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The study sample consisted of 100 children with visual impairment aged 6–14 years. 6-n-propylthiouracil (PROP) sensitivity test was carried out. The Caries experience was recorded, estimation of Streptococcus mutans done and their taste likes and dislikes assessed through a food preference questionnaire. The Caries experience and S. mutans levels were highest in the non-tasters, comparatively low in medium tasters and the least in the supertasters. Dietary preferences indicated tasters were sweet dislikers and non-tasters, sweet likers. PROP test can be a useful tool in determining genetic taste sensitivity levels amongst the visually impaired children and thus used as a screening tool in those children who are at a high risk of developing dental caries.
PROP test: prediction of caries risk by genetic taste perception among the visually impaired children
Vabitha Shetty, MDS;1* Pooja B.L.;2 Amitha M. Hegde, BSc, BDS, MDS3
student; 3Sr Professor and Head of the Department, Department of Pedodontics and Preventive Children Dentistry, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka, India. *Corresponding author e-mail: email@example.com Spec Care Dentist 34(1): 34-40, 2014
Int r od uct ion
KEY WORDS: 6-n-propylthiouracil,
labeled magnitude scale, dental caries, S. mutans
Oral health is considered to be a mirror image of general health. Oral health is a vital component of overall health and is all the more important for children with special health needs.1 Special and medically compromised children present a unique population that challenges the dentist’s skills and knowledge.2 Challenges to the oral health are more complex for visually impaired children, who are often unable to adequately apply the techniques necessary to control plaque and are at greater risk for developing dental diseases.3 Literature review reveals high incidence of dental caries and periodontal diseases in physically handicapped children including the children who are visually impaired and they present a unique problem in dental management of this population because the chronicity of oral disease complicate the primary physical or mental disability.4 The development of dental caries is dependent upon critical interrelationship between susceptible host/tooth surface, specific oral bacteria and dietary carbohydrates. Several studies have indicated that children with high sugar intake have higher caries rate and this is positively related to sweet score and total sugar exposure.5 Inherited behavior and taste thresholds may play an important role in the frequency of carbohydrate intake. Genetic sensitivity to taste may be associated with the preference for rejection of some foods by children.6-8 The ability to taste bitter thiourea compound such as 6-n-propylthiouracil (PROP) is inherited. PROP tasters are more sensitive to many oral sensations, including bitter and sweet tastes and the sensation of fats. PROP status influences food selection and dietary habits in children.9,10 PROP in clinical practice is a medication used in the treatment of Grave’s disease (Hyperthyroidism).11 Being extremely bitter, PROP can be tasted at a very low concentration and this bitter property of PROP has proved to be a useful tool in determining the genetic sensitivity levels to bitter and sweet taste.12 PROP has already proven to be a useful tool to identify children at greater risk for dental caries by identifying the genetic sensitivity levels of the children.13,14 This study investigated the ability of the PROP test to facilitate the identification of children with visual impairment who are at an enhanced risk for developing dental caries thus enabling us to
34 S p e c C a r e D e n t i s t 3 4 ( 1 ) 2 0 1 4
©2012 Special Care Dentistry Association and Wiley Periodicals, Inc. doi: 10.1111/j.1754-4505.2012.00307.x
6 mg of 6-n-propylthiouracil on the dorsal surface of the anterior two-third region of the tongue for 30 seconds. whereas the non-tasters had a value of 2. Mangalore.15 Whatman filter paper was cut into 2 × 2 cm size and sterilized in an autoclave at 121°C for 15 minutes. 3 Subjects under any medication and antibiotics three months before the study. sour and strong taste preferences. When the differences in the mean values of the DMFT/dft scores were compared among the various taster groups shown in Table 2. Ten previously cut and sterilized Whatman filter paper strips were soaked in the above solution for one hour for the complete absorption of the drug.16 these children were subdivided into two groups as PROP tasters and PROP non-tasters. we observed that in the Permanent dentition.001). Tasters accounted for more than three fourth of all the children included in the study. 92% were tasters (Super tasters-27%. The Caries experience was recorded using DMFT/dft indices.125 was observed.88) and dietary preferences(X2 = 22. respectively.20 We considered a child frequently preferring two or more of the foods designated under the sweet category as a sweet liker. under good illumination using a sterile mouth mirror and CPI probe while taking protective cross infection control measures.PREDICTION OF CARIES RISK initiate aggressive preventive oral health care programs for them.S.G. Government Blind School. p < . mutans counts(X2 = 49. whereas for non-tasters. Bangalore.40 for DMFT and H = 43.001)and PROP status to S. super tasters and medium tasters had a mean DMFT value of 0. St a t is t ica l a na ly si s Recording of caries experience The visually impaired children were examined at their respective schools/ centers. which was statistically very highly significant (p < .0 was used to do the analysis. which was statistically very highly significant (p < . The sterilized strips were weighed and stored in the desicator until they were used for further preparation. Ours is a self-funded research study.677) by chi-square test(p < .16 In our study the examiner had to verbally explain in the local language regarding the details of LMS to the children and also about the strongest imaginable bitter taste perception with suitable dietary examples.17.68 for dft. Kasargod. respectively. Methodology Preparation of the PROP strips Pure samples of PROP was obtained from Macleod’s pharmaceuticals. A statistical package SPSS ver.625.17 Exclusion criteria 1 Subjects who are un-cooperative. 6-n-propylthiouracil (10 mg/ml) was dissolved in 5 ml of alcohol in a beaker. The tasters were further classified as super tasters and medium tasters.M Institute of Pharmaceutical Sciences. They were selected from two schools and centers for the visually impaired. a much higher value of 5. Table 1 shows that of the total population. We assessed the association between PROP status to caries experience by Kruskal Wallis test (H = 18. seated on an ordinary chair. while a child frequently preferring two or more of the foods designated under bitter/spicy/ pungent food was considered a disliker. Kerala and Karnataka Welfare Association for the Blind. The strips were removed and allowed to dry at room temperature. Mumbai and sterile PROP strips containing 6-n-propyltthiouracil were prepared at N.6 mg of drug was impregnated on each strip. PROP sensitivity test PROP sensitivity test was carried out by placing the filter paper containing approximately 1.259 and 1. The measures of central tendency(mean)and standard deviation were calculated for variables. Informed consent was taken from all parents/caretakers and ethical clearance obtained from the concerned institution. Table 1.001) In the mixed dentition. Distribution of genetic taste sensitivity based on PROP status. the mean dft values were 0 and 0. All collected data were collected on forms and subjected to Statistical analysis using the Kruskal Wallis Test (H) and Chi-Square Test (X2). 2 Subjects with underlying systemic disease.15 R es ul t s Estimation of streptococcus mutans levels Streptococcus mutans colony count was done using unstimulated salivary samples using the mutans-sanguis selective medium agar plates.349. Medium tasters-65%) and only 8% were non-tasters. Based on their ability to rate the intensity of bitter taste on a modified labeled magnitude scale (LMS).05 was considered as significant. Shetty et al.19 Evaluation of dietary preferences A food preference questionnaire was prepared (questionnaire enclosed as Annexure 2) and given to the parents/ caretakers/teachers of the children to establish their sweet. S p e c C a r e D e n t i s t 3 4 ( 1 ) 2 0 1 4 35 .18.184 for super tasters and medium tasters. Prop status Super tasters Medium tasters Non tasters Total Percentage 27% 65% 8% 100% Mater ials an d me tho ds Source of data A total number of 100 children with total visual impairment between the age groups of 6–14 years belonging to both the sexes formed the study group. A total DMFT/dft score of more than five was considered to have increased caries activity. namely. Approximately 1.001). p < .
0% Total Table 3 shows that 70.17261 0. which may lead to preference.001 vhs.5% 3 37.14 Published data for PROP taster status in India has been previously done on sighted populations including 36 S p e c C a r e D e n t i s t 3 4 ( 1 ) 2 0 1 4 Prediction of caries risk . Comparison of caries experience among the tasters and non-tasters. Deviation 0. p < 0.20 Studies have identified several indicators for an increased risk of dental caries e.44658 1. The values obtained were statistically very highly significant (p < .0% 100 100.30734 4. 0 .677.001 Vhs H P H = Kruskal Wallis test. PROP TEST DMFT Super tasters Medium tasters Non tasters dft Super tasters Medium tasters Non tasters N 27 65 8 27 65 8 Mean 0.6250 0.0% 25 25.2% of the medium tasters exhibited moderate counts and up to 62. The proportions of the world’s population affected by dental caries increased dramatically once refined carbohydrates became available to the developed and the developing nations.0% 27 100.0% 8 29. Of the 100 children who participated in the study.4% 27 100.001).0% 52 80. 0 .84580 4. 92% were tasters and only 8% were non-tasters.0% 19 19.0% 2 25.0% Non tasters 6 75.6% 19 70. mutans counts.21 on Indian children aged 6–12 years showed that the percentage distribution of non tasters were less compared to tasters. Dental caries and periodontal disease continue to present unique problems in the dental management of this patient population because the chronicity of oral disease complicates the primary physical or mental disability.1846 5. Two studies previously done in our department13. Brent P.0% 8 100.0% Non taster 5 62. Lin observed similar results in his study. high levels of cariogenic bacteria.001 vhs.001 Vhs 18.0% 19 19. Comparison of streptococcus mutans levels among the tasters and non-tasters.40 <0.3486 2.4% of the super tasters had low S.1250 Std.0 0. Developmental disabilities are conditions identified in early childhood and usually persist throughout an individual’s life.88 p < 0. cariogenic diet.g.0% 100 100.68 <0. Thus knowledge of an individual taste may facilitate the identification of children who are at high risk for developing dental caries.4 Dental caries is one of the most prevalent infectious diseases to afflict the mankind.5% 45 69. There is a paucity of data about the relationship of taste perception of these children as related to various risk factors associated with dental caries.PREDICTION OF CARIES RISK Table 2.2% 6 9.5% of the non tasters exhibited high counts. while 69. low socio economic status and influence of taste sensation.0% 65 100. or rejection of food.5% 0 .0% Medium taster 14 21. therefore the development of a child may be severely compromised by loss of one or more of the sensory modalities.0% 8 100.4 The sensory modalities are often taken for granted as long as they function normally. P = Level of Significance Table 3.0 0. Results of the food frequency questionnaire revealed that only 20% of the tasters preferred sweets while up to 75% of the non-tasters preferred sweets (Table 4). DIET PREFERENCESS Super tasters Sweet preference Non sweet preference Total Count % Count % Count % X2 = 22.0% 81 81. PROP TEST Super taster High Moderate Low Total Count % Count % Count % Count % X2 = 4 9. Comparison of dietary preferences among the tasters and non tasters.2 Blindness as a disability seems to produce difficulties to reach an ideal health status of the teeth. It is through the senses that we learn about our world.2% 65 100.08613 43. Dis cus s ion The term “disability” refers to any impairment that restricts or limits daily activity in some manner.0% 56 56. Disabilities can be developmental in origin or acquired.14 Early identification of the risk factors is all the more critical in the blind children who are at a magnified risk for the development of dental disease.2593 1. J.0% PROP STATUS Medium tasters 13 20.0% Total Table 4.0% 27 100.
J. the scale was effectively communicated to the children.. missing and filled groups were analyzed individually in both the mixed and permanent dentition. explaining the concepts of strongest imaginable taste to barely detectable taste using appropriate examples. very highly statistically significant results were obtained on correlating taster status with caries experience. the decayed group was found to be higher in non tasters group irrespective of type of dentition which was highly significant. 79% of the tasters did not prefer sweets and fatty foods and were dislikers while 75% of non-tasters preferred sweets and fatty foods frequently and were likers as mentioned in Table 4 (p < ..28 Estimation of S. The results of our study revealed that the overall Caries experience was significantly higher among the non tasters compared to super tasters and medium tasters as shown in Table 2 (p < . The low proportion of non-tasters (8%) found in our study could be attributed to the difficulty in separating the medium tasters from the non tasters. Bartoshuk believes that there are at least two solutions to the scaling problem. but also an absolute upper bound.29 suggested that a high intake of sweetened baked food might be a determinant of caries prevalence in children and high streptococcus count where as Beighton et al. LMS was developed by Green16 in 1993. vhs).25 Natalia et al. Garcia-Closas et al. have reported similar results which demonstrate that genetic sensitivity to bitter taste might be associated with the preference or rejection of some foods by children.PREDICTION OF CARIES RISK children while in our study.30 suggested that salivary concentration of mutans and lactobacilli and frequency of ingestion of confectionary were independently and positively related to caries experience. similar results were observed by three other studies conducted in Indian school going children without any disabilities. visually impaired children formed the study group. at which there is no sensation. a drug widely prescribed for hyperthyroidism. The alcohol used could have left some residue which could have affected the taste.27 Sarah V. mutans levels revealed that the 62.26 concluded that super tasters or sweet dislikers might avoid sweet food because their oral sensations are too intense and thus less pleasant to accept the intensely bitter. familiar to psychophysicists is magnitude matching. It is also possible that the alcohol used in the preparation of the PROP strips could have contributed to a higher than expected intensity ratings. labeled “strongly imaginable of any kind”.22 In our study a verbal reinforcement of the LMS was carried out.001. However. One.4 These children should learn about their teeth. clearly.5% of the nontasters had high counts which contrasted sharply with 70. The other called. 69. S p e c C a r e D e n t i s t 3 4 ( 1 ) 2 0 1 4 37 .16 The LMS circumvents the problem that besieges the traditional adjective scale by not only providing an absolute lower bound. the benefits of proper oral hygiene procedures and the importance of a proper diet. Children younger than 6 years of age were not included in our study group due to their inability to understand the LMS Scale. When the decayed. In our study. research has reported 25 members in the TAS2R family of bitter taste receptors which are selectively sensitive to particular compounds for instance.4% of the super tasters who exhibited low counts. such as immediately wanting to swish and wash their mouth with water to identify their taster status. placing the non-tasters at a higher risk of developing dental Caries. We have also taken into account the facial expressions and other physical actions these children had displayed upon administration of the PROP test. The magnitude increases as the intensity increases. S. Lin who found that non-tasters had significantly higher mean DMFS/dfs compared to tasters. Although the percentage of non-tasters was 8%. shifting the population distribution in our study towards an unusually higher percentage of tasters. Bartoshuk and Green believed that anchoring the scale in this way puts different peoples responses on the same metric scale creating a “universal ruler”. It is a semantically labeled scale of sensation intensity that was developed for the study of oral somatosensation and gestation. vhs). These results were statistically very highly significant (Table 3 [p < . Lipchock et al. The medium taster children perceived the PROP taste as moderately bitter and non tasters as absolutely tasteless. The large majority of patients with disabilities require no specific dental treatment other than aggressive preventive measures and regular dental visits. strong and sweet substance thus making super tasters less prone to decay. During the past decade.23 These findings could be due to the increased consumption of sugar and sugar containing food by the non taster children. Anilker et al. vhs]). The afore mentioned three children were given special attention and guided through the LMS rating. it has been reported that the TAS2R38 receptor responds to propylthiouracil.22 Only three children of the study group were aged between 6–7 years while all remaining children were above 9 years of age. Dietary preferences among the PROP tasters showed an inverse relationship.31 In developing countries where resources for health care are limited and Shetty et al.2% of the medium tasters showed moderate counts.21. This scale is composed of seven verbal labels arranged according to the geometric means of their rated magnitudes.13. explored the association between bitter taste receptor TAS2R38 genotype and experience in medication in solid formulation (pills) and concluded that taste genotype was associated with experience with solid medication formulations and preference for more intense sweetness. The LMS was used to measure the intensity of bitter taste of PROP.13 Also.001. mutans counts and dietary preferences. and Adam Drewnowski et al. Similar results were observed by Brent P . we have deviated from Zhao’s method for the preparation of PROP strips.24. Hence.001.
38 S p e c C a r e D e n t i s t 3 4 ( 1 ) 2 0 1 4 Prediction of caries risk . 1970. Ullrich. Keller KL. PROP can be a useful tool in identifying those children amongst the blind children who are at highest risk of developing dental caries. Dental clinics of North America 38. World Health Organisation. Obesity Res 2004.104:543-9. Jenen B. Chem Senses 1993. Genetic sensitivity to the bitter taste of 6-n-propylthiouracil: A new risk determinant for dental caries in children. Bufe B. Fisher JO. Kuhn C. Fiske J. 1988–1994.24:63-68. References 1. New York) pp. Karnataka. Reed DR. 5. 1482-90.29:239–46.855:802-4.16:18-21. 2. 18. Sharma A. Duffy VB. 13. Genetic sensitivity to 6-n-propylthiouracil(PROP) as a screening tool for obesity and dental caries in children.54:316-20.propylthiouracil. If these facilities are used for the differently abled children it will definitely ease the burden of oral health care borne by their parents/caretakers and will prioritize the need for preventive care. says NIH consensus panel. Oral hygiene etc could be warranted in these children. J Clin Pediatr Dent 200833(2):21-6. Pediatrics 1998. Narayana Charyulu. Volume II. cost effective screening tools to identify children at high risk for oral disease. Physiol Behav 1994. mutans levels and Dietary preferences.101:539-49. Spec Care Dent 2001. Gilman A. Dietary habits and dental health over the first 18 months of life.4th ednGeneva: World Health Organisation. Sanford J. Hegde AM. J Nutr Educ 1979.Streptococci in human saliva. Gilmore MM. Ann N Y Acad Sci 1998. Future investigations utilizing a more objective and precise genetic indicator of taste and using a more representative sample population. Brent P-J Lin. Nov 3 July 1994.S. Pedod Prev Dent 2003. Nayak UA. Ferris AM. 1997. Tepper BJ. Zhao LKirkmeyer SV. Birch LL. Per Axelson. Miller IJ. Tepper BJ. Am J Clin Nutr 1991. 3. Diagnosis and management of dental caries throughout life. Genetic sensitivity to 6-n-propylthiouracil and sensory responses to sugar and fat mixtures. Diagnosis and risk prediction of dental caries. J. J Clin Pediatr Dent 2001. The implications of visual impairment in an elderly population in recognizing oral disease and maintaining Oral Health.propylthiouracil in Diet and body weight in childern. et al. New insights into improving the oral health of visually impaired children. Oral health needs of persons with physical or mental disabilities.G. 23. Schembri A. 26. Quintessence Publishing Co. Verma P . PROP strips could be marketed or made available over the counter to be used under supervised care in dental institutions and schools for effective screening of those children who are at a high risk for developing dental caries and also to promote balanced nutrition as it marks for the genetic taste in food preferences which would aid in overall growth and development. Inc. Nurse RJ. Bartoshuk LM. Institute of Pharmaceutical Sciences. A strong positive correlation was established between the genetic taste sensitivity levels of the PROP non taster children and their Caries experience. Shetty V.34(3):728-33. 12. Department of Pharmaceutics.129:1229-38.18:683-702.26:111-8. 8. Tesini. Oral health status in Greek children and teenagers with disabilities. PTC/ PROP tasting: anatomy. 28. The pharmacological basis of therapeutics (Mac Millan. Oral Health Survey: Basic Methods. Anilker JA. Shaffer GS. Socio-demographic distribution of pediatric dental caries: NHANES III. 27.25:37-42. Green BG.2(14):142-3.12:904-12.11:189-93. Pediatr Dent 2001. Pediatr Dent 2003. Hegde AM. Tepper BJ. India. Caries experience in children with various genetic sensitivity levels to the bitter taste of 6-n-propylthiouracil(PROP):A pilot study. S. Karidis AG. Goodman. 7. N. 15. 17. JADA 1998. A paper screening test to assess genetic taste sensitivity to 6-n. Downer MC.23:123-4. new release. J Dent Res 1989. 4. Bratthal D. Barratt-fornell A. PROP taster status is related to fat perception and preference. Fenton. Ackn owl e dge me nt Prof. Henderson SA.15:322-7. Natalia V. Professor. Inherited taste sensitivity to 6-n. 20. The molecular basis of individual differences in phenylthiocarbamide and propylthiouracil bitterness perception.21:222-6. streptococcus mutans levels and dietary preferences in children. 156-68. 19. Derivation and evaluation of a semantic scale of oral sensation magnitude with apparent ratio properties. Community Dent Oral Epidemiology 2001. Lipchock SV.63(5):771-7. Indian Soc.78:625-33. it is vital to implement simple. Nandini NS.68:468-71. Development of eating behaviors among children and adolescents. Preschool children’s food preferences and consumption patterns. Physiol Behav 2003. Caries experience and sucrose availability: an analysis of the relationship in the United Kingdom over 50 yrs. JA. Mitsea AG. 25. psychophysics and sex effects. 9. Propylthiouracil (PROP)—A tool to determine taster status in relation to caries experience. 6. A new method for the estimation of m. J Indian Soc Pedod Prev Dent 2006. Spyropoulous ND. Community Dent Health 1999.PREDICTION OF CARIES RISK government backed programs are unable to meet the increasing demands of a growing population. NIH Consensus development conference.M. Bartoshuk LM. Children’s food preferences and genetic sensitivity to the bitter taste of PROP . LS. 16. as well as correlating other associated etiological factors like Salivary flow rate. (Dr). Habibian M. J Am Diet Assoc 2004. 14. More rigorous studies needed to advance emerging dental caries diagnostic and management strategies. Mangalore. Sweden. C on clu s io n Most of the children in our study comprised of tasters while only 8% of the children comprised of non tasters. Hooks LD. 22. 21. J Clin Pediatr Dent 200631(2):113-7. Donta Bakoyani C. Relationship between bitter—taste receptor genotype and solid medication formulation usage among young children: a retrospective analysis. Physiol Behav 1998. Roberts G. R. Mennella. Birch LL. 24. Clin Ther 2012. Lawson M. MS PROP taster status and self-perceived food adventurousness influence food preferences. Curr Biol 2005. 10. Drewnowski A. David A. 11.56:1165-71. Breslin PA. Rupesh S.
Associations between dietary intake.PREDICTION OF CARIES RISK 29. Closas RG. ANNE XURE .41:271-80. 31. J Dent 2000. mutans c o l ony count 18. Roux D. dental caries experience and salivary bacterial levels in 12 year old English school children. Arch Oral Biol 1996.1 G r adi n g u s ed fo r S. 30. and salivary counts of streptococcus mutans in children in Spain.2 D i etar y P r ef e r e nc e s Que sti o nna re: NAME: ADDRESS: AGE: SEX: FATHER’S NAME: FATHER’S OCCUPATION: MOTHER’S OCCUPATION: NAME OF THE SCHOOL: CONTACT NO: FREQUENCY OF FOOD SWEETS Candy Biscuits Bread/Pastries Jam Chocolates Ice-creams Soft-drinks Fruit Juices Jaggery/Honey Solid sugar DOES NOT PREFER PREFERS OCCASIONALLY PREFERS FREQUENTLY Shetty et al. 19 GRADE 1 2 3 4 5 COUNT (In C.f. Am J Clin Nutr 1997. Majem LS. intake of confectionary and foods rich in starch and sugar. A cross-sectional study of dental caries. Rugg-Gunn A. Accuracy of dental treatment need in special care patients. Hennequin M. Faulks D. S p e c C a r e D e n t i s t 3 4 ( 1 ) 2 0 1 4 39 . Closas MG.u) 103 104 105 106 107 High (107) Moderate (105 to 106) LEVEL Low (103 to 104) ANNE XURE .28:131-6. Beighton D.66:1257-63. Adamson A.
PREDICTION OF CARIES RISK Sheera* Halwa* Laddoos* Any other sweets (Specify) BITTER/SPICY/PUNGENT Spinach/Palak Bitter Gourd Coffee/Tea without sugar Coffee/Tea with sugar Pickles Citrus fruits Grapes Raw Onions Raw Mangoes Bimbli Tamarind Pungent flavored potato chips Goose berries Spicy Papad *Common local Indian sweets 40 S p e c C a r e D e n t i s t 3 4 ( 1 ) 2 0 1 4 Prediction of caries risk .
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