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Han D, Gupta A, Adeniyi A, De Souza G, Tam LE, Tikhonova S, Santos J, Jessani A. Methods used for caries detection and diagnosis in Ontario dental practices: a cross-sectional survey. BMC Oral Health 2024; 24:1160. [PMID: 39343878 PMCID: PMC11441147 DOI: 10.1186/s12903-024-04934-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 09/19/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND Early detection of caries is essential for applying non-surgical treatment procedures and preventing the formation of cavitated lesions leading to unnecessary removal of tooth structure. Understanding dentists' preferences for caries detection tools can inform stakeholders about their strategies and knowledge of contemporary, evidence-based caries management approaches. However, there is a lack of research exploring the detection methods of caries commonly used by dentists in Ontario, Canada. The objective of this study was to investigate the methods of caries detection and diagnosis preferred by dentists in Ontario. METHODS A 21-item self-reported survey was mailed to one thousand Ontario dental practices in the Winter of 2022. Descriptive and bivariate data analysis were performed to determine the associations between: demographics and professional practice characteristics (explanatory variables), and methods for detecting and diagnosing dental caries (outcome variables) using SPSS Statistics 29.0. RESULTS A total of 325 dentists (33%) responded to the survey, with 274 answering all of the questions completely. The highest proportion of respondents were 35-44 years of age (32.8%) and male (53.4%). More than half of the respondents reported using a dental explorer to assess primary occlusal caries (57.6%), secondary caries (57.1%), and cervical caries (57.5%). Likewise, 57.9% of the participants reported using dental radiographs to diagnose proximal caries. Among additional caries detection tools, digital radiography (89.8%) and traditional radiography (84.7%) were the most used methods/modalities, while cone beam computed tomography was the least (12.8%). Most study participants did not use any caries classification system (77.7%) or caries risk assessment tool (85.3%). CONCLUSIONS Participants preferred conventional methods for caries detection, instead of contemporary visual-tactile caries lesions classification and/or caries risk assessment systems. These findings indicate a need for continuing dental education programs tailored to evidence-based caries management approaches.
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Affiliation(s)
- Daniel Han
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Akshay Gupta
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Abiola Adeniyi
- Department of Public and Global Affairs, Fairleigh Dickson University, Vancouver, Canada
| | - Grace De Souza
- Department of Comprehensive Dentistry, School of Dentistry, University of Louisville, Louisville, USA
| | - Laura E Tam
- Department of Clinical Sciences, Faculty of Dentistry, University of Toronto, Toronto, Canada
| | - Svetlana Tikhonova
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Canada
| | - Jacinta Santos
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Abbas Jessani
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, Canada.
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada.
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Kühnisch J, Aps JK, Splieth C, Lussi A, Jablonski-Momeni A, Mendes FM, Schmalz G, Fontana M, Banerjee A, Ricketts D, Schwendicke F, Douglas G, Campus G, van der Veen M, Opdam N, Doméjean S, Martignon S, Neuhaus KW, Horner K, Huysmans MCD. ORCA-EFCD consensus report on clinical recommendation for caries diagnosis. Paper I: caries lesion detection and depth assessment. Clin Oral Investig 2024; 28:227. [PMID: 38514502 PMCID: PMC10957694 DOI: 10.1007/s00784-024-05597-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVES The aim of the present consensus paper was to provide recommendations for clinical practice considering the use of visual examination, dental radiography and adjunct methods for primary caries detection. MATERIALS AND METHODS The executive councils of the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) nominated ten experts each to join the expert panel. The steering committee formed three work groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity assessment and (3) forming individualised caries diagnoses. The experts responsible for "caries detection and diagnostic methods" searched and evaluated the relevant literature, drafted this manuscript and made provisional consensus recommendations. These recommendations were discussed and refined during the structured process in the whole work group. Finally, the agreement for each recommendation was determined using an anonymous Delphi survey. RESULTS Recommendations (N = 8) were approved and agreed upon by the whole expert panel: visual examination (N = 3), dental radiography (N = 3) and additional diagnostic methods (N = 2). While the quality of evidence was found to be heterogeneous, all recommendations were agreed upon by the expert panel. CONCLUSION Visual examination is recommended as the first-choice method for the detection and assessment of caries lesions on accessible surfaces. Intraoral radiography, preferably bitewing, is recommended as an additional method. Adjunct, non-ionising radiation methods might also be useful in certain clinical situations. CLINICAL RELEVANCE The expert panel merged evidence from the scientific literature with practical considerations and provided recommendations for their use in daily dental practice.
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Affiliation(s)
- Jan Kühnisch
- Department of Conservative Dentistry and Periodontology, University Hospital, Ludwig-Maximilians Universität München, Poliklinik für Zahnerhaltung und Parodontologie, Goethestraße 70, 80336, München, Germany.
| | | | - Christian Splieth
- Preventive and Pediatric Dentistry, Center for Oral Health, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adrian Lussi
- University Hospital for Conservative Dentistry and Periodontology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Restorative, Preventive and Pediatric Dentistry, School of Dental Medicine, University of Bern, Bern, Switzerland
| | | | - Fausto M Mendes
- Department of Pediatric Dentistry, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Gottfried Schmalz
- Department of Conservative Dentistry and Periodontology, University Hospital Regensburg, Regensburg, Germany
- Department of Periodontology, University of Bern, Bern, Switzerland
| | - Margherita Fontana
- Department of Cariology, Restorative Sciences and Endodontics, University of Michigan School of Dentistry, Ann Arbor, USA
| | - Avijit Banerjee
- Conservative & MI Dentistry, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
| | - David Ricketts
- Unit of Restorative Dentistry, University of Dundee, Dundee, UK
| | - Falk Schwendicke
- Department of Conservative Dentistry and Periodontology, University Hospital, Ludwig-Maximilians Universität München, Poliklinik für Zahnerhaltung und Parodontologie, Goethestraße 70, 80336, München, Germany
| | - Gail Douglas
- Department of Dental Public Health, University of Leeds Dental School, Leeds, UK
| | - Guglielmo Campus
- Department of Restorative, Preventive and Pediatric Dentistry, School of Dental Medicine, University of Bern, Bern, Switzerland
- Department of Surgery, Microsurgery and Medicine Sciences, School of Dentistry, University of Sassari, Sassari, Italy
| | - Monique van der Veen
- Departments of Preventive Dentistry and Paediatric Dentistry, Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University, Amsterdam, The Netherlands
- Oral Hygiene School, Inholland University of applied sciences, Amsterdam, The Netherlands
| | - Niek Opdam
- Department of Dentistry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sophie Doméjean
- Centre de Recherche en Odontologie Clinique EA 4847, UFR d'Odontologie, Département d'Odontologie Conservatrice, Université Clermont Auvergne, Clermont-Ferrand, France
- Service d'Odontologie, CHU Estaing Clermont-Ferrand, Clermont-Ferrand, France
| | - Stefania Martignon
- UNICA - Caries Research Unit, Research Department, Universidad El Bosque, Bogotá, Colombia
| | - Klaus W Neuhaus
- Department of Pediatric Oral Health, University Center for Dental Medicine Basel (UZB), University of Basel, Basel, Switzerland
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Keith Horner
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Blumer S, Zidani S, Peretz B, Kats L, Azem H, Naishlos S, Kharouba J. Dental Loupe's Role in Detection of Caries of Molars in Children by Student and Dentists. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1050. [PMID: 37371281 DOI: 10.3390/children10061050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE The objectives of this study were to examine the effectiveness of diagnosing occlusal caries in molar teeth in children under the use of loupes and, secondarily, to examine whether there is a difference in the diagnosis between permanent and primary teeth using dental loupes. In addition, to check whether the student's diagnosis using loupes improves caries diagnosis compared to dentists' diagnosis in both methods. METHODS The data were collected from 163 patients aged 6-14 who sought treatment in the Pedodontic Department of the Faculty of Dentistry at Tel-Aviv University during 2020-2021. The first and second permanent molars and second primary molars with deep groves were examined. A student and dentists made the diagnosis with and without loupes while using the ICDAS criteria. RESULTS The student's examinations without the loupes detected no caries in 60% of the cases compared to 76.9% in the examinations with the loupes and found initial caries without cavitation (ICDAS1) in only 17.6% of teeth without loupes examination compared to 33% using loupes. The dentist correctly diagnosed no caries (ICDAS0) in 82.1% of cases without loupes and initial caries without cavitation (ICDAS1) in 62.5% of cases. The dentist correctly diagnosed distinct caries without cavitation (ICDAS2) in 90.8% of cases. No differences were observed in caries diagnosis between primary and permanent teeth when the examiner was a specialist/intern using loupes; however, there was a statistically significant difference (p = 0.047) when the diagnosis was made by a student using loupes. CLINICAL SIGNIFICANCE The use of dental loupes is an effective method for the correct and early diagnosis of occlusal caries lesions in children's molar teeth by both dentists and students, and this is in accordance with the principle of minimally invasive dentistry. There is a justification for the use of dental loupes for the diagnosis of initial occlusal caries in primary and permanent molars in children in a precise way. Using loupes especially improves the correct diagnosis of initial caries in primary teeth by students.
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Affiliation(s)
- Sigalit Blumer
- Department of Paediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Siwar Zidani
- Department of Paediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Benjamin Peretz
- Department of Paediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Lazar Kats
- Department of Oral Pathology, Oral Medicine and Maxillofacial Imaging, The Maurice and Gabriela Goldschleger School of Dental Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Hanaa Azem
- Department of Paediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Sarit Naishlos
- Department of Paediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Johnny Kharouba
- Department of Paediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
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Macey R, Walsh T, Riley P, Glenny AM, Worthington HV, O'Malley L, Clarkson JE, Ricketts D. Visual or visual-tactile examination to detect and inform the diagnosis of enamel caries. Cochrane Database Syst Rev 2021; 6:CD014546. [PMID: 34124773 PMCID: PMC8428329 DOI: 10.1002/14651858.cd014546] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The detection and diagnosis of caries at the initial (non-cavitated) and moderate (enamel) levels of severity is fundamental to achieving and maintaining good oral health and prevention of oral diseases. An increasing array of methods of early caries detection have been proposed that could potentially support traditional methods of detection and diagnosis. Earlier identification 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 visual classification systems for the detection and diagnosis of non-cavitated coronal dental caries for different purposes (detection and diagnosis) and in different populations (children or adults). SEARCH METHODS Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 30 April 2020); Embase Ovid (1980 to 30 April 2020); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 30 April 2020); and the World Health Organization International Clinical Trials Registry Platform (to 30 April 2020). We studied reference lists as well as published systematic review articles. SELECTION CRITERIA We included diagnostic accuracy study designs that compared a visual classification system (index test) with a reference standard (histology, excavation, radiographs). This included cross-sectional 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 considered. Studies that explicitly recruited participants with caries into dentine or frank cavitation 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 We extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on QUADAS-2 specific to the review context. Estimates of diagnostic accuracy were determined using the bivariate hierarchical method to produce summary points of sensitivity and specificity with 95% confidence intervals (CIs) and regions, and 95% prediction regions. The comparative accuracy of different classification systems was conducted based on indirect comparisons. Potential sources of heterogeneity were pre-specified and explored visually and more formally through meta-regression. MAIN RESULTS We included 71 datasets from 67 studies (48 completed in vitro) reporting a total of 19,590 tooth sites/surfaces. The most frequently reported classification systems were the International Caries Detection and Assessment System (ICDAS) (36 studies) and Ekstrand-Ricketts-Kidd (ERK) (15 studies). In reporting the results, no distinction was made between detection and diagnosis. Only two studies were at low risk of bias across all four domains, and 15 studies were at low concern for applicability across all three domains. The patient selection domain had the highest proportion of high risk of bias studies (49 studies). Four studies were assessed at high risk of bias for the index test domain, nine for the reference standard domain, and seven for the flow and timing domain. Due to the high number of studies on extracted teeth concerns regarding applicability were high for the patient selection and index test domains (49 and 46 studies respectively). Studies were synthesised using a hierarchical bivariate method for meta-analysis. There was substantial variability in the results of the individual studies: sensitivities ranged from 0.16 to 1.00 and specificities from 0 to 1.00. For all visual classification systems the estimated summary sensitivity and specificity point was 0.86 (95% CI 0.80 to 0.90) and 0.77 (95% CI 0.72 to 0.82) respectively, diagnostic odds ratio (DOR) 20.38 (95% CI 14.33 to 28.98). In a cohort of 1000 tooth surfaces with 28% prevalence of enamel caries, this would result in 40 being classified as disease free when enamel caries was truly present (false negatives), and 163 being classified as diseased in the absence of enamel caries (false positives). The addition of test type to the model did not result in any meaningful difference to the sensitivity or specificity estimates (Chi2(4) = 3.78, P = 0.44), nor did the addition of primary or permanent dentition (Chi2(2) = 0.90, P = 0.64). The variability of results could not be explained by tooth surface (occlusal or approximal), prevalence of dentinal caries in the sample, nor reference standard. Only one study intentionally included restored teeth in its sample and no studies reported the inclusion of sealants. We rated the certainty of the evidence as low, 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 inconsistency of results. AUTHORS' CONCLUSIONS Whilst the confidence intervals for the summary points of the different visual classification systems indicated reasonable performance, they do not reflect the confidence that one can have in the accuracy of assessment using these systems due to the considerable unexplained heterogeneity evident across the studies. The prediction regions in which the sensitivity and specificity of a future study should lie are very broad, an important consideration when interpreting the results of this review. Should treatment be provided as a consequence of a false-positive result then this would be non-invasive, typically the application of fluoride varnish where it was not required, with low potential for an adverse event but healthcare resource and finance costs. 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. Studies to determine the diagnostic accuracy of methods to detect and diagnose caries in situ are particularly challenging. Wherever possible future studies should be carried out in a clinical setting, to provide a realistic assessment of performance within the oral cavity with the challenges of plaque, tooth staining, and restorations, and consider methods to minimise bias arising from the use of imperfect reference standards in clinical studies.
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Affiliation(s)
- Richard Macey
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Tanya Walsh
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Philip Riley
- Cochrane Oral Health, Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Anne-Marie Glenny
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Helen V Worthington
- Cochrane Oral Health, Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Lucy O'Malley
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Janet E Clarkson
- Division of Oral Health Sciences, Dundee Dental School, University of Dundee, Dundee, UK
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Knowledge and Use of Caries Detection Methods among Dental Students and Dental Practitioners in Riyadh, Saudi Arabia. Int J Dent 2020; 2020:8825890. [PMID: 33343666 PMCID: PMC7725580 DOI: 10.1155/2020/8825890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/13/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022] Open
Abstract
Aim Accurate detection and diagnosis of dental caries is an integral part of achieving adequate comprehensive dental care. Furthermore, the high prevalence of caries and generally poor oral health in Saudi Arabia is a public health concern. In addition to necessary preventive programs and awareness initiatives, understanding diagnostic practices plays an important role in garnering broad background knowledge regarding the routine diagnostic means utilized by our targeted respondents. Therefore, this study aimed to assess the methods of caries detection among dental students and dental practitioners in Riyadh using a cross-sectional observational study design. Methods The sample comprised 496 dental students, interns, postgraduate residents, general dental practitioners, specialists, and consultants from the Riyadh region of Saudi Arabia. A survey was designed to assess caries detection methods, risk assessment practices, and knowledge of advanced diagnostic methods. The responses were correlated with demographic and educational variables. Regression models were used to predict associations. Results 42.3% and 32.7% use sharp explorers in diagnosing caries always and most of the time, respectively. When conducting caries risk assessment practices, 64.4% was very likely to review the patient's medical history and lifestyle. In terms of knowledge of advanced diagnostic methods, 47.8% know “much” to “very much” about FOTI. The knowledge of advanced caries diagnostic methods and practices of advanced diagnostic methods were significantly positively correlated (r = 0.388, P < 0.001). Linear regression analysis indicated that higher experience (10+ years) was associated with higher knowledge regarding advanced caries diagnostic methods (β = 0.27, P=0.009). The mean rank for risk assessment practices was significantly lower in GPs compared to consultants (P < 0.05). Conclusions The use of traditional and invasive methods of caries detection is prevalent among our respondents, while the usage of advanced diagnostic methods is for the most part low. Therefore, we advocate for more minimally invasive approaches and as such encourage the practice and availability of advanced diagnostic methods.
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Gupta N, Sandhu M, Sachdev V, Jhingan P. Comparison of Visual Examination and Magnification with DIAGNOdent for Detection of Smooth Surface Initial Carious Lesion-Dry and Wet Conditions. Int J Clin Pediatr Dent 2019; 12:37-41. [PMID: 31496570 PMCID: PMC6710936 DOI: 10.5005/jp-journals-10005-1588] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective The aim of this study was to assess the effectiveness and reliability of magnification, DIAGNOdent in detection of smooth surface white spot lesions. Study design Three hundred children aged 5–10 years were examined by two examiners for presence of smooth surface white spot lesions using naked eye and magnifying loupes in wet and dry conditions followed by DIAGNOdent analysis. Data was analysed using Cohen's kappa coefficient, Friedman test and Paired t test. Accuracy was assessed by sensitivity and positive predicted values. Results Significant difference was found between naked eyes and magnifying loupes with and without air drying. While insignificant difference was found between DIAGNOdent and loupes. Conclusion Magnifying loupes with air drying is an effective method in detection of smooth surface white spot lesion. Clinical significance With the increased knowledge about the pathogenesis of dental caries and its ability to be remineralisable if detected early, makes it all the more important for the clinician to be vigilant in detection of early lesion to prevent the avoidable restorative approach for the same. Incorporation of magnification to routine dental examination by general dentist can help in early diagnosis and treatment of dental decay. This could prevent further progression of dental caries and reduces the incidence of tooth decay How to cite this article Gupta N, Sandhu M, et al. Comparison of Visual Examination and Magnification with DIAGNOdent for Detection of Smooth Surface Initial Carious Lesion—Dry and Wet Conditions. Int J Clin Pediatr Dent 2019;12(1):37–41.
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Affiliation(s)
- Noopur Gupta
- Department of Pedodontics and Preventive Dentistry, ITS-CDSR, Ghaziabad, Uttar Pradesh, India
| | - Meera Sandhu
- Department of Pedodontics and Preventive Dentistry, ITS-CDSR, Ghaziabad, Uttar Pradesh, India
| | - Vinod Sachdev
- Department of Pedodontics and Preventive Dentistry, ITS-CDSR, Ghaziabad, Uttar Pradesh, India
| | - Pulkit Jhingan
- Department of Pedodontics and Preventive Dentistry, ITS-CDSR, Ghaziabad, Uttar Pradesh, India
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