives, alternative approaches to expressing health risk, and methods for comparing the predictive accuracy of alternative risk assessment models. The third section of the paper develops a conceptual framework for risk assessment in dentistry. Particular emphasis is devoted to the identification of risk factors and their incorporation into alternative statistical models. In the fourth section, empirical data are offered by which certain comparisons of the alternative risk models can be drawn. The paper concludes with a discussion that emphasizes data and technical limitations, speculates on future applications, and suggests new avenues for research.

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The baseline caries experienced of approximately 5,000 children in South Carolina and Maine was used as the dependent variable in caries risk assessment analyses. Clinical, microbiologic, and demographic factors served as independent variables in a multivariate relationship to caries through regression and discriminant function analyses. Four factors--number of dental visits by the child in the past year, presence of white spot lesions, and both the urgency of need for restorative care and the future caries increment predicted by the examiner--associated significantly and consistently with caries prevalence in primary and permanent teeth of first and fifth graders at both study sites. Several factors associated significantly with caries prevalence at only one site or grade within a site, suggesting that wide applicability of a specific caries risk assessment model may be limited. In these analyses, sensitivity ranged from .60 to .72 and specificity varied from .86 to .91 in the four grade-site groups. The ultimate goal of this longitudinal study is to identify highly caries-prone children in time to prevent the occurrence of a future caries increment. Although the lack of consistent association of many variables, including microbiologic factors, with baseline caries prevalence was unexpected, it is expected that some of these variables will contribute predictive power in the prospective study.

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This paper presents the events surrounding the dissemination of the results of a major preventive dentistry demonstration program designed and conducted to provide evidence of the effectiveness and actual costs of a combination of commonly used preventive procedures. It then reviews the controversy provoked when the results of that program were counter to the conventional wisdom of the day, prevailing national policy, and public health practice. An analysis of possible reasons for this reaction follows. The paper concludes with some observations about how such a situation might be approached to minimize similar controversy in the future.

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Baseline clinical dental examinations were conducted on 5,233 children in grades 1 or 5 from the areas surrounding Aiken, SC, and Portland, ME, as part of a longitudinal study being conducted to predict children at high risk to dental caries. Mean caries levels in the Aiken area were nearly twice those of the Portland area. Black children experienced slightly more disease than whites. In addition to lower levels of caries experience, Portland children also had more treatment needs met, as indicated by higher filled ratio scores.

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This paper presents the comparative effectiveness of fluoride mouthrinse (FMR) on high and low caries forming children after a 4-yr exposure to weekly rinse beginning in the first grade. Over 1200 grade 1 children drawn from both fluoride deficient and fluoridated sites were divided into treatment and concurrent, longitudinal control groups. After 4 yr these children were stratified according to caries increment; those above the 75th percentile were considered high caries formers, all others were designated low caries formers. After adjustment of the mean increments for differences in SES, age, race, and sex in rinse and control groups, high caries formers (approximately 25% of the children) in the rinse and control groups in fluoride deficient areas showed increments of 7.00 and 7.79 surfaces, respectively, indicating a savings of 0.79 surfaces. Low caries formers (approximately 75% of the children) demonstrated increments of 1.11 DMFS in the rinse group and 1.40 in the control group (savings 0.29 DMFS). The pattern was quite similar for children in fluoridated areas except that the increments, as well as the savings realized, were lower. The results raise questions as to the practical effectiveness of school based FMR programs even for high caries forming children.

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This article presents the rationale and content of a current study that seeks to improve methods to identify children at high risk to dental caries. It summarizes the results of the development of a 12-factor, preliminary caries prediction model based on data derived from the National Preventive Demonstration Program. Despite data limitations, the model produced a sensitivity of .5 and specificity of .8 for four-year caries increment prediction in first- and fifth-grade children. Data on a number of additional potential predictors are being collected in two sites to expand and improve the existing model. These factors are identified.

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The development and testing methods for assessing the quality of private general dental practice are described. The assessment instrument, evolved through the contributions of a panel of private practitioners, provides for the evaluation of the structure, process, and outcome of practice. General practitioners, trained as evaluators, tested the instrument in 300 urban group, urban nongroup, and rural practices in 14 states. The distribution of assessment scores for the entire project sample is compared with those of the sample dentists who graduated before and after 1974. The implications of the project and its results to dental education are discussed.

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The development and validation of a caries prediction model comprising 13 sociodemographic and dental examination variables on Grade 1 and Grade 5 children in the National Preventive Dentistry Demonstration Program are described. The objective was to derive a method of predicting children at high risk to caries early in order that preventive measures might be undertaken. True high risk children were defined in two ways: highest 25% of children based on their 4-yr DMFS increment, and their total DMFS score at the end of the study. In both cases, children predicted to be at high risk were defined as the 25% with the highest discriminant score. Discriminant function and logistic regression analyses were used to determine the extent to which the 13 variables collectively discriminated between true high risk and non-high risk children so defined. Sensitivity was approximately 0.50 and specificity around 0.82, using the 4-yr increment as the criterion for defining true high risk, and approximately 0.64 and 0.88, respectively, using the final DMFS score for defining true high risk.

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Probabilities of caries risk over time measured from eruption of first and second molars are illustrated using life table methodology. Life table rates based on 4,365 children in the National Preventive Dentistry Demonstration Program indicate that both fluoridation and sealants are effective in preventing caries on occlusal and buccal/lingual surfaces of molars. Effectiveness would probably have been greater on occlusal surfaces if sealants had been applied closer to the time of eruption. Similarities and differences between conventional DMFS indices and life table probabilities are discussed.

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An 18-month longitudinal study of 197 5 to 18-yr-old children was conducted to assess the performance of multiple baseline variables in predicting which children would experience high increments of caries. Nine predictors were assessed; DMFS and defs scores, number of permanent teeth, indices of fissure retentiveness and occlusal morphology, S. mutans and lactobacilli levels, and sex and race. Discriminant analyses were applied to data for children in five age groups to identify the 30% who would have the largest 18-month DMFS increments. Prediction performance was assessed by comparisons with the actual high increment group, defined as those children with increments in the upper quartiles of the DMFS distributions within age groups. The analyses predicted between 56% and 91% of actual high increment children depending on age group. The children identified in the analyses experienced between 59% and 91% of the disease experienced by the actual high increment groups.

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This report presents dental caries and treatment patterns found in a longitudinal study of US children between 1978 and 1982 who were geographically dispersed across several fluoridated and nonfluoridated sites. The analyses include first- and fifth-grade children examined annually for four years in the National Preventive Dentistry Demonstration Program and who did not receive effective preventive procedures. The results indicate that in association with the caries decline in US children, treatment ratios increased by over 20 percent during the study period. FS/DFS ratios averaged 79 percent for the four grade/fluoridation status cohorts analyzed and were significantly higher in fluoridated than in nonfluoridated sites. The single-fissured surface was the dominant treatment or disease area observed and these surfaces tended to be restored early. In assessing tooth-surface status changes annually, tooth surfaces were more than twice as likely to change from sound to filled than from sound to decayed between yearly examinations at fluoridated sites. The lower levels of decay and higher degree of restorative care observed were not observed in lower SES and black children nearly to the extent as those for higher SES and white children in the population. The dental profession should shift its emphasis from the early restoration of fissured-surface defects to an expanded use of sealants for those with reduced decay and focus resources on a minority of the population with high caries levels who receive limited care.

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The National Preventive Dentistry Demonstration Program assessed the cost and effectiveness of various types and combinations of school-based preventive dental care procedures. The program involved 20,052 first, second, and fifth graders from five fluoridated and five nonfluoridated communities. These children were examined at baseline and assigned to one of six treatment regimens. Four years later, 9,566 members of this group were examined again. Analyses of their dental examination data showed that dental health lessons, brushing and flossing, fluoride tablets and mouthrinsing, and professionally applied topical fluorides were not effective in reducing a substantial amount of dental decay, even when all of these procedures were used together. Occlusal sealants prevented one to two carious surfaces in four years. Children who were especially susceptible to decay did not benefit appreciably more from any of the preventive measures than did children in general. Annual direct per capita costs were $23 for sealant or fluoride prophy/gel applications and $3.29 for fluoride mouthrinsing. Communal water fluoridation was reaffirmed as the most cost-effective means of reducing tooth decay in children.

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