A comparison of primary root caries lesions classified according to colour

Tooth Discoloration from 2 Silver Fluorides Used in Adults with Special Needs: A Randomized Trial

BACKGROUND

Discoloration of carious lesions after application of silver diamine fluoride lowers patient acceptance and limits its wider use for caries arrest.

OBJECTIVE

To assess lesion and tooth color changes from 2 novel silver fluoride (AgF) products and its relationship to caries activity (clinical visuo-tactile scores) and bacterial load (using laser fluorescence with the DIAGNOdent).

METHODS

A split-mouth design was followed, with matched smooth surface carious lesions in the same arch in adults with special needs randomized for 1-min treatments with AgF/potassium iodide (KI) (Riva Star Aqua, SDI) and AgF/stannous fluoride (SnF2) (Caries Status Disclosing Solution; Whiteley). Standardized images taken at baseline, immediately postoperatively, and at 3-mo review were subjected to digital image analysis to calculate delta-E and to track changes in luminosity of carious lesions.

RESULTS

Twelve participants were recruited in the study. A total of 56 teeth (28 pairs) were included. Significantly greater changes were seen in treated lesions than in the adjacent noncarious natural tooth structure, both immediately after treatment and at the 3-mo review (P < 0.0001). Color change and caries activity were not affected by tooth type, tooth location, plaque status, salivary status, or special needs condition. AgF/SnF2 caused transitory darkening immediately on application, while AgF/KI caused the immediate formation of yellow deposits (silver iodide). Both products caused significant darkening of treated lesions at 3 mo (P = 0.0009; P = 0.0361), with no differences between them (P = 0.506). Responding lesions showed larger and more perceptible color changes immediately after either AgF application (P = 0.002; P = 0.024).

CONCLUSIONS

Both AgF products were highly effective for caries arrest in this patient population. Despite minor differences in the appearance of treated lesions at the time of application, both products lead to similar darkening of treated sites at 3 mo.

KNOWLEDGE TRANSFER STATEMENT

This study shows the usefulness of silver fluoride used in conjunction with potassium iodide or stannous fluoride for achieving caries arrest in smooth surface lesions in adults with special needs. Patients need to be informed that long-term staining of the lesion occurs with both, similar to silver diamine fluoride.

Organization for Caries Research-European Federation of Conservative Dentistry Consensus Report on Clinical Recommendations for Caries Diagnosis Paper II: Caries Lesion Activity and Progression Assessment

INTRODUCTION

This consensus paper provides recommendations for oral health professionals on why and how to assess caries activity and progression with special respect to the site of a lesion.

METHODS

An expert panel was nominated by the executive councils of the European Organization for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD). The steering committee built three working groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity and progression assessment, and (3) obtain individualized caries diagnoses. The experts of work group 2 phrased and agreed on provisional general and specific recommendations on caries lesion activity and progression, based on a review of the current literature. These recommendations were then discussed and refined in a consensus workshop followed by an anonymous Delphi survey to determine the agreement on each recommendation.

RESULTS

The expert panel agreed on general (n = 7) and specific recommendations (n = 6). The specific recommendations cover coronal caries on pits and fissures, smooth surfaces, proximal surfaces, as well as root caries and secondary caries/caries adjacent to restorations and sealants. 3/13 recommendations yielded perfect agreement.

CONCLUSION

The most suitable method for lesion activity assessment is the visual-tactile method. No single clinical characteristic is indicative of lesion activity; instead, lesion activity assessment is based on assessing and weighing several clinical signs. The recall intervals for visual and radiographic examination need to be adjusted to the presence of active caries lesions and recent caries progression rates. Modifications should be based on individual patient characteristics.

Diagnosing and recording root caries: A survey among Swiss dentists

OBJECTIVES

Despite the increase in the root caries prevalence, little is still known about how dentists manage this condition. The present study aimed to evaluate the knowledge of dentists on diagnosing and recording root caries lesions (RCL).

METHODS

The survey consisted of three domains: (1) dentists' knowledge on diagnosing, recording and managing RCL; (2) information about their current general clinical routines; and (3) their demographics. The four Swiss Universities distributed the survey via e-mail lists for alumni or professionals participating in continuing education. The data was quality checked. Construct validity, internal reliability and intraclass correlation (ICC) were assessed.

RESULTS

The survey was answered by 383 dentists from 25(out of 26) cantons [mean(SD) working experience: 22.5(12) years]. The majority replied that they see less than 5 patients with RCL per week, whereas 41 have at least 5 per week, and 40 % (157 dentists) do not distinguish RCL from coronal caries in their patients' medical records. When diagnosing active RCL, tactile sensation was the most predominant criterion (n = 380), whereas color (n = 224) and visual appearance (n = 129) of the lesion were less often selected. The most often chosen risk factors for RCL were poor oral hygiene and presence of biofilm.The responses were significantly influenced by the participants' place of education, their age and working area.

CONCLUSION

The present survey highlights the huge diversity in diagnosing, recording and assessing risk factors of RCL. The benefits of an appropriate diagnosis, recording and management of risk factors of RCL should be highlighted in under- and postgraduate dental education.

CLINICAL SIGNIFICANCE

A great diversity in diagnosing, recording and assessing risk factors of RCL was observed, which migh strongly impact how dentists manage RCL. The study emphasizes the necessity for intensive efforts to bridge the gap between guideline recommendations and their implementation in private dental practices.

Silver Diamine Fluoride Staining With Potassium Iodide: A Prospective Cohort Study

BACKGROUND

Staining after silver diamine fluoride (SDF) treatment limits treatment acceptability but is also used as a clinical indicator of lesion stability. Potassium iodide (KI) has been postulated to modify SDF staining. Understanding the natural history and resultant shade of SDF/KI-treated lesions will inform clinical decision-making. This study describes the change in colour of carious lesions in primary teeth treated with SDF and KI.

METHODS

One hundred carious lesions in primary teeth were treated with SDF + KI (Riva Star, SDI) and followed up over 6 months. Lesion shade was determined using standardised intraoral photography and broadly categorised into 4 shades: yellow, light brown, dark brown, and black. Lesions were digitally isolated, and colour was evaluated using CIELAB (L*: lightness, a*/b*: hue) and perceptible colour change (ΔE).

RESULTS

One hundred valid observations were analysed on 129 lesions included in the study. Lesions were excluded if subsequently restored (n = 15), teeth exfoliated (n = 2), exhibited pulpal exposure (n = 1), or failed to attend at follow-up visits (n = 11). At baseline, the shade of carious lesions was yellow (n = 22), light brown (n = 19), dark brown (n = 29), or black (n = 30). The changes in shade between baseline and 6 months were clinically perceptible to the human eye, with the mean ΔE being 12.2 (SD = 6.9). Neither tooth type, lesion severity, nor baseline shade was statistically associated with the degree of perceptible change at 6 months.

CONCLUSIONS

Carious lesions exhibited clinically significant changes in colour after application of SDF + KI, primarily attributed to differences in L* of lesions over the 6 months.

Active Surveillance of Root Caries in Vivo with CP-OCT

The active surveillance of root caries lesions to monitor potential remineralization or decay progression is challenging for the clinician, due to unreliable diagnostic information. The conventional visual and tactile methods for assessing the lesion activity are not reliable, and the clinician is often unable to determine if the lesion is progressing or has been arrested. An important marker of an arrested lesion is a highly mineralized transparent surface zone (TSL) that forms when the mineral is deposited in the outer layer of the lesion. The purpose of this study was to determine if cross-polarization optical coherence tomography (CP-OCT) could be used to detect changes in the lesion severity and activity during active monitoring. In total, 18 subjects with 22 suspected active root caries lesions were evaluated using CP-OCT at the baseline, 3 months, and 6 months. All subjects were instructed to use a high fluoride dentifrice at the baseline. The results showed that CP-OCT was able to discriminate the active from the arrested lesions by identifying the presence of a TSL on arrested lesions. The results also indicated that the mean TSL thickness increased significantly (p < 0.05) for the nine lesion areas. In addition, CP-OCT was able to show the progression of demineralization, erosion, and changes in gingival contours in scanned areas. CP-OCT was valuable for monitoring the activity and severity of root caries lesions in vivo. CP-OCT can be used to assess the activity of root caries lesions at a single time point by detecting the presence of a TSL at the lesion surface indicative of the lesion arrest.

Tests to detect and inform the diagnosis of root caries

BACKGROUND

Root caries is a well-recognised disease, with increasing prevalence as populations age and retain more of their natural teeth into later life. Like coronal caries, root caries can be associated with pain, discomfort, tooth loss, and contribute significantly to poorer oral health-related quality of life in the elderly. Supplementing the visual-tactile examination could prove beneficial in improving the accuracy of early detection and diagnosis. The detection of root caries lesions at an early stage in the disease continuum can inform diagnosis and lead to targeted preventive therapies and lesion arrest.

OBJECTIVES

To assess the diagnostic test accuracy of index tests for the detection and diagnosis of root caries in adults, used alone or in combination with other tests.

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 one or more index tests (laser fluorescence, radiographs, visual examination, electronic caries monitor (ECM), transillumination), either independently or in combination, with a reference standard. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. In vitro and in vivo studies were eligible for inclusion but studies that artificially created carious lesions were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) specific to the review context. Estimates of diagnostic test accuracy were expressed as sensitivity and specificity with 95% confidence intervals (CI) for each dataset. We planned to use hierarchical models for data synthesis and explore potential sources of heterogeneity through meta-regression.

MAIN RESULTS

Four cross-sectional diagnostic test accuracy studies providing eight datasets with data from 4997 root surfaces were analysed. Two in vitro studies evaluated secondary root caries lesions on extracted teeth and two in vivo studies evaluated primary root caries lesions within the oral cavity. Four studies evaluated laser fluorescence and reported estimates of sensitivity ranging from 0.50 to 0.81 and specificity ranging from 0.40 to 0.80. Two studies evaluated radiographs and reported estimates of sensitivity ranging from 0.40 to 0.63 and specificity ranging from 0.31 to 0.80. One study evaluated visual examination and reported sensitivity of 0.75 (95% CI 0.48 to 0.93) and specificity of 0.38 (95% CI 0.14 to 0.68). One study evaluated the accuracy of radiograph and visual examination in combination and reported sensitivity of 0.81 (95% CI 0.54 to 0.96) and specificity of 0.54 (95% CI 0.25 to 0.81). Given the small number of studies and important differences in the clinical and methodological characteristics of the studies we were unable to pool the results. Consequently, we were unable to formally evaluate the comparative accuracy of the different tests considered in this review. Using QUADAS-2 we judged all four studies to be at overall high risk of bias, but only two to have applicability concerns (patient selection domain). Reasons included bias in the selection process, use of post hoc (data driven) positivity thresholds, use of an imperfect reference standard, and use of extracted teeth. We downgraded the certainty of the evidence due to study limitations and serious imprecision of the results (downgraded two levels), and judged the certainty of the evidence to be very low.

AUTHORS' CONCLUSIONS

Visual-tactile examination is the mainstay of root caries detection and diagnosis; however, due to the paucity of the evidence base and the very low certainty of the evidence we were unable to determine the additional benefit of adjunctive diagnostic tests for the detection and diagnosis of root caries.

The burden of root caries: Updated perspectives and advances on management strategies

BACKGROUND

Root caries has gained much attention in the last few years. As the world's population is ageing and people currently tend to retain more teeth compared with older generations, there is an increased prevalence of periodontal disease and gingival recession, which may accelerate the onset of root caries.

OBJECTIVE

This review aims to summarise recent findings related to the diagnosis, prevention and treatment of root caries.

MATERIALS AND METHODS

MEDLINE (OVID) and Scopus (Elsevier) searches were performed to identify and discuss articles that address the pathogenicity and clinical management of root caries.

RESULTS

Root caries is a multifactorial disease. Cariogenic species involved in root caries are less dependent on carbohydrates since collagen degradation inside the dentinal tubules can provide nutrients and microcavities for the invading microorganisms. Furthermore, the root surface has fewer minerals in comparison with enamel, which may accelerate the onset of demineralisation. Root caries could be prevented by patient education, modification of risk factors, and the use of in-office and home remineralisation tools. The use of non-invasive approaches to control root caries is recommended, as the survival rate of root caries restorations is poor. When plaque control is impossible and a deep/large cavity is present, glass ionomer or resin-based restorations can be placed.

CONCLUSION

The assessment of root carious lesions is critical to determine the lesion activity and the required intervention. Dental practitioners should also be aware of different prevention and treatment approaches to design optimum oral health care for root caries-affected patients.

Contemporary Challenges and Management of Dental Caries in the Older Population

The prevalence of caries is set to increase in the coming years as a result of a growing ageing population and a concomitant reduction in levels of edentulousness. Evidence for management of caries in older adults is scarce compared to that for the child population, however, similar principles of risk assessment, prevention and minimal intervention should be applied by dental health professionals. Early identification of high-risk older adults facilitates the implementation of risk reduction strategies, such as topical fluoride regimes. When operative intervention cannot be avoided, Atraumatic Restorative Technique (ART) may allow for conservative cavity preparation and has the advantage of being suitable for the domiciliary setting.

Thermal Imaging of Root Caries In Vivo

Improved methods are needed to assess the structure and activity of lesions on root surfaces in order to improve clinical decision making. Conventional visual and tactile methods for assessing lesion activity are not reliable, and the clinician is often unable to evaluate if the lesion is progressing or has remineralized. An important marker of an arrested lesion is a highly mineralized surface zone that forms when mineral is deposited in the outer layer of the lesion. In vitro studies have shown that a mineralized surface zone influences the kinetics of water evaporation and the surface temperature while drying. Temperature changes can be monitored by measuring the thermal emission with thermal imaging. Studies have also shown that the depth and severity of demineralization and the thickness of the highly mineralized transparent surface zone on arrested lesions can be measured nondestructively with optical coherence tomography (OCT). Thermal imaging at 8-µm to 13-µm wavelengths was completed on 30 test subjects with a suspected active root caries lesion by monitoring thermal emission from the tooth surfaces during 30 s of air drying. Lesions were also evaluated using cross-polarization OCT (CP-OCT) during lesion dehydration to identify transparent surface zones indicative of arrested lesions and determine if shrinkage occurred during drying. The overall thermal emission recorded during drying was significantly different (P < 0.001) when comparing sound tooth surfaces, lesion areas identified as arrested, and lesion areas identified as active, demonstrating that thermal imaging is a promising approach for the clinical assessment of lesion activity on root surfaces. Ten of the lesions in this study had distinct areas with transparent surface zones that were visible in CP-OCT images. Shrinkage was detected with CP-OCT during drying for 12 lesions. This study confirms that these novel approaches for assessing lesion activity on root surfaces can be implemented in vivo.

A thermal imaging handpiece for the clinical assessment of lesion activity on root surfaces via dehydration

New imaging methods are needed to assess the activity of caries lesions on tooth surfaces. Recent studies have shown that thermal imaging of lesions on root surfaces during dehydration with air can be used to determine if the lesions are active or arrested. In this study changes in the thermal emission of root caries lesions on extracted teeth during dehydration with air was monitored using an imaging system with a miniature thermal camera and a 3D printed handpiece with an integrated air nozzle suitable for clinical use. This study evaluated the performance of the thermal camera for imaging root caries on extracted teeth prior to it's use for in vivo studies. There was a significant difference in the thermal response of sound and root lesion areas of human teeth under dehydration at constant airflow.

SWIR, Thermal and CP-OCT imaging probes for the in vivo assessment of the activity of root caries lesions

New imaging technologies are needed for the clinical assessment of lesions on root surfaces. It is not sufficient to simply detect caries lesions; methods are needed to assess lesion depth, structural composition and activity to determine if chemical intervention has the potential to be effective and if remineralization has occurred. Lesions were monitored using CP-OCT during lesion dehydration to assess the lesion structure and any shrinkage. Thermal imaging at 6-10 μm wavelengths and short wavelength-IR imaging at 1450-1750-nm were used to monitor thermal emission during lesion dehydration to assess lesion activity. Imaging probes were custom fabricated for clinical use. We present the first clinical results of a small feasibility study employing CP-OCT, thermal and SWIR imaging to assess lesion activity in vivo on thirty test subjects with suspected root caries lesions.

Measurement of the shrinkage of natural and simulated lesions on root surfaces using CP-OCT

OBJECTIVES

Demineralized root dentin and cementum is made up of mostly collagen that shrinks significantly upon dehydration or drying with air. During remineralization mineral is deposited on the outside of the lesion creating a highly mineralized surface layer that inhibits diffusion, arrests the lesion and prevents shrinkage. Previous studies suggest that active root caries lesions manifest shrinkage, while arrested lesions no longer manifest shrinkage upon dehydration. The purpose of this study was to demonstrate that the shrinkage of root caries lesions can be monitored during dehydration using an optical coherence tomography probe suitable for clinical use.

METHODS

In this in vitro study the shrinkage of simulated and natural root caries lesions on extracted teeth was measured using a cross polarization optical coherence tomography (CP-OCT) system and a 3D printed appliance with an integrated air nozzle suitable for clinical use. Two methods were employed to assess shrinkage, changes in the position of the lesion surface and changes in the thickness of the lesion.

RESULTS

CP-OCT was successful in measuring a significant (P < 0.05) contraction of the lesion surface, significant decrease in the lesion thickness and increase in the reflectivity per micron upon drying natural lesions on extracted teeth.

CONCLUSIONS

In this preclinical study, we have demonstrated that a CP-OCT handpiece modified for infection control with an attached air nozzle suitable for in vivo use can be used to monitor the shrinkage of root caries lesions. In addition, we have developed a new approach to measuring lesion shrinkage with OCT, namely monitoring changes in the lesion thickness as opposed to the position of the lesion surface, that does not require an initial reference position and is more easily implemented in vivo.

Reliability of colour and hardness clinical examinations in detecting dentine caries severity: a systematic review and meta-analysis

Dental caries is the most common human infectious disease and is caused by microorganisms producing acids, resulting in changes in dental tissue hardness and colour. However, the accuracy and reliability of dentine colour and hardness as indicators for carious lesion severity has never been assessed in a systematic review. By applying strict criteria, only seven papers (five randomized control trials and two diagnostic studies) were considered for full text qualitative and quantitative assessment. Only three studies produced high quality evidence and only four articles were considered for meta-analysis, as these provided log₁₀ colony forming units (CFU) data from caries biopsies following colour and hardness clinical examinations. When comparing the amount of CFU isolated from carious biopsies from different colour and hardness categories, hardness clinical examination was found to be a statistically more discriminate test than colour clinical examination. Therefore, hardness clinical examination is more specific and reliable than colour to detect dentine carious lesion severity. Further large carefully designed clinical studies are needed to consolidate the findings of this systematic review.

An appliance for monitoring the shrinkage of root caries with OCT

Demineralized root dentin and cementum are mostly collagen that shrinks significantly upon dehydration. Active root caries lesions manifest shrinkage upon dehydration, however during the remineralization of root caries lesions mineral is deposited on the outside of the lesion arresting the lesion and arrested lesions no longer manifest shrinkage upon dehydration. Optical coherence tomography is ideally suited for the measurement of that shrinkage for the assessment of lesion activity. In this study the shrinkage of natural root caries lesions on extracted teeth were measured using a CP-OCT system with a 3D printed appliance with an integrated air nozzle suitable for clinical use.

Assessment of root caries under wet and dry conditions using swept-source optical coherence tomography (SS-OCT)

The purpose of this study was to compare optical properties of root caries under two observing conditions using swept-source optical coherence tomography (SS-OCT). In vitro and natural root caries were observed by SS-OCT under wet and dry conditions, followed by confocal laser scanning microscope (CLSM) and transverse microradiography (TMR). Signal intensity (SI), distance between SI peaks (SI-distance) and optical lesion depth were obtained from OCT. Lesion depth was measured from CLSM; lesion depth (LD_TMR) and mineral loss (ML) were obtained from TMR. In vitro root caries under wet and dry conditions showed different OCT images and SI patterns. Lesion depth of OCT and that of CLSM, SI-distance and LD_TMR, LD_TMR and ML significantly correlated. Under dry conditions, half natural root caries showed similar OCT images and SI patterns as in vitro root caries. The base of demineralized dentin could be detected more clearly under dry conditions than under wet conditions.

Activity assessment of root caries lesions with thermal and near-IR imaging methods

The purpose of this study was to evaluate thermal and near-infrared (NIR) reflectance imaging methods for the assessment of the activity of root caries lesions. In addition, changes in the lesion structure were monitored with polarization sensitive optical coherence tomography (PS-OCT). Artificial bovine and natural root caries lesions were imaged with PS-OCT, and their dehydration rate was measured with thermal and NIR cameras. The lesion activity of the natural root caries samples was also assessed by two clinicians by conventional means according to ICDAS II guidelines. The thickness of the highly mineralized transparent surface layer measured using PS-OCT increased and the area enclosed by the time-temperature curve, ΔQ, measured with thermal imaging decreased significantly with longer periods of remineralization in simulated dentin lesions, but the NIR reflectance intensity differences, ΔI, failed to show any significant relationship with the degree of remineralization. The PS-OCT algorithm for the automated assessment of remineralization successfully detected the highly mineralized surface layer on both natural and simulated lesions. Thermal imaging provided the most accurate diagnosis of root caries lesion activity. These results demonstrate that thermal imaging and PS-OCT may be ideally suited for the nondestructive root caries lesion activity during a clinical examination.

Root caries: a periodontal perspective

BACKGROUND AND OBJECTIVE

A prevailing dental problem in the periodontal patient is root caries. Specifically, periodontal involvement often results in root surfaces becoming exposed and at risk for this condition. Periodontal therapy often leads to increased gingival recession as well, and the associated increased root caries risk may compromise the long-term success and survival of periodontally treated teeth.This narrative review will address the topic of root caries in the periodontal patient, focusing on unmet research needs.

MATERIAL AND METHODS

The Medline database was searched to identify items dealing with root caries, in terms of clinical features, diagnosis, pathogenic mechanisms and histopathology, as well as epidemiology, focusing then on the relationship between root caries and periodontal disorders.

RESULTS

Although there is extensive literature on root caries, consensus is lacking regarding certain aspects, such as diagnostic criteria, prevalence within populations and indisputable risk factors. Advancing age could be an aggravating factor in susceptibility to root caries for the periodontal patient; however, definitive evidence in this regard is still missing. Similarly, full awareness of the increased risk of root caries in patients with periodontal disease or long-term periodontal treatment appears to be still lacking.

CONCLUSION

Research regarding root caries in age-specific (elderly) periodontal patients is needed. Improved oral hygiene practices, locally applied preventive measures, good dietary habits and regular dental check-ups are crucial approaches to prevent both periodontal disease progression and root caries. Periodontal patients with root exposure should follow a strict root caries prevention protocol, as an integral component of their periodontal maintenance therapy.

Cariotester, a new device for assessment of dentin lesion remineralization in vitro

This study aimed to evaluate the potential of a new device (Cariotester) for monitoring of incipient carious lesion remineralization in root dentin by topical fluoride in vitro. Demineralized bovine dentin specimens were treated by fluoride solutions (APF or neutral NaF) and remineralized for 4 weeks. Cariotester was used to measure penetration depth (CTR depth) of the indenter into the de- and remineralized specimen surface. The specimens were assessed by transverse microradiography (TMR) to determine lesion parameters (depth: LD, mineral loss: ΔZ). Pearson's correlation analysis showed an overall significant relationship between CTR depth and both TMR parameters. CTR depth appeared to distinguish the positive effect that topical fluoride application had on the remineralization of the outer zone of dentin lesions. Cariotester had the potential to serve as a quantitative tool for monitoring of incipient carious lesion remineralization in root dentin.

Root caries: a survey of Queensland dentists

BACKGROUND

Root caries stands to be a significant burden for Australia's ageing population. The objective of this study was to describe Queensland dental practitioners' perceptions of root caries prevalence, presentation and predisposing factors as well as diagnosis and recording practices.

METHODS

Using the Queensland Dental Board register, all 2,515 dentists and dental specialists practising in Queensland were invited to participate in a questionnaire-based postal survey.

RESULTS

Of the 660 responses received, 638 were included for final analysis. Use of diagnostic measures such as surface elasticity and contour were reported frequently. A majority of respondents (77%) reported not recording root caries in a way that could be distinguished from coronal caries. Dietary analysis was the most commonly reported adjunctive aid for risk assessment. Recommendations for use of remineralizing agents were frequently reported (home use 90%; in office use 71%). Salivary impairment was reported to be an important risk factor for root caries by 93% of respondents, but only 18% reported performing salivary analysis. A large proportion of respondents (32%) considered patients with diabetes to be of low or no risk of root caries.

CONCLUSIONS

While the Queensland dental practitioners who participated in this survey demonstrated an awareness of root caries and its predisposing factors, clinical risk assessment particularly for patients with diabetes should be further examined.

Clinical and ultrastructural effects of different liners/restorative materials on deep carious dentin: a randomized clinical trial

We evaluated the effect of calcium hydroxide cement (CHC) and glass ionomer cement (GIC) on carious dentin and bacterial infections after partial caries removal and sealing. Sixty permanent teeth with deep lesions underwent partial caries removal, the application of CHC, GIC or wax, i.e. negative control (NC), and were then sealed for 3-4 months. After the partial caries removal and the sealing period, the dentin was clinically assessed (colour and consistency) and analysed by scanning electron microscopy to assess dentin organization and bacterial infections. The effect of the treatment in each group was assessed by the Wilcoxon and χ2 tests, differences among groups by the Kruskal-Wallis test and the correlations between variables by Spearman correlation. No clinical symptoms or radiographic signals of pulpits or pulp necrosis were observed during the study. Dentin darkening was observed after the sealing period in the CHC and NC groups (p < 0.05). However, there was no difference in the colour after treatment among the 3 groups (p > 0.05). Dentin hardening occurred in all groups after treatment (p < 0.05), also with no differences (p > 0.05). Dentin samples showed better organization after the sealing period than after partial caries removal, with total or partial obliteration of dentinal tubules (CHC p < 0.03, GIC p < 0.05, NC p < 0.01) and a reduction of bacterial infections (CHC p < 0.03, GIC p < 0.05, NC p < 0.03). No differences were observed. Correlations between the different criteria, except for colour and bacterial infection, were detected in all cases. Partial caries removal and sealing resulted in dentin hardening, decreased bacterial numbers and dentin reorganization, irrespective of the dentin protection used.

Root caries and diabetes: risk assessing to improve oral and systemic health outcomes

This report reviews the current understanding of the relationship between diabetes and root caries, and investigates the evidence for dental chairside testing of gingival crevicular blood (GCB) glucose levels to assess risk for type 2 diabetes mellitus. Diabetes is linked with the progression of periodontal disease and a greater number of exposed root surfaces at risk for root caries. The rapidly increasing prevalence of type 2 diabetes coupled with a general trend towards retention of teeth means that the number of patients with increased risk for root caries is expanding significantly. Many patients with diabetes or abnormal blood glucose levels are unaware of their condition or that they are at increased risk for oral disease. Systemic blood glucose concentrations are comparable to those found in GCB and therefore may be a useful adjunctive clinical aid in determining appropriate care for patients and providing timely referrals to general medical practitioners. Use of GCB testing within the dental clinic is described. It is proposed that future studies be undertaken to provide clinicians with improved risk assessment strategies and to evaluate GCB glucose screening models.

Assessment of dentifrices against Candida biofilm

The invasion of opportunistic pleiomorphic Candida albicans into oral cavity environment leads to development and progression of its resistance to both naturally occurring antifungal peptides in human saliva as well as commercially available antifungal therapies. As a result of this, the usage and popularity of natural medicine and dentifrices had increased significantly in the last decade. In the present investigation, we have assessed the action of locally available dentifrices against C. albicans biofilm. Disk diffusion test showed maximum zone of inhibition (20 mm) by herbal dentifrice (D-5) as compared to other dentifrices when incubated at 37 °C and 48 h. Assessment of dentifrice D-5 for its effectiveness against C. albicans was further shown in MIC(90) (3.12 mg mL(-1)) and SMIC(90) (6.2 mg mL(-1)) values for planktonic and sessile cells (biofilm forming), respectively. Our data depicted 80% reduction in the cell surface hydrophobicity when 6.2 mg mL(-1) of herbal dentifrice D-5 was used against 48-h grown Candida biofilm at 37 °C. Visualization of herbal dentifrice D-5-treated C. albicans biofilm under SEM revealed drastic reduction in the dense network of yeast, hyphae, and pseudohyphae enclosed in its ECM as compared to its control biofilm. The data were further supported by CLSM analysis which depicted C. albicans architecture disruption by herbal dentifrices. From the above data, it is inferred that these studies would provide researchers and medical practitioners with better insight into the antifungal effect of natural herbal dentifrices.

International Caries Detection and Assessment System: A new paradigm in detection of dental caries

A new emphasis on caries measurement and management is required for the dental community. The dental professionals need new approaches in caries detection, its assessment, and management. The future of research, practice, and education in Cariology requires the development of an integrated definition of dental caries, and uniform systems for measuring the caries process. Keeping this in view, the International Caries Detection and Assessment System (ICDAS) has presented a new paradigm for the measurement of dental caries, which was developed from the systematic reviews of literature on the clinical caries detection system and other sources. The ICDAS can serve as a basis and benchmark for clinical and epidemiological research and inform dental undergraduate and postgraduate teaching in Cariology. The ICDAS system was developed to bring forward the current understanding of the process of initiation and progression of dental caries to the fields of epidemiological and clinical research.

The effect of chlorhexidine varnish on root caries: a systematic review

OBJECTIVE

The aim of this study was to systematically review the present literature on the effect of chlorhexidine varnish (CHX-V) on root caries.

MATERIALS AND METHODS

The MEDLINE-PubMed, the Cochrane-CENTRAL and EMBASE databases were searched through December 2010 to identify any appropriate studies. Root caries incidence and root caries activity were selected as outcome variables.

RESULTS

An independent screening of the unique titles and abstracts of 24 MEDLINE-PubMed, 14 Cochrane-CENTRAL and 18 EMBASE papers resulted in 6 publications that met the eligibility criteria. Data extraction provided no conclusive evidence that the application of CHX-V is effective in patients when regular professional oral prophylaxis is performed. If effective, the 40% CHX-V was found to provide a benefit over a control or fluoride varnish. CHX-V at lower concentrations (1 and 10%) may provide protection against root caries in high-risk patients (such as geriatric and xerostomia patients) in the absence of regular professional oral prophylaxis.

CONCLUSION

Within the limitations of this review, it may be concluded that in the absence of regular professional tooth cleaning and oral hygiene instructions, CHX-V may provide a beneficial effect in patients in need of special care. The strength of this recommendation is graded as 'weak'.

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

OBJECTIVES

(i) Initially, to devise and examine the validity of a system for determining lesion activity on root surfaces, and (ii) compare the effectiveness of two preventive programmes in controlling root caries in elderly people using the devised system.

MATERIALS AND METHODS

(i) Four clinical variables: texture, contour, location and colour of root caries lesions were selected to evaluate lesion activity. The intraexaminer reproducibility of the scoring system was assessed on 28 elderly patients. The accuracy was assessed on 10 of these persons using an impression material (Clinpro, 3M ESPE). (ii) Of total, 215 homebound 75+ year olds were randomly assigned to one of three groups: group 1, once a month a dental hygienist brushed the teeth of the participants and applied Duraphat vanish to active root caries lesions. The participants in groups 2 and 3 received 5000 and 1450 ppm F-toothpaste, respectively, to use twice a day. This study included an interview, a baseline examination and a final follow-up examination after 8 months.

RESULTS

(i) Intraexaminer reproducibility of the root caries scoring system was 0.86 (Kappa). The sensitivity and specificity was 0.86 and 0.81. (ii) Data from those 189 (88%) who completed the study disclosed that there were no inter-group differences at the baseline examination concerning relevant conditions. At the end of the study, the root caries status of participants in groups 1 and 2 had improved significantly when compared with group 3 (p < 0.02). No significant difference was observed between groups 1 and 2 (p = 0.14).

CONCLUSION

The data suggest that the root caries scoring system is reliable. Both the intervention programmes controlled root caries development; the hygienist in eight of 10 persons, the 5000 ppm F-toothpaste in seven of 10. In contrast, five of 10 participants who only brushed with 1450 ppm F-toothpaste had root caries progression.

Microbiota of Exposed Root Surfaces After Fluoride, Chlorhexidine, and Periodontal Maintenance Therapy: A 3-Year Evaluation

BACKGROUND

Fluoride and chlorhexidine (CHX) are state-of-the-art preventive measures for remineralizing teeth and for preventing plaque accumulation. The aim of this study was to examine the effects of fluoride and CHX varnishes on root caries and microbiota located on root surfaces.

METHODS

Thirty-three patients from a periodontal maintenance program, having at least one tooth with gingival recession in each quadrant, participated in this study. One tooth per quadrant was assigned randomly to the control group or to one of the test groups that were treated with fluoride varnish, 1% CHX, or 40% CHX. The varnish treatment and the tooth cleaning were repeated every 3 months. Clinical examinations were performed at baseline and once a year for 3 years. Caries status and oral hygiene indices were evaluated clinically. The total cultivable microbiota and percentage of Mutans streptococci (MS), Actinomyces (ACC), and lactobacilli (LB) were analyzed.

RESULTS

Oral hygiene was improved greatly during the course of the study. The percentage of MS, ACC, and LB of the total cultivable microbiota revealed a statistically significant reduction between baseline and final examination for each of the four groups.

CONCLUSION

Professional tooth cleaning alone at 3-month intervals might be as effective in reducing MS, ACC, and LB as adjunctive treatment with fluoride or chlorhexidine.

Microbiological assessment of occlusal brown-spot lesions in primary molars

Conventional cultural methods were used to compare the plaque flora and the level of infection of the dentine underlying 51 occlusal brown-spot lesions and 21 sound occlusal sites on the primary dentition. Freshly extracted primary molar teeth were used, and occlusal brown-spot lesions and sound occlusal sites were identified using laser fluorescence (LF) and clinical visual methods. A standardized plaque sample was taken from each site, and an LF score was recorded for one discrete site per tooth. The teeth were carefully opened at each predetermined site to determine the clinical status of the underlying dentine, and samples were collected using a sterile bur. The microbiota of the plaque and dentine samples were enumerated and identified. The mean LF scores for the sound sites and brown-spot lesions were 1.2 and 30.5 (p < 0.001), and all the sound sites exhibited hard sound dentine, but 6 out of 51 brown spots exhibited softened dentine. Overall there was no significant (p > 0.1) difference between the level of infection of the dentine of the sound and brown-spot sites, although some sites in the brown-spot lesions yielded high numbers of bacteria. However, the numbers of bacteria as log10(CFU per sample + 1) +/- SE recovered from the plaque above the brown-spot lesions were significantly greater than above the sound sites, i.e. 2.89 +/- 0.24 and 0.89 +/- 0.33, respectively. These data indicate that brown-spot lesions may be more plaque retentive than sound sites and that they are either arrested or arresting lesions, which may require preventive intervention.

Amine fluoride/stannous fluoride and incidence of root caries in periodontal maintenance patients. A 2-year evaluation

AIM

The purpose of the present study was to evaluate in a group of periodontal maintenance patients, the effect of using a dentifrice and mouthrinse containing amine fluoride (AmF) and stannous fluoride (SnF2) as compared with a dentifrice and mouthrinse both containing sodium fluoride (NaF) with regard to their root caries experience.

MATERIAL

In total, 80 patients who had been treated for moderate-to-severe periodontitis agreed to participate in this study. Subjects received supportive periodontal therapy at regular intervals of 3-4 months for at least a period of 1 year. The patients were randomly divided into two groups: (1) the test group used an AmF/SnF2 dentifrice and mouthrinse and (2) the control group used an NaF-containing dentifrice and mouthrinse. Root caries was recorded at four sites per tooth at baseline and 24 months.

RESULTS

An increase in number of the exposed root surfaces was noted for both groups during the experimental period (p<0.05). The mean number of active caries lesions at baseline was 2.1 and 1.8 for the test group and control group, respectively. At 24 months, the corresponding values were 1.8 for the test and 2.2 for the control group. An increase of the mean number of restored surfaces was noted for the AmF/SnF2 group (from 7.3 to 13.4) and the control group (from 7.9 to 14.7) during the course of the study. This increase was found to be statistically significant for both groups in comparison with the baseline values (p< or =0.01). No statistically significant differences were noted between groups. Further analysis of the restored surfaces revealed that the major increase in number of the restorations was associated with restorations involving three to four root surfaces in the same tooth. Molars and premolars were the teeth receiving most new restorations.

CONCLUSION

The present study did not detect a difference in terms of root caries development between the two groups. Root caries development is a common finding associated with surfaces developing recession in patients once treated for periodontal problems.

Clinical reversal of root caries using ozone, double-blind, randomised, controlled 18-month trial

OBJECTIVE

To assess the effect of an ozone delivery system, combined with the daily use of a remineralising patient kit, on the clinical severity of non-cavitated leathery primary root carious lesions (PRCL's), in an older population group.

DESIGN

A total of 89 subjects, (age range 60-82, mean +/- SD, 70.8 +/- 6 years), each with two leathery PRCL's, were recruited. The two lesions in each subject were randomly assigned for treatment with ozone or air, in a double-blind design, in a general dental practice. Subjects were recalled at three, six, 12 and 18 months. Lesions were clinically recorded at each visit as soft, leathery or hard, scored with a validated root caries severity index.

RESULTS

There were no observed adverse events. After three months, in the ozone-treated group, 61 PRCL's (69%) had become hard and none had deteriorated, whilst in the control group, four PRCL's (4%) had become worse (p<0.01). At the six-month recall, in the ozone group, seven PRCL's (8%) remained leathery, the remaining 82 (92%) PRCL's had become hard, whilst in the control group, 10 PRCL's had become worse (11%) and one had become hard (p<0.01). At 12 and 18 months, 87 Subjects attended. In the ozone group at 12 months, two PRCL's remained leathery, compared to 85 (98%) that had hardened, whilst in the control group 21 (24%) of the PRCL's had progressed from leathery to soft, i.e. became worse, 65 PRCL's (75%) were still leathery, and one remained hard (p<0.01). At 18 months, 87 (100%) of ozone-treated PRCL's had arrested, whilst in the control group, 32 lesions (37%) of the PRCL's had worsened from leathery to soft (p<0.01), 54 (62%) PRCL's remained leathery and only one of the control PRCL's had reversed (p<0.01).

CONCLUSIONS

Leathery non-cavitated primary root caries can be arrested non-operatively with ozone and remineralising products. This treatment regime is an effective alternative to conventional "drilling and filling".

Candida yeasts in chronic periodontitis tissues and subgingival microbial biofilms in vivo

The frequency of Candida infection in periodontal tissues of chronic periodontitis (CP) patients and the extent of candidal penetration into gingival tissues was studied. Tissue specimens collected from 25 CP patients during periodontal flap operations of initial periodontal therapy were examined by immunohistochemistry using Candida albicans-specific antibodies. Sections were also stained with periodic acid-Schiff (PAS) and subgingival plaque samples from 17 patients were cultured. Immunoreactivity for Candida was present in four of the 25 CP specimens (16%). Only one yeast-positive specimen was found when PAS-staining was used (4%) and two yeast-positive specimens were found with plaque culture (8%). Hyphal formation seemed essential and candidal hyphae were found to extend into the periodontal connective tissue. The degree and type of inflammation adjacent to the hyphae varied from a site and a patient to another. The sensitivity of specific antibodies was superior to PAS-stain or plaque culture in detection of Candida in tissues.

Restorative management of the elderly patient

It is predicted that geriatric patients will dramatically increase in number within our working lives. Although they are considered to demand treatment less frequently than the younger age groups, there are specific issues that need to be considered when providing dental treatment for these patients. The term gerodontics has been coined to describe this subject. The need to consider family relationships and the role of carers may play a greater part in their dental management than that of the general population. As well as oral disease, the incidence of general disease is higher in this population, as is the amount of medication prescribed to treat it; these factors often complicate dental management. Special problems that will have a high dental impact on the geriatric patient may be lack of adaptive potential, poor plaque control, root caries, periodontal breakdown and levels of toothwear.

1H-NMR analysis of microbial-derived organic acids in primary root carious lesions and saliva

In addition to lowered pH values, the molecular profile and concentrations of microbial-derived organic acids in carious dentin are important demineralization parameters involved in the induction, development and progression of dental caries. High-resolution proton ((1)H) NMR spectroscopy was employed to examine the organic acid status of primary root carious lesions. (1)H-NMR analysis of post-neutralized perchloric acid extracts of active carious lesions revealed that at an operating frequency of 600 MHz, the (1)H-NMR-detectable organic acid composition of carious dentin samples (mean molecular percentage content +/- standard error; the mean molecular percentage content is defined here as the mean of the concentration of each (1)H-NMR-visible organic acid/anion expressed as a percentage of total (1)H-NMR-detectable organic acid/anion level in each sample) was acetate 51 +/- 2%, formate 37 +/- 2%, lactate 5 +/- 1%, propionate 3 +/- 0.8%, pyruvate 2.4 +/- 0.3%, n-butyrate 1.2 +/- 0.2%; succinate 0.1 +/- 0.1%; iso-butyrate, n- and iso-valerate, and n- and iso-caproate (total) <0.2%. Further components detectable included alanine, glycine, choline, phosphorylcholine, trimethylamine oxide, methanol, glycolate and assorted saccharides. In view of their high dissociation constants (K(a)), our results demonstrate that formic and pyruvic acids (K(a) = 1.77 x 10(-4) and 3.20 x 10(-3) mol/dm(3), respectively) contribute substantially to the decreased pH values associated with active caries lesions (cf. lactate K(a) = 1.40 x 10(-4) mol/dm(3)), and hence the pathogenesis of primary root caries.

Discoloration of dental carious lesions (a review)

The discoloration of dental carious lesions is a marked feature which has received relatively little attention from dental researchers. In this short review, possible causes are considered: the formation of Maillard pigments, melanins, and lipofuscins, and the uptake of food dyes, metals, and bacterial pigments. It is concluded that the Maillard reaction between proteins and small aldehydes produced by bacteria probably accounts for the discoloration.

Colonization of Candida albicans on cleaned human dental hard tissues

Candida albicans is a fungus that commonly infects oral mucosal surfaces. Limited data exist on biofilm formation by C. albicans on dental surfaces. Human premolar teeth were infected with C. albicans for 10 days and hard-tissue surfaces were examined with a scanning electron microscope. Enamel, cementum and dentine, in the absence or presence of a smear layer, were readily colonized by this micro-organism. Hyphae penetrated into cracks, followed the ridges of the cavities and migrated into dentinal tubules. Blastospores and hyphae were embedded in an extracellular material. These findings suggest that dental hard tissues may be invaded by C. albicans and thus can potentially present a reservoir for disseminating candidal infections.

The Maillard reaction in demineralized dentin in vitro

The Maillard reaction between carbohydrate and protein has been proposed as a cause of the browning of carious lesions. The aim of the present investigation was to determine the occurrence of this reaction in bovine dentin collagen in vitro and to establish the effect of the reaction on the proteolytic degradation of bovine dentin collagen in vitro. Slices of demineralized bovine dentin were incubated with 0.2 M glucose or buffer for 10 weeks at 37 degrees C. The formation of initial (furosine) and advanced (pentosidine) products of the Maillard reaction in dentin exposed to glucose was confirmed by HPLC. After reduction with NaBH4 to prevent intermediate Maillard products from further reaction, slices were either degraded with collagenase for fluorescence measurement or incubated with trypsin or pepsin to assess enzymatic degradation. Fluorescence characteristic for the Maillard reaction increased in glucose-exposed slices. Degradation of collagen by pepsin, but not by trypsin, was greatly depressed following glucose pretreatment. This may indicate an altered sensitivity to proteolytic degradation; the Maillard reaction thus has a potential role in caries arrestment.

Clinical diagnosis of precavitated carious lesions

During the 20th century, dental caries was usually diagnosed using tactile-visual criteria that detected the presence of cavitation rather than measured the disease process as a continuum that starts from the appearance of microporosity, as a result of demineralization, to the occurrence of cavitation. With increasing understanding of the dental caries process and the role of primary and secondary prevention in arresting it, sensitive and specific diagnostic systems are needed that could enable dentists to detect signs of early demineralization and possible progression of precavitated carious lesions before the occurrence of cavitation. In this review of the literature, published validity studies of diagnosis of precavitated lesions were reviewed. Overall, the current clinical diagnostic systems have low sensitivity and moderate specificity. Good reliability of diagnosing precavitated carious lesions could be obtained for diagnosing pits and fissures but for smooth tooth surfaces the reliability is poor. As our diagnostic capability of precavitated lesions improves, there is a need for a significant change in dental education, dental insurance, and dental practice to reward dentists for promoting oral health and preserving tooth structure. In this paper, a new model for classifying carious lesions based upon the type of intervention strategies is proposed to assist in this new approach of caries management.

Assessing the stage of caries lesion activity on the basis of clinical and microbiological examination

The dynamic nature of caries lesion progression may require that classification of caries lesions makes distinctions in activity status. The aim of the present review was to compile and discuss the literature which pertains to clinical assessment of caries lesion activity, and to examine whether recent developments in microbiological research may justify the use of microbiological methods for evaluation of caries activity. Clinical observations suggest that caries lesion progression can be arrested at any stage of lesion development, provided that clinically plaque-free conditions are obtained. However, there is no universal level of oral hygiene to be recommended. The diagnoses "active" and "inactive/arrested" caries have been validated by a range of histological and chemical methods which have supported a separation into distinct clinical categories. Simple microbiological methods have so far not been useful in differentiating between active and inactive caries lesions. Very few studies have evaluated the inter- and intraexaminer reliability of caries diagnostic criteria based on assessment of the activity state of lesions, but recent data indicate that active and inactive caries lesions can be diagnosed with a high degree of reliability. A decision-making tree for dental caries is presented by means of which it is possible to associate the assessment of caries lesion activity with an appropriate treatment modality. It is concluded that research into better methods of assessing caries lesion activity clinically should be stimulated.

Examiner agreement on caries detection and plaque accumulation during dental surveys of elders

Indices used to evaluate plaque accumulation and coronal caries have been widely accepted in epidemiological studies, yet their reliability cannot be guaranteed. The aim of this study was to evaluate the reliability of clinical criteria used in coronal and root caries diagnosis and oral hygiene evaluation as applied in elders. Nineteen elderly subjects, 73 years old on average, were examined at a first appointment by two independent examiners. They were re-examined two weeks later. Plaque accumulation was evaluated using the Plaque Index (PI) and coronal and root caries were detected according to the WHO criteria and Fejerskov et al. (1991), respectively. Recurrent caries was recorded as recommended by WHO and by probing at the interface tooth-restoration. Inter- and intra-examiner agreement was evaluated using kappa statistics. The PI score showed good reliability except for examiner b, for whom a simplification of the 4-point scale in 3-point scale improved significantly the reliability. The prevalence of coronal caries was very low and intra- and inter-examiner agreement was poor. Most of the root caries lesions were covered by plaque and the kappa values indicated only poor agreement. Recurrent caries were found with good agreement using WHO criteria but the detection with the probe was not reliable. In conclusion, it seems that examiners should be trained carefully to maximise their reliability and that plaque should be removed to obtain reliable diagnoses of caries. Retraining and calibration may be necessary for surveys continuing over a long period.