Diagnosing and recording root caries: A survey among Swiss dentists

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL SIGNIFICANCE

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

Can hyperglycemia be associated with caries activity and root caries in adults?

AIMS

A previous meta-analysis showed that individuals with Type 2 diabetes mellitus (T2D) have a greater chance of developing both coronal caries and root caries than systemically healthy ones, which can be influenced by hyperglycemia per se. This study aimed to associate blood and salivary glucose levels with caries.

METHODS

This research is a subset of a cross-sectional study. N = 39 individuals underwent a dental examination and salivary glucose, fasting blood glucose (FBG) and glycated hemoglobin (A1c) measurements.

RESULTS

The prevalence of active coronal caries was 10.2%, and that of root caries was 20.5%. A1c and FBG averages were higher in individuals with root caries (9.75 ± 1.71 and 186.3 ± 62.5) than without (7.01 ± 2.23 and 115.1 ± 48.6; p < 0.05). Individuals with T2D showed weak correlation of salivary glucose and number of active coronal caries. Significant correlations were observed between salivary and blood glucose. There was relevance of A1c (0.53; CI=0.124-0.941; p = 0.01) and FBG (0.019; CI=0.006-0.033; p = 0.006) toward the increased number of root caries lesions, even after adjustment for salivary flow and age.

CONCLUSION

Blood glucose levels are associated with an increased number of root caries in adults with or without T2D. In individuals with T2D, salivary glucose was correlated with active coronal caries. Additional studies are needed to support this association.

Tests to detect and inform the diagnosis of root caries

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effectiveness of DIAGNOdent in Detecting Root Caries Without Dental Scaling Among Community-dwelling Elderly

PURPOSE

The purpose of this clinical research was to analyze the effectiveness of DIAGNOdent in detecting root caries without dental scaling.

MATERIALS AND METHODS

The status of 750 exposed, unfilled root surfaces was assessed by visual-tactile examination and DIAGNOdent before and after root scaling. The sensitivity and specificity of different cut-off DIAGNOdent values in diagnosing root caries with reference to visual-tactile criteria were evaluated on those root surfaces without visible plaque/calculus. The DIAGNOdent values from sound and carious root surfaces were compared using the nonparametric Mann-Whitney U-test. The level of statistical significance was set at 0.05.

RESULTS

On root surfaces without plaque/calculus, significantly different (p < 0.05) DIAGNOdent readings were obtained from sound root surfaces (12.2 ± 11.1), active carious root surfaces (37.6 ± 31.7) and inactive carious root surfaces (20.9 ± 10.5) before scaling. On root surfaces with visible plaque, DIAGNOdent readings obtained from active carious root surfaces (29.6 ± 20.8) and inactive carious root surfaces (27.0 ± 7.2) were not statistically significantly different (p > 0.05). Furthermore, on root surfaces with visible calculus, all DIAGNOdent readings obtained from sound root surfaces were > 50, which might be misinterpreted as carious. After scaling, the DIAGNOdent readings obtained from sound root surfaces (8.1 ± 11.3), active carious root surfaces (37.9 ± 31.9) and inactive carious root surfaces (24.9 ± 11.5) presented significant differences (p < 0.05). A cut-off value between 10 and 15 yielded the highest combined sensitivity and specificity in detecting root caries on root surfaces without visible plaque/calculus before scaling, but the combined sensitivity and specificity are both around 70%.

CONCLUSION

These findings suggest that on exposed, unfilled root surfaces without visible plaque/calculus, DIAGNOdent can be used as an adjunct to the visual-tactile criteria in detecting root-surface status without pre-treatment by dental scaling.

A Population Health Management Approach to Oral Health

Clinical outcomes have been shown to be better, and total costs lower, when patients with chronic illness such as diabetes are managed using a population health strategy in a primary care setting that includes structured coordination of care with specialty services. This "population health management approach" offers a promising new vision for addressing oral disease as a chronic illness through a collaborative partnership between primary care teams and dental professionals.

Estimation of lesion progress in artificial root caries by swept source optical coherence tomography in comparison to transverse microradiography

This study aimed to investigate whether swept source optical coherence tomography (SS-OCT) could estimate the lesion depth and mineral loss quantitatively without the use of polarization sensitivity, and to examine a relationship between OCT data and transverse microradiography (TMR) lesion parameters. Twenty-four bovine root dentin specimens were allocated to three groups of 4-, 7-, and 14-day demineralization. Cross-sectional images of the specimens before and after the demineralization were captured by OCT at 1319 nm center wavelength. Following the demineralization, these specimens were cut into sections for TMR analysis. Correlations between the OCT data and TMR lesion parameters were examined. TMR images of the specimens showed cavitated lesions (lesion depth or LD(TMR): 200 to 500 μm, ΔZ or mineral loss: 10,000 to 30,000 vol % μm). The OCT images showed "boundaries," suggesting the lesion front. Integrated dB values before and after the demineralization and their difference (R(D), R(S), and ΔR, respectively) were calculated from the lesion surface to the corrected depth of boundary (LD(OCT)). A statistically significant correlation was found between LD(OCT) and LD(TMR) (p < 0.05, r = 0.68). Similarly, statistically significant correlations were found between ΔZ and R(D) or ΔR. The OCT showed a potential for quantitative estimation of lesion depth and mineral loss with cavitated dentin lesions in vitro.

Comparison of visual-tactile, radiographic, and histologic diagnoses of subgingival crown margin caries- an in vitro study

The purpose of this study was to investigate the accuracy of diagnosing interproximal subgingival caries at crown margins. A total of 32 subgingival interproximal crown margin areas were examined by 10 clinicians (n = 320) using conventional diagnostic methods on extracted, crowned teeth mounted in a specially designed cast. Crown margins were located 1.5 mm below the level of the artificial gingiva. Clinical and radiographic diagnoses were compared to the histopathologic findings for each site. Both visual-tactile and radiographic evaluations revealed a weak diagnostic accuracy for interproximal subgingival crown margin caries.

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.

Caries detection and quantification with DIAGNOdent: prospects for occlusal and root caries?

A possible consequence of light absorption as the interaction of electromagnetic radiation with molecules of the tooth's hard substances is, apart from the emission of heat, fluorescence. It was demonstrated that the emission spectra of enamel, dentin, and caries look alike upon excitation with red light; however, fluorescence increases with the process of carious destruction. Based on that, the DIAGNOdent System was developed, which simultaneously injects red light into the tooth surface and detects the resulting fluorescence. Due to this design, clinical application is currently limited to accessible occlusal and smooth surfaces. For occlusal caries detection, it was shown that validity and reproducibility could be optimized over classical diagnostic tests for deep dentin lesions with seemingly intact surfaces. The detection of root caries does not play a relevant role in the directly accessible areas, but estimation of the lesion's activity and progression rate is a prerequisite for differentiated lesion management Excellent reproducibility of the laser fluorescence measurements was confirmed for this scenario. Lesions with a soft surface texture show significantly higher fluorescence values than leathery or hard lesions, and values also increase with increasing cavity depth. DIAGNOdent offers the potential to improve follow-ups and estimation of the prognosis and to support clinical management of primary carious lesions.

Ten-year cross-sectional and incidence study of coronal and root caries and some related factors in elderly Swedish individuals

OBJECTIVE

The 10-year incidence of dental caries was related to some associated factors in a random sample of 65, 75 and 85-year-old inhabitants of Gothenburg.

SUBJECTS

Of the 208 persons examined at baseline, 102 (49%) participated in the follow-up examination; 56, 37 and nine, respectively, in the different age groups. For the purpose of time-trend comparisons, a new random sample of 98 individuals aged 55 years was examined.

RESULTS

Ninety-five per cent of the participants had developed one or more carious lesions during the 10-year period and the incidence of coronal and root caries increased with age. In the 65-year-olds, 9% of the root surfaces had decayed during the period, compared with 25% in the 85-year-olds. Secondary caries predominated over primary caries and prosthetic crowns accounted for 70% of the restored tooth surfaces. Twenty per cent of the individuals were daily smokers and 61% were taking drugs with hyposalivatory side-effects. The mean saliva secretion rates were lower in the older groups compared with the 'younger' ones. The overall salivary counts of mutans streptococci and lactobacilli had increased during the period and the values were highest in the oldest age groups. Salivary levels of lactobacilli and mutans streptococci, number of teeth, daily numbers of cigarettes and drugs and oral hygiene were the best predictors of the incidence of caries.

CONCLUSION

The findings indicate that there is an increased risk of dental caries with age owing to unfavourable caries-related factors.

Remineralisation study of artificial root caries lesions after fluoride treatment. An in vitro study using Electric Caries Monitor and Transversal Micro-Radiography

AIMS

To evaluate and compare remineralisation of root caries lesions after in vitro treatment with various fluoride (F) agents using an Electric Caries Monitor (ECM) and Transversal Micro-Radiography (TMR).

MATERIALS

Permanent human teeth were extracted and root surface specimens were sectioned, prepared (n = 35), and randomly allocated into seven different experimental groups (groups 1-7).

METHODS

Root surfaces were demineralised in an acidified gel (pH = 5.0) for 3 weeks followed by various F treatments and stored in a standardised remineralising solution at 37 degrees C for 6 weeks. The root surfaces were treated twice daily with different dentifrice slurries for 2 min, either with a neutral placebo dentifrice without F (group 5); or a neutral sodium fluoride (NaF) 1400 p.p.m. F dentifrice (group 1); or a neutral 1250 p.p.m. F dentifrice (group 6); or an acid dentifrice (pH 4.7) with 1400 p.p.m. F containing amine fluoride (AmF) (groups 3 and 4) or a 1250 p.p.m. (pH 4.7) AmF dentifrice (group 6). In groups 1, 2, 5, 6, and 7, the root surfaces were additionally rinsed for 2 min with a neutral non-F placebo solution. In groups 3 and 4, rinsing were performed for 2 min with an acid (pH 4.7) 250 p.p.m. F solution, containing 125 p.p.m. F as AmF and 125 p.p.m. F as potassium fluoride (KF), once or twice per day respectively. ECM was used to measure electrical resistance on root surfaces at baseline and after 3 and 6 weeks respectively. TMR technique was used to measure and compare root surface lesion depths and mineral loss.

RESULTS

Six weeks daily treatment with a dentifrice slurry containing AmF followed by rinsing with a combination of equal amounts of AmF and KF solution twice a day showed a statistical significant higher ECM values compared with the other groups. TMR data measuring lesion depths and mineral loss reduction supported the results of the ECM findings.

CONCLUSIONS

Daily application of a dentifrice slurry containing 1400 p.p.m. F as AmF combined with twice daily rinsing with a 250 p.p.m. F solution containing equal amount of AmF and KF significantly remineralise primary root caries lesions in vitro. ECM and TMR are valuable complementary methods in order to analyse the remineralisation processes.

Clinical criteria used to detect primary root caries with electrical and mechanical measurements in vitro

PURPOSE

To relate the Electrical Caries Monitor (ECM) and Resilience Caries Monitor (RCM) readings with clinical criteria used to define primary root carious lesions (PRCLs) in vitro.

METHODS

PRCLs were classified according to color, texture, hardness, cavitation, size and severity before ECM and RCM readings were recorded.

RESULTS

There was a poor but significant correlation between the ECM and RCM phase readings (P < 0.05). ECM readings for color, all five classes of severity and all three classes of hardness of lesions were significantly different from each other and from sound root tissue (P < 0.05). There was a significant correlation for ECM readings and cavitation (P < 0.05). There was a clear logarithmic relationship between ECM end values and size (P < 0.05). RCM amplitude measurements for hardness and all five classes of severity were significantly different from each other and from sound root tissue (P < 0.05). However, the RCM readings failed to correlate with color, cavitation or size (P > 0.05). In conclusion, the relationship between ECM and RCM data and some clinical detection criteria for PRCLs is promising and warrants further investigation in vitro and in vivo.

CLINICAL SIGNIFICANCE

The ECM is capable of distinguishing the severity of PRCLs since it is a less invasive but accurate method of detecting carious lesions when compared to tactile methods. The RCM was able to differentiate sound root dentine from soft lesions in vitro but this device is currently in a very early stage of development, and many mechanical and electronic problems must be solved prior to application of the device in clinical practice.

Detection of subgingival calculus and dentine caries by laser fluorescence

OBJECTIVES

Detection of subgingival calculus and dentine caries in the bottom of deep periodontal pockets is often difficult without visual observation. We thus examined the possibility of its detection using autofluorescence induced by laser irritation.

METHODS

Autofluorescence was measured at various excitation and emission wavelength settings in five specimens each of sound dentine and enamel, subgingival calculus, and root caries. Periodontopathic model teeth with bacterial cells and blood clots were also irritated by laser to obtain autofluorescent images.

RESULTS

Subgingival calculus and dentine caries showed a characteristic 700 nm emission when excited at 635 nm or a 720 nm emission when excited at 655 nm; sound dentine or enamel, however, did not. The calculus differentiation power, however, was higher with excitation at 635 nm than at 655 nm. The autofluorescent images photographed at an excitation of 633 nm provided clear calculus identification in periodontopathic model teeth when a 700 nm band-pass filter or a 700 nm high-pass filter was used. However, fluorescence intensity was masked when the calculus surface was covered by bacterial cells or blood clots. For clinical use, it would be important to remove subgingival plaque and debris from root surfaces before attempting to detect subgingival calculus and root caries with this manner.

CONCLUSION

The autofluorescence method employing excitation of 633-635 nm was found to be a powerful tool for detecting subgingival calculus and root caries.

Quantification of root caries using optical coherence tomography and microradiography: a correlational study

PURPOSE

The use of transverse microradiography (TMR) to quantify the amount of mineral lost during demineralization of tooth tissue has long been established. In the present study, the use of an en-face Optical Coherence Tomography (OCT) technology to detect and quantitatively monitor the mineral changes in root caries was investigated and correlated with TMR.

MATERIALS AND METHODS

We used an OCT system, developed initially for retina imaging, and which can collect A-scans, B-scans (longitudinal images) and C-scans (en-face images) to quantitatively assess the development of root caries. The power to the sample was 250 microW, wavelength lambda = 850 nm and the optical source linewidth was 16 microm.

RESULTS

Both the transversal and longitudinal images showed the caries lesion as volumes of reduced reflectivity. Quantitative analysis using the A-scan (reflectivity versus depth curve) showed that the tissue reflectivity decreased with increasing demineralization time. A linear correlation (r = 0.957) was observed between the mineral loss measured by TMR and the percentage reflectivity loss in demineralized tissue measured by OCT.

CONCLUSION

We concluded that OCT could be used to detect incipient root caries, and that the reflectivity loss in root tissue during demineralization, measured by OCT, could be related to the amount of mineral lost during the demineralization.

Explorer probing of root caries lesions: an in vitro study

Probing with a dental explorer is the preferred method of root caries diagnoses. However, studies suggest that use of a dental explorer in coronal caries detection may damage tooth structure. This pilot study investigated the effect of probing on remineralization of root surface lesions in vitro. Root-surface lesions were created on 10 extracted teeth by exposing them to a demineralizing solution for 21 days. One side of each lesion was then randomly selected and probed with an explorer, while the other side was not probed. The teeth then were placed in a remineralizing solution containing 10 parts per million (ppm) fluoride for 21 days. Of the 9 teeth with usable sections, all showed frank evidence of defects on the probed halves. Sites of remineralization were seen in the non-probed halves and adjacent to the probed defects, but not within or at the base of these defects. These results suggest that probing of root surfaces may create defects that do not fully remineralize.

Non-invasive management of superficial root caries lesions in disabled and infirm patients

In disabled and infirm patients with limited, if any, capacity for independent oral self-care, it is difficult to control progression of root caries lesions.

OBJECTIVE

To evaluate the effect of non-restorative cariostatic treatment on progression of active superficial root caries lesions (n = 56).

DESIGN

Pilot study.

SETTING

Department of Cariology, Institute of Odontology, Karolinska Institutet, Huddinge.

SUBJECTS

15 physically-dependent patients.

INTERVENTION

The patients were allotted to one of the following groups. Group 1, professional tooth cleaning and application of tap water flavoured with eucalyptus oil; Group 2, professional tooth cleaning and application of Cervitec, (1% chlorhexidine in thymol-containing varnish), Group 3, professional tooth cleaning and application of Cervitec and Fluor Protector (varnish containing 0.1% fluoride). Every three months for 18 months, each subject received the treatment twice within a 10-day interval.

MEASUREMENTS

The status of the 56 root caries lesions was evaluated every six months using a root caries index based on visual and tactile criteria. The examiners were blind to which treatment group the patients belonged.

RESULTS

In most subjects (14 out of 15), progression of root caries lesions was arrested. No statistically significant differences could be demonstrated between the three treatment groups. However, regardless of treatment regimen, there was a statistically significant difference between the greater number of subjects exhibiting no progression of root caries lesions and those with lesion progression, at 6 (p = 0.022), 12 (p = 0.006) and 18 months (p < 0.001).

CONCLUSION

This pilot study suggests that in disabled and infirm patients regular professional tooth cleaning with a fluoride containing paste, with or without supplementary varnishing with chlorhexidine-thymol and/or fluoride can prevent further progression of existing superficial root caries lesions.

New caries detection technologies and modern caries management: merging the strategies

Literature over the past decade has suggested that dental caries be treated as a curable and preventable infectious disease. The emphasis is placed on early detection and intervention, including chemical therapies and minimally invasive strategies. There are now new detection technologies commercially available to help detect carious lesions early; however, what seems to be lacking is a clear strategy on how to merge these new technologies in a way consistent with today's changing paradigm of caries management. There is a real danger that these early detection technologies may be used to unnecessarily and overaggressively "drill and fill" using Black's "extension for prevention" preparations. This paper will review the literature and key strategies for caries management and early detection and suggest one way (not necessarily the only way) in which they may be used in harmony. Two relatively new detection technologies (DIAGNOdent and DIFOTI) will be reviewed.

Endoscopic visualization of the submarginal gingiva dental sulcus and tooth root surfaces

BACKGROUND

Direct, real-time visualization of the hard and soft tissues within the gingival sulcus may aid the clinician in diagnosis and therapy of periodontal disease. This report describes an endoscope specifically designed for this purpose and the interpretation of dental endoscopic images.

METHODS

Medical endoscope technology was modified for application in the dental environment. A fixed, fused fiber optic bundle, less than 1 millimeter in diameter, was coupled to an active matrix LCD-TFT flat panel video monitor for viewing by the clinician. A bilumen sheath was designed to provide irrigation of the sulcus and a sterile barrier between the patient and the fiber bundle. Standard dental curets and ultrasonic scalers were adapted for instrumentation aided by the endoscope.

RESULTS

Endoscope technology has been successfully adapted for use in periodontal diagnosis and therapy. Techniques for identification and interpretation of the hard and soft tissue images, as well as the location of root deposits and caries, have been developed.

CONCLUSIONS

The dental endoscope gives the clinician direct, real-time visualization and magnification of the subgingival tooth root surface, aiding in the location of deposits on the tooth root. The subgingival soft tissue, including the gingival attachment, sulcus wall, and sulcus contents, can be assessed. Identification and location of subgingival caries, root fractures, tooth root deposits, post perforations, and open restoration margins may aid the clinician in diagnosis and therapy.

Clinical decision-making for caries management in root surfaces

This report presents the results of an evidence-based approach to obtaining the best available information on the natural history, prevalence, incidence, diagnosis, and treatment of root caries. Searches of electronic databases produced 807 references; from these and from citations in the selected articles, a final 161 references were used. We found that the information on the natural history of the disease does not provide practitioners with probabilities of, or time estimates for, progression of the disease through stages. For patients aged thirty and older, the prevalence of root caries is roughly 20 to 22 percent less than a person's age. Severity reaches over one lesion by age fifty, two lesions by age seventy, and just over three lesions for those seventy-five and older. About 8 percent (odds of 1:11) of the population would be expected to acquire one or more new root caries lesions in one year. The accuracy of current systems of diagnosis is unknown, although color has been shown to have little validity. Using the criteria of "softness" to define active lesions has been validated by the presence of microbes in the lesion. One strong study and other studies with weaker design or shorter duration add consistent support for the use of fluorides in the remineralization of root caries. Every three-month application of chlorhexidine varnish was shown to be efficacious in one arm of one study. Evidence for restoration of root caries is tentative since the studies were of limited design and duration.

The diagnosis of root caries

The most commonly used clinical signs of root caries are visual (color, contour, surface cavitation) and tactile (surface texture) descriptions of a lesion. The traditional methods of visual-tactile diagnosis for root caries can produce a correct diagnosis but usually not until the lesion is at an advanced stage. Despite the subjectivity inherent in interpreting the clinical signs of root caries diagnosis, good to excellent inter-examiner reliability has been reported in clinical studies; however, the presence of filled surfaces dramatically enhances the agreement. When only untreated root caries is diagnosed, examiner reliability is reduced considerably. Clinicians look to diagnostic tests in the hope that they will perform better (that is, be more reliable) than clinical diagnosis and, therefore, can be used to replace clinical diagnosis. From the limited data available on diagnostic tests for root caries, tests determining the presence or absence of mutans streptococci and Lactobacilli are the most clinically helpful, producing calibrated efficiency scores exceeding 40 percent. The risk assessment approach to root caries diagnosis involves the determination of a patient's risk through the interpretation of clinical signs and the selection and application of an appropriate diagnostic test if the clinician is unsure of the diagnosis.

How to measure the effects of fluoride treatments in clinical trials? Assessment: modern versus traditional methods

In recent years there has been a pronounced change in the epidemiology and disease pattern of dental caries. In the current context, traditional methods of caries assessment, discriminating lesions at cavitation, are clinically inappropriate, and obsolete for research requiring detection of a very early phase of mineral loss. Modern prospective caries studies require sensitive methods permitting the measurement of small changes in tooth mineral content, and objective, quantitative measurements of such changes are now possible in a single caries lesion. For longitudinal studies there are noninvasive methods for assessment of new lesions as well as quantitative changes (progression or regression) in existing lesions. Among as yet unresolved issues are improved methods to assess the current activity of a lesion, methods for detection and quantification of secondary caries and root caries, calibration of methodologies between different research institutes, and methods capable of assessment of the whole continuum in the development of a caries lesion, from initial loss of mineral to cavitation.

Take two dentists: a tale of root caries

Take two dentists, whose practices are about as different as they could possibly be, who both have a healthy respect for root caries. Our paper will start by describing these two practices and then review the literature to show what is known about the management of root caries. The paper ends by returning to the two dentists, who describe how the research reviewed in the literature may affect their work.

Root caries among Benghazi patients

A total of 420 Benghazi patients were clinically examined for root caries. Root caries was not limited to older patients and the proportion of root caries among young adults was similar to that of the older age groups. Most of the lesions were located proximally and underneath restorations rather than labially or lingually. Our results may serve as baseline data for further studies on root caries in the Libyan Arab Jamahiriya.

Issues in the treatment of root caries in older adults

Increased life expectancy, improvements in tooth retention, and higher expectations about oral health will continue to result in an increased demand for esthetic restorative dental care. Using demographics as a predictor of future dental treatment needs, root caries may be one of the most significant patient management issues of the next decade. Root caries also can present the clinician with challenging restorative problems. The best treatment option is determined by the lesion, the caries rate, the condition of the patient, and the esthetic requirement or desire. Material selection is critical for successful restoration of root caries. The treatment of root caries also should include methods for the prevention of future lesions. Although caries risk assessment is not a perfected science, models can assist in estimating caries risk and then guide the clinician toward the most suitable preventive approach.

A study of the classification and treatment of noncarious cervical lesions by general practitioners

PURPOSE

This study presented a survey to determine what general practitioners in Nova Scotia perceived to be the cause of noncarious cervical lesions, and to ascertain their most frequent method of treatment.

METHODS

The survey was completed by 63% of the 343 dentists polled.

RESULTS

Ninety-four percent classified the lesion as abrasion, and 66% rated toothbrushing as the most likely cause. Treatment methods were varied, with no clear preference.

CONCLUSION

The most frequently used restorative materials were GI/composites (29%) and composites (27%). The results of the survey suggest that treatment provided for noncarious cervical lesions may not be based on the correct diagnosis.

Visualization of root caries lesions by means of a diazonium dye

A diazonium dye was used to visualize caries lesions in root tissue. Root caries lesions were created in vitro according to a variety of protocols based on methylcellulose gel (6% w/v) and/or lactic acid buffer (0.05 M, pH 4.5). Teeth containing lesions were soaked overnight in an alkaline solution of 2% (w/v) 2-naphthol or resorcinol, rinsed with distilled water, and immersed in a diazonium solution (prepared by titration of aniline with sodium nitrite in 1 M HCl at 5 degrees C) for up to 10 min, prior to being thoroughly rinsed with distilled water. The area of the caries lesion on the anatomical surface was clearly marked with a red/orange color following 5 minutes' incubation in the diazonium solution. The diazonium complex formed with 2-naphthol was found to be more resistant to leaching during rinsing and sectioning than that formed with resorcinol. Microscopic examination of sections taken in the apicalcoronal plane showed that the depth of area of the lesion was also marked by the red/orange coloration. Chemical changes in root mineral monitored during lesion formation showed some degree of correlation between lesion area and mineral dissolution. Visualization of coronal caries by this technique is currently under investigation. The visualization technique provides a simple means of determining the extent and severity of root caries lesions and may be a useful first step in their classification.

Root caries in the older patient: significance, prevention, and treatment

Root caries is an emerging challenge to the dental professions because of the growing number of increasingly aging adults who have retained many or all of their teeth. Risk factors for developing root caries point to both intraoral and environmental factors, making the management of root caries complex and multidisciplinary. Prevention based on a composite of risk factors is the most desirable approach for management. Patients who have developed caries of the roots can be treated with remineralization strategies, recontouring techniques, intracoronal restorations of a variety of established and recently introduced materials, or extracoronal restoration. Dental professionals need to keep abreast of new approaches that are emerging for the management of root caries.

Diagnostic tools and measurements--impact on appropriate care

The diagnosis of primary coronal caries should be seen as a complex process, comprising both detection and measurement phases, which enables clinicians, researchers and epidemiologists to make informed decisions about the management and prognosis of the disease process. The different diagnostic thresholds employed for measurements of caries experience can be viewed as an iceberg, a metaphor which demonstrates the ambiguity of the term "caries free" and which can also represent the differing management options appropriate for the care of different types of active and inactive lesions: NAC (No Active Care). PCA (Preventive Care Advised) and OCA (Operative Care Advised). There are considerable methodological difficulties in drawing valid comparisons between studies using incompatible criteria and simulations. However, it is apparent that no caries diagnostic tool in current clinical use fulfils all of the ideal criteria for measurements needed to plan and monitor appropriate care. Systems providing reliable serial measurements with which to assess future caries risk and present caries activity are urgently required as diagnostic tasks are becoming both more difficult and more important from the standpoint of long-term oral health. Existing diagnostic tools frequently rely on subjective judgements and provide only semi-quantitative measures insensitive to smaller lesions. In the future tools are needed which are objective, quantitative and which can provide acceptable compromises between sensitivity and specificity for a wide range of applications for individual patient care as well as for research and survey use. Key problem areas with existing tools include confusion in terminology and between caries assessments made by clinicians and epidemiologists as well as the lack of valid measurements relating to the activity of primary root caries and secondary caries. Deficiencies with current tools impact on the care of individuals by allowing false negative diagnoses of hidden occlusal dentine lesions and approximal cavities on the one hand, whilst generating some false positive diagnoses on sound surfaces leading to inappropriate decisions to restore on the other. At the population level, current conventional tools significantly underestimate overall caries experience. In future the adoption of more accurate and reliable methods would facilitate more effective preventive care and promote more appropriate restorative treatment decisions. Research in this area should focus for the next five years on diagnostic technologies which: 1) inform valid prospective caries risk assessments for different age groups, 2) can help to determine present caries activity and monitor lesion behaviour over time and 3) help identify methods which can implement existing and new research knowledge about diagnostic tools into clinical and research practice.

A fiber-optic setup for quantification of root surface demineralization

A fiber-optic fluorescence observation (FOFO) technique has been developed for the quantification of demineralized root dentin. The method was tested on 40 specimens of in vitro demineralized parts of human root dentin. Fluorescein sodium salt was used as a penetrating dye. The fluorescein sodium salt was excited using light around 465 nm. The fluorescence signal around 527 nm measured for demineralized dentin was corrected for lamp output and then divided by the corrected fluorescence signal for the sound control dentin on the same root, resulting in a FOFO-value. FOFO-values correlate linearly (r = 0.91) with mineral loss measured by transverse microradiography. Therefore, it was concluded that the FOFO-technique provides a good, non-destructive measure of the severeness of in vitro demineralized human root dentin, and is applicable on bulk dentin. Future work on natural lesions in vivo will be needed to investigate the applicability of the technique in a clinical situation.

The RCI revisited after 15 years: used, reinvented, modified, debated, and natural logged

OBJECTIVES

The purpose of this article is to review the status of the Root Caries Index (RCI) 15 years after it was first introduced in the dental literature as a method for the reporting of supragingival root lesions. This review focuses on the extent to which the RCI has been used by epidemiologic researchers, as well as on the issues concerning the RCI as a useful index that have been raised and debated in the literature by those epidemiologic researchers.

METHODS

The debated points are categorized into six issues, including whether: (1) the RCI underestimates the prevalence of root caries by omitting subgingival root caries lesions; (2) the RCI overestimates the prevalence of root caries by using too rigid a definition of when recession can be visualized; (3) the RCI makes the assumption that there is a linear relationship between root caries lesions and the occurrence of at-risk surfaces, i.e., surfaces with recession; (4) the RCI, by ignoring missing teeth, distorts the descriptive epidemiologic picture of root caries; (5) recession is a predictor of root caries versus merely being an antecedent state; and (6) the imprecision of diagnosing gingival recession renders the RCI useless.

RESULTS

Given both the evidence from recent studies and the professional interest in subgingival root caries, as addressed in the first debated point, it seems reasonable to modify the RCI to include a separate reporting of subgingival root caries. Of the remaining debated points over the past 15 years, three of these (points #2, #4, and #5 above) seemingly serve to clarify specific aspects of the RCI that were intended as inherent elements of the RCI as originally presented. The question as to whether there is an assumption of a linear relationship between root caries lesions and the occurrence of at-risk surfaces (point #3) is answered in the negative. The final debated point (#6), while addressing a fundamental periodontal tissue measurement issue--namely the reliability of identifying gingival recession--and while theoretically interesting, should not undermine the current use, or utility, of the RCI, but rather suggests the need for improved periodontal diagnostic techniques for the condition of recession.

CONCLUSIONS

After 15 years, the RCI appears to be one of the two most common methods of reporting root caries in the epidemiologic literature (along with DFS counts). In fact, the best overall descriptive picture of root caries is achieved when those two reporting methods are presented in the same study accompanied by descriptive presentations of missing teeth and at-risk surfaces. Of all the debated points in the literature, the suggested modification of including subgingival lesions in the RCI leads now to the recommendation to collect subgingival data, but to do so in a manner that allows for separate presentation of supra- and subgingival root caries findings.

Evaluation of sodium fluorescein for quantitative diagnosis of root caries

The diagnosis of root caries, in particular the judgment of the activity of a visually observed lesion, is difficult. Quantitative determination of lesion severity would allow the lesion to be monitored with time, so that an indication of lesion activity could be obtained. This paper describes a step in the development of a method that provides such a quantitative determination. Specifically, fluorescein sodium salt is used as a penetrating dye, the subject of study being the relationship between dye concentration and porosity in demineralized root dentin. Fourteen human third molars were demineralized in vitro (lactic acid CMC-gel, pH 5; in each of 6 groups for 4, 7, 11, 14, 18, and 21 days). Fluorescein sodium salt (0.2 g/L) was applied for 2 min. Thin slices (+/- 130 microns) were cut from the root surfaces without water cooling. The dye fluorescence radiance in the demineralized dentin was determined by means of a micro-Raman spectroscope and compared with the mineral loss profiles measured with transverse microradiography (TMR). The TMR data were corrected for the difference in measurement area between the two measurement systems. Corrected TMR profiles were compared with the corresponding fluorescence scans, showing linear correspondence. The correlation coefficient was r = 0.96. We conclude that, after uptake of fluorescein sodium salt for 2 min, the dye concentration in an artificially produced root-surface caries lesion is proportional to the amount of mineral lost from that lesion.

Reproducibility of clinical caries diagnoses on coronal and root surfaces

Intra- and interexaminer reproducibility of clinical caries diagnoses was studied using 3 experienced dentists, who independently examined 20 patients twice at an interval of 2-6 weeks. The lesions were classified as one of the following four diagnoses: (1) initial active caries, (2) initial inactive caries, (3) manifest active caries, and (4) manifest inactive caries. For the various diagnoses, signs of cavitation, surface structure and discolouration were used. The reproducibility at a patient level was evaluated using intraclass correlation coefficients and at a surface level using kappa statistics. At a patient level, for the total number of lesions, the intraclass coefficients of correlation varied from 0.55 to 0.77. For the individual diagnoses, total manifest caries showed the highest coefficients of correlation, ranging from 0.73 to 0.92. At a tooth surface level, the kappa values varied from 0.29 to 0.61. The most common shift was that from any type of caries diagnosis to a diagnosis of a sound surface. There was little difference between the results for coronal and root caries and between initial and manifest lesions. Nor was there any difference for buccal + lingual surfaces only compared to all surfaces. Judging from the pattern of change in diagnosis between the repeated examinations, the main source of error seemed to be due to the fact that the lesions observed at one examination were overlooked at the other examination.

A method for adjusting caries increments for reversals due to examiner misclassification

Two types of reversals occur in longitudinal caries studies, remineralization (true reversals) and reversals due to examiner misclassification (D3 to S; F to S). Since 1966, the standard practice has been to subtract examiner reversals from the crude increment (CCI), resulting in a net caries increment (NCI). The use of the NCI has been based on the assumption that examiners make an equal number of false positive and false negative errors both at baseline and follow-up examination. Consequently, the difference between the two caries prevalence scores would provide an unbiased estimate of caries incidence between examinations. The NCI considers all reversals to be true reversals which is an extreme strategy, particulary when the level of diagnosis is set at lower thresholds. In this study we compromised between the NCI and CCI by creating a simple formula to calculate the caries increment using a prevalence-based adjustment for reversals. The formula is ADJCI = y2(1-(y3/(y3 + y4))), where y2 = S to D or F; y3 = D or F to S; y4 = D to D/F or F to F. The impact of this adjustment is illustrated using data from a random sample of 452 older black and white adults followed over a 3-yr period. The ADJCI was more likely to result in higher caries increments and more observed intergroup differences than the NCI, a finding that has implications for clinical trials. For example, the crude 3-yr coronal DS increment for whites was 0.62, the NCI was 0.26 and the ADJCI was 0.56. There were significant black-white differences for the CCI and ADJCI, but not the NCI. We conclude that the NCI was too severe of an adjustment for reversals for this study population.

Root caries: prevention and chemotherapy

PURPOSE

Root caries is a problem of importance among dentate elderly. Greater life expectancies at both birth and age 65, combined with improvements in tooth retention across all age groups, have resulted in an increasing number of Americans who have retained their teeth into old age. This increase in numbers of teeth combined with the increase in the percent of teeth with recession has in turn resulted in older persons with more root surfaces at risk for caries than ever before. The purpose of this article is to review the literature on the prevention and chemotherapeutic approach to root caries.

METHODS

A review of the literature and synthesis of this information resulted in recommendations for the improved root caries risk assessment and the development of clinical examination protocols and strategies for prevention and treatment.

RESULTS

Clinicians can better identify persons at risk for root caries in their practice. People who are older, have moderate to severe periodontal bone loss and gingival recession, are impaired, have poor oral hygiene, take multiple medications, have partials, have retained root tips and the recently unemployed or retired are all at increased risk for root caries. Examination strategies should include the use of at least annual bite-wing radiographs (vertical bite-wings in persons with significant attachment loss) and careful examination of the proximal tooth surfaces. Once identified as low, moderate or high risk, daily and professionally applied fluoride therapies should be combined with dietary modifications, and in high risk individuals, antimicrobial agents for both the remineralization of early lesions and prevention of further root caries.

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

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

Root resorption associated with hydroxyapatite particles: a case report

A case report of an unusual root resorption reaction associated with a graft of hydroxyapatite particles is presented. The hydroxyapatite particles were grafted to treat vertical infrabony defects at the distal aspect of the maxillary left canine and on the mesial side of the mandibular right first molar. The graft sites were monitored at maintenance visits. Root resorption was observed radiographically 9 to 10 months after grafting. The lesions were restored with a light-cured glass-ionomer cement and/or a resin composite. Possible etiologic factors associated with this condition are discussed.

Multifactorial modeling for root caries prediction: 3-year follow-up results

The study was part of a series aiming at the development of caries tests. The initial material (n = 104, age range 47-79 yr, mean 62 yr) was reduced to 96, who were observed for 3 yr. During the follow-up four subjects died, all due to myocardial infarction, and four refused to participate. Thorough oral examinations were conducted at the baseline, 1- and 3-yr registrations; coronal and root surface caries were registered separately according to WHO classification. The tests included salivary mutans streptococci, lactobacilli, candida/yeasts, secretion rate, buffer effect and sucrase activity, and quantitation of visible plaque. The association between prospective root caries increment and several tests was significant. Multifactorial modeling resulted in the combination of Past Root Caries Experience (OR 12.8), Lactobacilli (OR 8.6) and Candida (OR 2.8). At screening, the criterion "two or three positive tests" of these yielded acceptable accuracy (77.1) and a relative risk of 3.3.

A comparison of primary root caries lesions classified according to colour

Three hundred and ninety-five primary root caries lesions in 117 patients were included in this study. Each lesion was clinically characterised (colour, dimensions, distance from gingival margin and texture) and a sample of infected or altered dentine was taken using a standardised sampling procedure. The relationships between the colour and the microflora, texture, physical dimensions and distance from the gingival margin of the lesions were investigated. Lesions in each colour group (light brown, yellow, dark brown and black) were identified in each texture category (soft, leathery and hard), except for black lesions which were recorded as only soft or leathery. Black soft and black leathery lesions had a significantly greater area and harboured more lactobacilli than all other types of lesions while black leathery lesions also harboured significantly more yeasts. There were no significant differences in the number of bacteria or mutans streptococci isolated from soft or leathery lesions irrespective of lesion colour. Overall, these data indicate that the colour of primary root caries lesions is not a reliable indicator of primary root caries activity. Assessment of the clinical severity of primary root caries lesions requires consideration of lesion texture and the distance of the lesion from the gingival margin rather than the colour of the lesion.

Relationships between yeasts and primary root-caries lesions

A total of 447 primary root-caries lesions from 169 dental patients was studied to determine the relationships between their clinical severity and the number and frequency of isolation of yeasts. Yeasts were isolated more frequently from soft lesions, from lesions at the gingival margin and from lesions deemed to require restoration. These associations may be due to the aciduricity and acido- genicity of yeasts but the relatively low numbers found do not support a pathogenic role for yeasts in the aetiology of root caries: at best they may be marker organisms of the most severe disease.

Future directions for root caries research

Interest among researchers in the diagnosis, aetiology, prevention, and treatment of root caries has increased substantially over the past two decades. However, there are some fundamental problems impeding the advancement of the field which remain to be addressed and resolved. A universally acceptable definition of root caries is not yet available. The relationship of root caries to coronal caries has not been established. The underlying disease process is still not clearly understood. The optimal utilisation of preventive/therapeutic agents for the treatment or prevention of root caries has not been determined. New treatment materials and preventive agents have not yet been tested in controlled clinical trials. These are a few of the issues and problems which we address in this paper.

Epidemiology of root caries

Many epidemiological studies have been conducted on a variety of populations. Unfortunately, comparison of the prevalence data, and to a lesser degree of the incidence data, between the various studies is of little use due to the lack of standardised diagnostic criteria, reporting methods and population diversity. In the few incidence studies which have been conducted around 30-40% of people developed root caries, although many adults in the population appear to have been affected by root caries. Many risk factors associated with the occurrence of root caries have been identified and these include oral, medical, mental, behavioural and psychosocial conditions.

Relationships between mutans streptococci and perceived treatment need of primary root-caries lesions

A total of 447 primary root-caries lesions from 169 dental patients was studied to determine the relationships between mutans streptococci and the perceived treatment need of primary root-caries lesions. Samples of this altered dentine for microbiological culture were obtained. Lesions were classified into 5 treatment categories: soft and restore, leathery and restore, leathery and debride of caries, leathery and treat chemotherapeutically, and hard, to receive no treatment. The total numbers of mutans streptococci decreased significantly with decreased treatment need. The percentage of mutans streptococci from lesions requiring no treatment was significantly less than from lesions requiring treatment. The frequency of isolation of mutans streptococci was significantly greater from lesions requiring more treatment. Significantly more lesions containing > 10(2) mutans streptococci were distributed in the groups with a greater perceived treatment need or with larger dimensions occluso-gingivally and/or mesio-distally or bucco-lingually or with a closer proximity to the gingival margin.

Root caries: some clinical aspects

This paper has discussed some aspects of root surface caries which are of special relevance to the clinician. Epidemiological studies have suggested that root caries is not inevitable after gingival recession, but a small number of patients show a propensity for development of new lesions. Several risk factors have been identified. Thorough prophylaxis is essential for accurate diagnosis of root caries lesions, and radiographs can identify lesions which would otherwise be difficult to detect. The activity of any particular lesion can only be evaluated by observation at successive examinations. Fluoridated water may have a role in the prevention of root caries, but the evidence is not conclusive. Other forms of topical fluoride have been demonstrated to be effective. Cleansable and accessible lesions can be arrested with good oral hygiene and topical fluoride therapy. Teeth which require restoration may be restored with GIC, but limitations of the material make this unsuitable for all but readily accessible lesions, or where margins are supragingival. Clinicians should not rely on the fluoride released from GIC in situations where another material may provide a better restoration; in many situations, amalgam may be the material of choice. The longevity of bonded amalgam restorations has not been established, and conventional methods of amalgam retention remain a requirement of every restoration.

Diagnosis and prediction of root caries

Diagnosis is the process of recognizing diseases by their characteristic clinical signs and symptoms. Diagnostic ability varies considerably between and among examiners, and, consequently, the accuracy of the diagnosis can be questioned. Root caries is a disease for which there are several clinical signs (location, color, surface texture, and surface cavitation). Unfortunately, these signs are open to broad clinical interpretation. As a result, estimates of disease occurrence (incidence rate) have ranged from 0.87 to 8.20/100 surfaces at risk/year or 0.15 to 0.43 lesions/person/year for adults living independently in the community. When multiple examiners are utilized, interexaminer agreement has been reported to be relatively good but could be further improved by minimizing the effects of several sources of examiner disagreement, including the absence of a global consensus on the signs which indicate the presence of root caries. The use of a diagnostic test can enhance the diagnosis and prediction of root caries, but the development of useful tests is hindered by the lack of an accurate clinical standard of diagnosis. At this time, diagnostic tests for root caries are quite limited and of questionable value. A powerful predictive tool for root caries would result from the combination of risk assessment measures and a valid diagnostic test developed with use of standardized and accurate methods of clinical diagnosis.