Development and evaluation of two root caries controlling programmes for home-based frail people older than 75 years

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1 See discussions, stats, and author profiles for this publication at: Development and evaluation of two root caries controlling programmes for home-based frail people older than 75 years Article in Gerodontology June 2008 DOI: /j x Source: PubMed CITATIONS 43 READS 84 3 authors, including: Stefania Martignon El Bosque University 69 PUBLICATIONS 840 CITATIONS SEE PROFILE All in-text references underlined in blue are linked to publications on ResearchGate, letting you access and read them immediately. Available from: Stefania Martignon Retrieved on: 18 September 2016

2 Original article Development and evaluation of two root caries controlling programmes for home-based frail people older than 75 years Kim Ekstrand 1, Stefania Martignon 2 and Poul Holm-Pedersen 3 1 Department of Cariology and Endodontics, School of Dentistry, University of Copenhagen, Copenhagen N, Denmark; 2 Research Unit Unica-B, Dental Faculty, EL Bosque University, Bogotá, Colombia; 3 Copenhagen Gerontological Oral Health Research Center, School of Dentistry, University of Copenhagen, Copenhagen N, Denmark doi: /j x Development and evaluation of two root caries controlling programmes for home-based frail people older than 75 years Objectives: (i) Initially, to devise and examine the validity of a system for determining lesion activity on root surfaces, and (ii) compare the effectiveness of two preventive programmes in controlling root caries in elderly people using the devised system. Materials and methods: (i) Four clinical variables: texture, contour, location and colour of root caries were selected to evaluate lesion activity. The intraexaminer reproducibility of the scoring system was assessed on 28 elderly patients. The accuracy was assessed on 10 of these persons using an impression material (Clinpro, 3M ESPE). (ii) Of total, 215 homebound 75+ year olds were randomly assigned to one of three groups: group 1, once a month a dental hygienist brushed the teeth of the participants and applied Duraphat vanish to active root caries. The participants in groups 2 and 3 received 5000 and 1450 ppm F-toothpaste, respectively, to use twice a day. This study included an interview, a baseline examination and a final follow-up examination after 8 months. Results: (i) Intraexaminer reproducibility of the root caries scoring system was 0.86 (Kappa). The sensitivity and specificity was 0.86 and (ii) Data from those 189 (88%) who completed the study disclosed that there were no inter-group differences at the baseline examination concerning relevant conditions. At the end of the study, the root caries status of participants in groups 1 and 2 had improved significantly when compared with group 3 (p < 0.02). No significant difference was observed between groups 1 and 2 (p = 0.14). Conclusion: The data suggest that the root caries scoring system is reliable. Both the intervention programmes controlled root caries development; the hygienist in eight of 10 persons, the 5000 ppm F-toothpaste in seven of 10. In contrast, five of 10 participants who only brushed with 1450 ppm F-toothpaste had root caries progression. Keywords: caries control, elderly persons, root caries activity. Accepted 14 August 2007 Introduction In many countries the population are retaining more of their natural teeth into later life 1,2. In Denmark, it is expected that by 2020 about 20% of the population will be more than 65 years of age and the proportion who are edentulous has already declined from 40% in the 1980s to 27% in Reports from the 1980s and 1990s 3,4 indicate that the Danish Dental Health System was not designed to provide care for an increasing number of frail, dependent dentate elderly patients. Thus, in the mid 1990s the Danish Parliament put into force an Act (Act of 1993) which decreed that the Public Dental Health Service (PDHS) should offer dental services to functionally dependent, elderly persons, either at home or in nursing homes. A part of the service should be the prevention of plaque-induced diseases which, to date, unfortunately has received little attention. Similar oral health problems have been described from other industrialised countries, for example, in Australia 5. Both here and in Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25:

3 68 K. Ekstrand et al. Denmark irrespective of their differences in social and cultural background and in the structure of the dental health care systems, root caries in elderly people seems to be a major problem 2 5. Therefore the main aim of the present study was to evaluate two approaches to control root caries in elderly persons living at home. The first approach assessed the effect of professional cleaning of the participants teeth once a month and the application of Duraphat varnish on active root caries. A similar approach has been used by Axelsson and Lindhe back in the 1970s and excellent results were reported by Bellini et al., in the beginning of the 1980s 6. The second approach advised participants to use a toothpaste containing 5000 ppm fluoride since this had been shown to be more effective than one containing 1100 ppm F in remineralising root caries 7. Finally a control group used 1450 ppm fluoride toothpaste. It was expected that some root caries would progress whilst others would remain stable, some would regress and some would even disappear. An assessment of the activity of root caries, apart from very soft 8, is difficult. It was necessary, therefore, initially to devise and assess the reliability of a new clinical root caries scoring system. In summary the aims of this paper were: 1. To devise and examine the validity of a system for determining lesion activity on root surfaces. 2. To test the effectiveness of two preventive programmes in controlling root caries in elderly people. A pilot study 9 conducted in a nursing home for elderly people in Copenhagen indicated that an 8-month period was sufficient to observe differences in the appearance of caries as well as periodontal disease. As a result, the period of the present study was set to 8 months. Materials and methods The root caries scoring system (study I) Based on the literature and the appearance of root caries in 100 extracted teeth, the scoring system in Table 1 was devised by two of the authors (KE, SM). The teeth were selected in such a manner that the entire range of clinical appearance of root caries was represented within the sample. It should be mentioned that Nyvad and Fejerskov described that in cavitated arrested root caries the margins seemed smooth due to function, which is not the case in active root caries. This information led us to include Table 1 The four variables used to judge activity of root caries. Texture of the lesion when gentle probed Hard (0) Leathery (2) Soft (3) Contour of the surface No cavitation or the surroundings of the cavity smooth to probing (1) Cavitation with irregular boarder (2) Distance from the lesion to the gingival margin 1 mm from the gingiva margin (1) <1 mm from the gingiva margin (2) Colour of the lesion Dark brown/black (1) Light brown/yellowish (2) The figures in brackets indicate the point scoring. irregular or regular borders of the cavitated lesion to probing, as a part of the scoring system. The individual scores were summed to give a total score. A total score of 3 5 characterised as arrested, and 6 9 as active. The points system and the chosen thresholds will be discussed later. The reproducibility of the devised score system The clinical examiner was trained in the devised scoring system. Twenty-eight elderly patients (mean age 73.8; SD = 8.9), attending the School of Dentistry at the University of Copenhagen, were then examined by the examiner. The teeth were professionally cleaned and the root surfaces were scored twice according to the criteria in Table 1, with an interval of 1 day. The examiner was instructed to score each of the four variables, but not state whether he judged the lesion as active or arrested. When the data were entered, the programme computed this decision based on the thresholds given above. The accuracy of the devised score system After approximately 1 week, impressions were taken of tooth surfaces under investigation in 10 of the study group, using the impression-based diagnostic material described by Schmid and colleagues 13 (Clinpro Cario Diagnosis; Full Arch Lactic Acid Locator, 3M ESPE Seefeld, Germany). The impressions can detect lactic acid produced in metabolically active plaque based on a colour change within the material. Lactic acid formation is fundamentally associated with demineralisation of hard dental tissue 14. As such, this impression Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25:67 75

4 Evaluation of two root caries preventive programmes 69 technique has the potential to be used as a construct validity for lesion activity. The technique required the participant to brush their teeth as per their normal routine, before the impression was taken. The impression material is normally pale blue once set, but those areas in relation to a lactic acid producing plaque change the colour to a dark blue. The impressions were then inspected. A lesion which corresponded to a colour change in the impression material (signal), and hence lactic-acidproducing plaque, was classified as active and a lesion corresponding to no colour change (no signal) was classified as inactive 13,15,16. Clinical trial (study 2) Study participants were recruited through the local health board of Brønshøj, a suburban area west of Copenhagen. The financial status of the residents of Brønshøj is average for the country (Statistic Denmark). The concentration of fluoride in the drinking water was 0.5 ppm, which was above the average (0.3 ppm) 17. The nurses were asked to identify 75+ year olds who (i) needed help from the medical team (frail elderly) and (ii) had five or more of their own teeth. Contact was established with nurses at the local health centre who, according to the law, made preventive home visits to people older than 75 years who had agreed to treatment. The authors provided the nurses with written material, which they passed on to the 75+ year olds during their visits. The purpose of the study was explained and if the elderly person gave permission, the nurse passed the phone number to the investigators. Further contact was made, the purpose of the study was explained again and if agreeing to participate, the elderly person signed a written consent form. By means of a number system, the participants were randomly assigned to one of the following three groups: Group 1 was visited once a month by a dental hygienist who brushed their teeth (professionally) using a 1450 ppm fluoride toothpaste (Colgate Palmolive, Manchester, UK Sensitive). Active root caries, identified by either the examiner, who then passed the information to the dental hygienist, or the dental hygienist herself during the study period, were fluoride-treated with Duraphat varnish. Between the visits from the dental hygienist, the participants in this group brushed teeth using the above-mentioned toothpaste. Group 2 received 5000 ppm fluoridated toothpaste (Duraphat; Colgate Palmolive) and the participants were instructed to brush their teeth twice a day using a pea-sized amount of the toothpaste on each occasion. Group 3 received 1450 ppm fluoridated toothpaste and followed the same procedure as group 2. The participants in groups 2 and 3 did not know which group they belonged to as information about fluoride concentration on the tubes was erased. The study was approved by the Ethical Board of Frederiksberg and Copenhagen. Baseline visit Interview. Initially, an interview was performed and consisted of 20 questions focusing on factors such as social background, whether the elderly person needed help from nurses during the day, oral hygiene habits, diet, and the medication they were taking. Clinical examination. The clinical examination started with collection of unstimulated saliva for 5 min. The presence of buccal plaque was scored on five selected teeth using the following score system: 0, no visible plaque; 1, plaque covering not more than the gingival one-third part of the surface; 2, plaque covering one-third to two-thirds of the surface and finally 3, plaque covering more than two-thirds of the surface. Occurrence of partial dentures and type were recorded from both upper and lower jaws. The examiner then brushed the teeth of the participants. The dental status of the teeth was classified according to the following system: (i) teeth present; (ii) retained roots; and (iii) bridge extension. The status of the root surfaces of the teeth present was classified according to the following system: 0, sound; 1, primary caries; 2, restored with plastic material; 3, as 2 but with caries; 4, crowned and no caries; 5, as 4 but with caries; 6, could not be recorded (attrition etc). Activity status of the root caries were characterised by means of the devised scoring system. Time The travel time between participants and the time it took for the dental hygienist to clean the participants teeth and apply Duraphat varnish, was recorded for participants in group 1. Follow-up examination Teeth were cleaned and examined for status and root caries, using the same methods and scoring Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25: 67 75

5 70 K. Ekstrand et al. systems as at the baseline examination. The examiner was blinded to who were in the three groups. The follow-up examinations took place approximately 8 months after the baseline examination. Statistical considerations Study 1: reproducibility. Percentage of agreement was used to express the reproducibility of the four individual caries scores. Un-weighted Kappa statistic was used to express intraexaminer agreement. The units of measurement were sound, arrested or active and not the individual scores. Perfect agreement was used to express agreement between active or arrested observed at the first as well as at the second examination. Study 1: accuracy. For each lesion under investigation, the visual appearance, contour, location and tactile sensation were recorded as described, together with the corresponding score. Finally a cumulative score was calculated. Using signal/no signal from the impression material as a construct validity, the sensitivity and specificity was determined using the cumulative score cut-off point (threshold), 3 5 points (arrested lesion) and 6 9 points (active lesion). Study 2: interview. Data about age, sex, number of visits to the dentist, number of times they brushed each day, use of fluoridated toothpaste and finally the number of medications used were obtained and expressed using descriptive statistics. The other information from the interview will be reported in a separate paper, focusing on the importance of social conditions at elderly people living in the municipality of Brønshøj. Predictive value of saliva. The participants were dichotomised as follows; cases with one or more active /cases with no active ; into cases with 0.16 ml per minute or <0.16 ml per minute. The positive and negative predictive values were calculated. Baseline examination. By means of non-parametric tests, any inter-group differences at the baseline examination concerning age, partial dentures and number of teeth were determined. Occurrence of plaque at the individual level was expressed by the median of the scores for the five teeth. By means of a median test, any difference within the three groups was tested. Possible inter-group differences concerning number of root caries, active as well as arrested and saliva secretion, were tested by means of Kruskal Wallis one-way analysis of variance, as the distributions were not normal and the variances were too different. These calculations were only carried out in 189 of the 225 participants who completed the study. Follow-up examination and difference to the baseline examination. At baseline, the root surfaces could be scored as sound, arrested (3 5 points) or active (6 9 points). The surfaces were scored in a similar way at the final examination, but in addition, some surfaces were restored or lost. New which developed or new restorations which were placed during the study period, were also recorded. Finally, surfaces with active or arrested scored at baseline could be scored as sound at the final examination. Table 2 shows how it was possible to characterise changes from baseline to final examination in terms of regression ()1), staying stable (0) or progression (1). Next, each participant was classified as being in a worse, stable or better condition concerning root caries at the final examination vs. the baseline examination. Any cases of progression or regression overruled cases of stabilization. The number of, which progressed, were subtracted from number of which regressed, if positive then the participant had worsened; if negative the participant had become better and if 0 the participant was classified as stable. Table 3 shows some relevant examples and how they were characterised. Inter-group differences were tested by means of Kruskal Wallis one-way analysis of variance, followed by Wilcoxon Mann Whitney s test for twoindependent sample cases. Table 2 The definitions relating to regression ()1), staying stable (0) or progression (1) from baseline to follow-up examination. Baseline Sound Follow-up Arrested 3 5 points Active Lost >5 for any points Restored reason Sound Not Excluded recorded Arrested Excluded 3 5 points Active >5 points )1 )1 0 1 Excluded Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25:67 75

6 Evaluation of two root caries preventive programmes 71 Table 3 Some relevant examples of and how they were characterised. Participants Number of which regressed Number of which stayed stable Number of which progressed A S B B C W D S E B F W Better (B), Stable (S) or Worse (W) Maxillary Mandibular M 3 M 2 M 1 P 2 P 1 C I 2 I 1 Tooth type Table 4 Raw data from the 28 patients in study 1. Results Second Sound Arrested Active First Sound Arrested Active Study I: reproducibility The characteristics of the 28 participants were: Mean age 73.8 years (1SD = 8.9), mean number of teeth 19 (1SD = 6.1), mean number of surfaces with gingival recession 27.1 (1SD = 19.6), mean number of arrested 1.6 (1SD = 2.8) and active 1.6 (1SD = 3.0). Intra-reproducibility of the individual parameters was: texture 82%; contour 92%; localization 98% and colour 79%. Table 4 presents the raw data in terms of sound, arrested or active. The intraexaminer reproducibility concerning sound, arrested or active was kappa = Perfect agreement between active scored at the first examination and again at the second examination was (41/ 47) = 87%. Corresponding data for the arrested (35/43) was 81%. Study 1: accuracy Sensitivity and specificity values between clinical scores in terms of arrested or active and the signals in the Clinpro impression material were 86% and 81% respectively. Figure 1 Distribution of teeth related to tooth type observed at the baseline examination on the participants. Study 2: general information about the sample A total of 215 persons agreed to participate, of which 140 (69%) were women. The mean age was 81.6 years (1SD = 4.3). Sixty percent had one or two partial dentures. Only five participants (2.3%) had not seen a dentist in the last 3 years, the remainder had seen their dentist at least once a year. All participants reported that they brushed their teeth at least once a day, 76% brushed twice, and 13% brushed more than twice per day. All, apart from one, used fluoridated toothpaste. Only 28 participants (13%) were not taking any medication. The mean number of teeth was 19.8 (SD = 6.1). Figure 1 shows the distribution of recorded toothtypes in both jaws. There was no difference between left and right sides and so the data were merged. Twenty-five participants refused to make the saliva test, thus 190 saliva tests were obtained from the 215 participants (88.4%). When the data were dichotomised (Table 5) the positive-predictive Table 5 Data regarding carious related to saliva secretion rate. Saliva secretion rate Participants with one or more active (6 9 points) Participants with no active Participants with <0.16 ml/min Participants with ml/min Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25: 67 75

7 72 K. Ekstrand et al. value was 0.53 (60/114) and the negative-predictive value was 0.55 (42/76). The time spend by the dental hygienist on participants in group 1 was measured 190 times during the study period. The average time for cleaning the participants teeth and apply Duraphat, if necessary, was 32 min (SD = 7.89). The average time for the transportation was 6.33 min (SD = 3.85). Checking for relevant inter-group differences at the baseline examination. The numbers of participants initially examined in the three groups were 76, 74 and 65 respectively. However, only 71 (group 1), 64 (group 2) and 54 (group 3) participants completed the study. The following data concerns only those who completed the study. At the baseline examination there were no significant inter-group differences concerning age (v 2 = 3.01; d.f. = 2; p = 0.214); number of teeth (v 2 = 1.01; d.f. = 2; p = 0.603), persons with partial dentures (v 2 = 2.96; d.f. = 2; p = 0.254), use of medication (v 2 = 0.77; d.f. = 2; p = 0.576), plaque occurrence (v 2 = 0.640; d.f. = 2; p = 0.726), or differences in saliva secretion rate (F = 0.928; p = 0.397). The secretion rate in group 2 was on average 0.13 ml per min (1SD = 0.15), 0.14(0.06) in group 3 and 0.16 (0.10) in group 1. In those who completed the study, 395 root caries were identified at baseline examination (Table 6). The total mean number of root caries was 2.09, of which 61% were active and the remaining 39% were arrested. A Kruskal Wallis one-way analysis confirmed that there was no significant inter-group difference concerning number of active (v 2 = 0.042; d.f. = 2; p = 0.979) or arrested (v 2 = 0.562; d.f. = 2; p = 0.755) judged at baseline. Differences between baseline and final examination. Table 6 also shows the fate of the baseline in terms of whether they changed to sound, to arrested or to active, remained active or remained arrested. Very few of the baseline lesion teeth were extracted during the study. The raw data showed that many more active at baseline became sound or became arrested in group 1 (53/81 = 65%) and 2 (45/82 = 54%) vs. group 3 (31/77 = 40%). Further, very few arrested baseline became active in group 1 (1) and (2) vs. group 3 (12). Finally, a total of seven, 18 and 41 new active were scored in groups 1, 2 and 3 respectively. The statistical analysis confirms a significant reduction in number of active root caries between group 1 and 2 vs. group 3 (p < 0.02). At the final examination, a total number of 362 root caries were identified. The total mean number of root caries at final Table 6 Raw caries data at baseline and at the final examination. Baseline Fate of baseline New number of number of Number of active Number of arrested f Fate of active baseline Fate of arrested baseline New active New arrest ed le-sions active arrested number of Group 1 (n = 71) Group 2 (n = 64) Group 3 (n = 54) (n = 189) sound 11 sound 16 arrested 41 arrested extracted 3 extracted 23 active 1 active sound 12 sound 20 arrested 35 extracted extracted 1 extracted 35 active 3 active sound 8 sound 6 arrested 29 extracted extracted 45 active 12 active Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25:67 75

8 Evaluation of two root caries preventive programmes 73 Table 7 Characterisation of the participants as to whether the root caries status became better, stayed stable or worsened during the study. Groups Better Stable Worse examination was thus (362/189) = 1.92; total mean number of active (186/189) = 0.98; and total mean number of arrested (176/ 189) = Table 7 summarises at the individual level in the three groups, whether they became better, stayed stable or if they became worse regarding root caries status during the study period. Initially, a Kruskal Wallis one-way analysis of variance showed significant inter-group difference in root caries status (p = 0.02). Further, analyses showed that group 1 and 2 had improved significantly compared to group 3, (group 1/group 3; p < 0.001, group 2/group 3; p = 0.02), while there was no significant difference between group 1 and 2(p = 0.14). Discussion Study I: the scoring system for root caries activity Changes in dentine texture from soft to hard by probing is reported to be the best predictor for root caries lesion progression 7,8. Probing, however, is very subjective and in intervention studies taking place over a long time there is a risk of missing small changes in texture of the dentine (i.e. harder or softer) which eventually will influence the outcome of the study. In order not to rely on only one predictive variable (texture), a new system was devised which used a total of four variables. Besides the texture of the lesion, the contour of the lesion in terms of normal anatomy or breakdown due to caries, the location of the lesion in relation to the gingiva, and finally the colour of the lesion were assessed. In order not to overlook any root caries lesion, the teeth have to be examined clean and dry. Consequently, plaque, which might be yet another indicator for activity, has to be removed. The location of the lesion observed in the plaque stagnation area was therefore included, as suggested by Lynch and Beighton 8, and is in this case used as a surrogate for plaque. The reason is that caries mainly develops if plaque is allowed to stagnate 18, and plaque stagnates in other areas along the gingival margin. Concerning the variable distance to the gingival it was arbitrarily decided to use below or more than 1 mm from the gingival margin to the lesion as the threshold. Breakdown of the root surface may allow plaque stagnation, particularly if the border of the cavity is irregular, while on the other hand, if the border is smooth, it indicates function at the actual site and cariogenic plaque cannot develop, and thus in spite of breakdown the lesion may be arrested. Finally, it is well known that due to the dissolution of the collagen in the dentine, the tooth structure changes colour 19. This ranges from yellowish to brown/blackish indicating activity and inactivity respectively. However, it should be remembered that colour a weak predictor for activity 8. The data from study 1 indicate that the scoring system was both reproducible and accurate. Concerning accuracy, the impression material Clinpro Cario Diagnosis Full Arch Lactic Acid Locator was used as construct validity, as it had been shown that it could measure lactic acid production in the plaque 13,15,16. Thus the impression material seems to have construct validity. Study 2 From the point of view of the level of caries disease, the participants in the clinical intervention study could be classified as having an increased risk based on the following findings: (i) their health situation with regard to medication as only 13% did not take any medication, (ii) average low saliva secretion rate [mean 0.14 (1SD = 0.12)], (iii) 60% had removable partial dentures, and (iv) the plaque occurrence expressed as median was 1 (plaque covering not more than the gingival one-third part of the surface). On the other hand, the following data suggested a lower caries risk; (i) the participant use fluoridated toothpaste at least once a day, (ii) they lived in an area where the fluoride concentration in the water supply was 0.5 ppm, which is above average in Denmark, (iii) lived in an area recognised to be just above average concerning wealth, and finally (iv) the participants were regular attendees to their dentists. In terms of the number of root caries, the participants in this study had a low prevalence (mean 2.09), as well as low caries activity during the study. However, many of the participants (48%) in the control group became worse during the study despite the fact that everybody used Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25: 67 75

9 74 K. Ekstrand et al. toothpaste with at least 1450 ppm fluoride, this being the highest level commercially available in Denmark without prescription. This alone indicates that additional preventive regimens are necessary for elderly patients in addition to using fluoridated toothpaste and visiting the dentist on a regular basis. Less than one-third (28%) and <one in five (18%) became worse in groups 2 and 1, respectively, meaning that special efforts could reduce the number of elderly who have which progresses. Suggesting a model where a dental hygienist should clean community-dwelling, frail patients teeth once a month, could be expensive considering the caries activity among the participants in this study. The time study showed that on average it took, about 40 min per month, including transportation, corresponding to 8 hours per year per patient. The short transportation time (6 min in average) was related to the fact that the dental hygienist used a bicycle, she planned her visits well and the area where the study took place was about 10 km in diameter. The estimated cost would be 2400 DDK340US $ per year per participant. In contrast, the effect on root caries activity, which was obtained with 5000 ppm fluoridated toothpaste was lower, but not significantly lower compared to the effect of the dental hygienist. However, the cost was only about 10 US$ per month and only slightly higher than buying fluoridated toothpaste containing 1500 ppm fluoride. It should be taken into consideration, however, that the present study only examined root caries activity and not periodontal disease. Unfortunately, the saliva secretion level in the present study had poor predictive values. From to the findings of Bardow and co-workers 20 a cut-off point of 0.16 ml per min for determination of positive- and negative-predictive values had been chosen. Changing the thresholds did not influence the predictive values. Conclusion From this study, it can be concluded that the devised root caries scoring system was reliable. Study 2 showed that in a group of community-dwelling, frail 75+ years old people with a low/moderate root caries activity, an approach involving a dental hygienist cleaning the teeth once a month and adding Duraphat vanish to the active seemed to be able to control further development in eight of 10 participants. An approach where the elderly brushed with 5000 ppm fluoridated toothpaste twice a day seemed to be able to control further development in seven of 10 persons. In contrast, five of 10 participants who only brushed with 1450 ppm fluoridated toothpaste exhibited root caries progression. Acknowledgement The study was supported by a donation from Colgate Palmolive and by a grant from the Velux Foundation. Sincere thanks go to the nurses who helped in recruiting participants for the study. References 1. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005; 33: Petersen PE, Kjoller M, Christensen LB, Krustrup U. Changing dentate status of adults, use of dental health services, and achievement of national dental health goals in Denmark by the year Public Health Dent 2004; 80: Vigild M. Evaluation of an oral health service for nursing home residents. Acta Odontol Scand 1990; 48: Vigild M. Oral health care programs for elderly in Scandinavia. Int Dent J 1992; 42: Chalmers JM, Carter KD, Fuss JM, Spencer AJ, Hodge CP. Caries experience in existing and new nursing home residents in Adelaide, Australia. Gerodontology 2002; 19: Bellini HT, Arneberg P, von der Fehr FR. Oral hygiene and caries. A review. Acta Odontol Scand 1998; 39: Baysan A, Lynch E, Ellwood R, Davids R, Petersson L, Borsboom P. Reversal of primary root caries using dentifrices containing 5000 and 1100 ppm fluoride. Caries Res 2001; 35: Lynch E, Beighton D. A comparison of primary root caries classified according to colour. Caries Res 1994; 28: Ekstrand KR, Christensen J, Schmidt C. Implementering af professionelt udført tandrengøring på ældre handicappede. Effekt på forekomst af plakinducerede sygdomme. Tandlægebladet 1998; 102: (English summary). 10. Fejerskov O, Luan WM, Nyvad B, Budtz- Jørgensen E, Holm-Pedersen P. Active and inactive root surfaces caries in selected groups of 60-to 80-year-old Danes. Caries Res 1991; 25: Nyvad B, Fejerskov O. Active root surface caries converted into inactive caries as a response to oral hygiene. Scand J Dent Res 1986; 94: Fejerskov O, Nyvad B. Dental caries in aging individual. In: Holm-Pedersen P, Löe H eds. Textbook Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25:67 75

10 Evaluation of two root caries preventive programmes 75 of Geriatric Dentistry. Copenhagen: Munksgaard, 1996: Schmid B, Fischeder D, Arndt S, Haeberlein I. Site-specific detection of lactic acid production on tooth surfaces. Caries Res 2002; 36: Abstract Geddes DAM. Acids produced by human dental plaque metabolism in situ. Caries Res 1975; 9: Ekstrand KR, Ricketts DN, Longbottom C, Pitts NB. Visual and tactile assessment of arrested initial enamel carious : an in vivo pilot study. Caries Res 2005; 39: Ekstrand KR, Martignon S, Ricketts DNJ, Qvist V. Detection and activity assessment of primary coronal caries. A Methodologic Study. Oper Dent 2007; 32: Ekstrand KR, Christiansen MEC, Qvist V. The influence of different variables on the inter-municipality variation in caries experience in Danish adolescents. Caries Res 2003; 37: Thylstrup A, Bruun C, Holmen L. In vivo caries models mechanisms for caries initiation and arrest Adv Dent Res 1994; 8: Kidd EAM. Root caries. Dent Update 1989; 6: Bardow A, Nyvad B, Nauntofte B. Relationships between medication intake, complaints of dry mouth, salivary flow rate and composition, and the rate of tooth demineralization in situ. Arch Oral Biol 2001; 46: Correspondence to: Kim Ekstrand Department of Cariology and Endodontics, School of Dentistry, University of Copenhagen, Nörre Allé Copenhagen N, Denmark. Tel.: Fax: Kim@odont.ku.dk Ó 2008 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2008; 25: 67 75