Revista FOP n 13
1682
An overview of caries risk assessment in 0-18 year-olds over
the last ten years (1997-2007)
Elaine Pereira da Silva Tagliaferro1;Vanessa Pardi1,2; Gláucia Maria Bovi Ambrosano3; Marcelo de Castro Meneghim4;
Antonio Carlos Pereira5
1DDS, MS, PhD, Postdoctoral Student
2DDS, MS, PhD, Professor, Graduate Program in Community Health, Dental School, University of Sagrado Coração, Brazil
3Agr.Eng., MS, PhD Professor, Department of Community Dentistry, Dental School of Piracicaba, State University of Campinas, Brazil
4 DDS, MS, PhD, Professor, Department of Community Dentistry
5 DDS, MPH, DrPH, Professor, Department of Community Dentistry
Department of Community Dentistry, Piracicaba Dental School, University of Campinas, Brazil
Received for publication: September 05, 2008
Accepted: October 15, 2008
Correspondence to:
Prof. Dr. Antonio Carlos Pereira
Av. Limeira 901 - 13414-903, Piracicaba, SP, Brasil
Phone: +55-19-2106-5209.
Fax: +55-19-2106-5218
E-mail: apereira@fop.unicamp.br
A b s t r a c t
This study aimed to review the dental literature about caries risk assessment over the last 10 years in order to show which variables have
been considered risk predictors and risk factors of dental caries in infants, preschool-, schoolchildren and adolescents. A Medline search
of the published English language literature from 1997 to 2007 was made for papers of longitudinal studies that reported on caries risk
assessment. A total of 39 papers were included in this review. Most studies were conducted in schoolchildren (n=19), followed by
preschool children (n=9), adolescents (n=7) and infants (n=4). Variables such as caries experience, gingival status, microbiological
counts, oral hygiene, plaque mineral concentration, fluoride history, socioeconomic and educational level, demographic, anthropometrical,
oral, dietary and toothbrushing habits were studied. Past caries experience has been the predominant predictor for future caries in 0-18-
year-old subjects. Other variables, such as dietary habits, including sugar intake, and toothbrushing habits may also help identifying
high-risk individuals. In conclusion, the variables related to caries experience continue to be the main predictor of caries increment.
Key words: dental caries; risk; assessment; prediction
I n t r o d u c t i o n
One of the main goals of Dentistry has been to prevent
dental caries, which has been, according to Aoba and
Fejerskov1, the predominant cause of tooth loss in all
populations worldwide.
In general, two preventive strategies can be used to prevent
and/or control caries disease: the “high-risk strategy”,
which is directed towards individuals particularly
susceptible to developing dental caries2, and the
“population strategy”, which endeavors to protect all the
people, including high and low caries risk individuals.
Burt3 has referred to the “geographically targeted strategy”,
in which the preventive measures are targeted to a sub-
group or a specific area of the city/country, such as schools
in deprived areas of the city or an area of immigrant
population. However, all strategies have the same goal: to
prevent and/or to control the development of new carious
lesions or to arrest the progression of preexisting lesions.
In spite of increase in the adoption of preventive measures,
it seems that for a minority of children these procedures
have been insufficient for preventing and controlling the
disease, as the majority of carious lesions are concentrating
in this group. Therefore, oral health care providers have
been adopted the “high risk strategy” for these
individuals.
If individuals with a risk for developing dental caries are
correctly identified, planning specific measures for caries
control and prevention may become a biological and
socioeconomic measure, increasing the efficiency of
preventive programs, as emphasized by Giannoni et al.4.
Moreover, identifying caries risk factors/predictors allows
selecting the individuals or population groups that will
really benefit from preventive measures. This makes it
possible to use specific and appropriate preventive measures
in target people and may work as an alert for conducting
a more detailed dental examination. In addition to the
aforementioned advantages, knowing caries risk factors is
decisive in detecting those with initial carious lesions,
who may benefit from novel and emergent preventive
Braz J Oral Sci. October/December 2008 - Vol. 7 - Number 27
1683
technologies5. Fontana and Zero6 discussing caries risk
assessment in private practice have recommended that
factors such as caries experience, dietary habits, fluoride
exposure, presence of cariogenic bacteria, salivary status,
general medical history and sociodemographic
characteristics should be evaluated when assessing the
patient’s caries risk.
Assessing caries risk consists of determining which
individuals are more or less likely to prevent or to control
dental caries in the future by means of knowing the variables
associated with the disease5. Caries risk assessment studies
can be performed using cross-sectional data, in which the
subjects’ data, usually about a disease prevalence or severity,
are collected once or longitudinal data, in which the
individuals are examined repeatedly over time. In addition
to clinical variables, several others such as, socioeconomics,
demographics, and behavioral characteristics can be used
to assess their effects on caries levels (cross-sectional studies)
or in caries incidence and/or increment (longitudinal
studies). Although longitudinal studies are expensive,
difficult to conduct and depend on the participants´
willingness, their results are stronger than those obtained
in cross-sectional studies7. Moreover, when assessing caries
risk, the use of multiple regression analysis is preferable8-9
since the etiology of dental caries is multifactorial.
The aim of this work was to review the dental literature
about caries risk assessment over the last 10 years (1997-
2007), in order to show which variables have been
considered caries risk factors/predictors in longitudinal
studies conducted in infants, preschool-, schoolchildren
and adolescents.
Concepts and Terminology
As one of the study’s aims is to review the dental literature
about risk factors and risk predictors in longitudinal studies of
dental caries, it is important to consider the following terms.
Risk factor has been defined by Beck8 as “an
environmental, behavioral or biologic factor confirmed by
temporal sequence, usually in longitudinal studies, which
if present directly increases the probability of a disease
occurring, and if absent or removed reduces the probability.
Risk factors are part of the causal chain, or expose the
host to the causal chain. Once disease occurs, removal of
a risk factor may not result in a cure”.
Risk predictor is also named by Beck8 as a risk marker,
and is defined as a characteristic associated with a high
risk for the disease. The risk predictor predicts well but it
is not thought to be part of the causal chain. As a good
example, past caries experience has been strongly
associated with a high risk for caries increment in the future.
However, this variable is not part of the causal chain and
is therefore considered a risk predictor. Moreover, it has
been reported that in case of preventive measures being
introduced in the studied caries risk group to reduce the
disease activity, past caries experience becomes a risk
predictor with reduced worth.
In this study, the expressions “risk factor” (RF) and “risk
predictor” (RP) will be used for classifying those variables
statistically associated with caries increment in multivariate
regression analyses, if they were either part (RF) or not
(RP) of the causal chain of dental caries.
Material and Methods
A search of the English Language literature published from
1997 to 2007 was made in the Medline database for articles
that reported on caries risk assessment using the following
descriptors: longitudinal caries risk. Furthermore, MeSH
Database PubMed Service was used with some of the cited
terms: “Longitudinal Studies”[MeSH] AND “Dental
Caries”[MeSH] AND “Risk”[MeSH]. The limits for the
search included: “Publication Date from 1997 to 2007”;
Language: English; Ages: “All Child: 0-18 years”. Studies
were selected if they met the following criteria: longitudinal
study conducted with children aged 0-18 years, providing
information on sample size, age at initial examination
(baseline), variables collected at baseline, study lasting,
statistical tests used and a measure of caries increment/
incidence as an outcome variable. In accordance with the
search criteria, 189 papers were retrieved. A total of 59
were selected by reading the title and among them 30
were selected by reading the abstract and/or the full text.
Twenty-nine papers were excluded because they did not
report the outcome variable as caries incidence/increment
(n=9), were review articles (n=2), validation study (n=1)
evaluation/comparative studies (n=11) or used cross-
sectional data (n=6). Moreover, hand searching was
performed from the citations of the identified reports (n=3)
and other key papers (n= 6). Therefore, a total of 39 papers
were included in this review.
A variable that is part or expose the host to the causal
chain of dental caries and remained statistically significant
in multivariate regression models was considered risk factor.
Risk predictor was considered the variable that is not part
of the causal chain of dental caries and remained
statistically significant in multivariate regression models.
Results and Discussion
Researches on caries risk assessment have been conducted
since the 1980’s, focused on developing an easy tool for
identifying high-caries-risk individuals10. Published studies
in general have studied clinical, microbiological, salivary,
socioeconomic and demographic data, medical history,
dietary habits, fluoride history, use of dental services and
dental health behaviors, separately and in combination to
identify high-caries-risk individuals.
According to the dental literature, the use of caries increment
during a period of time is the primary outcome measure11
and statistical analysis based on logistic regression with
multiple factors are preferable because of the complex and
multifactorial etiology of the caries process8.
Braz J Oral Sci. 7(27):1682-1690 An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007)
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e
o
f
th
e
s
tu
d
ie
d
v
a
ri
a
b
le
re
a
c
h
e
d
a
n
a
c
c
u
ra
c
y
o
f
8
0
%
In
c
re
m
e
n
t
o
f
c
a
v
it
a
te
d
c
a
ri
o
u
s
le
s
io
n
s
a
n
d
o
r
fi
ll
in
g
s
>
0
M
L
R
,
R
O
C
3
V
B
:
C
a
ri
e
s
–
d
m
fs
(i
n
c
ip
ie
n
t
c
a
ri
e
s
le
s
io
n
s
in
e
n
a
m
e
l
+
d
e
n
ti
n
a
l
le
s
io
n
s
),
s
e
a
la
n
ts
(s
u
rf
a
c
e
le
v
e
l)
,
p
re
s
e
n
c
e
o
f
v
is
ib
le
p
la
q
u
e
(V
P
),
g
in
g
iv
a
l
b
le
e
d
in
g
(G
B
)
o
n
b
u
c
c
a
l
to
o
th
s
u
rf
a
c
e
s
,
M
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
(M
S
)
fr
o
m
p
ro
x
im
a
l
s
u
rf
a
c
e
o
f
a
c
e
n
tr
a
l
m
a
x
il
la
ry
in
c
is
o
r
a
n
d
o
f
th
e
m
o
s
t
d
is
ta
l
m
a
n
d
ib
u
la
r
ri
g
h
t
m
o
la
r,
q
u
e
s
ti
o
n
n
a
ir
e
(c
o
n
s
u
m
p
ti
o
n
o
f
fl
u
o
ri
d
e
s
a
n
d
c
a
n
d
ie
s
)
E
X
:
D
e
n
ta
l
u
n
it
w
it
h
g
o
o
d
li
g
h
t
a
n
d
c
o
m
p
re
s
s
e
d
a
ir
,
m
ir
ro
r
w
it
h
1
.6
-f
o
ld
m
a
g
n
if
ic
a
ti
o
n
,
b
lu
n
t
p
e
ri
o
d
o
n
ta
l
p
ro
b
e
a
n
d
fi
b
e
r-
o
p
ti
c
tr
a
n
s
il
lu
m
in
a
ti
o
n
2
2
2
6
•
P
ie
n
ih
ä
k
k
in
e
n
e
t
a
l.
1
2
,
2
0
0
4
(S
a
a
ri
jä
rv
i)
,
F
in
la
n
d
M
e
a
n
n
e
w
le
s
io
n
s
:
1
.7
(9
%
d
e
v
e
lo
p
e
d
�
3
m
a
n
if
e
s
t
c
a
ri
e
s
)
C
a
ri
e
s
in
c
id
e
n
c
e
a
s
s
o
c
ia
te
d
w
it
h
h
ig
h
M
S
le
v
e
ls
a
n
d
p
o
s
it
iv
e
ly
c
o
rr
e
la
te
d
w
it
h
W
IG
s
y
n
th
e
s
is
C
a
ri
e
s
in
c
id
e
n
c
e
(h
ig
h
ri
s
k
:
�
3
m
a
n
if
e
s
t
c
a
ri
e
s
)
M
W
,
C
S
,
C
A
1
V
B
:
C
a
ri
e
s
(i
n
it
ia
l
+
m
a
n
if
e
s
t
le
s
io
n
s
),
p
la
q
u
e
o
n
th
e
la
b
ia
l
s
u
rf
a
c
e
s
o
f
u
p
p
e
r
in
c
is
o
rs
,
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
v
ir
u
le
n
c
e
fa
c
to
rs
(M
S
a
c
id
o
g
e
n
e
s
is
,
w
a
te
r-
in
s
o
lu
b
le
g
lu
c
a
n
s
y
n
th
e
s
is
-
W
IG
,
a
d
h
e
re
n
c
e
a
n
a
ly
s
is
)
E
X
:
D
e
n
ta
l
s
u
rf
a
c
e
s
b
ru
s
h
e
d
a
n
d
d
ri
e
d
w
it
h
g
a
u
z
e
1
-
2
.5
1
4
2
/1
0
1
M
a
tt
o
s
-G
ra
n
e
r
e
t
a
l.
1
9
,
2
0
0
0
(P
ir
a
c
ic
a
b
a
),
B
ra
z
il
D
e
v
e
lo
p
in
g
c
a
ri
e
s
b
e
fo
re
th
e
a
g
e
o
f
2
in
d
ic
a
te
d
th
a
t
a
c
h
il
d
is
a
t
ri
s
k
fo
r
d
e
n
ta
l
c
a
ri
e
s
D
if
fe
re
n
c
e
s
in
d
ft
s
c
o
re
s
C
S
,
S
t
1
.5
V
B
:
C
a
ri
e
s
(c
a
v
it
a
ti
o
n
):
d
e
c
a
y
e
d
o
r
fi
ll
e
d
p
ri
m
a
ry
te
e
th
(d
ft
)
E
X
:
M
ir
ro
r,
e
x
p
lo
re
r,
o
p
ti
m
a
l
li
g
h
t
a
ft
e
r
d
ry
in
g
(c
o
tt
o
n
/a
ir
)
1
.5
3
7
4
Y
o
n
e
z
u
a
n
d
M
a
c
h
id
a
1
8
,
1
9
9
8
(T
o
k
y
o
),
J
a
p
a
n
M
a
in
re
s
u
lt
s
R
P
/R
F
§
O
u
tc
o
m
e
V
a
ri
a
b
le
D
a
ta
A
n
a
ly
s
is
¶
T
im e
‡
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
b
a
s
e
li
n
e
(V
B
)
E
x
a
m
in
a
ti
o
n
(E
X
)
A
g
e
†
S
a
m
p
l
e
*
A
u
th
o
r,
y
e
a
r
a
n
d
lo
c
a
l
1684
Tables 1 to 4 present a detailed review of the papers
published over the last 10 years (1997-2007) about caries
risks assessment in infants (<2 years), preschool children
(2-5 years), schoolchildren (6-12 years) and adolescents
(13-18 years) is presented. The age groups were established
based on those of Medline. The studies on caries risk
assessment during the last 10 years were conducted mainly
in schoolchildren (n=19), followed by preschool children
(n=9), adolescents (n=7), and infants (n=4). The majority
of them were related to data collected in Finland (n=7),
followed by Brazil (n=4), Sweden (n=3), China (n=3),
Norway (n=3), USA (n=3), the Netherlands (n=3),
Belgium (n=2), Greece (n=2), Japan (n=2), Australia
(n=1), Denmark (n=1), Germany (n=1), Israel (n=1),
Italy (n=1), Mexico (n=1) and New Zealand (n=1). As
one can see, European countries have contributed a great
deal to the dental literature on caries risk assessment over
the last decade. For classifying a variable as a risk factor
(RF) or risk predictor (RP), the study had to use
multivariate regression analyses including several variables
in the regression models.
There are few studies targeting infants at baseline
examination, and these collected mainly dental variables
(Table 1). Only one study12 used logistic regression models
with multiple variables for identifying risk predictors/
factors (RP/RF) for caries development, which are the
preferable model for this type of study, as dental caries
presents a multifactorial and complex etiology8. In the
Pienihäkkinen’s et al.12 study the mutans streptococcus
counts, the presence of incipient caries lesions, and the
use of candies were predictors for caries increment after a
3-year-follow-up. Another study13 used survival analysis
and identified the consumption of candies and the lack of
daily toothbrushing as the variables that impacted on caries
onset. As one can see, sugar consumption is an important
variable that may identify children at risk of caries in this
age group. It is an important finding since according to
Zero14, the relationship between sugar consumption and
dental caries is less strong in comparison to that from the
prefluoride era. Therefore dietary counseling is highly
recommended to mothers and should be part of oral health
preventive programs in public health services. Considering
the small number of studies in this age group during the
last 10 years, further studies should be conducted and make
use of more appropriate statistical analysis.
As regards studies concerning preschool children (Table
2), 9 papers published over the last 10 years were selected.
Variables such as dental, socioeconomic, behavioral,
dietary, microbiological, medical and demographic data
have been collected in study periods ranging from 0.5 to
10 years. Most studies (n=7) used regression models as
statistical analyses and showed that the main risk predictor
was caries experience and the risk factors were sugar
consumption and the presence of plaque/toothbrushing
related habits. Caries experience detected at baseline has
T
a
b
le
1
-
R
ev
ie
w
o
f
li
te
ra
tu
re
o
n
c
ar
ie
s
ri
sk
a
ss
es
sm
en
t
in
i
n
fa
n
ts
(
0
-2
y
ea
rs
o
ld
)
o
v
er
t
h
e
la
st
1
0
y
ea
rs
(
1
9
9
7
-2
0
0
7
)
Braz J Oral Sci. 7(27):1682-1690 An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007)
1685
T
a
b
le
2
-
R
ev
ie
w
o
f
li
te
ra
tu
re
o
n
c
ar
ie
s
ri
sk
a
ss
es
sm
en
t
in
p
re
sc
h
o
o
l
ch
il
d
re
n
(
2
-5
y
ea
rs
o
ld
)
o
v
er
t
h
e
la
st
1
0
y
ea
rs
(
1
9
9
7
-2
0
0
7
)
*
S
am
p
le
s
iz
e
at
i
n
it
ia
l/
fi
n
al
e
x
am
in
at
io
n
;
†
A
g
e
at
b
as
el
in
e
(y
ea
rs
);
‡
S
tu
d
y
l
as
ti
n
g
(
y
ea
rs
);
¶
S
ta
ti
st
ic
al
t
es
ts
:
A
N
O
V
A
=
A
n
al
y
si
s
o
f
V
ar
ia
n
ce
;
C
A
=
C
o
rr
el
at
io
n
a
n
al
y
si
s;
C
S
=
C
h
i-
sq
u
ar
e;
K
W
=
K
ru
sk
al
l
W
al
li
s;
M
L
R
=
M
u
lt
ip
le
l
o
g
is
ti
c
re
g
re
ss
io
n
;
M
N
=
M
cN
em
ar
;
M
W
=
M
an
n
-W
h
it
n
ey
;
P
V
=
P
re
d
ic
ti
v
e
v
al
u
es
;
R
O
C
=
R
ec
ei
v
er
o
p
er
at
o
r
ch
ar
ac
te
ri
st
ic
c
u
rv
es
;
S
ch
=
S
ch
ef
fe
;
S
n
=
S
en
si
ti
v
it
y
;
S
p
=
S
p
ec
if
ic
it
y
;
S
t=
S
tu
d
en
t’
s
t-
te
st
;
W
=
W
il
co
x
o
n
;
§
R
P
/R
F
:
R
is
k
p
re
d
ic
to
rs
/R
is
k
f
ac
to
rs
o
b
ta
in
ed
i
n
R
eg
re
ss
io
n
A
n
al
y
se
s
Braz J Oral Sci. 7(27):1682-1690 An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007)
S
ig
n
if
ic
a
n
t
c
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
c
a
ri
e
s
in
th
e
p
ri
m
a
ry
d
e
n
ti
ti
o
n
a
n
d
in
p
e
rm
a
n
e
n
t
te
e
th
R
P
:
�
1
c
a
ri
o
u
s
le
s
io
n
o
n
p
ri
m
a
ry
s
e
c
o
n
d
m
o
la
rs
H
ig
h
e
s
t
s
u
m
o
fS
n
a
n
d
S
p
(1
4
8
%
):
p
re
d
ic
to
r
“m
o
re
th
a
n
tw
o
le
s
io
n
s
in
p
ri
m
a
ry
s
e
c
o
n
d
m
o
la
rs
”
T
a
k
in
g
p
a
rt
o
f
a
ri
s
k
g
ro
u
p
(b
a
s
e
d
o
n
c
a
ri
e
s
in
c
re
m
e
n
t
in
p
e
rm
a
n
e
n
t
te
e
th
)
C
S
,
S
t,
C
A
,
M
L
R
,
S
n
,
S
p
,
P
V
,
R
O
C
5
V
B
:
C
a
ri
e
s
(e
n
a
m
e
l
+
d
e
n
ti
n
c
a
ri
e
s
;
v
is
u
a
l
in
s
p
e
c
ti
o
n
)
E
X
:
T
e
e
th
p
o
li
s
h
e
d
w
it
h
p
ro
p
h
y
la
c
ti
c
p
a
s
te
,
a
ir
-d
ri
e
d
/c
o
tt
o
n
ro
ll
s
,
o
p
e
ra
ti
n
g
li
g
h
ts
,
b
it
e
w
in
g
ra
d
io
g
ra
p
h
s
5
2
1
7
/1
8
6
S
k
e
ie
e
t
a
l.
2
8
,
2
0
0
6
(B
e
rg
e
n
),
N
o
rw
a
y
M
e
a
n
in
c
re
m
e
n
t
(e
n
a
m
e
l
+
d
e
n
ti
n
le
s
io
n
s
):
3
.0
5
R
P
:
�
1
le
s
io
n
s
o
n
p
ro
x
im
a
l
s
u
rf
a
c
e
s
o
f
th
e
p
ri
m
a
ry
m
o
la
rs
T
a
k
in
g
p
a
rt
o
f
a
ri
s
k
g
ro
u
p
(c
a
ri
e
s
in
c
re
m
e
n
t
in
p
ri
m
a
ry
te
e
th
)
S
t,
M
L
R
5
V
B
:
C
a
ri
e
s
(e
n
a
m
e
l
+
d
e
n
ti
n
e
le
s
io
n
s
)
E
X
:
T
e
e
th
p
o
li
s
h
e
d
a
n
d
d
ri
e
d
,
p
ro
b
e
s
,
p
la
in
,
m
ir
ro
rs
,
fa
v
o
ra
b
le
lig
h
t
c
o
n
d
it
io
n
s
,
b
it
e
w
in
g
ra
d
io
g
ra
p
h
s
5
2
1
7
/1
8
6
S
k
e
ie
e
t
a
l.
2
7
,
2
0
0
4
(B
e
rg
e
n
),
N
o
rw
a
y
M
e
a
n
d
m
fs
:
4
.4
3
a
t
b
a
s
e
li
n
e
a
n
d
6
.7
8
a
t
fo
ll
o
w
-u
p
.
G
ro
u
p
s
w
it
h
h
ig
h
M
u
ta
n
s
S
tr
e
p
to
c
o
c
c
i
(M
S
)
a
n
d
/o
r
h
ig
h
p
la
q
u
e
M
S
s
c
o
re
s
:
s
ig
n
if
ic
a
n
tl
y
h
ig
h
e
r
c
a
ri
e
s
in
c
id
e
n
c
e
R
P
:
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
a
t
b
a
s
e
li
n
e
;
R
F
:
h
ig
h
p
la
q
u
e
M
S
s
c
o
re
�
1
n
e
w
c
a
ri
o
u
s
s
u
rf
a
c
e
S
n
,
S
p
,
P
V
,
C
S
,
M
L
R
0
.5
V
B
:
C
a
ri
e
s
(W
H
O
c
ri
te
ri
a
),
d
e
n
ta
l
p
la
q
u
e
(v
is
u
a
ll
y
o
n
th
e
la
b
ia
l
su
rf
a
c
e
o
f
th
e
m
a
x
il
la
ry
in
c
is
o
rs
w
it
h
o
u
t
d
is
c
lo
s
in
g
s
o
lu
ti
o
n
),
o
ra
l
m
ic
ro
b
io
lo
g
y
(u
n
s
ti
m
u
la
te
d
s
a
li
v
a
a
n
d
p
la
q
u
e
in
fo
u
r
p
ro
x
im
a
l
s
u
rf
a
c
e
s
:
5
4
-d
,
5
5
-m
,
7
4
-d
,
7
5
-m
)
E
X
:
V
is
u
a
l
in
s
p
e
c
ti
o
n
1
.5
-
5
1
4
7
/1
2
9
S
e
k
i
e
t
a
l.2
6
,
2
0
0
3
(T
o
k
y
o
),
J
a
p
a
n
C
h
il
d
re
n
w
it
h
E
C
C
h
a
d
th
e
h
ig
h
e
s
t
n
u
m
b
e
r
o
f
n
e
w
a
ff
e
c
te
d
s
u
rf
a
c
e
s
p
e
r
y
e
a
r,
fo
ll
o
w
e
d
b
y
th
e
c
h
il
d
re
n
w
it
h
p
o
s
te
ri
o
r
c
a
ri
e
s
a
n
d
th
e
c
a
ri
e
s-
fr
e
e
c
h
il
d
re
n
.
E
C
C
g
ro
u
p
s
d
if
fe
re
d
s
ta
ti
s
ti
c
a
ll
y
fr
o
m
c
a
ri
e
s-
fr
e
e
g
ro
u
p
a
n
d
p
o
s
te
ri
o
r
c
a
ri
e
s
g
ro
u
p
N
e
w
a
ff
e
c
te
d
s
u
rf
a
c
e
s
p
e
r
y
e
a
r
A
N
O
V
A
,
S
c
h
7
-
1
0
V
B
:
C
a
ri
e
s
:
3
g
ro
u
p
s
w
it
h
5
0
c
h
il
d
re
n
e
a
c
h
b
e
in
g
c
a
ri
e
s
fr
e
e
c
h
il
dr
e
n
(C
F
),
c
h
il
d
re
n
w
it
h
e
a
rl
y
c
h
il
d
h
o
o
d
c
a
ri
e
s
(E
C
C
),
a
n
d
c
h
il
d
re
n
w
it
h
p
o
s
te
ri
o
r
c
a
ri
e
s
o
n
ly
(P
C
)
E
X
:
F
il
e
s
o
f
tw
o
p
ri
v
a
te
p
e
d
ia
tr
ic
d
e
n
ta
l
c
li
n
ic
s
,
ra
d
io
g
ra
p
h
ic
e
xa
m
in
a
ti
o
n
s
3
-5
1
5
0
P
e
re
tz
e
t
a
l.
2
5
,
2
0
0
3
,
(J
e
ru
s
a
le
m
a
n
d
P
e
ta
h
T
ik
v
a
),
Is
ra
e
l
R
P
:
c
a
ri
e
s
in
p
ri
m
a
ry
te
e
th
(c
a
ri
e
s
o
n
p
ri
m
a
ry
m
o
la
rs
:
h
ig
h
e
s
t
p
re
d
ic
ti
v
e
v
a
lu
e
-
8
5
.4
%
)
D
e
v
e
lo
p
in
g
c
a
ri
e
s
in
p
e
rm
a
n
e
n
t
d
e
n
ti
ti
o
n
M
L
R
,
C
A
,
P
V
8
V
B
:
C
a
ri
e
s
(d
m
f/
D
M
F
-
W
H
O
c
ri
te
ri
a
)
o
n
e
n
ti
re
d
e
n
ti
ti
o
n
a
n
d
o
n
s
u
b
s
e
ts
o
f
te
e
th
:
m
a
x
ill
a
ry
in
c
is
o
rs
,
m
a
x
il
la
ry
a
n
te
ri
o
r
te
e
th
,
m
a
x
il
la
ry
fi
rs
t
a
n
d
s
e
c
o
n
d
m
o
la
rs
,
m
a
n
d
ib
u
la
r
fi
rs
t
a
n
d
s
e
c
o
n
d
m
o
la
rs
,
a
ll
p
ri
m
a
ry
m
o
la
rs
E
X
:
C
la
s
s
ro
o
m
s
e
tt
in
g
,
n
a
tu
ra
l
li
g
h
t,
m
o
u
th
m
ir
ro
rs
,
e
x
p
lo
re
rs
3
-
5
5
0
4
/3
6
2
L
i
a
n
d
W
a
n
g
2
4
,
2
0
0
2
(B
e
ij
in
g
),
C
h
in
a
R
P
:
p
re
v
io
u
s
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
(m
o
s
t
im
p
o
rt
a
n
t
fa
c
to
r)
,
fl
u
o
ri
d
e
u
s
a
g
e
;
R
F
:
n
o
t
a
tt
e
n
d
in
g
n
u
rs
e
ri
e
s
w
it
h
g
u
id
e
li
n
e
s
fo
r
s
u
g
a
r
in
ta
k
e
,
fr
e
q
u
e
n
c
y
a
n
d
a
m
o
u
n
t
o
f
s
u
g
a
r
in
ta
k
e
,
to
o
th
b
ru
s
h
in
g
re
la
te
d
h
a
b
it
s
C
a
ri
e
s
in
c
re
m
e
n
t
M
L
R
1
V
B
:
C
a
ri
e
s
(W
H
O
c
ri
te
ri
a
),
e
n
a
m
e
l
h
y
p
o
p
la
s
ia
(D
D
E
in
d
e
x
–
D
e
v
e
lo
p
m
e
n
ta
l
D
e
fe
c
ts
o
f
E
n
a
m
e
l)
,
n
u
tr
it
io
n
a
l
s
ta
tu
s
,
s
u
g
a
r
in
ta
k
e
d
u
ri
n
g
3
n
o
n-
c
o
n
s
e
c
u
ti
v
e
d
a
y
s
,
d
a
il
y
fr
e
q
u
e
n
c
y
o
f
s
u
g
a
r
in
ta
k
e
,
2
4
-h
p
e
ri
o
d
d
ie
ta
ry
re
c
a
ll
a
t
h
o
m
e
,
q
u
e
s
ti
o
n
n
a
ir
e
(s
o
c
io
e
c
o
n
o
m
ic
,
m
e
d
ic
a
l,
d
e
m
o
g
ra
p
h
ic
,
d
ie
ta
ry
h
is
to
ry
a
n
d
d
e
n
ta
l-r
e
la
te
d
in
fo
rm
a
ti
o
n
)
E
X
:
C
la
s
s
ro
o
m
,
h
e
a
d
la
m
p
,
m
o
u
th
m
ir
ro
r,
p
ro
b
e
s
3
6
5
0
/5
1
0
R
o
d
ri
g
u
e
s
a
n
d
S
h
e
ih
a
m
2
3
,
2
0
0
0
(R
e
c
if
e
),
B
ra
z
il
H
ig
h
c
a
ri
e
s
ri
s
k
c
h
il
d
re
n
a
t
b
a
s
e
li
n
e
(>
5
0
c
o
lo
n
y
fo
rm
in
g
u
n
it
s
):
s
ig
n
if
ic
a
n
tl
y
g
re
a
te
r
c
a
ri
e
s
s
c
o
re
s
a
t
fi
n
a
l
e
x
a
m
in
a
ti
o
n
D
if
fe
re
n
c
e
s
in
c
a
ri
e
s
s
c
o
re
s
K
W
,
M
W
6
V
B
:
C
a
ri
e
s
(R
a
d
ik
e
m
e
th
o
d
),
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
c
o
u
n
ts
in
s
a
li
v
a
E
X
:
P
o
rt
a
b
le
d
e
n
ta
l
c
h
a
ir
,
m
ir
ro
r,
#
2
3
e
x
p
lo
re
r
fo
c
u
s
a
b
le
fl
a
s
h
li
gh
ts
3
.8
(m
e
a
n
)
8
5
/8
3
T
h
ib
o
d
e
a
u
a
n
d
O
’S
u
ll
iv
a
n
2
2
,
1
9
9
9
(H
a
rt
fo
rd
),
U
S
A
R
P
:
p
a
c
if
ie
r-
s
u
c
k
in
g
�
2
y
e
a
rs
;
R
F
:
u
s
e
o
f
n
u
rs
in
g
b
o
tt
le
a
t
n
ig
h
t
O
c
c
u
rr
e
n
c
e
o
f
c
a
ri
e
s
(y
e
s
/n
o
)
C
S
,
M
L
R
2
V
B
:
C
a
ri
e
s
(i
n
it
ia
l
+
m
a
n
if
e
s
t
c
a
ri
e
s
),
s
a
li
v
a
ry
la
c
to
b
a
c
il
li
a
n
d
c
a
n
d
id
a
,
q
u
e
s
ti
o
n
n
a
ir
e
(p
a
c
if
ie
r-
a
n
d
th
u
m
b
-s
u
c
k
in
g
,
b
re
a
s
tf
e
e
d
in
g
,
b
o
tt
le
-f
e
e
d
in
g
a
t
n
ig
h
t,
s
o
c
ia
l
c
la
s
s
o
f
th
e
fa
m
il
y
)
E
X
:
A
t
d
e
n
ta
l
h
e
a
lt
h
c
e
n
te
rs
2
.5
(m
e
a
n
)
1
6
6
/1
5
2
O
ll
il
a
e
t
a
l.
2
1
,
1
9
9
8
(O
u
lu
),
F
in
la
n
d
R
P
:
M
o
th
e
rs
’e
d
u
c
a
ti
o
n
(u
p
to
n
in
e
y
e
a
rs
o
f
b
a
s
ic
e
d
u
c
a
ti
o
n
),
p
re
s
e
n
c
e
o
f
c
a
ri
e
s
;
R
F
:
p
re
s
e
n
c
e
o
f
p
la
q
u
e
C
h
a
n
g
e
s
in
d
m
f
in
d
e
x
C
S
,
M
W
,
K
W
,
W
,
M
L
R
2
V
B
:
C
a
ri
e
s
(e
n
a
m
e
l
le
s
io
n
s
+
d
m
f
in
d
e
x
),
d
e
n
ta
l
c
le
a
n
li
n
e
s
s
(n
o
d
is
c
lo
s
in
g
s
o
lu
ti
o
n
),
q
u
e
s
ti
o
n
n
a
ir
e
(b
a
s
ic
e
d
u
c
a
ti
o
n
a
l
le
v
e
l,
o
c
c
u
p
a
ti
o
n
a
l
e
d
u
c
a
ti
o
n
,o
c
c
u
p
a
ti
o
n
,
to
o
th
b
ru
s
h
in
g
b
e
h
a
v
io
rs
,
u
s
e
o
f
x
y
li
to
l
c
h
e
w
in
g
g
u
m
,
s
n
a
c
k
in
g
o
n
s
w
e
e
ts
a
n
d
fre
q
u
e
n
c
y
o
f
s
n
a
c
k
in
g
,
d
ri
n
k
in
g
s
o
m
e
th
in
g
o
th
e
r
th
a
n
p
u
re
w
a
te
r)
E
X
:
P
u
b
li
c
d
e
n
ta
l
c
e
n
te
rs
3
1
2
9
2
/1
0
0
3
M
a
tt
il
a
e
t
a
l.2
0
,
1
9
9
8
(T
u
rk
u
),
F
in
la
n
d
M
a
in
re
s
u
lt
s
R
P
/R
F
§
O
u
tc
o
m
e
V
a
ri
a
b
le
D
a
ta
A
n
a
ly
s
is
¶
T
im e
‡
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
b
a
s
e
li
n
e
(V
B
)
E
x
a
m
in
a
ti
o
n
(E
X
)
A
g
e
†
S
a
m
p
l
e
*
A
u
th
o
r,
y
e
a
r
a
n
d
lo
c
a
l
S
ig
n
if
ic
a
n
t
c
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
c
a
ri
e
s
in
th
e
p
ri
m
a
ry
d
e
n
ti
ti
o
n
a
n
d
in
p
e
rm
a
n
e
n
t
te
e
th
R
P
:
�
1
c
a
ri
o
u
s
le
s
io
n
o
n
p
ri
m
a
ry
s
e
c
o
n
d
m
o
la
rs
H
ig
h
e
s
t
s
u
m
o
fS
n
a
n
d
S
p
(1
4
8
%
):
p
re
d
ic
to
r
“m
o
re
th
a
n
tw
o
le
s
io
n
s
in
p
ri
m
a
ry
s
e
c
o
n
d
m
o
la
rs
”
T
a
k
in
g
p
a
rt
o
f
a
ri
s
k
g
ro
u
p
(b
a
s
e
d
o
n
c
a
ri
e
s
in
c
re
m
e
n
t
in
p
e
rm
a
n
e
n
t
te
e
th
)
C
S
,
S
t,
C
A
,
M
L
R
,
S
n
,
S
p
,
P
V
,
R
O
C
5
V
B
:
C
a
ri
e
s
(e
n
a
m
e
l
+
d
e
n
ti
n
c
a
ri
e
s
;
v
is
u
a
l
in
s
p
e
c
ti
o
n
)
E
X
:
T
e
e
th
p
o
li
s
h
e
d
w
it
h
p
ro
p
h
y
la
c
ti
c
p
a
s
te
,
a
ir
-d
ri
e
d
/c
o
tt
o
n
ro
ll
s
,
o
p
e
ra
ti
n
g
li
g
h
ts
,
b
it
e
w
in
g
ra
d
io
g
ra
p
h
s
5
2
1
7
/1
8
6
S
k
e
ie
e
t
a
l.
2
8
,
2
0
0
6
(B
e
rg
e
n
),
N
o
rw
a
y
M
e
a
n
in
c
re
m
e
n
t
(e
n
a
m
e
l
+
d
e
n
ti
n
le
s
io
n
s
):
3
.0
5
R
P
:
�
1
le
s
io
n
s
o
n
p
ro
x
im
a
l
s
u
rf
a
c
e
s
o
f
th
e
p
ri
m
a
ry
m
o
la
rs
T
a
k
in
g
p
a
rt
o
f
a
ri
s
k
g
ro
u
p
(c
a
ri
e
s
in
c
re
m
e
n
t
in
p
ri
m
a
ry
te
e
th
)
S
t,
M
L
R
5
V
B
:
C
a
ri
e
s
(e
n
a
m
e
l
+
d
e
n
ti
n
e
le
s
io
n
s
)
E
X
:
T
e
e
th
p
o
li
s
h
e
d
a
n
d
d
ri
e
d
,
p
ro
b
e
s
,
p
la
in
,
m
ir
ro
rs
,
fa
v
o
ra
b
le
lig
h
t
c
o
n
d
it
io
n
s
,
b
it
e
w
in
g
ra
d
io
g
ra
p
h
s
5
2
1
7
/1
8
6
S
k
e
ie
e
t
a
l.
2
7
,
2
0
0
4
(B
e
rg
e
n
),
N
o
rw
a
y
M
e
a
n
d
m
fs
:
4
.4
3
a
t
b
a
s
e
li
n
e
a
n
d
6
.7
8
a
t
fo
ll
o
w
-u
p
.
G
ro
u
p
s
w
it
h
h
ig
h
M
u
ta
n
s
S
tr
e
p
to
c
o
c
c
i
(M
S
)
a
n
d
/o
r
h
ig
h
p
la
q
u
e
M
S
s
c
o
re
s
:
s
ig
n
if
ic
a
n
tl
y
h
ig
h
e
r
c
a
ri
e
s
in
c
id
e
n
c
e
R
P
:
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
a
t
b
a
s
e
li
n
e
;
R
F
:
h
ig
h
p
la
q
u
e
M
S
s
c
o
re
�
1
n
e
w
c
a
ri
o
u
s
s
u
rf
a
c
e
S
n
,
S
p
,
P
V
,
C
S
,
M
L
R
0
.5
V
B
:
C
a
ri
e
s
(W
H
O
c
ri
te
ri
a
),
d
e
n
ta
l
p
la
q
u
e
(v
is
u
a
ll
y
o
n
th
e
la
b
ia
l
su
rf
a
c
e
o
f
th
e
m
a
x
il
la
ry
in
c
is
o
rs
w
it
h
o
u
t
d
is
c
lo
s
in
g
s
o
lu
ti
o
n
),
o
ra
l
m
ic
ro
b
io
lo
g
y
(u
n
s
ti
m
u
la
te
d
s
a
li
v
a
a
n
d
p
la
q
u
e
in
fo
u
r
p
ro
x
im
a
l
s
u
rf
a
c
e
s
:
5
4
-d
,
5
5
-m
,
7
4
-d
,
7
5
-m
)
E
X
:
V
is
u
a
l
in
s
p
e
c
ti
o
n
1
.5
-
5
1
4
7
/1
2
9
S
e
k
i
e
t
a
l.2
6
,
2
0
0
3
(T
o
k
y
o
),
J
a
p
a
n
C
h
il
d
re
n
w
it
h
E
C
C
h
a
d
th
e
h
ig
h
e
s
t
n
u
m
b
e
r
o
f
n
e
w
a
ff
e
c
te
d
s
u
rf
a
c
e
s
p
e
r
y
e
a
r,
fo
ll
o
w
e
d
b
y
th
e
c
h
il
d
re
n
w
it
h
p
o
s
te
ri
o
r
c
a
ri
e
s
a
n
d
th
e
c
a
ri
e
s-
fr
e
e
c
h
il
d
re
n
.
E
C
C
g
ro
u
p
s
d
if
fe
re
d
s
ta
ti
s
ti
c
a
ll
y
fr
o
m
c
a
ri
e
s-
fr
e
e
g
ro
u
p
a
n
d
p
o
s
te
ri
o
r
c
a
ri
e
s
g
ro
u
p
N
e
w
a
ff
e
c
te
d
s
u
rf
a
c
e
s
p
e
r
y
e
a
r
A
N
O
V
A
,
S
c
h
7
-
1
0
V
B
:
C
a
ri
e
s
:
3
g
ro
u
p
s
w
it
h
5
0
c
h
il
d
re
n
e
a
c
h
b
e
in
g
c
a
ri
e
s
fr
e
e
c
h
il
dr
e
n
(C
F
),
c
h
il
d
re
n
w
it
h
e
a
rl
y
c
h
il
d
h
o
o
d
c
a
ri
e
s
(E
C
C
),
a
n
d
c
h
il
d
re
n
w
it
h
p
o
s
te
ri
o
r
c
a
ri
e
s
o
n
ly
(P
C
)
E
X
:
F
il
e
s
o
f
tw
o
p
ri
v
a
te
p
e
d
ia
tr
ic
d
e
n
ta
l
c
li
n
ic
s
,
ra
d
io
g
ra
p
h
ic
e
xa
m
in
a
ti
o
n
s
3
-5
1
5
0
P
e
re
tz
e
t
a
l.
2
5
,
2
0
0
3
,
(J
e
ru
s
a
le
m
a
n
d
P
e
ta
h
T
ik
v
a
),
Is
ra
e
l
R
P
:
c
a
ri
e
s
in
p
ri
m
a
ry
te
e
th
(c
a
ri
e
s
o
n
p
ri
m
a
ry
m
o
la
rs
:
h
ig
h
e
s
t
p
re
d
ic
ti
v
e
v
a
lu
e
-
8
5
.4
%
)
D
e
v
e
lo
p
in
g
c
a
ri
e
s
in
p
e
rm
a
n
e
n
t
d
e
n
ti
ti
o
n
M
L
R
,
C
A
,
P
V
8
V
B
:
C
a
ri
e
s
(d
m
f/
D
M
F
-
W
H
O
c
ri
te
ri
a
)
o
n
e
n
ti
re
d
e
n
ti
ti
o
n
a
n
d
o
n
s
u
b
s
e
ts
o
f
te
e
th
:
m
a
x
ill
a
ry
in
c
is
o
rs
,
m
a
x
il
la
ry
a
n
te
ri
o
r
te
e
th
,
m
a
x
il
la
ry
fi
rs
t
a
n
d
s
e
c
o
n
d
m
o
la
rs
,
m
a
n
d
ib
u
la
r
fi
rs
t
a
n
d
s
e
c
o
n
d
m
o
la
rs
,
a
ll
p
ri
m
a
ry
m
o
la
rs
E
X
:
C
la
s
s
ro
o
m
s
e
tt
in
g
,
n
a
tu
ra
l
li
g
h
t,
m
o
u
th
m
ir
ro
rs
,
e
x
p
lo
re
rs
3
-
5
5
0
4
/3
6
2
L
i
a
n
d
W
a
n
g
2
4
,
2
0
0
2
(B
e
ij
in
g
),
C
h
in
a
R
P
:
p
re
v
io
u
s
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
(m
o
s
t
im
p
o
rt
a
n
t
fa
c
to
r)
,
fl
u
o
ri
d
e
u
s
a
g
e
;
R
F
:
n
o
t
a
tt
e
n
d
in
g
n
u
rs
e
ri
e
s
w
it
h
g
u
id
e
li
n
e
s
fo
r
s
u
g
a
r
in
ta
k
e
,
fr
e
q
u
e
n
c
y
a
n
d
a
m
o
u
n
t
o
f
s
u
g
a
r
in
ta
k
e
,
to
o
th
b
ru
s
h
in
g
re
la
te
d
h
a
b
it
s
C
a
ri
e
s
in
c
re
m
e
n
t
M
L
R
1
V
B
:
C
a
ri
e
s
(W
H
O
c
ri
te
ri
a
),
e
n
a
m
e
l
h
y
p
o
p
la
s
ia
(D
D
E
in
d
e
x
–
D
e
v
e
lo
p
m
e
n
ta
l
D
e
fe
c
ts
o
f
E
n
a
m
e
l)
,
n
u
tr
it
io
n
a
l
s
ta
tu
s
,
s
u
g
a
r
in
ta
k
e
d
u
ri
n
g
3
n
o
n-
c
o
n
s
e
c
u
ti
v
e
d
a
y
s
,
d
a
il
y
fr
e
q
u
e
n
c
y
o
f
s
u
g
a
r
in
ta
k
e
,
2
4
-h
p
e
ri
o
d
d
ie
ta
ry
re
c
a
ll
a
t
h
o
m
e
,
q
u
e
s
ti
o
n
n
a
ir
e
(s
o
c
io
e
c
o
n
o
m
ic
,
m
e
d
ic
a
l,
d
e
m
o
g
ra
p
h
ic
,
d
ie
ta
ry
h
is
to
ry
a
n
d
d
e
n
ta
l-r
e
la
te
d
in
fo
rm
a
ti
o
n
)
E
X
:
C
la
s
s
ro
o
m
,
h
e
a
d
la
m
p
,
m
o
u
th
m
ir
ro
r,
p
ro
b
e
s
3
6
5
0
/5
1
0
R
o
d
ri
g
u
e
s
a
n
d
S
h
e
ih
a
m
2
3
,
2
0
0
0
(R
e
c
if
e
),
B
ra
z
il
H
ig
h
c
a
ri
e
s
ri
s
k
c
h
il
d
re
n
a
t
b
a
s
e
li
n
e
(>
5
0
c
o
lo
n
y
fo
rm
in
g
u
n
it
s
):
s
ig
n
if
ic
a
n
tl
y
g
re
a
te
r
c
a
ri
e
s
s
c
o
re
s
a
t
fi
n
a
l
e
x
a
m
in
a
ti
o
n
D
if
fe
re
n
c
e
s
in
c
a
ri
e
s
s
c
o
re
s
K
W
,
M
W
6
V
B
:
C
a
ri
e
s
(R
a
d
ik
e
m
e
th
o
d
),
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
c
o
u
n
ts
in
s
a
li
v
a
E
X
:
P
o
rt
a
b
le
d
e
n
ta
l
c
h
a
ir
,
m
ir
ro
r,
#
2
3
e
x
p
lo
re
r
fo
c
u
s
a
b
le
fl
a
s
h
li
gh
ts
3
.8
(m
e
a
n
)
8
5
/8
3
T
h
ib
o
d
e
a
u
a
n
d
O
’S
u
ll
iv
a
n
2
2
,
1
9
9
9
(H
a
rt
fo
rd
),
U
S
A
R
P
:
p
a
c
if
ie
r-
s
u
c
k
in
g
�
2
y
e
a
rs
;
R
F
:
u
s
e
o
f
n
u
rs
in
g
b
o
tt
le
a
t
n
ig
h
t
O
c
c
u
rr
e
n
c
e
o
f
c
a
ri
e
s
(y
e
s
/n
o
)
C
S
,
M
L
R
2
V
B
:
C
a
ri
e
s
(i
n
it
ia
l
+
m
a
n
if
e
s
t
c
a
ri
e
s
),
s
a
li
v
a
ry
la
c
to
b
a
c
il
li
a
n
d
c
a
n
d
id
a
,
q
u
e
s
ti
o
n
n
a
ir
e
(p
a
c
if
ie
r-
a
n
d
th
u
m
b
-s
u
c
k
in
g
,
b
re
a
s
tf
e
e
d
in
g
,
b
o
tt
le
-f
e
e
d
in
g
a
t
n
ig
h
t,
s
o
c
ia
l
c
la
s
s
o
f
th
e
fa
m
il
y
)
E
X
:
A
t
d
e
n
ta
l
h
e
a
lt
h
c
e
n
te
rs
2
.5
(m
e
a
n
)
1
6
6
/1
5
2
O
ll
il
a
e
t
a
l.
2
1
,
1
9
9
8
(O
u
lu
),
F
in
la
n
d
R
P
:
M
o
th
e
rs
’e
d
u
c
a
ti
o
n
(u
p
to
n
in
e
y
e
a
rs
o
f
b
a
s
ic
e
d
u
c
a
ti
o
n
),
p
re
s
e
n
c
e
o
f
c
a
ri
e
s
;
R
F
:
p
re
s
e
n
c
e
o
f
p
la
q
u
e
C
h
a
n
g
e
s
in
d
m
f
in
d
e
x
C
S
,
M
W
,
K
W
,
W
,
M
L
R
2
V
B
:
C
a
ri
e
s
(e
n
a
m
e
l
le
s
io
n
s
+
d
m
f
in
d
e
x
),
d
e
n
ta
l
c
le
a
n
li
n
e
s
s
(n
o
d
is
c
lo
s
in
g
s
o
lu
ti
o
n
),
q
u
e
s
ti
o
n
n
a
ir
e
(b
a
s
ic
e
d
u
c
a
ti
o
n
a
l
le
v
e
l,
o
c
c
u
p
a
ti
o
n
a
l
e
d
u
c
a
ti
o
n
,o
c
c
u
p
a
ti
o
n
,
to
o
th
b
ru
s
h
in
g
b
e
h
a
v
io
rs
,
u
s
e
o
f
x
y
li
to
l
c
h
e
w
in
g
g
u
m
,
s
n
a
c
k
in
g
o
n
s
w
e
e
ts
a
n
d
fre
q
u
e
n
c
y
o
f
s
n
a
c
k
in
g
,
d
ri
n
k
in
g
s
o
m
e
th
in
g
o
th
e
r
th
a
n
p
u
re
w
a
te
r)
E
X
:
P
u
b
li
c
d
e
n
ta
l
c
e
n
te
rs
3
1
2
9
2
/1
0
0
3
M
a
tt
il
a
e
t
a
l.2
0
,
1
9
9
8
(T
u
rk
u
),
F
in
la
n
d
M
a
in
re
s
u
lt
s
R
P
/R
F
§
O
u
tc
o
m
e
V
a
ri
a
b
le
D
a
ta
A
n
a
ly
s
is
¶
T
im e
‡
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
b
a
s
e
li
n
e
(V
B
)
E
x
a
m
in
a
ti
o
n
(E
X
)
A
g
e
†
S
a
m
p
l
e
*
A
u
th
o
r,
y
e
a
r
a
n
d
lo
c
a
l
M
e
a
n
D
M
F
S
i
n
c
re
m
e
n
t:
1
.1
4
R
P
:
p
la
q
u
e
C
a
c
o
n
c
e
n
tr
a
ti
o
n
,
b
a
s
e
li
n
e
D
M
F
S
s
c
o
re
(
u
s
e
fu
l
p
re
d
ic
to
r)
;
R
F
:
to
o
th
b
ru
s
h
in
g
fr
e
q
u
e
n
c
y
D
M
F
S
i
n
c
re
m
e
n
t
�
3
M
W
,
W
,
M
L
R
2
V
B
:
C
a
ri
e
s
(
c
a
v
it
a
ti
o
n
le
v
e
l)
,
p
la
q
u
e
s
c
o
re
(
Q
u
ig
le
y
a
n
d
H
e
in
i
n
d
e
x
),
fl
u
o
ro
s
is
s
c
o
re
(
T
F
i
n
d
e
x
),
i
n
o
rg
a
n
ic
c
o
m
p
o
u
n
d
s
i
n
d
e
n
ta
l
p
la
q
u
e
(
s
u
p
ra
g
in
g
iv
a
l
p
la
q
u
e
c
o
ll
e
c
ti
o
n
f
ro
m
b
u
c
c
a
l
a
n
d
l
in
g
u
a
l
s
u
rf
a
c
e
s
a
ft
e
r
3
d
a
y
s
w
it
h
n
o
o
ra
l
h
y
g
ie
n
e
),
to
o
th
b
ru
s
h
in
g
fr
e
q
u
e
n
c
y
,
s
n
a
c
k
s
u
s
e
,
p
a
re
n
ts
‘
o
c
c
u
p
a
ti
o
n
E
X
:
C
h
il
d
s
e
a
te
d
i
n
a
n
u
p
ri
g
h
t
c
h
a
ir
,
a
d
e
q
u
a
te
i
ll
u
m
in
a
ti
o
n
,
s
h
a
rp
p
ro
b
e
1
2
1
7
5
/1
6
4
P
e
a
rc
e
e
t
a
l.
3
7
,
2
0
0
2
(
B
e
ij
in
g
),
C
h
in
a
N
o
s
ta
ti
s
ti
c
a
ll
y
s
ig
n
if
ic
a
n
t
p
re
d
ic
to
r
(p
>
0
.0
5
)
C
a
ri
e
s
i
n
c
re
m
e
n
t
C
A
,
M
L
R
4
V
B
:
C
a
ri
e
s
(
in
c
ip
ie
n
t
+
c
a
v
it
a
te
d
le
s
io
n
s
+
f
il
li
n
g
s
),
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
-
M
S
a
n
d
l
a
c
to
b
a
c
il
li
(
L
B
)
c
o
u
n
ts
(s
ti
m
u
la
te
d
s
a
li
v
a
)
E
X
:
V
is
u
a
l
o
b
s
e
rv
a
ti
o
n
,
d
ri
e
d
s
u
rf
a
c
e
s
,
d
e
n
ta
l
la
m
p
,
s
m
a
ll
m
o
u
th
-l
ig
h
t,
r
a
d
io
g
ra
p
h
s
7
.5
6
9
/6
2
v
a
n
P
a
le
n
s
te
in
H
e
ld
e
rm
a
n
e
t
a
l.
3
6
,
2
0
0
1
(C
u
le
m
b
o
rg
),
T
h
e
N
e
th
e
rl
a
n
d
s
R
P
:
n
u
m
b
e
r
o
f
c
a
v
it
a
te
d
a
n
d
n
o
n
-c
a
v
it
a
te
d
fi
s
s
u
re
s
o
f
th
e
n
e
w
ly
e
ru
p
te
d
p
e
rm
a
n
e
n
t
fi
rs
t
m
o
la
r
H
ig
h
c
a
ri
e
s
i
n
c
re
m
e
n
t
(�
D
3
s
u
rf
a
c
e
s
>
0
;
>
2
;
>
4
,
>
7
)
C
A
,
M
L
R
,
R
O
C
8
V
B
:
C
a
ri
e
s
(
n
o
n
c
a
v
it
a
te
d
a
n
d
c
a
v
it
a
te
d
c
a
ri
e
s
,
fi
ll
in
g
)
a
n
d
s
e
a
la
n
ts
E
X
:
V
is
u
a
l
e
x
a
m
in
a
ti
o
n
,
d
e
n
ta
l
p
ro
b
e
,
d
e
n
ta
l
la
m
p
a
n
d
s
m
a
ll
m
o
u
th
-l
ig
h
t,
b
it
e
w
in
g
r
a
d
io
g
ra
p
h
s
7
.5
3
1
8
/2
8
7
v
a
n
P
a
le
n
s
te
in
H
e
ld
e
rm
a
n
e
t
a
l.
3
5
,
2
0
0
1
(
T
ie
l,
C
u
le
m
b
o
rg
)
T
h
e
N
e
th
e
rl
a
n
d
s
R
P
:
d
m
fs
,
e
d
u
c
a
ti
o
n
a
l
s
y
s
te
m
;
R
F
:
fr
e
q
u
e
n
c
y
o
f
b
ru
s
h
in
g
,
d
a
il
y
u
s
e
o
f
s
u
g
a
r
-c
o
n
ta
in
in
g
d
ri
n
k
s
D
M
F
S
i
n
c
re
m
e
n
t
�
2
o
n
p
e
rm
a
n
e
n
t
1
s
t
m
o
la
rs
M
L
R
,
S
n
,
S
p
,
R
O
C
,
C
S
3
V
B
:
C
a
ri
e
s
(
B
A
S
C
D
c
ri
te
ri
a
–
c
a
v
it
a
ti
o
n
le
v
e
l)
,
o
ra
l
h
y
g
ie
n
e
(
S
il
n
e
s
s
a
n
d
L
ö
e
’s
p
la
q
u
e
i
n
d
e
x
a
n
d
p
la
q
u
e
in
d
e
x
o
n
o
c
c
lu
s
a
l
s
u
rf
a
c
e
s
–
C
a
rv
a
lh
o
’s
in
d
e
x
),
e
ru
p
ti
o
n
s
ta
g
e
,
q
u
e
s
ti
o
n
n
a
ir
e
(
o
ra
l
h
y
g
ie
n
e
,
d
ie
ta
ry
h
a
b
it
s
,
fl
u
o
ri
d
e
e
x
p
o
s
u
re
,
a
c
c
e
s
s
t
o
o
ra
l
h
e
a
lt
h
c
a
re
s
e
rv
ic
e
s
,
m
e
d
ic
a
l
h
is
to
ry
,
s
o
c
io
e
c
o
n
o
m
ic
l
e
v
e
l)
E
X
:
M
o
b
il
e
d
e
n
ta
l
c
li
n
ic
,
W
H
O
/C
P
IT
N
p
ro
b
e
7
3
3
0
3
/3
0
0
2
V
a
n
o
b
b
e
rg
e
n
e
t
a
l.
3
4
,
2
0
0
1
(F
la
n
d
e
rs
),
B
e
lg
iu
m
M
e
a
n
c
a
ri
e
s
i
n
c
re
m
e
n
t:
0
.4
5
d
m
ft
/D
M
F
T
R
P
:
m
o
th
e
r
’s
p
re
v
io
u
s
c
a
ri
e
s
(
d
e
c
id
u
o
u
s
t
e
e
th
);
R
F
:
to
o
th
b
ru
s
h
in
g
o
n
ly
o
c
c
a
s
io
n
a
ll
y
,
c
h
il
d
f
re
q
u
e
n
t
u
s
e
o
f
s
w
e
e
ts
a
n
d
c
h
il
d
’s
b
e
d
ti
m
e
a
ft
e
r
9
p
.
m
.
(p
e
rm
a
n
e
n
t
te
e
th
),
e
a
t
s
w
e
e
ts
f
re
q
u
e
n
tl
y
a
t
3
y
e
a
rs
o
f
a
g
e
(
b
o
th
d
e
n
ti
ti
o
n
s
)
C
a
ri
e
s
i
n
c
re
m
e
n
t
C
S
,
M
L
R
3
V
B
:
C
a
ri
e
s
(
D
M
F
T
/
d
m
ft
),
q
u
e
s
ti
o
n
n
a
ir
e
(
s
o
c
io
e
c
o
n
o
m
ic
,
d
e
m
o
g
ra
p
h
ic
,
fa
m
il
y
f
a
c
to
rs
,
d
i
e
t,
d
e
n
ta
l
h
y
g
ie
n
e
,
p
a
re
n
ts
’
o
w
n
e
a
rl
ie
r
d
e
n
ta
l
h
e
a
lt
h
h
a
b
it
s
,
p
a
re
n
ts
´
p
re
v
io
u
s
d
e
n
ta
l
h
e
a
lt
h
,
c
h
il
d
re
n
’s
d
is
e
a
s
e
s
a
n
d
p
h
y
s
ic
a
l
s
y
m
p
to
m
s
)
E
X
:
M
ir
ro
r,
p
ro
b
e
,
fi
b
e
r
-o
p
ti
c
l
ig
h
t
7
1
0
7
4
M
a
tt
il
a
e
t
a
l.
3
3
,
2
0
0
1
(
T
u
rk
u
),
F
in
la
n
d
R
P
:
p
re
s
e
n
c
e
o
f
d
e
c
a
y
e
d
t
e
e
th
a
n
d
d
e
c
a
lc
if
ic
a
ti
o
n
s
(
m
o
s
t
s
ig
n
if
ic
a
n
t)
;
R
F
:
d
ie
ta
ry
f
a
c
to
rs
,
p
o
o
r
o
ra
l
h
y
g
ie
n
e
C
u
m
u
la
ti
v
e
f
u
tu
re
c
a
ri
e
s
le
s
io
n
s
(
h
ig
h
r
is
k
:
�
5
n
e
w
s
u
rf
a
c
e
l
e
s
io
n
s
)
C
S
,
M
L
R
,
A
N
O
V
A
2
.5
V
B
:
C
h
a
rt
s
o
f
p
a
ti
e
n
ts
c
o
n
ta
in
in
g
:
m
e
d
ic
a
l,
d
e
n
ta
l
a
n
d
f
lu
o
ri
d
e
h
i
s
to
ry
,
d
ie
t,
o
ra
l
h
y
g
ie
n
e
,
re
te
n
ti
v
e
p
it
s
a
n
d
f
is
s
u
re
s
,
e
x
is
ti
n
g
r
e
s
to
ra
ti
o
n
s
,
n
e
w
ly
e
ru
p
te
d
t
e
e
th
,
c
a
ri
e
s
/d
e
c
a
lc
if
ic
a
ti
o
n
s
,
p
u
lp
it
s
/a
b
s
c
e
s
s
,
g
in
g
iv
it
is
,
c
ro
w
d
in
g
,
b
e
h
a
v
io
r,
a
g
e
,
g
e
n
d
e
r
E
X
:
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
p
a
ti
e
n
t
’s
c
h
a
rt
s
(
re
tr
o
s
p
e
c
ti
v
e
l
o
n
g
it
u
d
in
a
l
s
tu
d
y
)
0
.9
-1
1
1
4
0
W
a
n
d
e
ra
e
t
a
l.
3
2
,
2
0
0
0
(
M
ic
h
ig
a
n
),
U
S
A
R
P
:
E
p
in
e
p
h
ri
n
e
l
e
v
e
ls
C
a
ri
e
s
i
n
c
re
m
e
n
t
S
t,
L
iR
A
,
M
L
R
1
V
B
:
C
a
ri
e
s
(
D
M
F
/
d
m
f)
,
d
e
n
ta
l
p
la
q
u
e
,
c
a
te
c
h
o
la
m
in
e
c
o
n
te
n
t
in
u
ri
n
e
s
a
m
p
le
,
b
o
d
y
w
e
ig
h
t,
p
a
re
n
ta
l
a
g
e
,
e
d
u
c
a
ti
o
n
a
n
d
p
ro
fe
s
s
io
n
,
m
e
d
ic
a
l
h
is
to
ry
a
n
d
m
e
d
ic
a
ti
o
n
s
E
X
:
B
it
e
w
in
g
r
a
d
io
g
ra
p
h
s
6
-8
3
1
4
/2
7
0
V
a
n
d
e
ra
s
e
t
a
l.
3
1
,
2
0
0
0
,
G
re
e
c
e
M
e
a
n
c
a
ri
e
s
i
n
c
re
m
e
n
t:
0
.6
8
t
e
e
th
T
h
e
m
o
re
o
ft
e
n
t
h
e
M
S
t
e
s
t
p
o
s
it
iv
e
,
th
e
h
ig
h
e
r
th
e
p
ro
p
o
rt
io
n
o
f
c
h
il
d
re
n
w
h
o
d
e
v
e
lo
p
e
d
c
a
ri
e
s
l
e
s
io
n
R
P
:
fl
u
o
ri
d
e
;
R
F
:
M
S
D
M
F
T
in
c
re
m
e
n
t
�
1
C
S
,
S
n
,
S
p
,
P
V
,
M
L
R
,
C
A
2
V
B
:
C
a
ri
e
s
(
W
H
O
c
ri
te
ri
a
),
p
la
q
u
e
i
n
d
e
x
(
S
il
n
e
s
s
a
n
d
L
ö
e
),
m
ic
ro
b
io
lo
g
ic
a
l
a
n
a
ly
s
is
o
f
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
-
M
S
,
(n
o
n
-s
ti
m
u
la
te
d
s
a
li
v
a
s
a
m
p
le
s
),
q
u
e
s
ti
o
n
n
a
ir
e
(
s
u
c
ro
s
e
i
n
ta
k
e
,
fl
u
o
r
id
e
e
x
p
o
s
u
re
)
E
X
:
C
li
n
ic
a
l
e
x
a
m
in
a
ti
o
n
,
v
is
u
a
l
in
s
p
e
c
ti
o
n
,
b
it
e
w
in
g
r
a
d
io
g
ra
p
h
s
6
-7
3
1
4
/3
0
4
(C
a
ri
e
s
-
fr
e
e
)
P
e
tt
i
a
n
d
H
a
u
s
e
n
1
5
,
2
0
0
0
(R
o
m
e
),
I
ta
ly
M
e
a
n
c
a
ri
e
s
i
n
c
id
e
n
c
e
:
0
.6
9
D
M
F
S
S
ig
n
if
ic
a
n
t
c
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
i
n
it
ia
l
M
S
s
c
o
re
s
a
n
d
c
a
ri
e
s
d
e
v
e
lo
p
m
e
n
t
C
a
ri
e
s
d
e
v
e
lo
p
m
e
n
t
C
A
,
K
W
,
M
W
,
S
n
,
S
p
2
V
B
:
C
a
ri
e
s
(
D
M
F
S
/
d
m
fs
–
W
H
O
c
ri
te
ri
a
,
in
it
ia
l
le
s
io
n
s
),
s
e
a
la
n
ts
f
o
r
a
ll
m
o
la
r
fi
s
s
u
re
s
,
o
c
c
lu
s
a
l
p
la
q
u
e
s
a
m
p
le
s
f
ro
m
t
e
e
th
1
6
a
n
d
3
6
(
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
te
s
ts
),
p
la
q
u
e
i
n
d
e
x
(
Q
u
ig
le
y
-H
e
in
)
E
X
:
E
x
p
lo
re
r
w
it
h
o
u
t
p
re
s
s
u
re
,
li
g
h
t
s
o
u
rc
e
6
-7
2
3
0
/1
6
9
S
p
li
e
th
a
n
d
B
e
rn
h
a
rd
t
3
0
,
1
9
9
9
,
G
e
rm
a
n
y
M
e
a
n
c
a
ri
e
s
i
n
c
re
m
e
n
t:
0
.9
5
D
M
F
S
C
a
ri
e
s
i
n
c
re
m
e
n
t:
n
e
g
a
ti
v
e
c
o
rr
e
la
ti
o
n
s
w
it
h
b
a
s
e
li
n
e
la
c
to
fe
rr
in
,
to
ta
l
Ig
G
a
n
d
t
o
ta
l
a
n
a
e
ro
b
e
s
;
p
o
s
it
iv
e
c
o
rr
e
la
ti
o
n
w
it
h
s
p
e
c
if
ic
a
n
ti
-S
.
m
u
ta
n
s
,
Ig
G
a
n
ti
b
o
d
y
l
e
v
e
ls
,
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i,
l
a
c
to
b
a
c
il
li
a
n
d
s
p
e
c
if
ic
a
n
ti
-S
.
m
u
ta
n
s
Ig
G
.
C
h
il
d
re
n
w
it
h
s
ig
n
if
ic
a
n
tl
y
h
ig
h
e
r
b
a
s
e
li
n
e
c
o
n
c
e
n
tr
a
ti
o
n
s
o
f
h
y
p
o
th
io
c
y
a
n
it
e
,
to
ta
l
Ig
G
a
n
ti
b
o
d
ie
s
a
n
d
t
o
ta
l
a
n
a
e
ro
b
e
s
:
n
o
n
e
w
c
a
ri
e
s
l
e
s
io
n
s
D
M
F
i
n
c
re
m
e
n
t
>
0
S
t,
C
A
2
V
B
:
C
a
ri
e
s
(
D
M
F
/
d
m
f
-
W
H
O
c
ri
te
ri
a
,
w
h
it
e
s
p
o
ts
l
e
s
io
n
s
),
p
e
ri
o
d
o
n
ta
l
s
ta
tu
s
(
b
le
e
d
in
g
a
n
d
c
a
lc
u
lu
s
),
u
s
a
g
e
o
f
fl
u
o
ri
d
a
te
d
d
e
n
ti
fr
ic
e
s
,
s
a
li
v
a
s
a
m
p
le
s
(
b
u
ff
e
r
c
a
p
a
c
it
y
,
h
y
p
o
th
io
c
y
a
n
it
e
a
s
s
a
y
,
to
ta
l
s
tr
e
p
to
c
o
c
c
i
a
n
d
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i,
la
c
to
fe
rr
in
a
n
d
ly
s
o
z
y
m
e
a
n
a
ly
s
is
,
a
g
g
lu
ti
n
a
ti
o
n
a
s
s
a
y
,
to
ta
l
s
a
li
v
a
ry
p
e
ro
x
id
a
s
e
a
c
ti
v
it
y
,
to
ta
l
a
n
d
s
p
e
c
if
ic
Ig
A
a
n
d
Ig
G
a
n
ti
b
o
d
ie
s
)
E
X
:
V
is
u
a
l
-t
a
c
ti
le
m
e
th
o
d
+
F
O
T
I
1
2
6
9
/6
3
K
ir
s
ti
lä
e
t
a
l.
2
9
,
1
9
9
8
(
T
u
rk
u
),
F
in
la
n
d
M
a
in
r
e
s
u
lt
s
R
P
/R
F
§
O
u
tc
o
m
e
V
a
ri
a
b
le
D
a
ta
A
n
a
ly
s
is
¶
T
im
e
‡
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
b
a
s
e
li
n
e
(
V
B
)
E
x
a
m
in
a
ti
o
n
(
E
X
)
A
g
e
†
S
a
m
p
le
*
A
u
th
o
r
,
y
e
a
r
a
n
d
lo
c
a
l
M
e
a
n
D
M
F
S
i
n
c
re
m
e
n
t:
1
.1
4
R
P
:
p
la
q
u
e
C
a
c
o
n
c
e
n
tr
a
ti
o
n
,
b
a
s
e
li
n
e
D
M
F
S
s
c
o
re
(
u
s
e
fu
l
p
re
d
ic
to
r)
;
R
F
:
to
o
th
b
ru
s
h
in
g
fr
e
q
u
e
n
c
y
D
M
F
S
i
n
c
re
m
e
n
t
�
3
M
W
,
W
,
M
L
R
2
V
B
:
C
a
ri
e
s
(
c
a
v
it
a
ti
o
n
le
v
e
l)
,
p
la
q
u
e
s
c
o
re
(
Q
u
ig
le
y
a
n
d
H
e
in
i
n
d
e
x
),
fl
u
o
ro
s
is
s
c
o
re
(
T
F
i
n
d
e
x
),
i
n
o
rg
a
n
ic
c
o
m
p
o
u
n
d
s
i
n
d
e
n
ta
l
p
la
q
u
e
(
s
u
p
ra
g
in
g
iv
a
l
p
la
q
u
e
c
o
ll
e
c
ti
o
n
f
ro
m
b
u
c
c
a
l
a
n
d
l
in
g
u
a
l
s
u
rf
a
c
e
s
a
ft
e
r
3
d
a
y
s
w
it
h
n
o
o
ra
l
h
y
g
ie
n
e
),
to
o
th
b
ru
s
h
in
g
fr
e
q
u
e
n
c
y
,
s
n
a
c
k
s
u
s
e
,
p
a
re
n
ts
‘
o
c
c
u
p
a
ti
o
n
E
X
:
C
h
il
d
s
e
a
te
d
i
n
a
n
u
p
ri
g
h
t
c
h
a
ir
,
a
d
e
q
u
a
te
i
ll
u
m
in
a
ti
o
n
,
s
h
a
rp
p
ro
b
e
1
2
1
7
5
/1
6
4
P
e
a
rc
e
e
t
a
l.
3
7
,
2
0
0
2
(
B
e
ij
in
g
),
C
h
in
a
N
o
s
ta
ti
s
ti
c
a
ll
y
s
ig
n
if
ic
a
n
t
p
re
d
ic
to
r
(p
>
0
.0
5
)
C
a
ri
e
s
i
n
c
re
m
e
n
t
C
A
,
M
L
R
4
V
B
:
C
a
ri
e
s
(
in
c
ip
ie
n
t
+
c
a
v
it
a
te
d
le
s
io
n
s
+
f
il
li
n
g
s
),
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
-
M
S
a
n
d
l
a
c
to
b
a
c
il
li
(
L
B
)
c
o
u
n
ts
(s
ti
m
u
la
te
d
s
a
li
v
a
)
E
X
:
V
is
u
a
l
o
b
s
e
rv
a
ti
o
n
,
d
ri
e
d
s
u
rf
a
c
e
s
,
d
e
n
ta
l
la
m
p
,
s
m
a
ll
m
o
u
th
-l
ig
h
t,
r
a
d
io
g
ra
p
h
s
7
.5
6
9
/6
2
v
a
n
P
a
le
n
s
te
in
H
e
ld
e
rm
a
n
e
t
a
l.
3
6
,
2
0
0
1
(C
u
le
m
b
o
rg
),
T
h
e
N
e
th
e
rl
a
n
d
s
R
P
:
n
u
m
b
e
r
o
f
c
a
v
it
a
te
d
a
n
d
n
o
n
-c
a
v
it
a
te
d
fi
s
s
u
re
s
o
f
th
e
n
e
w
ly
e
ru
p
te
d
p
e
rm
a
n
e
n
t
fi
rs
t
m
o
la
r
H
ig
h
c
a
ri
e
s
i
n
c
re
m
e
n
t
(�
D
3
s
u
rf
a
c
e
s
>
0
;
>
2
;
>
4
,
>
7
)
C
A
,
M
L
R
,
R
O
C
8
V
B
:
C
a
ri
e
s
(
n
o
n
c
a
v
it
a
te
d
a
n
d
c
a
v
it
a
te
d
c
a
ri
e
s
,
fi
ll
in
g
)
a
n
d
s
e
a
la
n
ts
E
X
:
V
is
u
a
l
e
x
a
m
in
a
ti
o
n
,
d
e
n
ta
l
p
ro
b
e
,
d
e
n
ta
l
la
m
p
a
n
d
s
m
a
ll
m
o
u
th
-l
ig
h
t,
b
it
e
w
in
g
r
a
d
io
g
ra
p
h
s
7
.5
3
1
8
/2
8
7
v
a
n
P
a
le
n
s
te
in
H
e
ld
e
rm
a
n
e
t
a
l.
3
5
,
2
0
0
1
(
T
ie
l,
C
u
le
m
b
o
rg
)
T
h
e
N
e
th
e
rl
a
n
d
s
R
P
:
d
m
fs
,
e
d
u
c
a
ti
o
n
a
l
s
y
s
te
m
;
R
F
:
fr
e
q
u
e
n
c
y
o
f
b
ru
s
h
in
g
,
d
a
il
y
u
s
e
o
f
s
u
g
a
r
-c
o
n
ta
in
in
g
d
ri
n
k
s
D
M
F
S
i
n
c
re
m
e
n
t
�
2
o
n
p
e
rm
a
n
e
n
t
1
s
t
m
o
la
rs
M
L
R
,
S
n
,
S
p
,
R
O
C
,
C
S
3
V
B
:
C
a
ri
e
s
(
B
A
S
C
D
c
ri
te
ri
a
–
c
a
v
it
a
ti
o
n
le
v
e
l)
,
o
ra
l
h
y
g
ie
n
e
(
S
il
n
e
s
s
a
n
d
L
ö
e
’s
p
la
q
u
e
i
n
d
e
x
a
n
d
p
la
q
u
e
in
d
e
x
o
n
o
c
c
lu
s
a
l
s
u
rf
a
c
e
s
–
C
a
rv
a
lh
o
’s
in
d
e
x
),
e
ru
p
ti
o
n
s
ta
g
e
,
q
u
e
s
ti
o
n
n
a
ir
e
(
o
ra
l
h
y
g
ie
n
e
,
d
ie
ta
ry
h
a
b
it
s
,
fl
u
o
ri
d
e
e
x
p
o
s
u
re
,
a
c
c
e
s
s
t
o
o
ra
l
h
e
a
lt
h
c
a
re
s
e
rv
ic
e
s
,
m
e
d
ic
a
l
h
is
to
ry
,
s
o
c
io
e
c
o
n
o
m
ic
l
e
v
e
l)
E
X
:
M
o
b
il
e
d
e
n
ta
l
c
li
n
ic
,
W
H
O
/C
P
IT
N
p
ro
b
e
7
3
3
0
3
/3
0
0
2
V
a
n
o
b
b
e
rg
e
n
e
t
a
l.
3
4
,
2
0
0
1
(F
la
n
d
e
rs
),
B
e
lg
iu
m
M
e
a
n
c
a
ri
e
s
i
n
c
re
m
e
n
t:
0
.4
5
d
m
ft
/D
M
F
T
R
P
:
m
o
th
e
r
’s
p
re
v
io
u
s
c
a
ri
e
s
(
d
e
c
id
u
o
u
s
t
e
e
th
);
R
F
:
to
o
th
b
ru
s
h
in
g
o
n
ly
o
c
c
a
s
io
n
a
ll
y
,
c
h
il
d
f
re
q
u
e
n
t
u
s
e
o
f
s
w
e
e
ts
a
n
d
c
h
il
d
’s
b
e
d
ti
m
e
a
ft
e
r
9
p
.
m
.
(p
e
rm
a
n
e
n
t
te
e
th
),
e
a
t
s
w
e
e
ts
f
re
q
u
e
n
tl
y
a
t
3
y
e
a
rs
o
f
a
g
e
(
b
o
th
d
e
n
ti
ti
o
n
s
)
C
a
ri
e
s
i
n
c
re
m
e
n
t
C
S
,
M
L
R
3
V
B
:
C
a
ri
e
s
(
D
M
F
T
/
d
m
ft
),
q
u
e
s
ti
o
n
n
a
ir
e
(
s
o
c
io
e
c
o
n
o
m
ic
,
d
e
m
o
g
ra
p
h
ic
,
fa
m
il
y
f
a
c
to
rs
,
d
i
e
t,
d
e
n
ta
l
h
y
g
ie
n
e
,
p
a
re
n
ts
’
o
w
n
e
a
rl
ie
r
d
e
n
ta
l
h
e
a
lt
h
h
a
b
it
s
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p
a
re
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ts
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re
v
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u
s
d
e
n
ta
l
h
e
a
lt
h
,
c
h
il
d
re
n
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e
a
s
e
s
a
n
d
p
h
y
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ic
a
l
s
y
m
p
to
m
s
)
E
X
:
M
ir
ro
r,
p
ro
b
e
,
fi
b
e
r
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p
ti
c
l
ig
h
t
7
1
0
7
4
M
a
tt
il
a
e
t
a
l.
3
3
,
2
0
0
1
(
T
u
rk
u
),
F
in
la
n
d
R
P
:
p
re
s
e
n
c
e
o
f
d
e
c
a
y
e
d
t
e
e
th
a
n
d
d
e
c
a
lc
if
ic
a
ti
o
n
s
(
m
o
s
t
s
ig
n
if
ic
a
n
t)
;
R
F
:
d
ie
ta
ry
f
a
c
to
rs
,
p
o
o
r
o
ra
l
h
y
g
ie
n
e
C
u
m
u
la
ti
v
e
f
u
tu
re
c
a
ri
e
s
le
s
io
n
s
(
h
ig
h
r
is
k
:
�
5
n
e
w
s
u
rf
a
c
e
l
e
s
io
n
s
)
C
S
,
M
L
R
,
A
N
O
V
A
2
.5
V
B
:
C
h
a
rt
s
o
f
p
a
ti
e
n
ts
c
o
n
ta
in
in
g
:
m
e
d
ic
a
l,
d
e
n
ta
l
a
n
d
f
lu
o
ri
d
e
h
i
s
to
ry
,
d
ie
t,
o
ra
l
h
y
g
ie
n
e
,
re
te
n
ti
v
e
p
it
s
a
n
d
f
is
s
u
re
s
,
e
x
is
ti
n
g
r
e
s
to
ra
ti
o
n
s
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n
e
w
ly
e
ru
p
te
d
t
e
e
th
,
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a
ri
e
s
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e
c
a
lc
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ic
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ti
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n
s
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u
lp
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s
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b
s
c
e
s
s
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g
in
g
iv
it
is
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ro
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d
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g
,
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e
h
a
v
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r,
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g
e
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g
e
n
d
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r
E
X
:
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ri
a
b
le
s
c
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ll
e
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te
d
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t
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ti
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n
t
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h
a
rt
s
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re
tr
o
s
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e
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ti
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e
l
o
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g
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u
d
in
a
l
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y
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1
1
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0
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n
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ra
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t
a
l.
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2
,
2
0
0
0
(
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ic
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ig
a
n
),
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S
A
R
P
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p
in
e
p
h
ri
n
e
l
e
v
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ls
C
a
ri
e
s
i
n
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re
m
e
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t
S
t,
L
iR
A
,
M
L
R
1
V
B
:
C
a
ri
e
s
(
D
M
F
/
d
m
f)
,
d
e
n
ta
l
p
la
q
u
e
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a
te
c
h
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la
m
in
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t
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e
s
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m
p
le
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o
d
y
w
e
ig
h
t,
p
a
re
n
ta
l
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g
e
,
e
d
u
c
a
ti
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n
a
n
d
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ro
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s
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n
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m
e
d
ic
a
l
h
is
to
ry
a
n
d
m
e
d
ic
a
ti
o
n
s
E
X
:
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it
e
w
in
g
r
a
d
io
g
ra
p
h
s
6
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3
1
4
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7
0
V
a
n
d
e
ra
s
e
t
a
l.
3
1
,
2
0
0
0
,
G
re
e
c
e
M
e
a
n
c
a
ri
e
s
i
n
c
re
m
e
n
t:
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8
t
e
e
th
T
h
e
m
o
re
o
ft
e
n
t
h
e
M
S
t
e
s
t
p
o
s
it
iv
e
,
th
e
h
ig
h
e
r
th
e
p
ro
p
o
rt
io
n
o
f
c
h
il
d
re
n
w
h
o
d
e
v
e
lo
p
e
d
c
a
ri
e
s
l
e
s
io
n
R
P
:
fl
u
o
ri
d
e
;
R
F
:
M
S
D
M
F
T
in
c
re
m
e
n
t
�
1
C
S
,
S
n
,
S
p
,
P
V
,
M
L
R
,
C
A
2
V
B
:
C
a
ri
e
s
(
W
H
O
c
ri
te
ri
a
),
p
la
q
u
e
i
n
d
e
x
(
S
il
n
e
s
s
a
n
d
L
ö
e
),
m
ic
ro
b
io
lo
g
ic
a
l
a
n
a
ly
s
is
o
f
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
-
M
S
,
(n
o
n
-s
ti
m
u
la
te
d
s
a
li
v
a
s
a
m
p
le
s
),
q
u
e
s
ti
o
n
n
a
ir
e
(
s
u
c
ro
s
e
i
n
ta
k
e
,
fl
u
o
r
id
e
e
x
p
o
s
u
re
)
E
X
:
C
li
n
ic
a
l
e
x
a
m
in
a
ti
o
n
,
v
is
u
a
l
in
s
p
e
c
ti
o
n
,
b
it
e
w
in
g
r
a
d
io
g
ra
p
h
s
6
-7
3
1
4
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0
4
(C
a
ri
e
s
-
fr
e
e
)
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e
tt
i
a
n
d
H
a
u
s
e
n
1
5
,
2
0
0
0
(R
o
m
e
),
I
ta
ly
M
e
a
n
c
a
ri
e
s
i
n
c
id
e
n
c
e
:
0
.6
9
D
M
F
S
S
ig
n
if
ic
a
n
t
c
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
i
n
it
ia
l
M
S
s
c
o
re
s
a
n
d
c
a
ri
e
s
d
e
v
e
lo
p
m
e
n
t
C
a
ri
e
s
d
e
v
e
lo
p
m
e
n
t
C
A
,
K
W
,
M
W
,
S
n
,
S
p
2
V
B
:
C
a
ri
e
s
(
D
M
F
S
/
d
m
fs
–
W
H
O
c
ri
te
ri
a
,
in
it
ia
l
le
s
io
n
s
),
s
e
a
la
n
ts
f
o
r
a
ll
m
o
la
r
fi
s
s
u
re
s
,
o
c
c
lu
s
a
l
p
la
q
u
e
s
a
m
p
le
s
f
ro
m
t
e
e
th
1
6
a
n
d
3
6
(
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
te
s
ts
),
p
la
q
u
e
i
n
d
e
x
(
Q
u
ig
le
y
-H
e
in
)
E
X
:
E
x
p
lo
re
r
w
it
h
o
u
t
p
re
s
s
u
re
,
li
g
h
t
s
o
u
rc
e
6
-7
2
3
0
/1
6
9
S
p
li
e
th
a
n
d
B
e
rn
h
a
rd
t
3
0
,
1
9
9
9
,
G
e
rm
a
n
y
M
e
a
n
c
a
ri
e
s
i
n
c
re
m
e
n
t:
0
.9
5
D
M
F
S
C
a
ri
e
s
i
n
c
re
m
e
n
t:
n
e
g
a
ti
v
e
c
o
rr
e
la
ti
o
n
s
w
it
h
b
a
s
e
li
n
e
la
c
to
fe
rr
in
,
to
ta
l
Ig
G
a
n
d
t
o
ta
l
a
n
a
e
ro
b
e
s
;
p
o
s
it
iv
e
c
o
rr
e
la
ti
o
n
w
it
h
s
p
e
c
if
ic
a
n
ti
-S
.
m
u
ta
n
s
,
Ig
G
a
n
ti
b
o
d
y
l
e
v
e
ls
,
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i,
l
a
c
to
b
a
c
il
li
a
n
d
s
p
e
c
if
ic
a
n
ti
-S
.
m
u
ta
n
s
Ig
G
.
C
h
il
d
re
n
w
it
h
s
ig
n
if
ic
a
n
tl
y
h
ig
h
e
r
b
a
s
e
li
n
e
c
o
n
c
e
n
tr
a
ti
o
n
s
o
f
h
y
p
o
th
io
c
y
a
n
it
e
,
to
ta
l
Ig
G
a
n
ti
b
o
d
ie
s
a
n
d
t
o
ta
l
a
n
a
e
ro
b
e
s
:
n
o
n
e
w
c
a
ri
e
s
l
e
s
io
n
s
D
M
F
i
n
c
re
m
e
n
t
>
0
S
t,
C
A
2
V
B
:
C
a
ri
e
s
(
D
M
F
/
d
m
f
-
W
H
O
c
ri
te
ri
a
,
w
h
it
e
s
p
o
ts
l
e
s
io
n
s
),
p
e
ri
o
d
o
n
ta
l
s
ta
tu
s
(
b
le
e
d
in
g
a
n
d
c
a
lc
u
lu
s
),
u
s
a
g
e
o
f
fl
u
o
ri
d
a
te
d
d
e
n
ti
fr
ic
e
s
,
s
a
li
v
a
s
a
m
p
le
s
(
b
u
ff
e
r
c
a
p
a
c
it
y
,
h
y
p
o
th
io
c
y
a
n
it
e
a
s
s
a
y
,
to
ta
l
s
tr
e
p
to
c
o
c
c
i
a
n
d
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i,
la
c
to
fe
rr
in
a
n
d
ly
s
o
z
y
m
e
a
n
a
ly
s
is
,
a
g
g
lu
ti
n
a
ti
o
n
a
s
s
a
y
,
to
ta
l
s
a
li
v
a
ry
p
e
ro
x
id
a
s
e
a
c
ti
v
it
y
,
to
ta
l
a
n
d
s
p
e
c
if
ic
Ig
A
a
n
d
Ig
G
a
n
ti
b
o
d
ie
s
)
E
X
:
V
is
u
a
l
-t
a
c
ti
le
m
e
th
o
d
+
F
O
T
I
1
2
6
9
/6
3
K
ir
s
ti
lä
e
t
a
l.
2
9
,
1
9
9
8
(
T
u
rk
u
),
F
in
la
n
d
M
a
in
r
e
s
u
lt
s
R
P
/R
F
§
O
u
tc
o
m
e
V
a
ri
a
b
le
D
a
ta
A
n
a
ly
s
is
¶
T
im
e
‡
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
b
a
s
e
li
n
e
(
V
B
)
E
x
a
m
in
a
ti
o
n
(
E
X
)
A
g
e
†
S
a
m
p
le
*
A
u
th
o
r
,
y
e
a
r
a
n
d
lo
c
a
l
1686
T
a
b
le
3
-
R
ev
ie
w
o
f
li
te
ra
tu
re
o
n
c
ar
ie
s
ri
sk
a
ss
es
sm
en
t
in
s
ch
o
o
lc
h
il
d
re
n
(
6
-1
2
y
ea
rs
o
ld
)
o
v
er
t
h
e
la
st
1
0
y
ea
rs
(
1
9
9
7
-2
0
0
7
)
Braz J Oral Sci. 7(27):1682-1690 An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007)
S
ig
n
if
ic
a
n
t,
b
u
t
w
e
a
k
,
c
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
M
S
c
o
u
n
ts
a
n
d
c
a
ri
e
s
R
P
:
p
a
s
t
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
C
a
ri
e
s
i
n
c
re
m
e
n
t
(d
e
n
ti
n
le
v
e
l)
C
A
,
M
R
A
2
V
B
:
C
a
ri
e
s
(
e
n
a
m
e
l
+
d
e
n
ti
n
l
e
s
io
n
s
),
M
u
ta
n
s
S
tr
e
p
to
c
o
c
c
i
(M
S
)
c
o
u
n
ts
i
n
s
a
li
v
a
E
X
:
T
e
e
th
d
ri
e
d
,
fi
b
e
r
-o
p
ti
c
l
ig
h
t
o
n
a
m
o
u
th
m
ir
ro
r,
d
e
n
ta
l
p
ro
b
e
(
re
m
o
v
a
l
o
f
p
la
q
u
e
,
d
e
te
c
ti
o
n
o
f
fi
s
s
u
re
s
e
a
la
n
ts
)
6
-7
6
5
0
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3
3
Z
h
a
n
g
e
t
a
l.
4
5
,
2
0
0
7
(
W
u
h
a
n
),
C
h
in
a
T
o
ta
l
D
M
F
T
in
c
re
m
e
n
t:
0
.5
2
R
P
:
c
a
ri
e
s
i
n
p
e
rm
a
n
e
n
t
m
o
la
rs
,
D
M
F
T
,
c
a
ri
e
s
s
e
v
e
ri
ty
D
M
F
T
�
1
i
n
c
re
m
e
n
t
C
S
,
M
W
,
K
W
,
C
A
,
W
,
M
R
A
2
V
B
:
C
a
ri
e
s
(
D
M
F
T
,
d
m
ft
–
W
H
O
c
ri
te
ri
a
,
c
a
ri
e
s
i
n
a
n
y
f
ir
s
t
p
e
rm
a
n
e
n
t
m
o
la
r,
c
a
ri
e
s
i
n
a
n
y
p
e
rm
a
n
e
n
t
u
p
p
e
r
m
o
la
rs
,
c
a
ri
e
s
i
n
a
n
y
p
e
rm
a
n
e
n
t
lo
w
e
r
m
o
la
rs
,
c
a
ri
e
s
s
e
v
e
r
it
y
),
a
g
e
,
g
e
n
d
e
r
E
X
:
D
e
n
ta
l
m
ir
ro
r,
t
e
e
th
d
ri
e
d
w
it
h
g
a
u
z
e
,
n
a
tu
ra
l
d
a
y
li
g
h
t,
a
t
s
c
h
o
o
ls
6
-9
5
8
0
/4
5
2
V
a
ll
e
jo
s
-S
á
n
c
h
e
z
e
t
a
l.
4
4
,
2
0
0
6
(C
a
m
p
e
c
h
e
),
M
é
x
ic
o
M
e
a
n
D
M
F
S
i
n
c
re
m
e
n
t:
2
.6
3
R
P
:
d
m
fs
,
D
M
F
S
,
m
o
th
e
r
’s
e
d
u
c
a
ti
o
n
d
m
fs
>
0
:
h
ig
h
e
s
t
S
n
(6
9
%
)
D
M
F
S
>
0
:
h
ig
h
e
s
t
S
p
(
9
2
%
).
D
M
F
S
�
1
i
n
c
re
m
e
n
t
C
S
,
M
N
,
M
L
R
,
S
n
,
S
p
,
P
V
,
R
O
C
7
V
B
:
C
a
ri
e
s
(
D
M
F
/
d
m
f
-W
H
O
c
ri
te
ri
a
,
in
it
ia
l
c
a
ri
e
s
l
e
s
io
n
s
),
p
la
q
u
e
s
c
o
re
(
S
im
p
li
fi
e
d
O
ra
l
H
y
g
ie
n
e
I
n
d
e
x
),
d
e
n
ta
l
fl
u
o
ro
s
is
(D
e
a
n
i
n
d
e
x
),
q
u
e
s
ti
o
n
n
a
ir
e
(
to
o
th
b
ru
s
h
in
g
fr
e
q
u
e
n
c
y,
t
y
p
e
o
f
p
re
v
e
n
ti
v
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t
o
p
ic
a
l
m
e
th
o
d
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th
e
r’
s
a
n
d
m
o
th
e
r
’s
e
d
u
c
a
ti
o
n
a
l
le
v
e
l,
g
e
n
d
e
r,
r
a
c
e
,
n
u
m
b
e
r
o
f
w
o
rk
in
g
p
e
o
p
le
l
iv
i
n
g
i
n
t
h
e
h
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s
e
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o
ld
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m
o
n
th
ly
f
a
m
il
y
i
n
c
o
m
e
,
d
e
n
ta
l
v
is
it
s
i
n
t
h
e
y
e
a
r
p
ri
o
r
to
b
a
s
e
li
n
e
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re
a
s
o
n
f
o
r
d
e
n
ta
l
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is
it
,
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a
il
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s
u
g
a
r
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o
n
s
u
m
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ti
o
n
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u
m
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s
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g
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r
s
p
o
o
n
s
i
n
b
e
v
e
ra
g
e
s
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n
u
m
b
e
r
o
f
b
e
tw
e
e
n
-m
e
a
l
s
n
a
c
k
s
o
ra
l
h
y
g
ie
n
e
h
a
b
it
s
)
E
X
:
D
e
n
ta
l
p
ro
b
e
a
n
d
m
ir
ro
r,
u
n
d
e
r
n
a
tu
ra
l
li
g
h
t
in
o
u
td
o
o
r
s
e
tt
in
g
a
t
s
c
h
o
o
ls
6
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4
8
0
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0
6
T
a
g
li
a
fe
rr
o
e
t
a
l.
4
3
,
2
0
0
6
(P
ir
a
c
ic
a
b
a
),
B
ra
z
il
D
M
F
S
i
n
c
re
a
s
e
:
p
o
s
it
iv
e
ly
a
s
s
o
c
ia
te
d
w
it
h
d
m
fs
in
c
re
a
s
e
a
n
d
w
it
h
i
n
it
ia
l
c
a
ri
e
s
R
P
:
p
a
s
t
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
A
re
a
u
n
d
e
r
R
O
C
c
u
rv
e
:
7
6
%
C
a
ri
e
s
i
n
c
id
e
n
c
e
C
S
,
M
L
R
,
S
n
,
S
p
,
P
V
,
R
O
C
1
V
B
:
C
a
ri
e
s
(
d
m
fs
,
D
M
F
S
,
n
u
m
b
e
r
o
f
s
u
rf
a
c
e
s
w
it
h
i
n
it
ia
l
c
a
ri
e
s
,
n
º
o
f
s
u
rf
a
c
e
s
w
it
h
p
ri
m
a
ry
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n
d
s
e
c
o
n
d
a
ry
c
a
ri
e
s
,
n
u
m
b
e
r
o
f
fi
ll
e
d
s
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rf
a
c
e
s
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n
u
m
b
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o
f
s
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rf
a
c
e
s
m
is
s
in
g
d
u
e
t
o
c
a
ri
e
s
),
g
e
n
d
e
r,
y
e
a
r
o
f
b
ir
th
,
n
u
m
b
e
r
o
f
c
h
il
d
re
n
i
n
h
o
u
s
e
h
o
ld
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n
u
m
b
e
r
o
f
a
d
u
lt
s
i
n
h
o
u
s
e
h
o
ld
,
c
it
iz
e
n
s
h
ip
E
X
:
D
a
n
is
h
r
o
u
ti
n
e
d
e
n
ta
l
a
n
d
s
o
c
io
e
c
o
n
o
m
ic
r
e
g
is
te
rs
7
-
1
2
3
7
0
5
J
e
p
p
e
s
e
n
a
n
d
F
o
ld
s
p
a
n
g
4
2
,
2
0
0
6
(
A
a
rh
u
s
),
D
e
n
m
a
rk
M
e
a
n
c
a
ri
e
s
i
n
c
re
m
e
n
t:
4
.2
(
e
n
a
m
e
l
+
d
e
n
ti
n
a
l
le
s
io
n
s
)
H
ig
h
e
s
t
p
re
d
ic
ti
v
e
p
o
w
e
r:
p
ro
x
im
a
l
le
s
io
n
s
i
n
p
re
m
o
la
rs
a
n
d
s
e
c
o
n
d
m
o
la
rs
C
a
ri
e
s
(
d
e
n
ti
n
l
e
v
e
l)
in
c
re
m
e
n
t
o
n
p
ro
x
im
a
l
s
u
rf
a
c
e
s
(
D
F
S
>
0
,
1
,
2
,
3
a
n
d
4
)
S
t,
S
n
,
S
p
6
V
B
:
C
a
ri
e
s
(
e
n
a
m
e
l
+
d
e
n
ti
n
l
e
s
io
n
s
),
q
u
e
s
ti
o
n
n
a
ir
e
(
g
e
n
d
e
r,
m
o
th
e
r’
s
e
d
u
c
a
ti
o
n
)
E
X
:
T
e
e
th
p
o
li
s
h
e
d
a
n
d
d
ri
e
d
,
p
la
n
e
m
o
u
th
m
ir
ro
r,
p
ro
b
e
,
b
it
e
w
in
g
ra
d
io
g
ra
p
h
s
i
n
e
q
u
ip
p
e
d
d
e
n
ta
l
c
li
n
ic
s
1
2
1
5
9
/1
1
2
D
a
v
id
e
t
a
l.
4
1
,
2
0
0
6
(
B
e
rg
e
n
),
N
o
rw
a
y
R
P
:
g
e
n
d
e
r
(g
ir
ls
-
fo
r
lo
w
e
r
m
o
la
rs
),
c
a
v
it
y
e
x
p
e
ri
e
n
c
e
i
n
t
h
e
d
e
c
id
u
o
u
s
d
e
n
ti
ti
o
n
;
R
F
:
o
c
c
lu
s
a
l
p
la
q
u
e
a
c
c
u
m
u
la
ti
o
n
,
re
p
o
rt
e
d
b
ru
s
h
in
g
f
re
q
u
e
n
c
y
S
u
rv
iv
a
l
ti
m
e
o
f
a
P
F
M
S
A
6
V
B
:
C
a
ri
e
s
(
B
A
S
C
D
c
ri
te
ri
a
),
p
re
s
e
n
c
e
o
f
p
la
q
u
e
o
n
t
h
e
o
c
c
lu
s
a
l
s
u
rf
a
c
e
s
o
f
p
e
rm
a
n
e
n
t
fi
rs
t
m
o
la
rs
(P
F
M
),
t
im
in
g
o
f
to
o
th
e
m
e
rg
e
n
c
e
,
g
e
n
d
e
r ,
q
u
e
s
ti
o
n
n
a
ir
e
(
o
ra
l
h
y
g
ie
n
e
a
n
d
d
ie
ta
ry
h
a
b
it
s
)
E
X
:
V
is
u
a
l
in
s
p
e
c
ti
o
n
6
4
4
6
8
L
e
ro
y
e
t
a
l.
4
0
,
2
0
0
5
(
F
la
n
d
e
rs
),
B
e
lg
iu
m
R
P
:
P
re
s
e
n
c
e
o
f
c
a
ri
e
s
o
n
P
S
M
D
S
S
n
=
4
5
%
t
o
9
7
%
;
S
p
=
8
0
%
t
o
8
9
%
C
a
ri
e
s
i
n
c
id
e
n
c
e
o
n
m
e
s
ia
l
s
u
rf
a
c
e
s
o
f
p
e
rm
a
n
e
n
t
1
º
m
o
la
rs
(M
S
P
F
M
)
M
L
R
,
S
n
,
S
p
,
P
V
4
V
B
:
C
a
ri
e
s
(
p
re
s
e
n
c
e
o
f
c
a
ri
e
s
o
n
t
h
e
p
ri
m
a
ry
s
e
c
o
n
d
m
o
la
rs
’
d
is
ta
l
s
u
rf
a
c
e
s
-
P
S
M
D
S
),
a
g
e
,
g
e
n
d
e
r
E
X
:
B
it
e
w
in
g
r
a
d
io
g
ra
p
h
s
6
-8
3
1
4
/1
9
6
V
a
n
d
e
ra
s
e
t
a
l.
3
9
,
2
0
0
4
,
G
re
e
c
e
R
F
:
H
ig
h
M
S
l
e
v
e
ls
L
o
w
M
S
l
e
v
e
ls
:
s
ig
n
if
ic
a
n
t
e
ff
e
c
t
o
n
t
h
e
l
o
n
g
e
r
s
u
rv
iv
a
l
ti
m
e
s
T
im
e
t
o
c
a
ri
e
s
o
n
s
e
t
S
A
,
W
6
V
B
:
C
a
ri
e
s
(
v
is
u
a
l
-t
a
c
ti
le
c
ri
te
ri
a
o
f
R
a
d
ik
e
),
m
ic
ro
b
io
lo
g
ic
a
l
(M
S
c
o
u
n
ts
i
n
w
h
o
le
s
ti
m
u
la
te
d
s
a
li
v
a
:
if
�
1
0
6
C
F
U
/m
l
h
ig
h
l
e
v
e
ls
o
f
M
S
)
E
X
:
F
ib
e
r
-o
p
ti
c
l
ig
h
ts
,
p
la
n
e
m
ir
ro
rs
,
#
2
3
e
x
p
lo
re
rs
(
c
le
a
n
in
g
o
f
s
u
rf
a
c
e
s
a
n
d
d
e
te
c
ti
n
g
o
f
s
e
a
la
n
ts
)
6
-7
4
6
4
*/
1
6
0
*c
a
ri
e
s
-
fr
e
e
K
o
p
y
c
k
a
-
K
e
d
z
ie
ra
w
s
k
i
a
n
d
B
il
li
n
g
s
1
6
,
2
0
0
4
(N
e
w
Y
o
rk
),
U
S
A
M
e
a
n
D
M
F
S
i
n
c
re
m
e
n
t:
1
.0
(
in
c
lu
d
in
g
e
n
a
m
e
l
le
s
io
n
=
1
.8
8
)
R
P
:
p
re
v
io
u
s
e
x
p
e
ri
e
n
c
e
o
f
c
a
ri
e
s
,
s
o
c
io
e
c
o
n
o
m
ic
l
e
v
e
l
C
a
ri
e
s
i
n
c
re
m
e
n
t
P
R
2
V
B
:
C
a
ri
e
s
(
D
M
F
+
e
n
a
m
e
l
c
a
ri
e
s
),
s
e
a
la
n
ts
,
q
u
e
s
ti
o
n
n
a
ir
e
(
e
th
n
ic
i
ty
,
re
s
id
e
n
ti
a
l
a
re
a
,
s
o
c
io
e
c
o
n
o
m
ic
le
v
e
l)
E
X
:
C
li
n
ic
a
l
s
e
tt
in
g
:
m
ir
ro
r,
g
o
o
d
o
p
e
ra
ti
n
g
l
ig
h
t,
c
o
m
p
re
s
s
e
d
a
ir
,
c
o
tt
o
n
r
o
ll
s
,
tw
o
b
it
e
w
in
g
s
r
a
d
io
g
ra
p
h
s
1
2
3
3
7
3
/3
1
0
7
K
ä
ll
e
s
t
å
l
a
n
d
W
a
ll
3
8
,
2
0
0
2
,
S
w
e
d
e
n
M
a
in
r
e
s
u
lt
s
R
P
/R
F
§
O
u
tc
o
m
e
V
a
ri
a
b
le
D
a
ta
A
n
a
ly
s
is
¶
T
im
e
‡
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
b
a
s
e
li
n
e
(
V
B
)
E
x
a
m
in
a
ti
o
n
(
E
X
)
A
g
e
†
S
a
m
p
le
*
A
u
th
o
r
,
y
e
a
r
a
n
d
lo
c
a
l
T
a
b
le
3
–
c
o
n
t.
S
ig
n
if
ic
a
n
t,
b
u
t
w
e
a
k
,
c
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
M
S
c
o
u
n
ts
a
n
d
c
a
ri
e
s
R
P
:
p
a
s
t
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
C
a
ri
e
s
i
n
c
re
m
e
n
t
(d
e
n
ti
n
le
v
e
l)
C
A
,
M
R
A
2
V
B
:
C
a
ri
e
s
(
e
n
a
m
e
l
+
d
e
n
ti
n
l
e
s
io
n
s
),
M
u
ta
n
s
S
tr
e
p
to
c
o
c
c
i
(M
S
)
c
o
u
n
ts
i
n
s
a
li
v
a
E
X
:
T
e
e
th
d
ri
e
d
,
fi
b
e
r
-o
p
ti
c
l
ig
h
t
o
n
a
m
o
u
th
m
ir
ro
r,
d
e
n
ta
l
p
ro
b
e
(
re
m
o
v
a
l
o
f
p
la
q
u
e
,
d
e
te
c
ti
o
n
o
f
fi
s
s
u
re
s
e
a
la
n
ts
)
6
-7
6
5
0
/4
3
3
Z
h
a
n
g
e
t
a
l.
4
5
,
2
0
0
7
(
W
u
h
a
n
),
C
h
in
a
T
o
ta
l
D
M
F
T
in
c
re
m
e
n
t:
0
.5
2
R
P
:
c
a
ri
e
s
i
n
p
e
rm
a
n
e
n
t
m
o
la
rs
,
D
M
F
T
,
c
a
ri
e
s
s
e
v
e
ri
ty
D
M
F
T
�
1
i
n
c
re
m
e
n
t
C
S
,
M
W
,
K
W
,
C
A
,
W
,
M
R
A
2
V
B
:
C
a
ri
e
s
(
D
M
F
T
,
d
m
ft
–
W
H
O
c
ri
te
ri
a
,
c
a
ri
e
s
i
n
a
n
y
f
ir
s
t
p
e
rm
a
n
e
n
t
m
o
la
r,
c
a
ri
e
s
i
n
a
n
y
p
e
rm
a
n
e
n
t
u
p
p
e
r
m
o
la
rs
,
c
a
ri
e
s
i
n
a
n
y
p
e
rm
a
n
e
n
t
lo
w
e
r
m
o
la
rs
,
c
a
ri
e
s
s
e
v
e
r
it
y
),
a
g
e
,
g
e
n
d
e
r
E
X
:
D
e
n
ta
l
m
ir
ro
r,
t
e
e
th
d
ri
e
d
w
it
h
g
a
u
z
e
,
n
a
tu
ra
l
d
a
y
li
g
h
t,
a
t
s
c
h
o
o
ls
6
-9
5
8
0
/4
5
2
V
a
ll
e
jo
s
-S
á
n
c
h
e
z
e
t
a
l.
4
4
,
2
0
0
6
(C
a
m
p
e
c
h
e
),
M
é
x
ic
o
M
e
a
n
D
M
F
S
i
n
c
re
m
e
n
t:
2
.6
3
R
P
:
d
m
fs
,
D
M
F
S
,
m
o
th
e
r
’s
e
d
u
c
a
ti
o
n
d
m
fs
>
0
:
h
ig
h
e
s
t
S
n
(6
9
%
)
D
M
F
S
>
0
:
h
ig
h
e
s
t
S
p
(
9
2
%
).
D
M
F
S
�
1
i
n
c
re
m
e
n
t
C
S
,
M
N
,
M
L
R
,
S
n
,
S
p
,
P
V
,
R
O
C
7
V
B
:
C
a
ri
e
s
(
D
M
F
/
d
m
f
-W
H
O
c
ri
te
ri
a
,
in
it
ia
l
c
a
ri
e
s
l
e
s
io
n
s
),
p
la
q
u
e
s
c
o
re
(
S
im
p
li
fi
e
d
O
ra
l
H
y
g
ie
n
e
I
n
d
e
x
),
d
e
n
ta
l
fl
u
o
ro
s
is
(D
e
a
n
i
n
d
e
x
),
q
u
e
s
ti
o
n
n
a
ir
e
(
to
o
th
b
ru
s
h
in
g
fr
e
q
u
e
n
c
y,
t
y
p
e
o
f
p
re
v
e
n
ti
v
e
t
o
p
ic
a
l
m
e
th
o
d
,
fa
th
e
r’
s
a
n
d
m
o
th
e
r
’s
e
d
u
c
a
ti
o
n
a
l
le
v
e
l,
g
e
n
d
e
r,
r
a
c
e
,
n
u
m
b
e
r
o
f
w
o
rk
in
g
p
e
o
p
le
l
iv
i
n
g
i
n
t
h
e
h
o
u
s
e
h
o
ld
,
m
o
n
th
ly
f
a
m
il
y
i
n
c
o
m
e
,
d
e
n
ta
l
v
is
it
s
i
n
t
h
e
y
e
a
r
p
ri
o
r
to
b
a
s
e
li
n
e
,
re
a
s
o
n
f
o
r
d
e
n
ta
l
v
is
it
,
d
a
il
y
s
u
g
a
r
c
o
n
s
u
m
p
ti
o
n
,
n
u
m
b
e
r
o
f
s
u
g
a
r
s
p
o
o
n
s
i
n
b
e
v
e
ra
g
e
s
,
n
u
m
b
e
r
o
f
b
e
tw
e
e
n
-m
e
a
l
s
n
a
c
k
s
o
ra
l
h
y
g
ie
n
e
h
a
b
it
s
)
E
X
:
D
e
n
ta
l
p
ro
b
e
a
n
d
m
ir
ro
r,
u
n
d
e
r
n
a
tu
ra
l
li
g
h
t
in
o
u
td
o
o
r
s
e
tt
in
g
a
t
s
c
h
o
o
ls
6
-8
4
8
0
/2
0
6
T
a
g
li
a
fe
rr
o
e
t
a
l.
4
3
,
2
0
0
6
(P
ir
a
c
ic
a
b
a
),
B
ra
z
il
D
M
F
S
i
n
c
re
a
s
e
:
p
o
s
it
iv
e
ly
a
s
s
o
c
ia
te
d
w
it
h
d
m
fs
in
c
re
a
s
e
a
n
d
w
it
h
i
n
it
ia
l
c
a
ri
e
s
R
P
:
p
a
s
t
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
A
re
a
u
n
d
e
r
R
O
C
c
u
rv
e
:
7
6
%
C
a
ri
e
s
i
n
c
id
e
n
c
e
C
S
,
M
L
R
,
S
n
,
S
p
,
P
V
,
R
O
C
1
V
B
:
C
a
ri
e
s
(
d
m
fs
,
D
M
F
S
,
n
u
m
b
e
r
o
f
s
u
rf
a
c
e
s
w
it
h
i
n
it
ia
l
c
a
ri
e
s
,
n
º
o
f
s
u
rf
a
c
e
s
w
it
h
p
ri
m
a
ry
a
n
d
s
e
c
o
n
d
a
ry
c
a
ri
e
s
,
n
u
m
b
e
r
o
f
fi
ll
e
d
s
u
rf
a
c
e
s
,
n
u
m
b
e
r
o
f
s
u
rf
a
c
e
s
m
is
s
in
g
d
u
e
t
o
c
a
ri
e
s
),
g
e
n
d
e
r,
y
e
a
r
o
f
b
ir
th
,
n
u
m
b
e
r
o
f
c
h
il
d
re
n
i
n
h
o
u
s
e
h
o
ld
,
n
u
m
b
e
r
o
f
a
d
u
lt
s
i
n
h
o
u
s
e
h
o
ld
,
c
it
iz
e
n
s
h
ip
E
X
:
D
a
n
is
h
r
o
u
ti
n
e
d
e
n
ta
l
a
n
d
s
o
c
io
e
c
o
n
o
m
ic
r
e
g
is
te
rs
7
-
1
2
3
7
0
5
J
e
p
p
e
s
e
n
a
n
d
F
o
ld
s
p
a
n
g
4
2
,
2
0
0
6
(
A
a
rh
u
s
),
D
e
n
m
a
rk
M
e
a
n
c
a
ri
e
s
i
n
c
re
m
e
n
t:
4
.2
(
e
n
a
m
e
l
+
d
e
n
ti
n
a
l
le
s
io
n
s
)
H
ig
h
e
s
t
p
re
d
ic
ti
v
e
p
o
w
e
r:
p
ro
x
im
a
l
le
s
io
n
s
i
n
p
re
m
o
la
rs
a
n
d
s
e
c
o
n
d
m
o
la
rs
C
a
ri
e
s
(
d
e
n
ti
n
l
e
v
e
l)
in
c
re
m
e
n
t
o
n
p
ro
x
im
a
l
s
u
rf
a
c
e
s
(
D
F
S
>
0
,
1
,
2
,
3
a
n
d
4
)
S
t,
S
n
,
S
p
6
V
B
:
C
a
ri
e
s
(
e
n
a
m
e
l
+
d
e
n
ti
n
l
e
s
io
n
s
),
q
u
e
s
ti
o
n
n
a
ir
e
(
g
e
n
d
e
r,
m
o
th
e
r’
s
e
d
u
c
a
ti
o
n
)
E
X
:
T
e
e
th
p
o
li
s
h
e
d
a
n
d
d
ri
e
d
,
p
la
n
e
m
o
u
th
m
ir
ro
r,
p
ro
b
e
,
b
it
e
w
in
g
ra
d
io
g
ra
p
h
s
i
n
e
q
u
ip
p
e
d
d
e
n
ta
l
c
li
n
ic
s
1
2
1
5
9
/1
1
2
D
a
v
id
e
t
a
l.
4
1
,
2
0
0
6
(
B
e
rg
e
n
),
N
o
rw
a
y
R
P
:
g
e
n
d
e
r
(g
ir
ls
-
fo
r
lo
w
e
r
m
o
la
rs
),
c
a
v
it
y
e
x
p
e
ri
e
n
c
e
i
n
t
h
e
d
e
c
id
u
o
u
s
d
e
n
ti
ti
o
n
;
R
F
:
o
c
c
lu
s
a
l
p
la
q
u
e
a
c
c
u
m
u
la
ti
o
n
,
re
p
o
rt
e
d
b
ru
s
h
in
g
f
re
q
u
e
n
c
y
S
u
rv
iv
a
l
ti
m
e
o
f
a
P
F
M
S
A
6
V
B
:
C
a
ri
e
s
(
B
A
S
C
D
c
ri
te
ri
a
),
p
re
s
e
n
c
e
o
f
p
la
q
u
e
o
n
t
h
e
o
c
c
lu
s
a
l
s
u
rf
a
c
e
s
o
f
p
e
rm
a
n
e
n
t
fi
rs
t
m
o
la
rs
(P
F
M
),
t
im
in
g
o
f
to
o
th
e
m
e
rg
e
n
c
e
,
g
e
n
d
e
r ,
q
u
e
s
ti
o
n
n
a
ir
e
(
o
ra
l
h
y
g
ie
n
e
a
n
d
d
ie
ta
ry
h
a
b
it
s
)
E
X
:
V
is
u
a
l
in
s
p
e
c
ti
o
n
6
4
4
6
8
L
e
ro
y
e
t
a
l.
4
0
,
2
0
0
5
(
F
la
n
d
e
rs
),
B
e
lg
iu
m
R
P
:
P
re
s
e
n
c
e
o
f
c
a
ri
e
s
o
n
P
S
M
D
S
S
n
=
4
5
%
t
o
9
7
%
;
S
p
=
8
0
%
t
o
8
9
%
C
a
ri
e
s
i
n
c
id
e
n
c
e
o
n
m
e
s
ia
l
s
u
rf
a
c
e
s
o
f
p
e
rm
a
n
e
n
t
1
º
m
o
la
rs
(M
S
P
F
M
)
M
L
R
,
S
n
,
S
p
,
P
V
4
V
B
:
C
a
ri
e
s
(
p
re
s
e
n
c
e
o
f
c
a
ri
e
s
o
n
t
h
e
p
ri
m
a
ry
s
e
c
o
n
d
m
o
la
rs
’
d
is
ta
l
s
u
rf
a
c
e
s
-
P
S
M
D
S
),
a
g
e
,
g
e
n
d
e
r
E
X
:
B
it
e
w
in
g
r
a
d
io
g
ra
p
h
s
6
-8
3
1
4
/1
9
6
V
a
n
d
e
ra
s
e
t
a
l.
3
9
,
2
0
0
4
,
G
re
e
c
e
R
F
:
H
ig
h
M
S
l
e
v
e
ls
L
o
w
M
S
l
e
v
e
ls
:
s
ig
n
if
ic
a
n
t
e
ff
e
c
t
o
n
t
h
e
l
o
n
g
e
r
s
u
rv
iv
a
l
ti
m
e
s
T
im
e
t
o
c
a
ri
e
s
o
n
s
e
t
S
A
,
W
6
V
B
:
C
a
ri
e
s
(
v
is
u
a
l
-t
a
c
ti
le
c
ri
te
ri
a
o
f
R
a
d
ik
e
),
m
ic
ro
b
io
lo
g
ic
a
l
(M
S
c
o
u
n
ts
i
n
w
h
o
le
s
ti
m
u
la
te
d
s
a
li
v
a
:
if
�
1
0
6
C
F
U
/m
l
h
ig
h
l
e
v
e
ls
o
f
M
S
)
E
X
:
F
ib
e
r
-o
p
ti
c
l
ig
h
ts
,
p
la
n
e
m
ir
ro
rs
,
#
2
3
e
x
p
lo
re
rs
(
c
le
a
n
in
g
o
f
s
u
rf
a
c
e
s
a
n
d
d
e
te
c
ti
n
g
o
f
s
e
a
la
n
ts
)
6
-7
4
6
4
*/
1
6
0
*c
a
ri
e
s
-
fr
e
e
K
o
p
y
c
k
a
-
K
e
d
z
ie
ra
w
s
k
i
a
n
d
B
il
li
n
g
s
1
6
,
2
0
0
4
(N
e
w
Y
o
rk
),
U
S
A
M
e
a
n
D
M
F
S
i
n
c
re
m
e
n
t:
1
.0
(
in
c
lu
d
in
g
e
n
a
m
e
l
le
s
io
n
=
1
.8
8
)
R
P
:
p
re
v
io
u
s
e
x
p
e
ri
e
n
c
e
o
f
c
a
ri
e
s
,
s
o
c
io
e
c
o
n
o
m
ic
l
e
v
e
l
C
a
ri
e
s
i
n
c
re
m
e
n
t
P
R
2
V
B
:
C
a
ri
e
s
(
D
M
F
+
e
n
a
m
e
l
c
a
ri
e
s
),
s
e
a
la
n
ts
,
q
u
e
s
ti
o
n
n
a
ir
e
(
e
th
n
ic
i
ty
,
re
s
id
e
n
ti
a
l
a
re
a
,
s
o
c
io
e
c
o
n
o
m
ic
le
v
e
l)
E
X
:
C
li
n
ic
a
l
s
e
tt
in
g
:
m
ir
ro
r,
g
o
o
d
o
p
e
ra
ti
n
g
l
ig
h
t,
c
o
m
p
re
s
s
e
d
a
ir
,
c
o
tt
o
n
r
o
ll
s
,
tw
o
b
it
e
w
in
g
s
r
a
d
io
g
ra
p
h
s
1
2
3
3
7
3
/3
1
0
7
K
ä
ll
e
s
t
å
l
a
n
d
W
a
ll
3
8
,
2
0
0
2
,
S
w
e
d
e
n
M
a
in
r
e
s
u
lt
s
R
P
/R
F
§
O
u
tc
o
m
e
V
a
ri
a
b
le
D
a
ta
A
n
a
ly
s
is
¶
T
im
e
‡
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
b
a
s
e
li
n
e
(
V
B
)
E
x
a
m
in
a
ti
o
n
(
E
X
)
A
g
e
†
S
a
m
p
le
*
A
u
th
o
r
,
y
e
a
r
a
n
d
lo
c
a
l
T
a
b
le
3
–
c
o
n
t.
1687
*
S
am
p
le
s
iz
e
at
i
n
it
ia
l/
fi
n
al
e
x
am
in
at
io
n
;
†
A
g
e
at
b
as
el
in
e
(y
ea
rs
);
‡
S
tu
d
y
l
as
ti
n
g
(
y
ea
rs
);
¶
S
ta
ti
st
ic
al
t
es
ts
:
A
N
O
V
A
=
A
n
al
y
si
s
o
f
V
ar
ia
n
ce
;
C
A
=
C
o
rr
el
at
io
n
a
n
al
y
si
s;
C
S
=
C
h
i-
sq
u
ar
e;
K
W
=
K
ru
sk
al
l
W
al
li
s;
L
iR
A
=
L
in
ea
r
re
g
re
ss
io
n
a
n
al
y
si
s;
M
L
R
=
M
u
lt
ip
le
l
o
g
is
ti
c
re
g
re
ss
io
n
;
M
N
=
M
cN
em
ar
;
M
R
A
=
M
u
lt
ip
le
r
eg
re
ss
io
n
a
n
al
y
si
s;
M
W
=
M
an
n
-W
h
it
n
ey
;
P
R
=
P
o
is
so
n
R
eg
re
ss
io
n
;
P
V
=
P
re
d
ic
ti
v
e
v
al
u
es
;
R
O
C
=
R
ec
ei
v
er
o
p
er
at
o
r
ch
ar
ac
te
ri
st
ic
c
u
rv
es
;
S
A
=
S
u
rv
iv
al
A
n
al
y
si
s;
S
n
=
S
en
si
ti
v
it
y
;
S
p
=
S
p
ec
if
ic
it
y
;
S
t=
S
tu
d
en
t’
s
t-
te
st
;
W
=
W
il
co
x
o
n
;
§
R
P
/R
F
:
R
is
k
p
re
d
ic
to
rs
/R
is
k
f
ac
to
rs
o
b
ta
in
ed
i
n
R
eg
re
ss
io
n
A
n
al
y
se
s
Braz J Oral Sci. 7(27):1682-1690 An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007)
1688
*
S
am
p
le
s
iz
e
at
i
n
it
ia
l/
fi
n
al
e
x
am
in
at
io
n
;
†
A
g
e
at
b
as
el
in
e
(y
ea
rs
);
‡
S
tu
d
y
l
as
ti
n
g
(
y
ea
rs
);
¶
S
ta
ti
st
ic
al
t
es
ts
:
A
N
O
V
A
=
A
n
al
y
si
s
o
f
V
ar
ia
n
ce
;
C
A
=
C
o
rr
el
at
io
n
a
n
al
y
si
s;
C
S
=
C
h
i-
sq
u
ar
e;
M
L
R
=
M
u
lt
ip
le
l
o
g
is
ti
c
re
g
re
ss
io
n
;
M
R
A
=
M
u
lt
ip
le
r
eg
re
ss
io
n
a
n
al
y
si
s;
M
W
=
M
an
n
-W
h
it
n
ey
;
P
R
=
P
o
is
so
n
R
eg
re
ss
io
n
;
P
V
=
P
re
d
ic
ti
v
e
v
al
u
es
;
R
R
=
R
el
at
iv
e
ri
sk
;
S
n
=
S
en
si
ti
v
it
y
;
S
p
=
S
p
ec
if
ic
it
y
;
S
t=
S
tu
d
en
t’
s
t-
te
st
;
W
=
W
il
co
x
o
n
;
§
R
P
/R
F
:
R
is
k
p
re
d
ic
to
rs
/R
is
k
f
ac
to
rs
o
b
ta
in
ed
i
n
R
eg
re
ss
io
n
A
n
al
y
se
s
T
a
b
le
4
-
R
ev
ie
w
o
f
li
te
ra
tu
re
o
n
c
ar
ie
s
ri
sk
a
ss
es
sm
en
t
in
a
d
o
le
sc
en
ts
(
1
3
-1
8
y
ea
rs
o
ld
)
o
v
er
t
h
e
la
st
1
0
y
ea
rs
(
1
9
9
7
-2
0
0
7
)
Braz J Oral Sci. 7(27):1682-1690 An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007)
R
P
:
o
ra
l
h
e
a
lt
h
c
o
n
c
e
rn
;
R
F
:
o
ra
l
h
e
a
lt
h
b
e
h
a
v
io
r
(f
o
r
o
n
ly
th
o
s
e
a
g
e
d
1
7
y
e
a
rs
a
t
b
a
s
e
li
n
e
)
D
if
fe
re
n
c
e
s
b
e
tw
e
e
n
s
c
o
re
s
fr
o
m
b
a
s
e
li
n
e
a
n
d
fi
n
a
l
e
x
a
m
in
a
ti
o
n
S
t,
M
L
R
3
V
B
:
C
a
ri
e
s
,
q
u
e
s
ti
o
n
n
a
ir
e
(d
e
n
ta
l
k
n
o
w
le
d
g
e
,
o
ra
l
h
e
a
lt
h
b
e
h
a
v
io
r,
o
ra
l
h
e
a
lt
h
c
a
re
a
tt
it
u
d
e
s
)
E
X
:
C
li
n
ic
a
l
a
n
d
ra
d
io
g
ra
p
h
ic
e
x
a
m
in
a
ti
o
n
1
4
,
1
7
,
2
0
2
0
2
P
o
o
rt
e
rm
a
n
e
t
a
l.
5
2
,
2
0
0
3
,
T
h
e
N
e
th
e
rl
a
n
d
s
M
e
a
n
D
F
S
a
n
d
D
M
F
S
in
c
re
m
e
n
t:
0
.9
8
a
n
d
1
.1
0
,
re
s
p
e
c
ti
v
e
ly
R
F
:
lo
w
s
u
g
a
r-
h
ig
h
s
ta
rc
h
fo
o
d
s
fo
r
c
a
ri
e
s
in
c
re
m
e
n
t
o
n
a
ll
s
u
rf
a
c
e
s
a
n
d
p
it
a
n
d
fi
s
s
u
re
s
s
u
rf
a
c
e
s
T
o
ta
l
D
M
F
S
in
c
re
m
e
n
t;
p
it
a
n
d
fi
s
s
u
re
D
M
F
in
c
re
m
e
n
t;
s
m
o
o
th
s
u
rf
a
c
e
D
M
F
in
c
re
m
e
n
t
�
1
M
L
R
2
V
B
:
C
a
ri
e
s
(W
H
O
c
ri
te
ri
a
),
h
e
ig
h
t
a
n
d
w
e
ig
h
t
(
“e
s
ti
m
a
ti
o
n
o
f
s
u
b
je
c
ts
’
b
a
s
a
l
m
e
ta
b
o
li
c
ra
te
”)
,
fo
u
r-
d
a
y
d
ie
t
re
c
o
rd
s
,
q
u
e
s
ti
o
n
n
a
ir
e
(h
o
u
s
e
h
o
ld
in
c
o
m
e
,
e
d
u
c
a
ti
o
n
le
v
e
l,
o
c
c
u
p
a
ti
o
n
a
n
d
e
th
n
ic
it
y
)
E
X
:
F
ib
e
r-
o
p
ti
c
li
g
h
t
s
o
u
rc
e
,
p
la
n
e
m
o
u
th
m
ir
ro
r,
s
ic
k
le
p
ro
b
e
,
a
t
s
c
h
o
o
ls
1
2
-
1
3
6
4
5
/5
0
4
C
a
m
p
a
in
e
t
a
l.
5
1
,
2
0
0
3
(M
e
lb
o
u
rn
e
),
A
u
s
tr
a
li
a
M
e
d
ia
n
ti
m
e
to
th
e
fi
rs
t
n
e
w
p
ro
x
im
a
l
c
a
ri
e
s
le
s
io
n
:
2
y
e
a
rs
In
d
iv
id
u
a
ls
w
it
h
n
o
p
ro
x
im
a
l
le
s
io
n
s
a
t
b
a
s
e
li
n
e
:
0
.0
3
1
s
u
rf
a
c
e
/y
e
a
r
In
d
iv
id
u
a
ls
w
it
h
3
p
ro
x
im
a
l
le
s
io
n
s
a
t
b
a
s
e
li
n
e
:
0
.0
7
7
s
u
rf
a
c
e
/y
e
a
r
In
c
id
e
n
c
e
o
f
th
e
fi
rs
t
n
e
w
p
ro
x
im
a
l
c
a
ri
e
s
le
s
io
n
S
A
,
P
R
1
0
V
B
:
P
ro
x
im
a
l
s
u
rf
a
c
e
s
s
ta
tu
s
:
c
a
ri
e
s-
fr
e
e
o
r
in
a
c
a
ri
e
s
s
ta
tu
s
E
X
:
O
n
ly
ra
d
io
g
ra
p
h
ic
e
x
a
m
in
a
ti
o
n
1
1
-
1
3
5
3
6
/5
3
4
S
te
n
lu
n
d
e
t
a
l.
5
0
,
2
0
0
2
(S
to
c
k
h
o
lm
),
S
w
e
d
e
n
M
e
a
n
D
F
S
in
c
re
m
e
n
t:
2
.0
6
A
s
th
m
a
ti
c
g
ro
u
p
s
:
n
o
s
ig
n
if
ic
a
n
tl
y
h
ig
h
e
r
c
a
ri
e
s
in
c
re
m
e
n
t
th
a
n
th
e
n
o
n
-a
s
th
m
a
ti
c
g
ro
u
p
D
F
S
in
c
re
m
e
n
t
C
S
,
M
W
3
V
B
:
C
a
ri
e
s
(W
H
O
c
ri
te
ri
a
),
p
a
re
n
ta
l
s
o
c
io
e
c
o
n
o
m
ic
le
v
e
l,
a
s
th
m
a
s
t
a
tu
s
.
(
N
o
te
:
2
0
6
in
d
iv
id
u
a
ls
h
a
v
in
g
n
o
h
is
to
ry
o
f
a
s
th
m
a
w
e
re
u
s
e
d
a
s
th
e
c
o
m
p
a
ris
o
n
g
ro
u
p
)
E
X
:
F
ib
e
r-
o
p
ti
c
li
g
h
t,
p
la
n
e
d
e
n
ta
l
m
ir
ro
r
a
n
d
s
ic
k
le
e
x
p
lo
re
r
1
5
9
7
6
/7
8
1
M
e
ld
ru
m
e
t
a
l.
4
9
,
2
0
0
1
(O
ta
g
o
),
N
e
w
Z
e
a
la
n
d
S
u
b
je
c
ts
w
it
h
n
o
c
a
v
it
ie
s
a
t
b
a
s
e
li
n
e
:
6
0
%
re
m
a
in
e
d
c
a
v
it
ie
s
-f
re
e
S
u
b
je
c
ts
w
it
h
g
in
g
iv
a
l
h
e
a
lt
h
a
t
b
a
s
e
li
n
e
:
4
7
%
re
m
a
in
e
d
h
e
a
lt
h
y
a
t
th
e
fi
n
a
l
e
x
a
m
in
a
ti
o
n
R
P
:
D
M
F
T
>
2
,
D
T
>
0
,
g
re
a
t
g
in
g
iv
a
l
in
fe
c
ti
o
n
,
g
e
n
d
e
r
(m
a
le
s
)
N
u
m
b
e
r
o
f
c
a
v
it
a
te
d
te
e
th
d
u
ri
n
g
th
e
p
e
ri
o
d
M
L
R
2
V
B
:
C
a
ri
e
s
(D
M
F
in
d
e
x
,
D
c
o
m
p
o
n
e
n
t)
,
g
in
g
iv
it
is
(C
P
IT
N
in
d
e
x
),
q
u
es
ti
o
n
n
a
ir
e
(i
n
fo
rm
a
ti
o
n
o
n
s
m
o
k
in
g
)
E
X
:
A
n
n
u
a
l
d
e
n
ta
l
e
x
a
m
in
a
ti
o
n
s
in
h
e
a
lt
h
c
e
n
te
rs
a
n
d
a
t
s
c
h
o
o
ls
,
r
a
d
io
g
ra
p
h
ic
e
x
a
m
in
a
ti
o
n
s
1
3
2
4
2
2
/1
4
7
2
U
tr
ia
in
e
n
e
t
a
l.
4
8
,
1
9
9
8
(K
o
k
o
la
,
P
ie
ta
rs
a
a
ri
,
V
a
a
s
a
,
S
e
in
ä
jo
k
i)
F
in
la
n
d
R
P
:
F
lu
o
ri
d
e
le
v
e
l
in
th
e
d
ri
n
k
in
g
w
a
te
r,
c
a
ri
e
s
p
re
v
a
le
n
c
e
,
n
u
m
b
e
r
o
f
c
a
v
it
a
te
d
c
a
ri
o
u
s
le
s
io
n
s
;
R
F
:
to
o
th
b
ru
s
h
in
g
fr
e
q
u
e
n
c
y
C
a
ri
e
s
p
ro
g
re
s
s
io
n
S
t,
W
,
C
S
,
M
L
R
1
V
B
:
C
a
ri
e
s
(D
M
F
S
in
d
e
x
–
W
H
O
c
ri
te
ri
a
),
d
e
n
ta
l
p
la
q
u
e
(P
a
ti
e
n
t
H
y
g
ie
n
e
P
e
rf
o
rm
a
n
c
e
-
P
H
P
in
d
e
x
),
m
a
lo
c
c
lu
s
io
n
(W
H
O
c
ri
te
ri
a
),
e
n
a
m
e
l
d
e
fe
c
ts
(D
e
v
e
lo
p
m
e
n
ta
l
D
e
fe
c
ts
o
f
E
n
a
m
e
l-
D
D
E
in
d
e
x
),
a
t
b
a
s
e
li
n
e
a
n
d
fi
n
a
l
e
x
a
m
in
a
ti
o
n
,
in
te
rv
ie
w
(a
g
e
,
g
e
n
d
e
r,
s
o
c
io
e
c
o
n
o
m
ic
s
ta
tu
s
,
ra
c
e
,
fl
u
o
ri
d
e
e
x
p
o
s
u
re
,
re
s
id
e
n
c
e
h
is
to
ri
e
s
,
p
re
v
e
n
ti
v
e
d
e
n
ta
l
h
e
a
lt
h
b
e
h
a
v
io
rs
,
u
s
e
o
f
d
e
n
ta
l
s
e
rv
ic
e
s
,
to
o
th
b
ru
s
h
in
g
fr
e
q
u
e
n
c
y
,
to
o
th
p
a
s
te
b
ra
n
d
u
s
e
d
,
p
ro
fe
s
s
io
n
a
ll
y
a
p
p
li
e
d
fl
u
o
ri
d
e
g
e
l
ri
n
s
e
s
,
v
a
rn
is
h
e
s
o
r
s
e
a
la
n
t
s
,
h
o
m
e
u
s
e
o
f
fl
u
o
ri
d
e
m
o
u
th
ri
n
s
e
s
,
u
s
e
o
f
fl
u
o
ri
d
e
s
u
p
p
le
m
e
n
ts
d
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ri
n
g
e
a
rl
y
c
h
il
d
h
o
o
d
,
n
u
m
b
e
r
o
f
y
e
a
rs
o
f
re
s
id
e
n
c
e
in
th
e
re
s
e
a
rc
h
a
re
a
,
s
o
u
rc
e
s
o
f
d
o
m
e
s
ti
c
d
ri
n
k
in
g
w
a
te
r)
E
X
:
H
e
a
d
la
m
p
,
p
la
n
e
m
ir
ro
r,
c
a
ri
e
s
e
x
p
lo
re
r,
C
P
IT
N
p
ro
b
e
,
d
ry
in
g
a
t
d
e
n
ta
l
s
u
rg
e
ri
e
s
o
r
c
la
s
s
ro
o
m
s
a
t
s
c
h
o
o
ls
,
p
o
s
te
ri
o
r
b
it
e
w
in
g
s
1
2
-
1
6
4
2
0
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9
0
L
a
w
re
n
c
e
a
n
d
S
h
e
ih
a
m
4
7
,
1
9
9
7
(R
io
d
e
J
a
n
e
ir
o
,
M
a
n
-
g
a
ra
ti
b
a
a
n
d
A
n
g
ra
d
o
s
R
e
is
),
B
ra
z
il
R
P
:
In
c
ip
ie
n
t
c
a
ri
e
s
e
x
p
e
ri
e
n
c
e
;
R
F
:
s
a
li
v
a
ry
m
ic
ro
o
rg
a
n
is
m
s
In
c
ip
ie
n
t
+
m
a
n
if
e
s
t
le
s
io
n
s
:
c
o
m
b
in
e
d
v
a
lu
e
s
o
fS
n
a
n
d
S
p
a
ll
o
w
e
d
to
p
re
d
ic
t
c
a
ri
e
s
d
e
v
e
lo
p
m
e
n
t
in
th
e
m
a
jo
ri
ty
o
f
in
d
iv
id
u
a
ls
D
F
S
in
c
re
m
e
n
t
�
5
D
F
S
in
c
re
m
e
n
t
�
3
C
A
,
M
R
A
,
S
n
,
S
p
,
P
V
3
V
B
:
C
a
ri
e
s
(
c
a
v
it
a
ti
o
n
a
n
d
in
c
ip
ie
n
t
le
s
io
n
s
),
m
u
ta
n
s
s
tr
e
p
to
c
o
c
c
i
(M
S
)
a
n
d
la
c
to
b
a
c
il
lu
s
(L
B
)
c
o
u
n
ts
in
s
ti
m
u
la
te
d
s
a
li
v
a
E
X
:
C
li
n
ic
a
l
+
ra
d
io
g
ra
p
h
ic
e
x
a
m
in
a
ti
o
n
1
5
-
1
6
1
5
5
/8
7
B
ja
rn
a
s
o
n
a
n
d
K
ö
h
le
r4
6
,
1
9
9
7
,
S
w
e
d
e
n
M
a
in
re
s
u
lt
s
R
P
/R
F
§
O
u
tc
o
m
e
V
a
ri
a
b
le
D
a
ta
A
n
a
ly
s
is
¶
T
im e
‡
V
a
ri
a
b
le
s
c
o
ll
e
c
te
d
a
t
b
a
s
e
li
n
e
(V
B
)
E
x
a
m
in
a
ti
o
n
(E
X
)
A
g
e
†
S
a
m
p
le
*
A
u
th
o
r,
y
e
a
r
a
n
d
lo
c
a
l
R
P
:
o
ra
l
h
e
a
lt
h
c
o
n
c
e
rn
;
R
F
:
o
ra
l
h
e
a
lt
h
b
e
h
a
v
io
r
(f
o
r
o
n
ly
th
o
s
e
a
g
e
d
1
7
y
e
a
rs
a
t
b
a
s
e
li
n
e
)
D
if
fe
re
n
c
e
s
b
e
tw
e
e
n
s
c
o
re
s
fr
o
m
b
a
s
e
li
n
e
a
n
d
fi
n
a
l
e
x
a
m
in
a
ti
o
n
S
t,
M
L
R
3
V
B
:
C
a
ri
e
s
,
q
u
e
s
ti
o
n
n
a
ir
e
(d
e
n
ta
l
k
n
o
w
le
d
g
e
,
o
ra
l
h
e
a
lt
h
b
e
h
a
v
io
r,
o
ra
l
h
e
a
lt
h
c
a
re
a
tt
it
u
d
e
s
)
E
X
:
C
li
n
ic
a
l
a
n
d
ra
d
io
g
ra
p
h
ic
e
x
a
m
in
a
ti
o
n
1
4
,
1
7
,
2
0
2
0
2
P
o
o
rt
e
rm
a
n
e
t
a
l.
5
2
,
2
0
0
3
,
T
h
e
N
e
th
e
rl
a
n
d
s
M
e
a
n
D
F
S
a
n
d
D
M
F
S
in
c
re
m
e
n
t:
0
.9
8
a
n
d
1
.1
0
,
re
s
p
e
c
ti
v
e
ly
R
F
:
lo
w
s
u
g
a
r-
h
ig
h
s
ta
rc
h
fo
o
d
s
fo
r
c
a
ri
e
s
in
c
re
m
e
n
t
o
n
a
ll
s
u
rf
a
c
e
s
a
n
d
p
it
a
n
d
fi
s
s
u
re
s
s
u
rf
a
c
e
s
T
o
ta
l
D
M
F
S
in
c
re
m
e
n
t;
p
it
a
n
d
fi
s
s
u
re
D
M
F
in
c
re
m
e
n
t;
s
m
o
o
th
s
u
rf
a
c
e
D
M
F
in
c
re
m
e
n
t
�
1
M
L
R
2
V
B
:
C
a
ri
e
s
(W
H
O
c
ri
te
ri
a
),
h
e
ig
h
t
a
n
d
w
e
ig
h
t
(
“e
s
ti
m
a
ti
o
n
o
f
s
u
b
je
c
ts
’
b
a
s
a
l
m
e
ta
b
o
li
c
ra
te
”)
,
fo
u
r-
d
a
y
d
ie
t
re
c
o
rd
s
,
q
u
e
s
ti
o
n
n
a
ir
e
(h
o
u
s
e
h
o
ld
in
c
o
m
e
,
e
d
u
c
a
ti
o
n
le
v
e
l,
o
c
c
u
p
a
ti
o
n
a
n
d
e
th
n
ic
it
y
)
E
X
:
F
ib
e
r-
o
p
ti
c
li
g
h
t
s
o
u
rc
e
,
p
la
n
e
m
o
u
th
m
ir
ro
r,
s
ic
k
le
p
ro
b
e
,
a
t
s
c
h
o
o
ls
1
2
-
1
3
6
4
5
/5
0
4
C
a
m
p
a
in
e
t
a
l.
5
1
,
2
0
0
3
(M
e
lb
o
u
rn
e
),
A
u
s
tr
a
li
a
M
e
d
ia
n
ti
m
e
to
th
e
fi
rs
t
n
e
w
p
ro
x
im
a
l
c
a
ri
e
s
le
s
io
n
:
2
y
e
a
rs
In
d
iv
id
u
a
ls
w
it
h
n
o
p
ro
x
im
a
l
le
s
io
n
s
a
t
b
a
s
e
li
n
e
:
0
.0
3
1
s
u
rf
a
c
e
/y
e
a
r
In
d
iv
id
u
a
ls
w
it
h
3
p
ro
x
im
a
l
le
s
io
n
s
a
t
b
a
s
e
li
n
e
:
0
.0
7
7
s
u
rf
a
c
e
/y
e
a
r
In
c
id
e
n
c
e
o
f
th
e
fi
rs
t
n
e
w
p
ro
x
im
a
l
c
a
ri
e
s
le
s
io
n
S
A
,
P
R
1
0
V
B
:
P
ro
x
im
a
l
s
u
rf
a
c
e
s
s
ta
tu
s
:
c
a
ri
e
s-
fr
e
e
o
r
in
a
c
a
ri
e
s
s
ta
tu
s
E
X
:
O
n
ly
ra
d
io
g
ra
p
h
ic
e
x
a
m
in
a
ti
o
n
1
1
-
1
3
5
3
6
/5
3
4
S
te
n
lu
n
d
e
t
a
l.
5
0
,
2
0
0
2
(S
to
c
k
h
o
lm
),
S
w
e
d
e
n
M
e
a
n
D
F
S
in
c
re
m
e
n
t:
2
.0
6
A
s
th
m
a
ti
c
g
ro
u
p
s
:
n
o
s
ig
n
if
ic
a
n
tl
y
h
ig
h
e
r
c
a
ri
e
s
in
c
re
m
e
n
t
th
a
n
th
e
n
o
n
-a
s
th
m
a
ti
c
g
ro
u
p
D
F
S
in
c
re
m
e
n
t
C
S
,
M
W
3
V
B
:
C
a
ri
e
s
(W
H
O
c
ri
te
ri
a
),
p
a
re
n
ta
l
s
o
c
io
e
c
o
n
o
m
ic
le
v
e
l,
a
s
th
m
a
s
t
a
tu
s
.
(
N
o
te
:
2
0
6
in
d
iv
id
u
a
ls
h
a
v
in
g
n
o
h
is
to
ry
o
f
a
s
th
m
a
w
e
re
u
s
e
d
a
s
th
e
c
o
m
p
a
ris
o
n
g
ro
u
p
)
E
X
:
F
ib
e
r-
o
p
ti
c
li
g
h
t,
p
la
n
e
d
e
n
ta
l
m
ir
ro
r
a
n
d
s
ic
k
le
e
x
p
lo
re
r
1
5
9
7
6
/7
8
1
M
e
ld
ru
m
e
t
a
l.
4
9
,
2
0
0
1
(O
ta
g
o
),
N
e
w
Z
e
a
la
n
d
S
u
b
je
c
ts
w
it
h
n
o
c
a
v
it
ie
s
a
t
b
a
s
e
li
n
e
:
6
0
%
re
m
a
in
e
d
c
a
v
it
ie
s
-f
re
e
S
u
b
je
c
ts
w
it
h
g
in
g
iv
a
l
h
e
a
lt
h
a
t
b
a
s
e
li
n
e
:
4
7
%
re
m
a
in
e
d
h
e
a
lt
h
y
a
t
th
e
fi
n
a
l
e
x
a
m
in
a
ti
o
n
R
P
:
D
M
F
T
>
2
,
D
T
>
0
,
g
re
a
t
g
in
g
iv
a
l
in
fe
c
ti
o
n
,
g
e
n
d
e
r
(m
a
le
s
)
N
u
m
b
e
r
o
f
c
a
v
it
a
te
d
te
e
th
d
u
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1689
been a strong variable in identifying children at risk
because it shows that the oral environment was prone to
develop caries. Sugar consumption has played an important
role in caries risk assessment in young children, as
previously described for infants. Others variables related
to oral hygiene also showed their significance in
identifying children at risk. The presence of plaque on
teeth, due to the lack and/or deficiency in toothbrushing,
offers substrates to cariogenic bacteria favoring caries
development.
Schoolchildren have been the most studied group in caries
risk assessment (Table 3). From 1997 to 2007, 19 papers
were selected and reviewed. Study duration ranged from 1
to 8 years and, as usual, dental variables were collected at
baseline in all the papers. Other variables that also were
collected in a considerable number of studies were:
socioeconomic, microbiological and behavioral
characteristics. Among the studies that used regression
techniques (n=16) in statistical analysis the predominant
RP was past caries experience followed by others related
to socioeconomic level. The main RFs were the variables
related to oral hygiene. As previously reported, past caries
experience detected at baseline is the variable that best
indicates those at risk for developing new lesions and poor
oral hygiene increases the probability of caries increment.
Seven studies involving caries risk assessment in
adolescents (Table 4) were found from 1997 to 2007. The
researchers followed-up the participants from 1 to 10 years,
and collected data on dental, behavioral, demographic,
socioeconomic, anthropometric, medical and
microbiological variables and dietary habits. Caries
experience at baseline was the main RP obtained in
regression techniques.
In general, review of the papers demonstrated that past
dental caries was the risk predictor of the future disease for
all age groups. Others important RP include socioeconomic
level and fluoride usage. The risk factors obtained in
regression analyses were variables related to oral hygiene,
sugar consumption and microbiological counts.
Collecting data on dental caries is very easy and may
help in caries risk assessment. However, the disease has to
be present. Others risk factors such as sugar consumption
and oral hygiene related characteristics are also not difficult
to gather information on them from a community point of
view and help dental professionals in selecting those caries-
free individuals at risk. In fact, it has been suggested that
in caries risk assessment, variables such as caries experience
and severity, plaque index, fluoride use, socioeconomic
level status should be collected before the application of
the test for e.g. mutans streptococcus15. As reported by
Kopycka-Kedzierawski and Billings16, “a caries risk
assessment protocol must involve the use of measures that
are easily obtained, widely accepted, simple to use,
reproducible and cost-effective”.
It is important to take into consideration that this study
presents some limitations such as the absence of quality
criteria for selecting the papers (no score for papers), and
the selection of studies mainly from Medline database. In
spite of its limitations, by reviewing the published papers
over the last 10 years, this study could clearly demonstrate
that past caries experience has been the predominant
predictor for future caries in subjects from 0 to 18 years of
age. Therefore, those with previous contact with the disease
should receive good oral health education, preventive
measures and should be made aware that they are subjects
at risk for developing caries. Continuous monitored is
necessary to prevent the onset of new lesions.
On the other hand, as discussed by Tinanoff17, it would be
unwise to wait for the presence of caries to know which
subject will be more susceptible to develop lesions in the
future. Further studies involving a large number of caries-
free individuals should be conducted on caries risk
assessment. Nevertheless, the use of other variables such
as dietary habits, including sugar consumption, and
toothbrushing habits or presence of dental plaque may
help identifying those caries-free subjects who might be
more prone to have new carious lesions in the future.
In conclusion, the variables related to caries experience
collected at the initial examination continue to be the
main risk predictor of caries increment. Moreover, those
related to sugar consumption and oral hygiene could
identify subjects at caries risk.
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Braz J Oral Sci. 7(27):1682-1690 An overview of caries risk assessment in 0-18 year-olds over the last ten years (1997-2007)