The efficacy of combined arginine and probiotics as an add-on to 1450 ppm fluoride toothpaste to prevent and control dental caries in children - A randomized controlled trial

OBJECTIVES

To determine how daily consumption of a lozenge combining arginine and two probiotic strains affects the Relative Risk Reduction (RRR) in children regarding dental caries transitions and lesion activity at tooth surface level during 10-12 months.

METHODS

A total of 21,888 tooth surfaces in 288 children were examined. The intervention group (n = 141) received a lozenge containing 2% arginine, Lacticaseibacillus rhamnosus, LGG® (DSM33156), and Lactobacillus paracasei subsp. paracasei, L. CASEI 431® (DSM33451). The placebo group (n = 147) received a placebo lozenge. Both groups received 1,450 ppm F- toothpaste. Primary canines, molars, and first permanent molars were examined clinically (ICDAS0-6) and radiographically (R0-6) at baseline and follow-up. Sealed, filled, and missing surfaces were also included. Caries activity was computed as a sum of each caries lesion's location, color, texture, cavitation, and gingival bleeding. RRRs were computed with cluster effect on surface level. ICH-GCP was followed, including external monitoring.

RESULTS

A total of 19,950 surfaces were analyzed after excluding 1,938 tooth surfaces. No statistically significant differences were found between the groups. The RRRs showed less caries progression (13.6%, p = 0.20), more regression (0.3%, p = 0.44), and fewer active caries lesions (15.3%, p = 0.15) in the intervention group.

CONCLUSION

Daily consumption of a lozenge combining arginine and probiotics for 10-12 months given to 5-9-years-old children characterized being with low caries risk demonstrated a marked, though not statistically significant RRR for caries progression, regression, and number of active lesions in the intervention group compared to the placebo-group.

CLINICALTRIALS

gov (NCT03928587).

CLINICAL SIGNIFICANCE

Since all the RRRs were in favor of the intervention group and the PF of combined arginine and probiotics is high (81.6%) compared to fluoride toothpaste (24.9%) and arginine-fluoride toothpaste alone (19.6%) the combined pre-and probiotics approach may be a future additional tool regarding caries prevention and control.

An interdisciplinary intervention program to prevent early childhood caries in the Dominican Republic

Objective

The principal aim of this randomized clinical trial (RCT) was to test the effectiveness in the prevention of Early Childhood Caries (ECC) through an educational intervention program with the use of a printed guide for pediatricians and parents both designed by pediatric dentists.

Materials and methods

After ethical approval, the first step was to design the educational guides, which were based on the information obtained from a focus group with pediatricians (n = 3), phone interviews with mothers to toddlers' (n = 7), and the best evidence available about children's oral health. For the RCT, 309 parents with their 10-12 months old children were randomly allocated to either the intervention or the control group. Parents in the intervention group received oral health education from the pediatricians supported by the printed guides. Parents in both groups received an oral health kit with a toothbrush and toothpaste at the first visit as well as at each 6-month follow-up visit. After 18 months the children were evaluated using ICDAS criteria.

Results

At baseline, data were available from 309 children (49.8% girls). The mean age of the children was of 10.8 months (SD = 0.8) and 69.3% had not had their teeth brushed with toothpaste. After 18 months, a total of 28 (22%) children in the intervention group and 44 (24%) in the control group were clinically examined. Regarding the number of tooth surfaces with caries lesions, the children in the intervention group had a mean of 6.50 (SD = 6.58) surfaces, while the children in the control group had a mean of 5.43 (SD = 4.74) surfaces with caries lesions. This difference was not significant (p = 0.460).

Conclusion

The RCT showed no effectiveness in caries-progression control. Despite this result, this study managed to identify barriers that do not allow pediatricians from offering parents adequate oral health recommendations. With this learning, it is possible to work on collaborative programs with pediatricians that over time likely will increase dental health by controlling for ECC.

The effect of a lozenge combining prebiotic arginine and probiotics on caries increment in children during 10-12 months, a randomized clinical trial

OBJECTIVES

To investigate the effect of daily use of a lozenge containing arginine and probiotics for 10-12 months on caries increment, gingivitis- and plaque occurrence in children aged 5-9 years.

METHODS

In this placebo-controlled, double-blinded, parallel-grouped randomized clinical trial, 343 children were randomly assigned to one of the study arms (1:1). The intervention group (n = 172) received a lozenge containing Lacticaseibacillus rhamnosus, LGG® (DSM33156), Lactobacillus paracasei subsp. paracasei, L. CASEI 431® (DSM33451) and prebiotic (arginine 2%). The placebo group (n = 171) received an identical lozenge without arginine or probiotics. Primary canines and molars, and permanent first molars were examined clinically (d/D= ICDAS1-6) and radiographically (d/D = R1-6) at baseline and follow-up. Missing (m/M), sealed (s/S), and filled (f/F) surfaces (-s/-S) in both dentitions were also included. Utilizing clinical and radiographic scorings, caries experience was classified as dICDAS1-6msf-s (primary teeth), DICDAS1-6MSF-S (permanent teeth), d/DICDAS1-6 m/M-s/S-f/F-s/S (mixed dentition). A weighted and an unweighted score system was applied.

RESULTS

The study was completed by 288 children. The dropout rate was 15%. The increase in ∆mean dICDAS3-6msf-s and ∆mean d/DICDAS3-6m/M-s/S-f/F-s/S was lower in the intervention group (p = 0.007). No differences were found for gingivitis- and plaque occurrence. No product-related side effects were reported. This study followed ICH-GCP including external monitoring.

CONCLUSION

Daily consumption of a lozenge containing prebiotic arginine and two strains of probiotics showed safe use and statistically significantly reduction in caries incrementbut no effect on the mean plaque or gingivitis occurrence in children. The use of a lozenge with arginine and probiotics combined has a promising potential as a supplementary tool for future management of caries. www.

CLINICALTRIALS

gov (NCT03928587).

CLINICAL SIGNIFICANCE

The combination of prebiotic arginine and probiotics shows clinical potential as a supplementary approach to toothbrushing with fluoride toothpaste in managing caries increment in children. A new era in the management of caries may be emerging.

Secondary caries detection and treatment decision according to two criteria and the impact of three-dimensional intraoral scanner on gap evaluation

This study aimed to evaluate the in vitro performance in detecting caries around composite restorations in permanent posterior teeth and the impact of treatment decisions of two visual criteria: International Dental Federation (FDI) criteria and the Caries Associated with Restorations and Sealants (CARS) system. The correlation among secondary caries and the presence of gap measured with a three-dimensional (3D) intraoral scanner was also aimed. One hundred sixteen teeth were assessed by a trained and calibrated examiner according to the FDI criteria or CARS system. A second examiner measured the gap on the 3D models using specific software. The reference standard was the histological examination performed by a third examiner blind to the other evaluations. Other 30 extracted permanent teeth were used only to assess the reproducibility of the methods. The same random sample was selected for re-examination by all three methods, and there were seven days between the examinations. Unweighted and weighted kappa tests were conducted to assess intra-examiner reproducibility. Spearman's correlation coefficient (Rho) and 95% confidence intervals (95%CI) were calculated between the histological examination and scores obtained with FDI criteria, CARS system and treatment decisions. Spearman correlation between the visual and scanner evaluation with the reference standard was performed. Spearman's rank correlation analyses were conducted independently between the gap evaluated and measured by the visual inspection with the gap assessed using the scanner. The reproducibility of the visual score systems reached high values. Spearman's correlation coefficients (Rho; 95%CI) between the following variables versus histology were: FDI presence of caries (0.65; 0.53 to 0.74); CARS scores (0.65; 0.52 to 0.74); FDI treatment decision (0.46; 0.31 to 0.59); and CARS treatment decision (0.62; 0.49 to 0.72). Rho (95%CI) between histology and the gap assessment by the visual inspection was 0.59 (0.45 to 0.70), with the gap measurement by the visual inspection was 0.49 (0.33 to 0.62), and the gap measured by the scanner was 0.37 (0.18 to 0.53). Both visual criteria present similar performance in detecting caries. The correlation among treatment decisions is moderate for the FDI and CARS criteria, and both are moderately correlated with lesion depth, with a slight CARS superiority. However, visual examination presents better performance than the 3D intraoral scanner on gap size assessment.

Clinical accuracy of two different criteria for the detection of caries lesions around restorations in primary teeth

This is a delayed-type cross-sectional prospective accuracy study nested in a randomized clinical trial. The aim was to investigate the diagnostic accuracy of two visual criteria for caries lesions detection around restorations in primary teeth: the International Dental Federation (FDI) criteria, considering adaptation, staining and presence of caries, and the Caries Associated with Restorations and Sealants (CARS) system. For this, one examiner made the diagnosis and subsequent treatment decision using visual assessment in 163 children (3 to 10 years old) with both FDI and CARS criteria. The order of criteria used was defined by randomization. The reference standard was composed of two approaches: (i) presence of carious tissue after restoration removal or (ii) presence of caries lesions after six and 12 months of follow-up. Sensitivity, specificity, and accuracy parameters were calculated at the dentin threshold. Poisson multilevel regression analyses were performed to evaluate the association of the diagnostic methods and other explanatory variables with the outcomes. Of the 651 restorations included, 480 were evaluated by the reference standard methods and were analyzed. The CARS system presented higher accuracy (0.721) than those obtained with FDI recurrence of caries (0.702), FDI marginal adaptation (0.700) and FDI marginal staining criteria (0.681). The FDI marginal staining showed the study's lowest sensitivity (0.280) and accuracy (0.681) values. The specificity values of FDI recurrence of caries and FDI marginal adaptation were lower than the CARS system. Restorations assessed after the follow-up period resulted in lower sensitivity but higher specificity than those replaced after initial evaluation. In conclusion, the CARS system is more accurate in detecting caries around restorations in primary teeth than the FDI system, in general. However, the FDI recurrence of caries and FDI marginal adaptation present similar performance to the CARS system when the dentin threshold is considered. On the other hand, marginal staining is not an accurate parameter to evaluate caries around restorations.

How combining different caries lesions characteristics may be helpful in short-term caries progression prediction: model development on occlusal surfaces of primary teeth

Background

Few studies have addressed the clinical parameters' predictive power related to caries lesion associated with their progression. This study assessed the predictive validity and proposed simplified models to predict short-term caries progression using clinical parameters related to caries lesion activity status.

Methods

The occlusal surfaces of primary molars, presenting no frank cavitation, were examined according to the following clinical predictors: colour, luster, cavitation, texture, and clinical depth. After one year, children were re-evaluated using the International Caries Detection and Assessment System to assess caries lesion progression. Progression was set as the outcome to be predicted. Univariate multilevel Poisson models were fitted to test each of the independent variables (clinical features) as predictors of short-term caries progression. The multimodel inference was made based on the Akaike Information Criteria and C statistic. Afterwards, plausible interactions among some of the variables were tested in the models to evaluate the benefit of combining these variables when assessing caries lesions.

Results

205 children (750 surfaces) presented no frank cavitations at the baseline. After one year, 147 children were reassessed (70%). Finally, 128 children (733 surfaces) presented complete baseline data and had included primary teeth to be reassessed. Approximately 9% of the reassessed surfaces showed caries progression. Among the univariate models created with each one of these variables, the model containing the surface integrity as a predictor had the lowest AIC (364.5). Univariate predictive models tended to present better goodness-of-fit (AICs < 388) and discrimination (C:0.959–0.966) than those combining parameters (AIC:365–393, C:0.958–0.961). When only non-cavitated surfaces were considered, roughness compounded the model that better predicted the lesions' progression (AIC = 217.7, C:0.91).

Conclusions

Univariate model fitted considering the presence of cavitation show the best predictive goodness-of-fit and discrimination. For non-cavitated lesions, the simplest way to predict those lesions that tend to progress is by assessing enamel roughness. In general, the evaluation of other conjoint parameters seems unnecessary for all non-frankly cavitated lesions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01568-2.

What is the most accurate method for detecting caries lesions? A systematic review

OBJECTIVE

To perform a systematic review and meta-analysis of the performance of different methods for detecting carious lesions in permanent and primary teeth, considering all types of tooth surface.

METHODS

Two reviewers searched PubMed, Embase, Scopus and other sources up to November 2020 to identify published and nonpublished studies in English. We focused on three caries detection methods: visual inspection (VI), radiographic (RX) and fluorescence-based (LF). We included studies investigating at least one of these methods which (a) assessed the accuracy of the method in detecting caries lesions; (b) considered occlusal, proximal or free smooth surfaces in primary or permanent teeth; (c) used a reference standard other than one of the three methods; and (d) reported data on sample size and accuracy. Multilevel analyses, meta-regressions and comparisons of bivariate summary receiver operating characteristics curves were undertaken.

RESULTS

Two hundred and forty manuscripts from 14 129 articles initially identified met the inclusion criteria. VI was better than RX on occlusal surfaces at all caries lesion thresholds and proximal surfaces of permanent teeth only at all lesion thresholds in laboratory setting. LF was slightly better than VI for advanced lesions on occlusal surfaces of permanent teeth in the clinical setting and for all lesions on proximal surfaces of permanent teeth in the laboratory setting. Still, LF was worse than VI for advanced occlusal lesions in permanent teeth in the laboratory setting. Although LF showed slightly better performance than VI with advanced lesions, the latter had significantly higher specificity than other methods in all settings.

CONCLUSION

Visual caries detection alone is adequate for most patients in daily clinical practice regardless of tooth type or surface.

Development of a Fluorescence-Based Caries Scoring System for an Intraoral Scanner: An in vitro Study

OBJECTIVES

To develop an automated fluorescence-based caries scoring system for an intraoral scanner and totest the performance of the system compared to state-of-the-art methods.

METHODS

Seventy-three permanent posterior teeth were scanned with a three-dimensional (3D) intraoral scanner prototype which emitted light at 415 nm. An overlay representing the fluorescence signal from the tissue was mapped onto 3D models of the teeth. Multiple examination sites (n = 139) on the occlusal surfaces were chosen, and their red and green fluorescence signal components were extracted. These components were used to calculate 4 mathematical functions upon which a caries scoring system for the scanner prototype could be based. Visual-tactile (International Caries Detection and Assessment System, ICDAS), radiographic (ICDAS), and histological assessments were conducted on the same examination sites.

RESULTS

Most index tests showed significant correlation with histology. The strongest correlation was observed for the visual-tactile examination (rs = 0.80) followed by the scanner supported by the caries classification function that quantifies the overall fluorescence compared to sound surfaces (rs = 0.78). Additionally, this function resulted in the highest intra-examiner reliability (κ = 0.964), and the highest sum of sensitivity (SE) and specificity (SP) (sum SE-SP: 1.60-1.84) at the 2 histological levels where the comparison with visual-tactile assessment was possible (κ = 0.886, sum SE-SP = 1.57-1.81) and at the 3 out of 4 histological levels where the comparison with radiographic assessment was possible (κ = 0.911, sum SE-SP = 1.37-1.78); the only exception was for the lesions in the outer third of dentin, where the radiographic assessment showed the highest sum SE-SP (1.78).

CONCLUSION

A fluorescence-based caries scoring system was developed for the intraoral scanner showing promising performance compared to state-of-the-art caries detection methods. The intraoral scanner accompanied by an automated caries scoring system may improve objective caries detection and increase the efficiency and effectiveness of oral examinations. Furthermore, this device has the potential to support reliable monitoring of early caries lesions.

Dental Caries in 7-17-Year-Old Children in Moscow: A Clinical and a Questionnaire Study

PURPOSE

Sparse data is available concerning the distribution of decayed, extracted, filled/decayed, missing, filled tooth surfaces (defs/DMFS) and the impact of influencing risk factors in Moscow. We thus aimed to measure caries experience and to estimate its associations with relevant risk factors in schoolchildren.

MATERIALS AND METHODS

Data was obtained from 1004 schoolchildren aged 7-17. The clinical examination included the status of dental plaque, gingival bleeding and caries experience; defs/DMFS. The questionnaire was introduced to the children/parents, in order to measure socioeconomic and behavioural variables. The Fisher Exact test and chi-squared test were used to assess statistical significance of the distribution of the variables among groups. Bivariate and general estimating equations (GEE) analyses were applied to estimate the relative effect of the independent variables on the outcomes defined as median defs and median DMFS.

RESULTS

The median defs and median DMFS varied among age groups. In the primary dentition, the bivariate analyses showed association between median defs and gender, plaque, toothache, self-satisfaction with the appearance of teeth, and intake of milk with sugar were associated (p <0.05). The multivariate analyses revealed that the median defs was lower in girls (OR = 0.9) and children with evidence of no plaque (OR = 0.7)/thin plaque (OR = 0.8), (p ≤ 0.002). In the permanent dentition, the bivariate analyses showed association between median DMFS and plaque, gingival bleeding, healthy dentition, use of toothpicks/dental floss, intake of biscuits etc, soft drinks and jam/honey, and education of the child's mother (p ≤ 0.02). Only gingival bleeding after probing (OR = 1.2) and higher education level of the mothers (OR = 0.9) were associated with the median DMFS in the multivariate analyses (p < 0.05).

CONCLUSIONS

Clinical, socioeconomic and behavioural determinants were identified to influence caries in primary and permanent dentition in schoolchildren in Moscow. The findings might provide a reliable basis for improvements and education programmes in oral health promotion for children and adolescents.

Influence of different clinical criteria on the decision to replace restorations in primary teeth

OBJECTIVES

This cross-sectional study is nested in a randomized clinical trial. It was designed to evaluate the influence of using two different clinical criteria to assess caries lesion around restorations on the decision to replace restorations in primary posterior teeth. Variables that might influence this decision were also considered.

METHODS

One trained and calibrated examiner assessed 550 restorations of 160 children (3-10 years old). Children were randomized to have their restorations evaluated and subsequently treated according to World Dental Federation (FDI) or Caries Associated with Restorations and Sealants (CARS) criteria. After reaching the treatment decision, the same examiner performed another evaluation using the other criteria. Spearman's correlation coefficients and 95 % confidence intervals (95 %CI) between the scores obtained with both criteria and respective treatment decisions were calculated. Poisson multilevel regression analysis were performed between the exploratory variables related to children, restored tooth and restoration assessment; the outcome variables were decisions related to restoration replacement, any operative intervention and presence of secondary caries.

RESULTS

The strongest correlation observed between the methods was for recurrence of caries. A total of 94 restorations (17.1 %) were indicated for replacement with FDI criteria and 30 (5.5 %) were indicated for replacement with CARS. Besides the diagnostic method used, number of decayed teeth and restorations with two and three restored surfaces were associated with the decision of replacement and presence of recurrent caries lesions.

CONCLUSIONS

The decision to replace posterior restorations in primary teeth is influenced by the criteria used for the restorations assessment and also by the children's caries experience and multisurface restorations. The restoration material did not influence the decision of restorations replacement.

CLINICAL SIGNIFICANCE

The decision to replace posterior restoration in primary teeth is strongly related to the evaluation method and not only by patients' risk factors.

How to Intervene in the Caries Process in Children: A Joint ORCA and EFCD Expert Delphi Consensus Statement

This paper provides recommendations for dentists for the treatment of dental caries in children, with an emphasis on early childhood caries (ECC), primary teeth, and occlusal surfaces in permanent teeth. A consensus workshop followed by an e-Delphi consensus process was conducted with an expert panel nominated by the European Organization for Caries Research (ORCA) and European Federation of Conservative Dentistry (EFCD)/German Association of Conservative Dentistry (DGZ) boards. Based on 3 systematic reviews and a nonsystematic literature search, recommendations were developed. The caries decline has led to a more polarized disease distribution in children and adolescents along social gradients which should be taken into account when managing the caries process at all levels, such as the individual, the group, or a population. The control or reduction of caries activity is the basis for successful caries management. In children, caries management requires adequate daily oral hygiene and fluoride application via toothpaste, ensured by caregivers, and especially for ECC prevention an emphasis on sugar intake reduction is needed. These noninvasive interventions are also suitable to arrest or control initial or even cavitated dentine caries lesions in the absence of irreversible pulpitis. Fluoride varnish or silver diammine fluoride can be added as supplementary agents. In pits and fissures, composite resin materials can be used as preventive sealants and for defect-oriented minimally invasive restorations. In primary molars, preformed metal crowns are more successful than multisurface fillings, especially in caries-active patients. With persisting high caries activity, multiple lesions, and limited cooperation, caries control should consist of robust measures with high success rates, even including extraction in selected cases. This applies especially to treatments performed under general anesthesia.

The effect of two clinical criteria in the assessment of caries lesions around restorations in children (CARDEC-03): study protocol for a diagnostic randomized clinical trial

Introduction: The detection of caries lesions around restoration can be challenging. Therefore, the use of some criteria has been proposed in order to give more objectivity to the diagnosis process. Two of them are the International Dental Federation (FDI) and the Caries Associated with Restorations and Sealants (CARS) criteria. Both methods have a different approach to caries, and it is not possible to know which one of them is the best to use in clinical practice to assess restorations in children. Thus, the present protocol aims to evaluate the effect of the use of the FDI and CARS criteria in the assessment of caries lesions around restorations in primary teeth on outcomes related to oral health in children and costs resulting from the assessments.

Methods and analysis: A total of 626 restorations of children from three to 10 years were randomly assessed and are being treated following the FDI criteria (FDI group) or CARS criteria (CARS group). Participants will be followed-up after six, 12, 18, and 24 months. The primary outcome will be the need for a new intervention in the evaluated restorations. This outcome consists of several components, and each of these events will be analyzed separately as secondary outcomes. The changes in children’s oral health-related quality of life and the cost of the restoration dental treatments will also be analyzed as secondary outcomes. The methods will be compared using the Cox regression model with shared frailty. A significance level of 5% will be adopted for all statistical analyses.

Discussion: This will be the first randomized clinical study carried out regarding the detection of caries lesions around restorations in primary teeth.

Trial registration: The study underwent registration in Clinicaltrials.gov ( NCT03520309) on 9 May 2018.

Terminology of Dental Caries and Dental Caries Management: Consensus Report of a Workshop Organized by ORCA and Cariology Research Group of IADR

A 2-day workshop of ORCA and the IADR Cariology Research Group was organized to discuss and reach consensus on definitions of the most commonly used terms in cariology. The aims were to identify and to select the most commonly used terms of dental caries and dental caries management and to define them based on current concepts. Terms related to definition, diagnosis, risk assessment, and monitoring of dental caries were included. The Delphi process was used to establish terms to be considered using the nominal group method favored by consensus. Of 222 terms originally suggested by six cariologists from different countries, a total of 59 terms were reviewed after removing duplicates and unnecessary words. Sixteen experts in cariology took part in the process of reaching consensus about the definitions of the selected caries terms. Decisions were made following thorough "round table" discussions of each term and confirmed by secret electronic voting. Full agreement (100%) was reached on 17 terms, while the definitions of 6 terms were below the agreed 80% threshold of consensus. The suggested terminology is recommended for use in research, in public health, as well as in clinical practice.

Visual and radiographic merged-ICDAS caries progression pattern in 2-6 years old Colombian children: Two-year follow-up

AIM

To describe the 2-year clinical and combined with radiographic caries progression pattern in three cohorts of 2-(a), 4-(b), and 6-yr-old children (c).

DESIGN

Baseline sample comprised 600 children (each-cohort: n = 200). Children's dental surfaces were clinically assessed at schools without air-drying (epi) in terms of: Clinical (C) caries lesions (d/D) with ICDASepi-merged system (C-ICDASepi-d/D:Sound/Initial-epi/Moderate/Extensive); fillings (f/F), and missing teeth (m/M). Clinical ICDAS (C) and Radiographic ICDAS (R) indexes were combined (C + R). Caries experience (dmf + DMF) was expressed as: C-dmfs + DMFS (Moderate/Extensive-d/D); C-ICDASepi-dmfs + DMFS (including Initial-epi-d/D); C + R-dmfs + DMFS; and C + R-ICDASepi-dmfs + DMFS. Follow-up caries progression corresponded to more severe caries score.

RESULTS

Two-year follow-up sample was n = 352 (58.7%-baseline sample): a: n = 81; b: n = 131; c: n = 140. Around 100% of children presented C + R-ICDASepi-dmf + DMF ≥ 1, with following C + R-ICDASepi-dmfs + DMFS means: a: 7.3 ± 14.1; b: 12.2 ± 19.5; c: 13.3 ± 16.9. Progression was about 60% in all cohorts, mainly corresponding, in cohort b and c, to occlusal and distal surfaces of lower first/second-molar-primary teeth, and in cohort a to buccal surfaces of upper primary-incisor teeth. The addition of radiographs increased caries mean and prevalence in 10% as compared to only visual examination.

CONCLUSIONS

Children showed a high C + R caries experience progression rate, mainly related to occlusal and proximal surfaces in lower-molar teeth and buccal in upper-incisor teeth.

In-vivo performance of impedance spectroscopy, laser fluorescence, and bitewing radiographs for occlusal caries detection

OBJECTIVE

To evaluate the clinical performance of impedance spectroscopy, laser fluorescence, and bitewing radiographs in detecting occlusal caries and compare them with visual scores.

METHOD AND MATERIALS

In 62 adults, one occlusal surface per person was selected and independently examined by two examiners using the visual ICDAS scoring system, CarieScan PRO (ACIS), DIAGNOdent pen (LF-pen), and bitewing radiographs. The procedures were repeated within 1 to 4 weeks. The diagnostic performance was expressed as sensitivity, specificity, predictive values, accuracy, and diagnostic odds ratio (DOR) using ICDAS as gold standard. Intra- and inter-examiner reproducibility was assessed with intra-class correlation coefficients (ICC) for numerical results and kappa values for categorical data. Five patients dropped out due to no-shows or restorative care.

RESULTS

In total, 54% of the teeth had early or no lesions (ICDAS 0 to 2) while 46% exhibited moderate to extensive lesions (ICDAS 3 to 5). The Spearman correlation coefficients were 0.65, 0.60, and 0.71 for ICDAS vs ACIS, LF-pen, and bitewing radiographs, respectively. ACIS demonstrated high specificity and positive predictive values but low sensitivity, whereas LF-pen had moderate sensitivity and high specificity. Accuracy and DOR was highest for bitewing radiographs. The ICC values ranged between 0.65 and 0.88 for ACIS and 0.89 and 0.94 for LF-pen. The weighted kappa values were 0.81 to 0.91 for ICDAS and 0.90 to 0.92 for bitewing radiographs.

CONCLUSION

All three methods were useful for detecting occlusal caries but bitewing radiography exhibited the best performance when compared with visual scoring. ACIS displayed the highest specificity and positive predictive value but the sensitivity was low and the clinical handling was less convenient. Further clinical studies are needed to evaluate the long-term effects of early caries detection on dental health.

Approximal sealings on lesions in neighbouring teeth requiring operative treatment: an in vitro study

OBJECTIVES

With this in vitro study we aimed to assess the possibility of precise application of sealant on accessible artificial white spot lesions (WSL) on approximal surfaces next to a tooth surface under operative treatment. A secondary aim was to evaluate whether the use of magnifying glasses improved the application precision.

MATERIAL AND METHODS

Fifty-six extracted premolars were selected, approximal WSL lesions were created with 15% HCl gel and standardized photographs were taken. The premolars were mounted in plaster-models in contact with a neighbouring molar with Class II/I-II restoration (Sample 1) or approximal, cavitated dentin lesion (Sample 2). The restorations or the lesion were removed, and Clinpro Sealant was placed over the WSL. Magnifying glasses were used when sealing half the study material. The sealed premolar was removed from the plaster-model and photographed. Adobe Photoshop was used to measure the size of WSL and sealed area. The degree of match between the areas was determined in Photoshop.

RESULTS

Interclass agreement for WSL, sealed, and matched areas were found as excellent (κ = 0.98-0.99). The sealant covered 48-100% of the WSL-area (median = 93%) in Sample 1 and 68-100% of the WSL-area (median = 95%) in Sample 2. No statistical differences were observed concerning uncovered proportions of the WSL-area between groups with and without using magnifying glasses (p values ≥ .19). However, overextended sealed areas were more pronounced when magnification was used (p = .01). The precision did not differ between the samples (p = .31).

CONCLUSIONS

It was possible to seal accessible approximal lesions with high precision. Use of magnifying glasses did not improve the precision.

Relationship between depth of approximal caries lesions and presence of bacteria in the dentine in primary and permanent posterior teeth: a radiographic examination with microbiological evaluation

OBJECTIVES

We aimed to determine the relation between the radiographical depth of approximal lesions and the presence of bacteria in the dentine in posterior teeth in both dentitions.

MATERIAL AND METHODS

Sample 1 consisted of 34 approximal lesions in primary molars in children aged 5-7 years old. Sample 2 consisted of 48 approximal lesions in molars and premolars in adult patients aged 18-67 years old. All lesions were in need of restorative treatment according to the dentists. During the operative interventions dentine biopsies were collected with a sterile bur just pulpally of the enamel-dentin junction. Two authors evaluated the presence/absence of bacterial colonies. The lesions depth on bitewing radiographs (R_SCORING) were assessed independently by two examiners twice using the ICCMS classification system: R_I=initial-; R_M=moderate-; R_E=extensive caries.

RESULTS

In sample 1, the R_SCORING was distributed as follows: R_I=15; R_M=12; RE = 7. In 9 cases the lesions were clinically cavitated. Bacteria were visible on the agar plates in one case (7%) of the R_I lesion, 86% of the R_M lesions and in all the R_E lesions, (p < .001). In sample 2, R_SCORING was distributed as follows R_I=14; R_M=23; R_E=9. In 15 cases, the lesions were clinically cavitated. In 2 cases (14%), there were visible bacteria on the agar plates among the R_I lesions, while this was the case in 86% of R_M lesions and in 100% of R_E lesions (p < .001).

CONCLUSIONS

R_M and R_E lesions seem to harbor bacteria in the dentine and are candidates for invasive treatment. In contrast, R_I lesions should in general be managed non-invasively.

European Organization for Caries Research Workshop: Methodology for Determination of Potentially Available Fluoride in Toothpastes

Toothpastes are the most universally accepted form of fluoride delivery for caries prevention. To provide anti-caries benefits, they must be able to release fluoride during the time of tooth brushing or post brushing into the oral cavity. However, there is no standard accepted procedure to measure how much fluoride in a toothpaste may be (bio) available for release. The European Organization for Caries Research proposed and supported a workshop with experts in fluoride analysis in toothpastes and representatives from industry. The objective of the workshop was to discuss issues surrounding fluoride analysis in toothpaste and reach consensus on terminology and best practices, wherever the available evidence allowed it. Participants received a background paper and heard presentations followed by structured discussion to define the problem. The group also reviewed evidence on the validity, reliability and feasibility of each technique (namely chromatography and fluoride electroanalysis) and discussed their strengths and limitations. Participants were able to reach a consensus on terminology and were also able to identify and summarize the advantages and disadvantages of each technique. However, they agreed that most currently available methods were developed for regulatory agencies several decades ago, utilizing the best available data from clinical trials then, but require to be updated. They also agreed that although significant advances to our understanding of the mechanism of action of fluoride in toothpaste have been achieved over the past 4 decades, this clearly is an extraordinarily complex subject and more work remains to be done.

Impact of a Tutored Theoretical-Practical Training to Develop Undergraduate Students' Skills for the Detection of Caries Lesions: Study Protocol for a Multicenter Controlled Randomized Study

BACKGROUND

Tutored laboratorial activities could be a manner of improving the competency development of students. However, its impact over conventional theoretical classes has not yet been tested. Additionally, different university contexts could influence this issue and should be explored.

OBJECTIVE

To assess the impact of a tutored theoretical-practical training for teaching undergraduate students to detect caries lesions as compared with theoretical teaching activities. The impact of these teaching/learning activities will be assessed in terms of efficacy, cost/benefit, retention of knowledge/acquired competences, and student acceptability.

METHODS

Sixteen centers (7 centers from Brazil and 9 centers from other countries throughout the world) are involved in the inclusion of subjects for this protocol. A randomized controlled study with parallel groups will be conducted. One group (control) will be exposed to a 60- to 90-minute conventional theoretical class and the other group (test) will be exposed to the same theoretical class and also a 90-minute laboratory class, including exercises and discussions based on the evaluation of a pool of images and extracted teeth. The mentioned outcomes will be evaluated immediately after the teaching activities and also in medium- and long-term analyses. To compare the long-term outcomes, students who enrolled in the university before the participating students will be interviewed for data collection and these data will be used as a control and compared with the trained group. This stage will be a nonrandomized phase of this study, nested in the main study. Appropriate statistical analysis will be performed according to the aims of this study. Variables related to the centers will also be analyzed and used to model adjustment as possible sources of variability among results.

RESULTS

This ongoing study is funded by a Brazilian national funding agency (CNPq- 400736/2014-4). We expect that the tutored theoretical-practical training will improve the undergraduate students' performance in the detection of caries lesions and subsequent treatment decisions, mainly in terms of long-term retention of knowledge. Our hypothesis is that tutored theoretical-practical training is a more cost-effective option for teaching undergraduate students to detect caries lesions.

CONCLUSIONS

If our hypothesis is confirmed, the use of laboratory training in conjunction with theoretical classes could be used as an educational strategy in Cariology to improve the development of undergraduate students' skills in the detection of caries lesions and clinical decision-making.

Caries status in young Colombian children expressed by the ICCMS™ visual/radiographic combined caries staging system

OBJECTIVE

To report (1) the caries experience prevalence and mean, and the caries severity and distribution patterns, expressed clinically and combined with radiographs with the conventional and ICCMS™ systems in young children from Bogotá, Colombia; (2) the contribution of including radiographs to the clinical caries scoring and (3) in which surfaces the radiograph adds to the clinical caries registration.

MATERIAL AND METHODS

Six hundred children from kindergartens/schools were enrolled: Cohort A: 2-year (n = 200), Cohort B: 4-year (n = 200) and Cohort C: 6-year (n = 200) olds. Radiographs were taken of the 4- and 6- year olds. Children were examined clinically using the Clinical (C) and Radiographic (R) ICCMS™-epi Caries Scoring Systems, staging caries lesions (d) as: Initial (C_epi/R_A), Moderate (C_M/R_B) or Extensive (C_E/R_C). Caries experience including missing (m) and filled (f) surfaces was expressed as follows: clinical conventional (Cd_MEmfs); clinical ICCMS™ (Cd_epiMEmfs); combined conventional (C + Rd_MEmfs) and combined ICCMS™ (C + Rd_epiMEmfs).

RESULTS

The prevalence of Cd_MEmfs was: Cohort A: 32%; Cohort B: 59%; Cohort C: 67.5%, increasing to 73.5%, 99.8% and 100%, respectively, with the C + R d_epiMEmfs. The Cd_MEmfs means doubled when initial caries lesions (Cd_epi) and radiographs (R) were included. The d component corresponded to over two-thirds of the caries experience. Findings on the radiographs significantly raised caries experience prevalence and means (p < .02), detecting primarily approximal lesions. Surfaces with highest caries frequency were occlusal/approximal of molar teeth and buccal of upper incisor teeth.

CONCLUSION

Participants' caries experience was high. The radiographic assessment significantly contributed to caries experience. Molar and upper incisor teeth were most prone to caries.

Improving Clinical Visual Detection—Potential for Caries Clinical Trials

It has been the norm in caries clinical trials to measure caries increment by several different caries-recording systems, including the crude DMF-S/T index. However, there is a reserved attitude as to whether to subdivide the non-cavitated lesions and use arrested lesions in clinical trials. This has been due to the belief that it is not possible to achieve reliable data of the early stages of the disease (Radike, 1972). However, recently, Ekstrand et al. (1997, 1998) showed that it was possible: (1) to differentiate between different stages of non-cavitated occlusal lesions, (2) to differentiate between active and inactive occlusal lesions, and (3) to predict the depth of the lesion. In at least 4 other clinical studies, the reproducibility of recording initial active lesions, cavitated active lesions, and arrested lesions was found to be adequate (Carvalho et al., 1989; Nyvad et al, 1999; Ekstrand et al., 2000; Machiulskiene et al., 2001). Since caries today is a more slowly developing disease in many countries in the world, this will result in prolongation of the duration of the clinical trial, which will increase the costs. As indicated above, there is now sufficient evidence that caries can be clinically diagnosed accurately and reliably in earlier stages as well as in an arrested stage. If such stages of caries are used as outcome variables in caries clinical trials, they may have a positive influence on the trials’ duration and costs.

Detection of occlusal caries with impedance spectroscopy and laser fluorescence before and after placement of fissure sealants: An in vitro study

PURPOSE

To (1) investigate the influence of fissure sealants on impedance spectroscopy (ACIS) and laser fluorescence (LF) readings, (2) compare the performance of the ACIS device with the LF technique and visual inspection (ICDAS) in permanent molars with various degrees of occlusal caries, and (3) validate all methods against radiographs and histological hemi-sectioning.

METHODS

102 permanent molars were randomly selected to represent different stages of occlusal caries, from clinically sound to minor cavities. The teeth were examined by one trained examiner and scored with CarieScan PRO, the DIAGNOdent pen and ICDAS at baseline, after bleaching, etching and placement of a clear fissure sealant. A digital radiograph was exposed at baseline. After the assessments, the actual lesion depth was histologically determined.

RESULTS

Bleaching did not affect the readings but significantly higher ACIS and LF-pen values were recorded after acid etching (P< 0.05). The placement of a fissure sealant increased the LF-pen readings significantly (P< 0.05) while no values could be obtained with the ACIS device. Both the baseline ACIS and LF-pen values were significantly associated (P< 0.05) with the lesion depth but visual inspection displayed the best correlation with radiographs and histology. The ACIS technology displayed high sensitivity and specificity for detecting extensive occlusal lesions.

CLINICAL SIGNIFICANCE

The findings demonstrated that placement of a fissure sealant had a significant impact on the ACIS and LF-pen readings. Both methods mirrored the actual histological and radiographic lesion depth to various extents but could not match the performance of visual inspection.

High Fluoride Dentifrices for Elderly and Vulnerable Adults: Does It Work and if So, Then Why?

The primary aim of this work is to present the available evidence that toothpastes containing >1,500 ppm fluoride (2,500-2,800 and 5,000 ppm F) provide an additional caries preventive effect on root caries lesions in elderly patients compared to traditional dentifrices (1,000-1,450 ppm F). The secondary aim of this paper is to discuss why high fluoride dentifrices in general should perform better than traditional F-containing toothpaste. When examining the few studies that have considered the preventive benefits of high fluoride products on root caries the relative risk appears to be around 0.5, and the risk can thus be halved by exchanging traditional F-containing toothpaste for toothpaste containing 5,000 ppm F. There is reasonable evidence that high fluoride dentifrices significantly increase the fluoride concentration in saliva during the day and the fluoride concentration in plaque compared to traditional F toothpaste. Furthermore, the use of toothpaste with 5,000 ppm F significantly reduces the amount of plaque accumulated, decreases the number of mutans streptococci and lactobacilli and possibly promotes calcium fluoride deposits to a higher degree than after the use of traditional F-containing toothpaste.

Whole-Saliva Fluoride Levels and Saturation Indices in 65+ Elderly during Use of Four Different Toothpaste Regimens

BACKGROUND

Elderly individuals suffering from subnormal saliva secretion combined with inadequate oral hygiene may develop rampant caries and caries in parts of the dentition not normally affected by caries if preventive measures are not undertaken. Such measures include elevating fluoride levels at the saliva/biofilm/tooth interface.

AIM

To analyse whole-saliva fluoride levels and mineral saturation indices during different fluoride toothpaste regimens in home-living elderly.

MATERIALS AND METHODS

Whole saliva was collected from 27 subjects (7 males and 20 females, mean age 73.5±6.1 years) at ten time points covering the whole day during five 2-week periods. During the first period, participants used their normal toothpaste without instructions (baseline). This was followed by TP1: 1,450-ppm NaF toothpaste; TP2: 1,450-ppm monofluorophosphate (MFP) toothpaste with addition of calcium; TP3: 5,000-ppm NaF toothpaste, and TP4: the same toothpaste with additional 'smearing' of toothpaste on the teeth, twice daily. During TP1-TP4, the participants were instructed to brush 3 times per day using 1.5 g of toothpaste without rinsing.

RESULTS

Salivary fluoride levels increased with toothpaste fluoride content (p<0.001), although major interindividual and intraindividual variations were observed. The highest fluoride values appeared in the morning and at night (p<0.001). Saturation indices for calcium fluoride were affected by the fluoride content in pastes (p<0.05). Concerning hydroxyapatite and fluorapatite, indices were highest with the MFP toothpaste and extra calcium (NS to p<0.05).

CONCLUSIONS

Use of a high-fluoride toothpaste resulted in significantly increased fluoride levels in whole saliva and mineral saturation indices were indeed influenced by choice of toothpaste.

How different do visuo-tactile criteria assess caries lesions activity status on occlusal surfaces?

OBJECTIVES

We tested the association between active caries lesions assessed by two different criteria and clinical features of these caries lesions.

MATERIALS AND METHODS

Three examiners examined forty-nine 3- to 12-year-old children: one examiner used the Nyvad criteria, another examiner used the International Caries Detection and Assessment System with an additional criteria--Lesion Activity Assessment (ICDAS + LAA), and a reference examiner classified lesions regarding plaque stagnation, colour, lustre, cavities, depth and texture. Logistic regressions were used to test associations. For analyses, we grouped sound sites and inactive lesions vs active caries lesions, but also considering only inactive vs active lesions.

RESULTS

Active lesions scored by both criteria were similarly associated with different clinical parameters tested, except when the sound sites were excluded from the analysis. In these cases, active lesions according to ICDAS + LAA were associated only with cavitation and texture. Texture was associated with divergences between criteria when differentiating sound or inactive lesions from active ones. Fewer divergences in differentiating active from inactive lesions were observed when lesions present lustre.

CONCLUSION

Most clinical signs associated with active caries lesions were similar, but texture and severity tend to have a greater importance when using ICDAS + LAA for distinguishing caries activity status. Attention should be given to differences due to texture and lustre when using different indices.

Validation of Visual Caries Activity Assessment: A 2-yr Cohort Study

We evaluated the predictive and construct validity of a caries activity assessment system associated with the International Caries Detection and Assessment System (ICDAS) in primary teeth. A total of 469 children were reexamined: participants of a caries survey performed 2 yr before (follow-up rate of 73.4%). At baseline, children (12-59 mo old) were examined with the ICDAS and a caries activity assessment system. The predictive validity was assessed by evaluating the risk of active caries lesion progression to more severe conditions in the follow-up, compared with inactive lesions. We also assessed if children with a higher number of active caries lesions were more likely to develop new lesions (construct validity). Noncavitated active caries lesions at occlusal surfaces presented higher risk of progression than inactive ones. Children with a higher number of active lesions and with higher caries experience presented higher risk of developing new lesions. In conclusion, the caries activity system associated with the ICDAS presents predictive and construct validity in primary teeth in the assessment of occlusal caries lesions, but predictive validity was not observed in smooth surfaces.

A randomized clinical trial of the anti-caries efficacy of 5,000 compared to 1,450 ppm fluoridated toothpaste on root caries lesions in elderly disabled nursing home residents

Root caries is prevalent in elderly disabled nursing home residents in Denmark. This study aimed to compare the effectiveness of tooth brushing with 5,000 versus 1,450 ppm of fluoridated toothpaste (F-toothpaste) for controlling root caries in nursing home residents. The duration of the study was 8 months. Elderly disabled residents (n = 176) in 6 nursing homes in the Copenhagen area consented to take part in the study. They were randomly assigned to use one of the two toothpastes. Both groups had their teeth brushed twice a day by the nursing staff. A total of 125 residents completed the study. Baseline and follow-up clinical examinations were performed by one calibrated examiner. Texture, contour, location and colour of root caries lesions were used to evaluate lesion activity. No differences (p values >0.16) were noted in the baseline examination with regards to age, mouth dryness, wearing of partial or full dentures in one of the jaws, occurrence of plaque and active (2.61 vs. 2.67; SD, 1.7 vs.1.8) or arrested lesions (0.62 vs. 0.63; SD, 1.7 vs. 1.7) between the 5,000 and the 1,450 ppm fluoride groups, respectively. Mean numbers of active root caries lesions at the follow-up examination were 1.05 (2.76) versus 2.55 (1.91) and mean numbers of arrested caries lesions were 2.13 (1.68) versus 0.61 (1.76) in the 5,000 and the 1,450 ppm fluoride groups, respectively (p < 0.001). To conclude, 5,000 ppm F-toothpaste is significantly more effective for controlling root caries lesion progression and promoting remineralization compared to 1,450 ppm F-toothpaste.

Infiltrating/sealing proximal caries lesions: a 3-year randomized clinical trial

This randomized split-mouth controlled clinical trial aimed at assessing the therapeutic effects of infiltration vs. sealing for controlling caries progression on proximal surfaces. Out of 90 adult students/patients assessed at university clinics and agreeing to participate, 39, each with 3 proximal lesions identified radiographically around the enamel-dentin junction to the outer third of the dentin, were included. Lesions were randomly allocated for treatment to test-A (Infiltration: ICON-pre-product; DMG), test-B (Sealing: Prime-Bond-NT; Dentsply), or control-C (Placebo). Primary outcome after 1, 2, and 3 yrs of radiographically observed lesion progression was assessed by an independent examiner blinded to groups, using pair-wise and digital-subtraction readings. No adverse events occurred. In 37 participants assessed after 3 yrs, 10 lesions (A-4; B-2; C-4) progressed deep into dentin and needed operative treatment. The 3-year therapeutic effect, based on pair-wise radiographic readings between infiltration and placebo, was 37.8% (95% CI: 20.5-55.2%) and that between sealing and placebo was 29.7% (95% CI: 20.2-35.0%). One-year follow-up digital-subtraction readings showed significant differences in lesion progression between infiltration and placebo (P = 0.0012) and between sealing and placebo (P = 0.0269). The study showed that infiltration and sealing are significantly better than placebo treatment for controlling caries progression on proximal lesions. No significant difference was seen between infiltration and sealing (ClinicalTrials.gov number NCT01417832).

The reliability and accuracy of two methods for proximal caries detection and depth on directly visible proximal surfaces: an in vitro study

This study aimed to determine the reliability and accuracy of the ICDAS and radiographs in detecting and estimating the depth of proximal lesions on extracted teeth. The lesions were visible to the naked eye. Three trained examiners scored a total of 132 sound/carious proximal surfaces from 106 primary teeth and 160 sound/carious proximal surfaces from 140 permanent teeth. The selected surfaces were first scored visually, using the 7 classes in the ICDAS. They were then assessed on radiographs using a 5-point classification system. Reexaminations were conducted with both scoring systems. Teeth were then sectioned and the selected surfaces histologically classified using a stereomicroscope (×5). Intrareproducibility values (weighted kappa statistics) for the ICDAS for both primary and permanent teeth were >0.9, and for the radiographs between 0.6 and 0.8. Interreproducibility values for the ICDAS were >0.85, for the radiographs >0.6. For both primary and permanent teeth, the accuracy of each examiner (Spearman's correlation coefficient) for the ICDAS was ≥0.85, and for the radiographs ≥0.45. Corresponding data were achieved when using pooled data from the 3 examiners for both the ICDAS and the radiographs. The associations between the 2 detection methods were measured to be moderate. In particular, the ICDAS was accurate in predicting lesion depth (histologically) confined to the enamel/outer third of the dentine versus deeper lesions. This study shows that when proximal lesions are open for inspection, the ICDAS is a more reliable and accurate method than the radiograph for detecting and estimating the depth of the lesion in both primary and permanent teeth.

Sealing distal proximal caries lesions in first primary molars: efficacy after 2.5 years

BACKGROUND

The prevalence of proximal caries in primary molar teeth is high in many countries.

AIMS

(1) To study by means of a split-mouth design the 1- and 2.5-year efficacy of sealing proximal lesions vs. flossing instructions (control) on primary molar teeth. (2) To assess children's behaviour and pain perception during the procedure.

METHODS

Ninety-one 4- to 6-year-old children from Bogotá, Colombia participated. Participants had to have at least two proximal lesions scored according to the following radiographic classification system: radiolucency (1) in enamel outer half, (2) restricted to enamel-dentine junction, or (3) restricted to dentine outer third. Baseline, 1- and 2.5-year follow-up bitewing radiographs were taken. Test and control lesions were randomly selected. After temporary separation test lesions were sealed (adhesive). Parents/caregivers received a flossing leaflet for their children. Progression of the lesions was assessed by means of independent reading of conventional bitewing radiographs.

RESULTS

One-year (n = 73) test vs. control lesion progression was 27.4 vs. 50.7%, respectively (p < 0.01, McNemar's test), and 2.5-year (n = 56) test vs. control lesion progression was 46.4 vs. 71.4%, respectively (p < 0.01). The dropouts did not differ from those who remained in the study regarding relevant caries baseline data. More than 88% of the participants presented positive to definitively positive behaviour and very low or low pain intensity at both first and second appointments.

CONCLUSION

The sealing technique was superior to flossing instructions both after 1 and 2.5 years of follow-up and the majority of the participants had no anxiety or pain during the treatment.

Plaque, caries level and oral hygiene habits in young patients receiving orthodontic treatment

OBJECTIVE

To assess plaque, caries, and oral hygiene habits amongst patients receiving fixed-orthodontic treatment at the Dental-Clinic, Universidad-El-Bosque, Bogotá, Colombia.

BASIC RESEARCH DESIGN

Test-group: 74 12-29-year-olds receiving fixed-orthodontic treatment; reference-group: 63 12-29-year-olds before they started the orthodontic treatment. Visual examinations (one examiner) recorded the following: Ortho-plaque-Index (OPI) expressed per patient as good, fair and poor-oral-hygiene. Caries was scored with the modified-ICDAS-II criteria as: 0-sound; 1B/1W-brown/white-opacity-after-air-drying; 2B/2W-brown/white-opacity-without-air-drying; 3-microcavity; 4-underlying-shadow; 5/6-distinct/extensive-cavity. Filled/missing surfaces due-to-caries and caries-lesions on buccal surfaces at three sites around the brackets were recorded. A 7-item self-administered oral-hygiene habits' questionnaire was used.

RESULTS

Chi-square test revealed that the oral-hygiene level was significantly better in the reference group compared to the test group (p < 0.05). The traditional mean DMF-S was 6.7 +/- 6.3 in the test- and 6.2 +/- 5.9 in the reference-group (p > 0.05). When adding modified-ICDAS-II lesions scores 1-4, the figure increased to 23.6 +/- 9.4 in the test- and to 13.6 +/- 10.3 in the reference-group (p < 0.001). A total of 96% had > or = 1 white-opacity in the test group versus 56% in the reference group (P < 0.001). In the test-group the buccal-surfaces accounted for most white-opacities and close to 1/3 of these lesions on the upper-anterior teeth were located around the brackets. The questionnaire disclosed that 58% in the test- vs. 44% in the reference-group did not accept having dental caries lesions during the orthodontic treatment.

CONCLUSIONS

The results showed a high prevalence of white-opacities related to orthodontic appliances and indicate the need to implement preventive programmes at the dental clinic.

Sealants in dentistry: outcomes of the ORCA Saturday Afternoon Symposium 2007

Sealants are a successful tool in caries prevention, but their role in preventive strategies after the caries decline has to be discussed. A survey of paediatric departments across Europe revealed that indications for pit and fissure sealants vary considerably, both nationally and internationally. Evidence for effectiveness of sealants in controlling caries in posterior teeth implies that sealants should be an integrated part of management of pit and fissure caries. Still, the indication for occlusal sealants seems to be shifting from primary prevention to a therapeutic decision for caries management of lesions in enamel and the outer part of the dentine. Sealants are also an interesting concept for caries management in approximal surfaces. Clinical trials suggest that novel techniques of sealing or infiltrating approximal lesions show promise. However, approximal sealing techniques are as complex to apply and time-consuming as approximal fillings. The article proposes guidelines for teaching on the use of sealants.

In vitro comparison of Nyvad's system and ICDAS-II with Lesion Activity Assessment for evaluation of severity and activity of occlusal caries lesions in primary teeth

This in vitro study of occlusal surfaces on primary molars aimed to: (1) evaluate the reproducibility of the Nyvad and ICDAS-II visual systems in detecting caries; (2) to test the accuracy of the systems in estimating lesion depth, and (3) to examine the association between the Nyvad system and the Lesion Activity Assessment system, an adjunct to ICDAS-II. Two samples of extracted primary molars (sample 1, n = 38; sample 2, n = 69) were evaluated independently by 2 examiners. In this in vitro study, evaluation of plaque in the Nyvad system was not possible. Histology (sample 2) was used to validate lesion depth. Area under ROC curves (A(z)), sensitivity, specificity and percent agreement of both systems were calculated at D1, D2 and D3 thresholds. Both systems showed kappa for intra- and inter-examiner agreement >0.86 and good correlation with histology: Spearman rho = 0.73 (Nyvad) and 0.78 (ICDAS-II). They presented similar performances except that ICDAS-II showed significantly higher sensitivity (Nyvad 0.89; ICDAS 0.92) and A(z) (Nyvad 0.85; ICDAS 0.90) for the D1 threshold. The correlation between the systems for lesion activity (Cramer's V) was 0.71. Therefore, both visual systems are reliable and can estimate caries lesion depth on primary teeth. Under in vitro conditions, there is no major difference between the Nyvad system and Lesion Activity Assessment in assessing caries activity.

Lesion activity assessment

This chapter focusses on the probability of a caries lesion detected during a clinical examination being active (progressing) or arrested. Visual and tactile methods to assess primary coronal lesions and primary root lesions are considered. The evidence level is rated as low (R(w)), as there are few studies with proper validation. The major problem is lack of an accepted clinical gold standard. Evidence from high-quality basic research and epidemiological, clinical and intervention studies is therefore discussed. High-quality basic research has mapped the patho-anatomical changes occurring in response to cariogenic plaque as well as lesion arrest. Based on this understanding, different clinical scoring systems have been developed to assess the severity/depth and activity of lesions. A recent system has been devised by the International Caries Detection and Assessment System Committee. The literature suggests that there is a fair agreement between visual/tactile external scripts of caries and the severity/depth of the lesion. The reproducibility of the different systems is, in general, substantial. No single clinical predictor is able to reliably assess activity. However, a combination of predictors increases the accuracy of lesion activity prediction for both primary coronal and root lesions. Three surrogate methods have been used for evaluating lesion activity (construct validity); all have disadvantages. If construct validity is accepted as a 'gold standard', it is possible to assess the activity of primary coronal and root lesions reliably and accurately at one examination by using the combined information obtained from a range of indicators--such as visual appearance, location of the lesion, tactile sensation during probing and gingival health.

Detection and activity assessment of primary coronal caries lesions: a methodologic study

This study has three main objectives: Study (1) test the reproducibility and accuracy of the ICDAS I and ICDAS II caries detection systems; Study (2) validate a new impression material (Clinpro, 3M ESPE), which is said to detect lactic acid in plaque fermenting sucrose; Study (3) devise and test a scoring system for the assessment of caries activity of coronal lesions. Study (1): 141 extracted teeth were examined by two examiners using the ICDAS I and ICDAS II caries detection systems and validated against a histological classification system. Study (2): The accuracy of the impression material in predicting plaque with pH lower/higher than 5.5 was determined in an in situ study of 45 root dentin specimens by comparing the color change in the impression with the actual pH of the plaque, determined with a pH meter. Study (3): A scoring system to assess lesion activity was devised based on the predictive power of the visual appearance of the lesion (ICDAS II system), location of the lesion in a plaque stagnation area and, finally, the tactile feeling, rough/soft or smooth/hard, when running a perio-probe over the lesion. The accuracy was tested in a clinical study of 35 children with 225 lesions/sound surfaces and was validated using the Clinpro impression material for construct validity. Study (1): Intra- and inter-examiner reproducibility was found to be excellent (Kappa-values > 0.82) and the associations strong (Spearmans correlation coefficients > 0.90). Study (2): The Clinpro impression material was found to be acceptable as compared to the results of a pH meter, the combined sensitivity and specificity was 1.63. Study (3): ROC analysis showed that the devised classification system for determining lesion activity had acceptable accuracy (area under curve = 0.84 and the highest combined sum of specificity and sensitivity was 1.67). Thus, it is possible to predict lesion depth and assess the activity of primary coronal caries lesions accurately by using the combined knowledge obtained from visual appearance, location of the lesion and tactile sensation during probing.

Frequency and distribution patterns of sealants among 15-year-olds in Denmark in 2003

AIMS

To provide information on the frequency and distribution patterns of sealants in the Public Dental Health Service for Children (PDHSC) in Denmark. A further aim was to determine whether there was a correlation between DMF-S and sealants.

DESIGN

A cross sectional survey using data from 15-year-old Danes in 2003. SAMPLE AND SUBJECTS: The sample consisted of 50 randomly selected municipalities from the 204 municipalities with public clinics. Thirty-nine municipalities (78%) forwarded useful data. A total number of 3,184 15-year-olds were involved in the study.

RESULTS

The mean DMF-S was 2.97 (SD = 1.40) and 42% had a DMF-S = 0. The mean number of sealants was 3.06 (SD = 1.60). Two-thirds of all participants had one or more sealed surfaces. At the individual level the correlation coefficient (rs) between sealants and DMF-S was -0.05 (p < 0.01). The mean number of sealants in one municipality was 0.26, in another 6.00. The surfaces most often sealed, were the occlusal surfaces on permanent second molars (35%), closely followed by the occlusal surfaces on permanent first molars (32%). Sealants on premolars were rare (1.5%). At the municipality level there was no significant correlation between mean DMF-S, % 15-year-olds with a DMF-S = 0 and mean number of sealants (rs = 0.02 (p = 0.90) and rs = 0.06 (p = 0.73), respectively).

CONCLUSION

The data indicate a high use of sealants on molar teeth, a very large inter-municipality variation, no correlation between sealants and DMF-S. These findings suggest that there are no clear guidelines for use of sealants in the PDHSC in Denmark.

Accuracy and reproducibility of conventional radiographic assessment and subtraction radiography in detecting demineralization in occlusal surfaces

Subjective interpretation of paired digital radiographic images viewed side by side to assess occlusal lesion progression, arrest or remineralization is difficult. The aim of this study was to compare the accuracy and reproducibility of a digital subtraction radiography technique and visual assessment of paired digital images in detecting changes in mineral content within occlusal cavities. Forty molar teeth with occlusal cavities were placed in arches and baseline digital radiographs taken. Nineteen teeth were randomly selected and had acid placed in the cavities and digital images taken after 3, 6, 12, 18 and 24 h of acid exposure. Paired baseline images and those taken at the various time intervals were examined side by side and assessed for demineralization by five examiners. Subtraction images prepared from the paired images were assessed in the same way. One fifth of the images were re-examined to determine intra-examiner reproducibility. After 12 h or longer the diagnostic accuracy (mean area under the ROC curve = 0.92-0.98 for subtraction radiography), intra-examiner and inter-examiner reproducibility for detection of demineralization from the subtraction images was significantly better than viewing the paired images side by side (p < 0.01). The subtraction radiography system used was found to be more accurate and reproducible than visual assessment of paired digital images. As such the technique shows promise for monitoring occlusal lesion progression in clinical studies.

Efficacy of sealing proximal early active lesions: an 18-month clinical study evaluated by conventional and subtraction radiography

This study assessed the efficacy of sealing proximal lesions on adult patients using a split-mouth design. Eighty-two 15- to 39-year-olds from the Dental Faculties in Copenhagen and Bogotá participated, each having 2 or more proximal lesions in the following radiographic stages: (1) lesion restricted to the outer half of enamel; (2) lesion from the inner half of enamel including the enamel dentine junction, and (3) lesion restricted to the outer third of dentine. Standardized geometrically aligned baseline and follow-up radiographs were obtained. One randomly selected lesion (test) in each patient was sealed with 1 of 2 resins. The patients were instructed to floss all the proximal lesions 3 times per week. The baseline to 18 months difference in caries lesion progression status was assessed using 3 methods: (1) radiographs were independently assessed visually; (2) radiographs were read in pairs, and (3) using subtraction radiography of digitized images. A total of 72 subjects finished the study (12.2% dropout). The compliance concerning flossing was poor (15%). For the repeated examinations kappa was 0.84 for the visual examination, 0.44 for the paired readings and 0.84 for the subtraction examination. Two test lesions and 1 control lesion were restored. For the independent radiograph assessment method 10 and 26% progressed in the test and control group, respectively (p > 0.05); with the paired radiograph method the corresponding data were 22% in the test and 47% in the control groups (p < 0.01). By subtraction radiography 44% of the test group and 84% of the control were judged to have progressed (p < 0.001). The sealing technique was superior to instructing patients to floss, and subtraction radiography appeared to be the most sensitive method for assessing lesion progression.

Outcomes of a Non-Operative Caries Treatment Programme for Children and Adolescents

This study assessed the effectiveness and performance of a non-operative caries treatment programme (NOCTP) used since 1987 in the municipality of Nexo in Denmark. The NOCTP emphasizes mechanical plaque control and considers the eruption period of molar teeth as a risk factor. The mean DMF-S among 18-year-olds in 1999 and 2000 in Nexo was 1.23 +/- 2.26 and 1.25 +/- 2.01 (medians 0); 55 and 56% had DMF-S = 0. The mean numbers of sealed surfaces were 4.6 +/- 3.25 and 4.0 +/- 3.22, respectively. The cost per child per year was marginally and significantly reduced in the years with the NOCTP compared to that before 1988 (p = 0.05). In 4 comparison municipalities with very low caries experience, mean DMF-S scores among 18-year-olds in 1999 were 2.73-3.25 (medians 1-2) and were significantly higher than in Nexo (p < 0.001). The NOCTP differed from the preventive programmes used in the comparison municipalities in the period 1988-1999 in emphasising care for the erupting molars, the use of a firm guideline and stated goals to be achieved, but with less emphasis on diet. The effectiveness and performance of the NOCTP were both considered high, as very low DMF-S and high %DMF-S = 0 had been achieved by 1999, and 18-year-olds in Nexo had significantly less caries than in the comparison municipalities. The latter difference could not be explained by difference in caries-related background variables.

Visual and tactile assessment of arrested initial enamel carious lesions: an in vivo pilot study

Accurate and reliable assessment of caries activity is important for determining appropriate treatment needs. The aim of this pilot study was to determine whether dentists could differentiate between the appearances (visual and tactile) of lesions inactivated by regular professional oral hygiene and those control lesions which were not cleaned (active). After a 3- to 4-week study period involving 10 children, with 4 similar carious lesions each, it was found that dentists were not able to reliably and reproducibly determine the subtle visual and tactile differences between active and inactive enamel lesions from a one-off clinical examination.

Time and duration of eruption of first and second permanent molars: a longitudinal investigation

OBJECTIVE

The aim of this study was to investigate the variation in (i) the time (age) of eruption and (ii) the duration of the eruption of first (M1) and second (M2) permanent molar teeth. Finally, the study also provides data about the association between time of eruption of the first of the M1s and the first of the M2s.

METHODS

The study was carried out in Nexö Public Dental Health Service, Denmark. All children who, in a period of 12 months, had the first of their M1s or M2s recorded as erupted and the occlusal surface still partly covered by gingiva formed the study groups (N = 69 and 112 children, respectively). The continued eruption of all four molar teeth was recorded at recall intervals not exceeding 4 months until functional occlusion was obtained.

RESULTS

First permanent molars: eruption time--girls: from the age of 5 years and 3 months to 7 years and 8 months (mean 6.1 years); boys: from 5 years and 2 months to 7 years and 10 months (mean 6.3 years). The duration of eruption--girls: from 5 to 32 months (mean 15.4 months); boys: from 7 to 28 months (mean 15.0). Second permanent molars: eruption time--girls: from the age of 8 years and 11 months to 14 years and 4 months (mean 11.3 years); boys: from 9 years and 11 months to 13 years and 11 months (mean 12.0 years). The duration of eruption--girls: from 12 to 44 months (mean 27.1 months); boys: from 9 to 45 months (mean 27.9 months). No correlation was found between the time of eruption and the duration of eruption of M1 or M2. There was a strong positive association between the time of eruption of the M1s and the M2s (r(s) = 0.81).

CONCLUSIONS

A tremendous variation was found in time of eruption and in duration of eruption of permanent molars. This variation highlights the importance of individualizing caries preventive strategies for children.

Influence of different variables on the inter-municipality variation in caries experience in Danish adolescents

This investigation sought to estimate the influence a number of variables had on the inter-municipality variation in caries experience across Denmark. Unit of measurement was the municipality with public clinics. Mean DMF-S and %DMF-S = 0 of 15- and 18-year-olds in 1999 were obtained from 204 and 143 municipalities, respectively, out of a total number of 206 municipalities with public clinics. The independent variables were: cost per child per year; children/dentist ratio; auxiliary personal/dentist ratio; fluoride concentration in the water supply [F]; average personal income; % of mothers of the 15- and 18-year-olds with < or =10 years education (EDU-15 or EDU-18); proportion of immigrants; and size of the municipality. Multiple regression analyses disclosed that [F] (p < 0.001) and EDU-15 (p < 0.001) were significant variables among the 15-year-olds explaining 45% of the variation in mean DMF-S and 31% of the variation in % DMF-S = 0. With respect to the 18-year-olds, [F] (p < 0.001) and average personal income (p < 0.001) explained 53% of the variation in mean DMF-S and 30% of the variation in %DMF-S = 0. Few municipalities were characterized as outliers with significantly lower or higher observed caries experience than expected. It is concluded that there is room for other explanatory factors--first and foremost the professional effort made in the individual Public Dental Health Service to control caries.

An in vitro comparison of a combined FOTI/visual examination of occlusal caries with other caries diagnostic methods and the effect of stain on their diagnostic performance

The aims of this in vitro study were to compare the combination of FOTI and visual inspection to other diagnostic methods for the detection and evaluation of the depth of occlusal caries and assess the effect of stain on diagnostic performance. Five diagnostic methods (combined FOTI/Visual (CFV), Visual, FOTI, DIAGNOdent and Electrical Caries Monitor) were considered. Histological validation was performed in the 152 occlusal molar sites (111 teeth) using 350-microm sections and a stereomicroscope. The rank correlation coefficients with histology ranged from 0.42 (DIAGNOdent) to 0.66 (CFV). The area under the ROC curves (AUC) for enamel lesions ranged from 0.82 (ECM) to 0.88 (CFV) and from 0.81 (DIAGNOdent) to 0.91 (CFV) for dentine lesions. The AUC at the dentine level for CFV and FOTI were similar (p > 0.05), but the AUC for CFV was significantly greater than for visual (p < 0.001), DIAGNOdent (p = 0.005) and the ECM (p = 0.04). FOTI was found to be particularly useful for the detection of dentine lesions. The exclusion of stain and brown spot lesions improved performance for all methods. It is concluded that CFV is useful for the determination of occlusal lesion depth and that in the presence of stain and brown spot lesions different cut-off points may be required for the ECM and DIAGNOdent to identify dentine lesions.

Relating visual and radiographic ranked scoring systems for occlusal caries detection to histological and microbiological evidence

This study compared a visual ranked scoring system and a radiographic ranked scoring system for occlusal caries detection with the level of infection of dentin. Seventy-five third-molars, designated for extraction, were professionally cleaned. Caries was scored according to a visual ranked scoring system at a selected site in the groove-fossa system. Radiographs of the teeth were available and caries was recorded along a five-point ranked scoring system. Each tooth was extracted and hemi-sectioned through the investigation site under aseptic conditions. A burful of dentin was removed from the EDJ of one of the section faces and these samples were processed to establish the level of dentin infection. The depth of the lesion was assessed on the other section face using a five-point ranked histological scoring system. A strong relationship was observed between the histological lesion depth and visual score (r(s)=0.93) while a moderate relationship was seen between lesion depth and radiographic scores (r(s)=0.77). The dentin from teeth with cavities exposing dentin was heavily infected. The dentin from teeth with microcavities or grey discoloration of the dentin was less infected than the lesions with frank cavitation (score 4) (p<0.05, t-test), but more infected than the initial lesions (p<0.05, t-test). The latter lesions showed minimal infection. A similar tendency was seen with respect to increasing radiographic scores and the level of infection of the dentin.

Occlusal caries: pathology, diagnosis and logical management

Occlusal caries now accounts for most of the lesions in children aged 8-15 years. This paper presents a ranked visual scoring system for occlusal caries diagnosis. It relates the clinical appearance of the lesion to its activity, the level of infection of the dentine and the histopathology. The appropriate management for each score is suggested.

An in vitro comparison of the ability of fibre-optic transillumination, visual inspection and radiographs to detect occlusal caries and evaluate lesion depth

The aim of this study was to compare the performance of fibre-optic transillumination (FOTI), visual inspection and bite-wing radiographs to detect occlusal caries and estimate the lesion depth. Fifty-nine extracted molars were assessed using FOTI and visual examination by 4 trained examiners and 1 examiner evaluated the bite-wing radiographs. Histological validation was performed using 250-microm sections examined with a stereomicroscope. For the three methods, the correlation between the lesion depth and the histological scores varied from 0.65 to 0.73. For dentinal caries detection, the areas under ROC curves ranged from 0.83 to 0.87. The radiographic method was poor at detecting lesions confined to enamel. FOTI, visual inspection and radiographs showed a good correlation with the histology but had difficulty in distinguishing lesions located deep in enamel or in the outer third of dentine. FOTI was shown to be as accurate as a detailed visual inspection in detecting occlusal caries.

Plaque and gingival status as indicators for caries progression on approximal surfaces

This study aimed to (1) record the plaque and gingival status on sound and carious approximal surfaces and (2) investigate whether the two parameters could predict approximal lesion progression. For this purpose two samples were selected among 18- to 25-year-old patients at the Dental Faculty in Copenhagen. Sample 1 consisted of 45 patients, each having an approximal posterior surface requiring operative treatment and a contralateral approximal space, where both surfaces were radiographically sound. Sample 2 consisted of 25 patients, each having a posterior approximal tooth surface with an enamel/initial dentinal lesion recorded on a bitewing. Plaque and gingival status were classified using 4-point ranked scales. The recordings were performed once on each participant in sample 1. The recordings in sample 2 were repeated 5 times during a 15-month period. In order to assess lesion progression in sample 2, two serial intraoral examinations were performed, i.e. at the beginning and end of the study. Less than 10% of the sound and carious surfaces were recorded as plaque-free, while about 40% had a thick or heavy plaque accumulation. No significant difference was observed between plaque scores on sound and carious surfaces (p = 0.5), in contrast to findings representing the gingival status (p < 0.001). Tooth surfaces requiring operative treatment were associated with bleeding of the gingiva after probing. In sample 2, 3 of the 25 participants did not finish the study. On the remaining participants caries progression was observed in 9 cases (41%), while no progression was observed in 13 cases. Analyses showed that there were no significant differences between plaque scores in cases with caries progression, as compared with no caries progression (p > 0.05). Similar analyses concerning gingival status showed that bleeding of the gingiva was related to cases with progressing caries. Analyses also disclosed no direct association between plaque and gingival status (Spearman correlation coefficient 0.39). Thus, the occurrence of plaque does not have the same predictive power as bleeding after probing in decision-making as to whether or not a lesion progresses.