Modern Concepts of Caries Measurement

Dental caries among children visiting a mobile dental clinic in South Central Kentucky: a pooled cross-sectional study

BACKGROUND

Dental caries is one of the most common chronic childhood diseases affecting a large portion of children in the United States. The prevalence of childhood dental caries in Kentucky is among the highest in the nation. The purposes of this study are to (1) compare sociodemographic differences between caries and no caries groups and (2) investigate factors associated with untreated dental caries among children who visited a mobile dental clinic in South Central Kentucky.

METHODS

Study subjects were children aged 6 to 15 years who participated in the school-based dental sealant program through the mobile dental clinic operated by the Institute for Rural Health at Western Kentucky University between September 2006 and May 2011 (n = 2,453). Descriptive statistics were calculated for sociodemographic factors (age, gender, race/ethnicity, insurance status, and urban versus rural residential location) and caries status. We used chi-square tests to compare sociodemographic differences of children stratified by caries and no caries status as well as three levels of caries severity. We developed a logistic regression model to investigate factors associated with untreated dental caries while controlling for sociodemographic characteristics.

RESULTS

The proportion of children having untreated dental caries was 49.7% and the mean number of untreated dental caries was 2.0. The proportion of untreated dental caries was higher in older children, children with no insurance and living in rural residential locations, and caries severity was also higher in these groups. Odds ratio indicated that older ages, not having private insurance (having only public, government-sponsored insurance or no insurance at all) and rural residential location were associated with having untreated dental caries after controlling for sociodemographic characteristics of children.

CONCLUSIONS

Untreated dental caries was more likely to be present in older children living in rural areas without insurance. Health interventionists may use this information and target rural children without having proper insurance in order to reduce geographic disparities in untreated dental caries in South Central Kentucky.

Reliability analysis of two methods for measuring active enamel demineralization: An in vitro study

OBJECTIVE

The aim was to evaluate the intra- and inter-examiner reliability of two methods, namely, digital caliper [DC] and computerized image analysis software (Image Tool [IT] version 4.1) for measuring the area of an active enamel demineralization lesion. The effect on that measurement of a window that delimits the lesion was also assessed.

MATERIALS AND METHODS

Thirty-eight circular artificial enamel demineralization lesions (r = 2 mm) were produced on bovine teeth in vitro, which were then measured three times by three examiners, with and without the presence of a window delimiting the area to be measured. The data were analyzed by the intraclass correlation coefficient (ICC) with 95% confidence interval (CI) and by the Altman and Bland analysis.

RESULTS

The intra-examiner correlation using the IT method showed excellent reproducibility (mean ICC values 0.922-0.970 with the delimiting window and 0.915-0.990 without the window). However, the intra-examiner correlation using the DC method showed comparatively less reproducibility in the measurements (mean ICC values 0.458-0.648 with the delimiting window and 0.378-0.665 without the window). The inter-examiner correlations showed very good reproducibility of the measurements regardless of the presence or absence of the window for both the DC method (0.811-0.846) and IT method (0.953-0.994). However, the latter method showed less variability within the measurements.

CONCLUSION

However, statistically no significant difference was found between both methodologies. Nevertheless, computerized image analysis with the Image Tool software demonstrated higher intra- and inter-examiner reliability than the digital caliper method, in estimating the area of the enamel demineralization lesion, regardless of the delimiting window.

Supragingival plaque microbial analysis in reflection to caries experience

Background

Dental caries develops as a result of the metabolism of carbohydrates by cariogenic bacteria present in a complex biofilm. The present study aimed to examine if bacteria in pooled supragingival plaque samples quantified using a “checkerboard DNA-DNA hybridization” based panel of caries-related bacteria, could reflect the caries experience in a manner similar to saliva samples analysed using a chair-side method in a previous investigation.

Methods

A total of 86 mothers and their children aged 4–6 years and 12–16 years old participated. Caries experience (DMFT/dmft; Decayed, Missing and Filled Teeth for permanent and primary teeth) was registered clinically and radiographically. Caries was recorded at the D₃ level (caries into dentine). The D/d component was divided into three categories. A pooled supragingival plaque sample per participant was obtained from posterior approximal sites. Analyses of 15 bacterial species were performed using the checkerboard DNA-DNA hybridisation technique.

Results

No significant relationships were found between the bacterial scores and DMFT/dmft nor D/d groups.

Conclusions

Unlike the saliva samples and the chair-side method, interproximal pooled plaque samples analysed using the “checkerboard DNA-DNA hybridization technique” did not reveal any significant relations between the bacterial counts and the caries experience.

The association between social deprivation and the prevalence and severity of dental caries and fluorosis in populations with and without water fluoridation

BACKGROUND

To determine the association between social deprivation and the prevalence of caries (including caries lesions restricted to enamel) and enamel fluorosis in areas that are served by either fluoridated or non-fluoridated drinking water using clinical scoring, remote blinded, photographic scoring for caries and fluorosis. The study also aimed to explore the use of remote, blinded methodologies to minimize the effect of examiner bias.

METHODS

Subjects were male and female lifetime residents aged 11-13 years. Clinical assessments of caries and fluorosis were performed on permanent teeth using ICDAS and blind scoring of standardized photographs of maxillary central incisors using TF Index (with cases for fluorosis defined as TF > 0).

RESULTS

Data from 1783 subjects were available (910 Newcastle, 873 Manchester). Levels of material deprivation (Index of Multiple Deprivation) were comparable for both populations (Newcastle mean 35.22, range 2.77-78.85; Manchester mean 37.04, range 1.84-84.02). Subjects in the fluoridated population had significantly less caries experience than the non-fluoridated population when assessed by clinical scores or photographic scores across all quintiles of deprivation for white spot lesions: Newcastle mean DMFT 2.94 (clinical); 2.51 (photo), Manchester mean DMFT 4.48 (clinical); 3.44 (photo) and caries into dentine (Newcastle Mean DMFT 0.65 (clinical); 0.58 (photo), Manchester mean DMFT 1.07 (clinical); 0.98 (photo). The only exception being for the least deprived quintile for caries into dentine where there were no significant differences between the cities: Newcastle mean DMFT 0.38 (clinical); 0.36 (photo), Manchester mean DMFT 0.45 (clinical); 0.39 (photo). The odds ratio for white spot caries experience (or worse) in Manchester was 1.9 relative to Newcastle. The odds ratio for caries into dentine in Manchester was 1.8 relative to Newcastle. The odds ratio for developing fluorosis in Newcastle was 3.3 relative to Manchester.

CONCLUSIONS

Water fluoridation appears to reduce the social class gradient between deprivation and caries experience when considering caries into dentine. However, this was associated with an increased risk of developing mild fluorosis. The use of intra-oral cameras and remote scoring of photographs for caries demonstrated good potential for blinded scoring.

Arrest of non-cavitated dentinal occlusal caries by sealing pits and fissures: a 36-month, randomised controlled clinical trial

OBJECTIVE

This study aimed to evaluate the progression of sealed non-cavitated dentinal occlusal caries in a randomised controlled clinical trial.

MATERIALS AND METHODS

Sixty teeth with non-cavitated dentinal occlusal caries were selected in patients with a high risk for caries. Patients were randomly divided into two groups so that each group included 30 teeth. Patients in the experiment group were given oral hygiene instructions and a fissure sealant. Patients in the control group were given oral hygiene instructions only. Caries progression and sealant loss were monitored over a period of 36 months by clinical and radiographic examinations.

RESULTS

Clinical and radiographic progression of caries was significantly more frequent in the control group than in the experiment group. Three teeth lost their sealant and showed caries progression, but this was apparent only at the 12-month follow-up. At the 24- and 36-month recall appointments, neither sealant loss nor caries progression were observed.

CONCLUSION

The pit and fissure sealant utilised in this study was shown to be effective in arresting carious lesions at 36 months.

Factors affecting the detection and treatment of occlusal caries using the International Caries Detection and Assessment System

OBJECTIVE

To assess the variability in diagnosis and treatment of occlusal caries among dental practitioners in Kuwait using the International Caries Detection and Assessment System (ICDAS) criteria.

METHODS

A representative random sample of 156 dentists were interviewed. After completing a survey that included information about their gender, age, years in practice, place of practice, place of dental education, and specialty, practitioners examined four separately mounted molars (I-IV) for probable occlusal caries according to the ICDAS-II visual criteria. They were then asked to answer a set of questions related to their diagnosis and treatment of each tooth. The teeth were then histologically sectioned, and two independent investigators evaluated the depth of the caries according to Hintze and Wenzel's histologic criteria.

RESULTS

According to the histologic examination, tooth I and III had caries into enamel, while tooth II and IV had caries into dentin. About 50% of the participants diagnosed teeth with enamel caries as sound. About 60% of the participants correctly diagnosed teeth with caries extending into dentin. A restorative treatment modality was recommended for enamel caries by approximately 50% of the participants and for dentin caries by more than 80% of the participants. Dentists with a specialty in restorative dentistry had a tendency to underdiagnose enamel caries, while general practitioners and other specialists tended to overtreat enamel caries.

CONCLUSIONS

There was an evident variability in the diagnosis and treatment choices of occlusal caries among dentists working in Kuwait. Among the factors studied, the specialty of the participants was the only factor that had an effect on the participants' diagnosis and treatment of occlusal caries.

Dental caries and pulpal disease

This article reviews the diagnostic process, from the first clinically evident stages of the caries process to development of pulpal pathosis. The caries diagnostic process includes 4 interconnected components-staging caries lesion severity, assessing caries lesion activity, and risk assessments at the patient and tooth surface level - which modify treatment decisions for the patient. Pulpal pathosis is diagnosed as reversible pulpitis, irreversible pulpitis (asymptomatic), irreversible pulpitis (symptomatic), and pulp necrosis. Periapical disease is diagnosed as symptomatic apical periodontitis, asymptomatic apical periodontitis, acute apical abscess, and chronic apical abscess. Ultimately, the goal of any diagnosis should be to achieve better treatment decisions and health outcomes for the patient.

Methods dentists use to diagnose primary caries lesions prior to restorative treatment: findings from The Dental PBRN

OBJECTIVE

To (1) quantify the diagnostic techniques used by Dental Practice-Based Research Network (DPBRN) dentists before they decide to treat primary caries lesions surgically and (2) examine whether certain dentist, practice, and patient characteristics are associated with their use.

METHODS

A total of 228 DPBRN dentists recorded information on 5676 consecutive restorations inserted due to primary caries lesions on 3751 patients. Practitioner-investigators placed a mean of 24.9 (SD=12.4) restorations. Lesions were categorised as posterior proximal, anterior proximal, posterior occlusal, posterior smooth, or anterior smooth. Techniques used to diagnose the lesion were categorised as clinical assessment, radiographs, and/or optical. Statistical analysis utilised generalised mixed-model ANOVA to account for the hierarchical structure of the data.

RESULTS

By lesion category, the diagnostic technique combinations used most frequently were clinical assessment plus radiographs for posterior proximal (47%), clinical assessment for anterior proximal (51%), clinical assessment for posterior occlusal (46%), clinical assessment for posterior smooth (77%), and clinical assessment for anterior smooth (80%). Diagnostic technique was significantly associated with lesion category after adjusting for clustering in dentists (p<0.0001).

CONCLUSION

These results - obtained during actual clinical procedures rather than from questionnaire-based hypothetical scenarios - quantified the diagnostic techniques most commonly used during the actual delivery of routine restorative care. Diagnostic technique varied by lesion category and with certain practice and patient characteristics.

A fractional electrical impedance model in detection of occlusal non-cavitated carious

Identification of occlusal caries remains a major concern for the diagnosis, which is still highly subjective and presents a considerable variability among clinicians. Dentists have been observed an increase of a specifically type of caries lesion, the hidden caries. Among the available techniques to assess the hidden caries, the measurement of electrical impedance has been shown to be one of the most promising. This paper presents a fractional electrical model for the tooth and uses such a model associated to a BioImpedance Spectroscopy (BIS) method based on the current response to a step voltage excitation. An analytical solution for the current response is presented based on a fractional calculus approach. Estimate parameters of the proposed model achieved using an in vitro data acquired in a protocol performed to collect bioimpedance data showed that it seems possible to detect occlusal non-cavitated caries, and that the principal confounding factor in the diagnosis of the incipient occlusal caries, the pigmented areas, can also be differentiated.

Defining dental caries for 2010 and beyond

This introductory article provides an overview of the caries disease process that will help guide readers into the world of evidence-based caries management in the beginning of the twenty-first century and help them understand the ongoing need to update in this field. This issue of Dental Clinics of North America provides clinically relevant reviews, full of chair-side recommendations based on best available evidence, on epidemiology, nomenclature, disease process, and management. A glossary of common terms in cariology is included.

What is an appropriate caries diagnosis?

This aim of this paper is to spur a discussion of the direction of caries-lesion detection activities in clinical dental practice. It is argued that since the dental clinician's caries-related decision making is a script-matching enterprise in which clinical decisions are made on the basis of 'this-lesion-needs-this-kind-of-treatment' reasoning, the methods and strategies employed for caries lesion detection should accommodate this fact. This may be done by employing a clinical visual-tactile method for caries lesion detection that evaluates the two aspects that are crucial for appropriate caries management: lesion activity and surface integrity. The use of diagnostic methods that do not assess these features directly but involve assumptions about activity status and surface integrity should be avoided. This includes the use of bite-wing radiography for the detection of approximal caries lesions, as it may be shown that plain reliance on radiographs leads to considerable overtreatment. If clinical dentistry is to retain its status as a profession committed to doing good, changes in diagnostic practices along these lines are warranted.

Development, methodology and potential of the new Universal Visual Scoring System (UniViSS) for caries detection and diagnosis

Given the limitations of adjunct caries detection and diagnostic tools, e.g., imperfect validity and reproducibility, as well as the difficulties in controlling all possible confounding factors, the need for an objective visual caries detection and diagnosis system has become evident. Our work has therefore aimed at systematizing caries lesions with the Universal Visual Scoring System (UniViSS) for occlusal and smooth surface lesions, which can be used for primary and permanent teeth, as well as under clinical, epidemiological, public health and laboratory conditions. Besides the description of the development and methodology of UniViSS, it is shown that UniViSS allows an accurate and reproducible classification of caries lesions on occlusal surfaces.

Influência de variáveis socioeconômicas, clínicas e demográfica na experiência de cárie dentária em pré-escolares de Piracicaba, SP

OBJETIVO: Avaliar a influência de variáveis socioeconômicas, clínicas e demográfica na experiência de cárie em pré-escolares de 5 anos de idade da cidade de Piracicaba. METODOLOGIA: A amostra consistiu de 728 crianças matriculadas em 22 pré-escolas públicas (n = 428) e 18 pré-escolas privadas (n = 300). A cárie dentária foi avaliada pelos índices ceo-d e ceo-s e pela detecção de lesão inicial (LI). Outras variáveis clínicas como gengivite, apinhamento, espaçamento, fluorose e respiração bucal também foram coletadas. As variáveis socioeconômicas (renda familiar mensal, número de residentes na mesma casa, escolaridade do pai e da mãe, habitação e posse de automóvel) foram obtidas por meio de um questionário semi-estruturado enviado aos pais. RESULTADOS: As médias (desvio-padrão) do ceo-d e ceo-s foram de 1,30 (2,47) e 3,08 (7,55), respectivamente, sendo que 62,2% da amostra estava livre de cárie. As médias (desvio-padrão) do ceo-d+LI e ceo-s+LI foram 1,72 (3,36) e 3,45 (7,94), respectivamente e 59,7% estavam livres de cáries. Por meio da análise de regressão logística múltipla, as crianças com fluorose (Odds Ratio-OR=0,40) ou de famílias com renda superior a 4 salários mínimos (OR = 0,49) apresentaram menor probabilidade de ter experiência de cárie. Aquelas com gengivite (OR = 1,87) tiveram maior chance de ter a doença. Para o critério de diagnóstico de cárie com a inclusão de LI, as crianças com fluorose (OR = 0,39) ou de famílias com renda superior a 4 salários mínimos (OR = 0,52) tiveram menor chance de ter cárie. Aquelas com gengivite (OR=1,80), apinhamento (OR = 2,63 e OR = 1,01) ou respiração bucal (OR = 1,37) apresentaram maior probabilidade de ter a doença. CONCLUSÃO: Os pré-escolares que apresentaram gengivite, apinhamento, respiração bucal ou renda familiar mensal inferior a 4 salários mínimos tiveram maior probabilidade de ter experiência de cárie. Assim, o planejamento de ações de prevenção e intervenção direcionadas a este público seria essencial para o controle da doença.

Diagnosing dental caries in populations with different levels of dental fluorosis

The aim of this study was to assess the reliability of the Nyvad visual-tactile caries-diagnostic criteria when used among children who have been lifelong residents in areas with 'optimal' or low concentrations of fluoride in the drinking water. In each of two areas with drinking water fluoride concentrations of 0.3 and 1.1 ppm (0.3 and 1.1 mg/l) fluoride, respectively, 150 children were clinically examined twice, 2 wk apart, for dental fluorosis, using the Thylstrup-Fejerskov index (TF index), and for dental caries using the Nyvad visual-tactile caries criteria. The prevalence of dental fluorosis was 45% in the 1.1 ppm fluoride area and 21% in the 0.3 ppm fluoride area. When the results of the duplicate caries recordings were compared at the surface level, only minute differences were observed in the percentage agreement (91.7 and 90.7%, respectively) and in the kappa values (0.73 and 0.72, respectively). When individual DFS counts were compared across examinations using Bland-Altman plots and estimation of prediction intervals for the differences, we observed a greater variability of the differences between recordings among children from the low-fluoride area. Contrary to our expectations, a pronounced dental fluorosis background did not reduce the reliability of the caries recordings, which appeared to be slightly less reliable at very low levels of dental fluorosis.

Dental caries: A complete changeover (Part II)-Changeover in the diagnosis and prognosis

Realization that dental caries is a reversible, dynamic biochemical event at a micron level has changed the way the profession recognizes the caries disease and the caries lesion. The diagnosis of dental caries poses challenges due to the complex interaction of multiple endogenous causal factors. The most appropriate diagnostic aid for this purpose is the risk model of caries risk assessment. The analyses of the biological determinants provide clues to the dominant causal factor. The detection of a carious lesion has undergone a rigorous revision and revolution in order to identify the earliest mineral change so that it can be controlled without resorting to invasive management options. Apart from detection, it became mandatory to assess the extent of the lesion (noncavitated/cavitated), assess the activity status of the lesion (active/arrested), monitor the lesion progress (progression/regression over a period of time), and finally to predict the prognosis of the lesion as well as the disease. The prognosis of the disease can be best assessed by analyzing the predictor factors in caries risk assessment. The ultimate objective of such a meticulous and methodical approach aids in devising a tailor-made treatment plan, using preventing measures precisely and restorative measures minimally. This ensures the best oral health outcome of the patient.

Validity of caries detection on occlusal surfaces and treatment decisions based on results from multiple caries-detection methods

The aim of this in vitro study was to evaluate whether having results available from multiple detection methods influences dentist's treatment decisions for incipient caries lesions on occlusal surfaces. The occlusal surface of 96 extracted permanent molars without frank cavitation was examined by three examiners initially by visual examination alone, following which they chose one of three treatment options: (i) no treatment, (ii) preventive or non-invasive treatment (sealants), and (iii) invasive treatment. Four weeks later the examiners again selected one of the three treatment options for the surfaces, but this time were able to refer to the results from additional caries-detection methods [bitewing radiographs, electric conductance measurement (ECM), quantitative light fluorescence (QLF), and DIAGNOdent] that had been performed in the interim time. Stereomicroscopy was used to evaluate sensitivity, specificity, accuracy, and area under the Receiver Operating Characteristic (ROC) curve (AUC) for the detection methods at the D1 diagnostic threshold. Slight improvement was obtained in the percentage of sites correctly diagnosed, and in the AUC, when referring to the results obtained from all detection methods compared with visual examination alone. However, a drastic effect on the selection of treatment options was observed by having results available from multiple methods, with the choice of invasive treatment increasing substantially. In conclusion, having data available from multiple methods did not improve the accuracy of examiners in detecting early occlusal caries lesions, but it had a great influence on the number of surfaces indicated for operative treatment. The potential decrease in overall specificity while using multiple methods of detection may be of concern in populations with a low prevalence of occlusal caries lesions.

Caries management decision: influence of dentist and patient factors in the provision of dental services

OBJECTIVES

Little is known about how dentists implement caries management and provide restorative dental services in everyday practice. This study explored whether or not recent concepts in caries management were implemented in practice by private practitioners. The influence of patient and practitioner characteristics on the provision of restorative dental services was also investigated through multidimensional analyses.

METHODS

A sample of French general private dental practitioners was asked to record the characteristics of 35 preventive or restorative treatments made on vital permanent teeth. The data collection form was designed to explore dentists' attitudes towards caries management and their use of minimally invasive therapies.

RESULTS

Twenty-six practitioners recorded the characteristics of 921 treatments performed on 457 patients. Results indicate that participants rarely performed non-invasive treatments. They used an inappropriate detection tool, as most of decisions to treat were based on visual inspection frequently associated with probing. Multidimensional analysis showed that dentists provided different restorative treatments depending on patient characteristics, with minimally invasive, esthetic restorations preferentially performed for healthy, young and well-insured patients. Restorative treatments and detection tools also varied markedly among practitioners. These variations in service patterns were not related to a specific patient profile in each dental practice.

CONCLUSIONS

Results indicate that recent concepts in caries management have not yet been adopted in everyday practice. Patient and dentist characteristics influence the provision of restorative dental services. Decision-making in caries management not only depends on pathophysiology but also seems to be influenced by many other factors.

Streptococcal Infections

The streptococci are a large heterogeneous group of gram-positive spherically shaped bacteria widely distributed in nature. They include some of the most important agents of human disease as well as members of the normal human flora. Some streptococci have been associated mainly with disease in animals, while others have been domesticated and used for the culture of buttermilk, yogurt, and certain cheeses. Those known to cause human disease comprise two broad categories: First are the pyogenic streptococci, including the familiar β-hemolytic streptococci and the pneumococcus. These organisms are not generally part of the normal flora but cause acute, often severe, infections in normal hosts. Second are the more diverse enteric and oral streptococci, which are nearly always part of the normal flora and which are more frequently associated with opportunistic infections.

Understanding measurement of dental diseases and research participation in practice set-up

A general understanding of the measurement of dental diseases can help practitioners in the process of assessing the patient's future risk of disease. More importantly, as clinical studies shift from the traditional academic setting to practice-based networks, practitioners might play a more significant role in research. An important issue in oral health disease management in the future will be the standardization of clinical criteria and the development of alternative mechanisms of data collection for epidemiologic purposes.

Determinants of dental care visits among low-income African-American children

BACKGROUND

The objective of the authors' analysis was to investigate the determinants of dental care visits among young, low-income African-American children.

METHODS

Trained researchers interviewed a representative sample of low-income black families (caregivers and children aged 0 through 5 years) in Detroit to assess their dental visit history, dental insurance status and oral health behaviors. Dental examinations were conducted using the International Caries Diagnosis Assessment System (ICDAS). Of the 1,021 families who completed an interview and examination, a subset of the 552 children aged 3 to 5 years (and their primary caregivers) was the focus of this analysis.

RESULTS

Children with private dental insurance had four times higher odds of having visited a dentist compared with those who had no dental insurance, and the odds for children receiving Medicaid were about 1.5 times higher. A child's age and a caregiver's educational attainment were positive and significant determinants of child dental visits. Caregivers who visited a dentist for preventive reasons were five times more likely to have taken their children to visit the dentist. Visiting a dentist was associated with an increased mean number of filled or missing tooth surfaces, but it was not significantly associated with the mean number of untreated decayed teeth.

CONCLUSION

Children's dental insurance status was a significant determinant of their having visited a dentist. Even after the authors accounted for insurance status and other risk indicators, they found that children of caregivers who reported visiting a dentist for preventive care had a higher number of dental care visits. Determinants of caregivers' preventive dental visits must be identified and encouraged to improve the percentage of low-income children who visit dentists.

Caries patterns in primary dentition in 3-, 5- and 7-year-old children: spatial correlation and preventive consequences

This study aimed to contribute to the descriptive information of oral health status in the primary dentition, especially concerning the distribution and spatial correlation of lesions. Data were obtained from two surveys. In the Signal-Tandmobiel project 4,468 7-year-old children in Flanders (Belgium) were selected by a stratified clustered random sample. In the Tandje de Voorste - Smile for Life (TDV) project, data were obtained from 1,291 3-year-old and 1,315 5-year-old children. The children were examined by trained dentists, using standardized and widely accepted criteria, based on the British Association for the Study of Community Dentistry criteria. At the population level, symmetry in the prevalence of caries experience across the midline was tested at the tooth and tooth surface levels using generalized estimating equations and alternating logistic regression (ALR) approaches. Individual symmetry was tested using an approach described by Hujoel et al. [J Dent Res 1994;73:1575-1580]. Descriptive observations suggested a symmetrical distribution of caries experience at the population level. The null hypothesis of symmetry could not be rejected at a 0.05 level, suggesting that caries experience might be symmetric in the deciduous dentition. Based on the ALR approach, 2 x 2 associations of caries experience at the tooth and surface levels, both in 5- and 7-year-olds, appeared to be strongest for the left-right pairs in the mandible, followed by the left-right pairs in the maxilla. At the individual level the hypothesis of random caries pattern was rejected (p < 0.0001). In conclusion, at the population level the null hypothesis of left-right symmetry could not be rejected, while at the individual level lesions tended to cluster on one side of the mouth.

Dental caries

Dental caries, otherwise known as tooth decay, is one of the most prevalent chronic diseases of people worldwide; individuals are susceptible to this disease throughout their lifetime. Dental caries forms through a complex interaction over time between acid-producing bacteria and fermentable carbohydrate, and many host factors including teeth and saliva. The disease develops in both the crowns and roots of teeth, and it can arise in early childhood as an aggressive tooth decay that affects the primary teeth of infants and toddlers. Risk for caries includes physical, biological, environmental, behavioural, and lifestyle-related factors such as high numbers of cariogenic bacteria, inadequate salivary flow, insufficient fluoride exposure, poor oral hygiene, inappropriate methods of feeding infants, and poverty. The approach to primary prevention should be based on common risk factors. Secondary prevention and treatment should focus on management of the caries process over time for individual patients, with a minimally invasive, tissue-preserving approach.

Dental caries paradigms in diagnosis and diagnostic research

In this article, the fundamentals of caries diagnosis are reviewed from the three component perspectives, namely the strategy, the logics, and the tactics. Strategy concerns the objectives of the diagnostic process (i.e. why we diagnose caries). The logics describe how we assemble and evaluate the information collected and how this leads to an assessment of diagnostic value. Finally, tactics are about how we collect the information necessary to arrive at a correct diagnosis. We argue that the hitherto-dominant essentialistic caries paradigm should be replaced by a nominalistic caries concept. This allows us to circumvent the problem of a lack of a caries gold standard and to proceed in caries-diagnostic research to find the diagnostic methods that result in the best health outcomes for our patients. We also demonstrate the limitations of the medical model when attempting to understand caries diagnosis, and adhere to the Bader & Shugars caries script model. It is concluded that the current caries profile, characterized by lower prevalence and extent, and slower progression, has increased the need for an academic strengthening of the dental curriculum with respect to diagnostic reasoning and clinical decision-making processes.

Prevention strategies for dental caries in the adolescent

The adolescent period presents a challenge for the dental health care professional--dentally, behaviorally, and developmentally. Changes in the frequency, distribution, and rate of progression for dental caries demand a re-evaluation of the treatment paradigm. The purpose of this article is to suggest dental caries preventive strategies for the adolescent dental patient.

Nonsurgical treatment of incipient and hidden caries

Traditionally, dentists have been trained in the surgical model for caries management whereby detection is akin to diagnosis. This model unfortunately has been translated to patient expectations. Nevertheless, a growing body of clinical evidence suggests that noncavitated lesions, even those extending into dentin, can be managed by nonsurgical means with an expectation for remineralization.

The challenges of validating diagnostic methods and selecting appropriate gold standards

Caries diagnostic methods are usually methods for caries lesion detection and measurement. Caries lesions occur on a continuous scale of tissue damage, from subclinical surface changes to macroscopic cavities reaching the pulp. Any change of a lesion on this continuous scale offers the opportunity for the diagnosis of disease activity or remission. Research aimed at remineralizing agents may focus on lesions that are amenable to remineralization, and select a method that will measure small changes in early lesions. General caries management strategies depend on detecting all stages of lesion development, and methods covering early to late stages are preferred. This paper addresses some methodological issues in validating caries diagnostic methods. The available gold standards for caries lesions are discussed, with their suitability in different applications, and their "validity" as far as it is known or can be inferred. The gold standards are compared as far as their measurement of lesion parameters and reproducibility is concerned. Tentative conclusions are formulated, and recommendations for future research are given.