Guidelines on the timing and frequency of bitewing radiography: a systematic review

Eligibility of a novel BW + technology and comparison of sensitivity and specificity of different imaging methods for radiological caries detection

OBJECTIVES

Bitewing radiography is considered to be of high diagnostic value in caries detection, but owing to projections, lesions may remain undetected. The novel bitewing plus (BW +) technology enables scrolling through radiographs in different directions and angles. The present study aimed at comparing BW + with other 2D and 3D imaging methods in terms of sensitivity, specificity, and user reliability.

MATERIALS AND METHODS

Five human cadavers were used in this study. In three cadavers, natural teeth were transplanted post-mortem. BW + , two-dimensional (digital sensors, imaging plates, 2D and 3D bitewing radiographs) and 3D methods (high and low dose CBCT) were taken. Carious lesions were evaluated on 96 teeth at three positions (mesial, distal, and occlusal) and scored according to their level of demineralization by ten observers, resulting in 35,799 possible lesions across all observers and settings. For reference, µCT scans of all teeth were performed.

RESULTS

Overall, radiographic evaluations showed a high rate of false-negative diagnoses, with around 70% of lesions remaining undetected, especially enamel lesions. BW + showed the highest sensitivity for dentinal caries and had comparatively high specificity overall.

CONCLUSIONS

Within the limits of the study, BW + showed great potential for added diagnostic value, especially for dentinal caries. However, the tradeoff of diagnostic benefit and radiation exposure must be considered according to each patient's age and risk.

Case Report on Caries Assessment Using Intraoral Scanner Compared with Bitewing Radiographs

Dental caries remains one of the main reasons patients seeing their dentist. They either show up for preventive measures, diagnostics, or treatment of present caries lesions. To date, diagnostics are performed visually, supported by using bitewing radiographs. While radiographic diagnostics should only be performed on a biannual basis, and some caries process will not be seen with visual diagnostics, there remains a lack in regular checkups. Therefore, different technical applications can be used for regular diagnostics. One of those is the near-infrared imaging (NIRI) technology. In this case report, a patient presented with incipient caries lesions. These lesions were diagnosed visually, radiographically, and using NIRI. After diagnosis of incipient caries lesions, the patient was advised to use a hydroxyapatite toothpaste and a hydroxyapatite gel for the remineralization of the lesions and prevention of caries progression. The patient was followed up for 6 months with regular checkups in between. Visual diagnostics and NIRI were used to detecting the caries progress. After 6 months, bitewing radiographs were used in addition. In this clinical investigation we were able to show for the first time that NIRI and bitewing radiographs are able to detect and follow incipient caries lesions. Additionally, this study highlights that hydroxyapatite-containing oral care products are able to arrest and remineralize the caries process.

Caries-preventing effect of a hydroxyapatite-toothpaste in adults: a 18-month double-blinded randomized clinical trial

Background

Dental caries is a worldwide challenge for public health. The aim of this 18-month double-blinded, randomized, clinical trial was to compare the caries-preventing effect of a fluoride-free, hydroxyapatite toothpaste (test) and a toothpaste with sodium fluoride (1450 ppm fluoride; positive control) in adults.

Methods

The primary endpoint was the percentage of subjects showing no increase in overall Decayed Missing Filled Surfaces (DMFS) index. The study was designed as non-inferiority trial. Non-inferiority was claimed if the upper limit of the exact one-sided 95% confidence interval for the difference of the primary endpoint DMFS between test and control toothpaste was less than the predefined margin of non-inferiority (Δ ≤ 20%).

Results

In total, 189 adults were included in the intention-to-treat (ITT) analysis; 171 subjects finished the study per protocol (PP). According to the PP analysis, no increase in DMFS index was observed in 89.3% of subjects of the hydroxyapatite group and 87.4% of the subjects of the fluoride group. The hydroxyapatite toothpaste was not statistically inferior to a fluoride toothpaste with regard to the primary endpoint.

Conclusion

Hydroxyapatite was proven to be a safe and efficient anticaries agent in oral care.

Clinical trial registration

NCT04756557.

Sociodemographic, behavioral, and clinical indicators for added value of radiography in caries diagnosis in adolescents: A cross-sectional study

OBJECTIVE

The aim was to assess the value of sociodemographic, behavioral, and clinical characteristics in identifying adolescents who would benefit from radiographs for dental caries detection in a high-caries experience population.

STUDY DESIGN

In total, 356 adolescents answered a validated questionnaire on sociodemographic characteristics and oral health behavior and were clinically and radiographically examined for caries. The outcome was the benefit arising from radiographs for caries detection at the patient level, defined as the number of surfaces clinically classified as sound but presenting radiolucency.

RESULTS

A total of 169 participants (47.5%) benefited from radiographs. One-third of approximal lesions were detected clinically, whereas two-thirds, mostly initial lesions, were detected radiographically only. Adolescents who reported frequent consumption of soft drinks and sugary food, those with D₁MFS (noncavitated and cavitated caries experience) ≥12, D₅MFS (cavitated caries experience) ≥1, clinically detected approximal lesions, and active caries were significantly more likely to benefit from radiographs (P ≤ .002). Although some indicators showed moderate-to-good sensitivity (consumption of sugary food, caries activity) or specificity (absence of clinically diagnosed approximal lesions), the accuracy of indicators evaluated (isolated or combined) never reached 0.60.

CONCLUSIONS

The possibility of correctly identifying which adolescents would benefit from radiographs for caries detection purposes was limited in a population with high-caries experience.

Reproducibility and diagnostic value of a new wedge-guided bitewing image receptor-holding device

OBJECTIVE

To assess the reproducibility of a wedge-guided bitewing image receptor-holding device (IRHD-WG) compared to a commercially available bitewing image receptor-holding device (IRHD-XCP).

METHODS AND MATERIALS

Ten operators randomly acquired bitewing radiographs of four posterior regions (Premolar, Molar 1, Molar 2, Molar 3) distributed in two dry bone skulls and mandibles using 2 IRHDs (IRHD-WG and IRHD-XCP). The radiographs corresponding to the same region and IRHD but acquired by different operators were paired for reproducibility comparison. A total of 360 pairs of radiographs were randomized for analysis. Objective analysis consisted of extracting the pixel values from each radiograph and comparing the values between each pair by intraclass correlation coefficient. For subjective analysis, the IRHDs images were digitally removed. Five oral radiologists blinded for the study conditions classified the radiograph pairs according to their similarity and diagnostic value. The answers' relative frequencies were compared by the chi-square test (α = 0.05).

RESULTS

The IRHD-WG presented a higher reproducibility (Mean = 0.850; SD = 0.144) than the IRHD-XCP (Mean = 0.615; SD = 0.287) in the objective analysis. Radiographs acquired with the IRHD-WG were more similar than those acquired with the IRHD-XCP (p < 0.001). The diagnostic value of bitewing radiographs acquired with the IRHD-WG was considered superior to those acquired with the IRHD-XCP (p < 0.001).

CONCLUSION

For the objective and subjective analyses of reproducibility, the IRHD-WG performed better than the commercial IRHD-XCP.

Effects of provider incentives on dental X-raying in NHS Scotland: what happens if patients switch providers?

BACKGROUND

In many market settings individuals are encouraged to switch health care providers as a means of ensuring more competition. Switching may have a potentially undesirable side effect of increasing unnecessary treatment. Focusing on the most common source of medical radiation (dental X-rays), the purpose of this study was to assess whether, upon switching dentist, X-ray exposure increases depending on the type of provider payment.

METHODS

The analysis used longitudinal data from 2005 to 2016 covering a 5% random sample of the Scottish adult population covered by the National Health Service (NHS). Multiple fixed-effects panel regression analyses were employed to determine the correlation of provider remuneration with patients' likelihood of receiving an X-ray upon switching to a new dentist other things equal. A broad set of covariates including a patient's copayment status was controlled for.

RESULTS

Upon switching to a dentist who was paid fee-for-service, patients had a by 9.6%-points (95% CI 7.4-11.8%) higher probability of receiving an X-ray, compared to switching to a salaried dentist. Results were robust when accounting for patient exemption status, as well as unobserved patient and dentist characteristics.

CONCLUSIONS

In comparison to staying with the same dentist, patients may be exposed to substantially more X-rays upon switching to a dentist who is paid fee-for-service. There may need to be better guidance and regulation to protect the health of those who have to switch provider due to moving and greater caution in advocating voluntary switching.

Imaging modalities to inform the detection and diagnosis of early caries

BACKGROUND

The detection and diagnosis of caries at the earliest opportunity is fundamental to the preservation of tooth tissue and maintenance of oral health. Radiographs have traditionally been used to supplement the conventional visual-tactile clinical examination. Accurate, timely detection and diagnosis of early signs of disease could afford patients the opportunity of less invasive treatment with less destruction of tooth tissue, reduce the need for treatment with aerosol-generating procedures, and potentially result in a reduced cost of care to the patient and to healthcare services.

OBJECTIVES

To determine the diagnostic accuracy of different dental imaging methods to inform the detection and diagnosis of non-cavitated enamel only coronal dental caries.

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 31 December 2018); Embase Ovid (1980 to 31 December 2018); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 31 December 2018); and the World Health Organization International Clinical Trials Registry Platform (to 31 December 2018). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy study designs that compared a dental imaging method with a reference standard (histology, excavation, enhanced visual examination), studies that evaluated the diagnostic accuracy of single index tests, and studies that directly compared two or more index tests. Studies reporting at both the patient or tooth surface level were included. In vitro and in vivo studies were eligible for inclusion. Studies that explicitly recruited participants with more advanced lesions that were obviously into dentine or frankly cavitated were excluded. We also excluded studies that artificially created carious lesions and those that used an index test during the excavation of dental caries to ascertain the optimum depth of excavation.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently and in duplicate using a standardised data extraction form and quality assessment based on QUADAS-2 specific to the clinical context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence regions. Comparative accuracy of different radiograph methods was conducted based on indirect and direct comparisons between methods. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression.

MAIN RESULTS

We included 104 datasets from 77 studies reporting a total of 15,518 tooth sites or surfaces. The most frequently reported imaging methods were analogue radiographs (55 datasets from 51 studies) and digital radiographs (42 datasets from 40 studies) followed by cone beam computed tomography (CBCT) (7 datasets from 7 studies). Only 17 studies were of an in vivo study design, carried out in a clinical setting. No studies were considered to be at low risk of bias across all four domains but 16 studies were judged to have low concern for applicability across all domains. The patient selection domain had the largest number of studies judged to be at high risk of bias (43 studies); the index test, reference standard, and flow and timing domains were judged to be at high risk of bias in 30, 12, and 7 studies respectively. Studies were synthesised using a hierarchical bivariate method for meta-analysis. There was substantial variability in the results of the individual studies, with sensitivities that ranged from 0 to 0.96 and specificities from 0 to 1.00. For all imaging methods the estimated summary sensitivity and specificity point was 0.47 (95% confidence interval (CI) 0.40 to 0.53) and 0.88 (95% CI 0.84 to 0.92), respectively. In a cohort of 1000 tooth surfaces with a prevalence of enamel caries of 63%, this would result in 337 tooth surfaces being classified as disease free when enamel caries was truly present (false negatives), and 43 tooth surfaces being classified as diseased in the absence of enamel caries (false positives). Meta-regression indicated that measures of accuracy differed according to the imaging method (Chi²(4) = 32.44, P < 0.001), with the highest sensitivity observed for CBCT, and the highest specificity observed for analogue radiographs. None of the specified potential sources of heterogeneity were able to explain the variability in results. No studies included restored teeth in their sample or reported the inclusion of sealants. We rated the certainty of the evidence as low for sensitivity and specificity and downgraded two levels in total for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the in vitro studies, and the observed inconsistency of the results.

AUTHORS' CONCLUSIONS

The design and conduct of studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ are particularly challenging. Low-certainty evidence suggests that imaging for the detection or diagnosis of early caries may have poor sensitivity but acceptable specificity, resulting in a relatively high number of false-negative results with the potential for early disease to progress. If left untreated, the opportunity to provide professional or self-care practices to arrest or reverse early caries lesions will be missed. The specificity of lesion detection is however relatively high, and one could argue that initiation of non-invasive management (such as the use of topical fluoride), is probably of low risk. CBCT showed superior sensitivity to analogue or digital radiographs but has very limited applicability to the general dental practitioner. However, given the high-radiation dose, and potential for caries-like artefacts from existing restorations, its use cannot be justified in routine caries detection. Nonetheless, if early incidental carious lesions are detected in CBCT scans taken for other purposes, these should be reported. CBCT has the potential to be used as a reference standard in diagnostic studies of this type. Despite the robust methodology applied in this comprehensive review, the results should be interpreted with some caution due to shortcomings in the design and execution of many of the included studies. Future research should evaluate the comparative accuracy of different methods, be undertaken in a clinical setting, and focus on minimising bias arising from the use of imperfect reference standards in clinical studies.

Radiographic assessment of proximal surface carious lesion progression in Chilean young adults

OBJECTIVE

To investigate the rate and associations of interproximal carious lesion progression.

METHODS

Retrospective data were analysed from 125 young adults (age range: 18-29 years) with repeated bitewing radiographs collected over a 6-year period. Participants were submitted to different protocols of radiographic examination frequency. Transitions from outer enamel to outer dentine (OE-to-OD) and from outer dentine to dentine (OD-to-D) were selected because of their clinical relevance. Factors associated with each transition were assessed in Cox regression models.

RESULTS

One hundred seven (85.6%) and 52 (41.6%) participants experienced OE-to-OD and OD-to-D transitions, respectively. In addition, 16.8% of 537 eligible surfaces progressed from OE-to-OD whereas 59.4% of 128 eligible surfaces progressed from OD-to-D. Incidence rates were 6.6 and 44.1 per 100 tooth surface-years, respectively. Mean survival time for OE-to-OD transition was 6.4 years (95% confidence interval: 6.0-6.9) and the median survival time for OD-to-D transition was 1.6 years (95%CI: 1.3-1.7). In adjusted Cox regression models, location in the lower jaw (hazard ratio: 0.34; 95% CI: 0.21-0.57) was inversely associated with OE-to-OD progression. In addition, proximal DMFS at baseline (HR: 0.93; 95%CI: 0.87-0.99) and location in the lower jaw (HR: 0.51; 95%CI: 0.26-0.99) were inversely associated with OD-to-D progression.

CONCLUSIONS

This group of Chilean young adults has a high progression rate of proximal caries lesions. Location of the caries lesion and proximal DMFS were the only factors associated with caries progression.

Diagnostic efficacy of and indications for intraoral radiographs in pediatric dentistry: a systematic review

PURPOSE

To systematically evaluate the diagnostic efficacy of intraoral radiographs and evidence supporting the indications for taking of intraoral radiographs in children in the following five clinical categories: caries, pathological conditions (including acute odontogenic infections and periodontal disease), dental/developmental anomalies, dental trauma, and enhancement of comfort/technique for taking radiographs in children. This was carried out to facilitate the updating of existing European Academy of Paediatric Dentistry (EAPD) guidelines on dental radiography in pediatric dentistry.

METHODS

A systematic electronic literature search was conducted on Cochrane Library (1992-24 July 2018), MEDLINE (PubMed, 1946-24 July 2018), EMBASE (Embase.com, 1974-24 July 2018) and Scopus (pre-1970-24 July 2018). Hand search of handbooks and grey literature search was also performed. Study screening and study inclusions were agreed upon by three authors. Data extraction, and methodological quality and risk of bias assessment were carried out in duplicate for each of the included studies.

RESULTS

A total of 9581 papers were identified. Following the primary and secondary assessment process, 36 papers were included in the final analysis. The included studies were further categorized into five main clinical categories for analysis: caries, pathological conditions, dental/developmental anomalies, dental trauma and comfort/technique-related studies. Only one paper was found to be of good quality and at low risk of bias; while, 9 papers were found of be at moderate risk of bias and 26 papers were at high risk of bias. Meta-analysis was not possible for any of the aforementioned clinical situations, and only a narrative synthesis was done.

CONCLUSION

There is insufficient high-quality evidence for the use of intraoral radiographs in pediatric dentistry and current guidelines are based largely on expert opinion. There is a clear need for well-conducted and standardized studies regarding the use of intraoral radiography in pediatric dentistry.

Best clinical practice guidance for prescribing dental radiographs in children and adolescents: an EAPD policy document

BACKGROUND

The European Academy of Paediatric Dentistry (EAPD) proposes this best clinical practice guidance to help practitioners decide when and how to prescribe dental radiographs in children and adolescents.

METHODS

Four expert working groups conducted each a systematic review of the literature. The main subjects were radiation protection, intraoral dental radiography (bitewing and periapical radiographs), panoramic radiography (PR) and cone-beam computed tomography (CBCT). In addition, three workshops were held during the corresponding EAPD Interim Seminar in Chania (Crete, Greece) in 2019. On the basis of the identified evidence, all invited experts presented their findings and during the workshops aspects of clinical relevance were discussed.

RESULTS

Several clinical-based recommendations and statements were agreed upon.

CONCLUSION

There is no or low-grade evidence about the efficacy of dental radiographic examinations in young populations. The given recommendations and rationales should be understood as best clinical practice guidance. It is essential to respect the radiological principles of an individualized and patient-specific justification. When a dental radiograph is required, its application needs to be optimized, aiming at limiting the patient's exposure to ionising radiation according to the ALADAIP principle (As Low As Diagnostically Achievable being Indication-oriented and Patient-specific).

Combined Near-Infrarred Light Transillumination and Direct Digital Radiography Increases Diagnostic In Approximal Caries

The objective of this study was to evaluate the clinical ability of Near-Infrared Light-Transillumination (NILT) for approximal dentinal caries detection and to compare with direct digital-radiography (DDR), as well as to determine whether the combination of both techniques improves the diagnostic capacity of the lesions. From 88 patients (over 18 years), 138 posterior teeth (76 molars and 62 premolars), that had approximal caries reached into dentine determined by DDR, were included. Lesion extension and DDR images were scored as follows: D0 = sound surface, D1/D2 = caries restricted to the outer/inner-half of the enamel, and D3/4 = caries restricted to the outer/inner-half of the dentin. Opening of the approximal surface using 0.5 mm-in-diameter diamond-bar was used as gold-standard. The lesion extension was then determined by the following criteria: no dentinal caries (D0/1/2) or dentinal caries (D3/4). Seventy-one lesions were D3 and 67 lesions were D4. Sensitivities of overall/D3/D4 were 98.0/95.7/100.0 (NILT) and 100/100/100 (DDR), respectively. Correlations with gold-standard were 0.92 (NILT) and 0.42 (DDR), respectively. The correlation increased to 0.97 (p = 0.045) on combining NILT and DDR. There was no difference in sensitivity between the methods (p > 0.05); but was differences in the correlation (p < 0.01). It can be concluded that NILT showed sensitivity similar to that of DDR and higher correlation than DDR for approximal dentinal caries detection. Accordingly, it may be used to monitor the progression of caries without exposing the patient to ionizing radiation, this being of particular interest in growing patients and in pregnant women. In this respect, NILT can be an effective diagnostic tool adjunctive to bitewing radiographs in detecting approximal dentinal caries. The combination of NILT and DDR represents an increase in the diagnosis of approximal lesions The proposed diagnostic protocol comprises visual examination, followed by NILT and DDR only if the former technique detects approximal caries.

Dental caries prevention in children and adolescents: a systematic quality assessment of clinical practice guidelines

OBJECTIVES

To evaluate the quality of clinical practice guidelines (CPGs) for dental caries prevention in children and adolescents MATERIALS AND METHODS: We performed a systematic search of CPGs on caries preventive measures between 2005 and 2016. We searched MEDLINE, EMBASE, LILACS, TripDatabase, websites of CPG developers, compilers of CPGs, scientific societies and ministries of health. We included CPGs with recommendations on sealants, fluorides and oral hygiene. Three reviewers independently assessed the included CPGs using the AGREE II instrument. We calculated the standardised scores for the six domains and made a final recommendation about each CPG. Also, we calculated the overall agreement among calibrated reviewers with the intraclass correlation coefficient (ICC).

RESULTS

Twenty-two CPGs published were selected from a total of 637 references. Thirteen were in English and nine in Spanish. The overall agreement between reviewers was very good (ICC = 0.90; 95%CI 0.89-0.92). The mean score for each domain was the following: Scope and purpose 89.6 ± 12%; Stakeholder involvement 55.0 ± 15.6%; Rigour of development 64.9 ± 21.2%; Clarity of presentation 84.8 ± 14.1%; Applicability 30.6 ± 31.5% and Editorial independence 59.3 ± 25.5%. Thirteen CPGs (59.1%) were assessed as "recommended", eight (36.4%) "recommended with modifications" and one (4.5%) "not recommended".

CONCLUSIONS

The overall quality of CPGs in caries prevention was moderate. The domains with greater deficiencies were Applicability, Stakeholder involvement and Editorial independence.

CLINICAL RELEVANCE

Clinicians should use the best available CPGs in dental caries prevention to provide optimal oral health care to patients.

Dental caries prevention in children and adolescents: a systematic quality assessment of clinical practice guidelines

OBJECTIVES

To evaluate the quality of clinical practice guidelines (CPGs) for dental caries prevention in children and adolescents MATERIALS AND METHODS: We performed a systematic search of CPGs on caries preventive measures between 2005 and 2016. We searched MEDLINE, EMBASE, LILACS, TripDatabase, websites of CPG developers, compilers of CPGs, scientific societies and ministries of health. We included CPGs with recommendations on sealants, fluorides and oral hygiene. Three reviewers independently assessed the included CPGs using the AGREE II instrument. We calculated the standardised scores for the six domains and made a final recommendation about each CPG. Also, we calculated the overall agreement among calibrated reviewers with the intraclass correlation coefficient (ICC).

RESULTS

Twenty-two CPGs published were selected from a total of 637 references. Thirteen were in English and nine in Spanish. The overall agreement between reviewers was very good (ICC = 0.90; 95%CI 0.89-0.92). The mean score for each domain was the following: Scope and purpose 89.6 ± 12%; Stakeholder involvement 55.0 ± 15.6%; Rigour of development 64.9 ± 21.2%; Clarity of presentation 84.8 ± 14.1%; Applicability 30.6 ± 31.5% and Editorial independence 59.3 ± 25.5%. Thirteen CPGs (59.1%) were assessed as "recommended", eight (36.4%) "recommended with modifications" and one (4.5%) "not recommended".

CONCLUSIONS

The overall quality of CPGs in caries prevention was moderate. The domains with greater deficiencies were Applicability, Stakeholder involvement and Editorial independence.

CLINICAL RELEVANCE

Clinicians should use the best available CPGs in dental caries prevention to provide optimal oral health care to patients.