The natural history of dental caries lesions: a 4-year observational study

Assessing the validity of existing dental sealant quality measures

BACKGROUND

Although sealants are highly effective in preventing caries in children, placement rates continue to be low. The authors' goals were to implement and assess the performance of 2 existing sealant quality measures against a manual audit of charts at 4 dental institutions and to identify measurement gaps that may be filled by using data from electronic health records.

METHODS

The authors evaluated the performance of 2 quality measures designed for claims-based data: the Dental Quality Alliance (DQA) sealant measure, which includes patients at risk of developing elevated caries, and the Oregon Health Authority (OHA) sealant measure (irrespective of caries risk). The authors adapted and validated these measures at 4 sites: 3 dental schools and 1 large dental accountable care organization.

RESULTS

The overall modified DQA and modified OHA measure scores in the 6- through 9-year-old age group were 37.0% and 31.6% and in the 10- through 14-year-old age group were 15.8% and 6.6%, respectively. Results from the manual review of charts showed that 67.6% of children who did not receive sealants did not have any teeth to seal because their molars had not yet erupted, had been extracted, had been sealed previously, or had existing caries or restorations.

CONCLUSIONS

Both the DQA and OHA measures, which rely mainly on Current Dental Terminology procedure codes, led to underestimation of the care delivered from a practice perspective. Future sealant quality measures should exclude patients whose teeth cannot be sealed.

PRACTICAL IMPLICATIONS

This study's results support the suitability of using electronic health record data for assessing the quality of oral health care, particularly for measuring sealant placement in children.

Long-term follow-up of inactive occlusal caries lesions: 4-5-year results

OBJECTIVE

To assess the clinical behavior of inactive caries lesion on the occlusal sites of permanent molars over 4-5 years and to estimate the risk for progression of caries-inactive sites compared with sound ones.

METHODS

Clinical examinations were conducted at baseline (n = 258) and after 4-5 years and included the recording of dental plaque and dental caries at the occlusal surfaces and the eruption stage of each permanent molar.

RESULTS

One hudred ninety-three schoolchildren were followed (response rate of 74.8%), totalizing 1152 teeth. Of the children, 30.6% (n = 59) presented at least one molar containing an active lesion, filling, or that had been extracted; according to the activity criterion, inactive lesions presented around a twofold increased risk for caries progression than sound surfaces (OR = 2.34 95%CI = 1.51-3.62). Thirteen percent (n = 25) of the children presented at least one molar progressing to dentine cavity, filling, or extraction; according to the severity criterion, inactive caries lesions presented a significantly higher risk for progression when compared with sound surfaces (OR = 2.69, 95% CI = 1.50-4.83).

CONCLUSION

The vast majority of lesions (85-90%) identified as inactive enamel caries at baseline did not progress over 4-5 years. Despite this fact, it was possible to detect an increased risk for caries progression in caries-inactive occlusal sites compared with the sound ones.

CLINICAL RELEVANCE

Considering the low progression rates, inactive caries lesions do not need a specific caries-controlling treatment and should be monitored longitudinally in the same manner as sound surfaces.

The International Caries Detection and Assessment System – ICDAS: A Systematic Review

The aims of this study were: (1) to evaluate the overall reproducibility and accuracy of the International Caries Detection and Assessment System (ICDAS) for assessing coronal caries lesions, and (2) to investigate the use of systems associated with the ICDAS for activity assessment of coronal caries lesions. Specific search strategies were adopted to identify studies published up to 2016. For the first objective, we selected studies that assessed primary coronal caries lesions using the ICDAS as a reference standard. A total of 54 studies were included. Meta-analyses summarized the results concerning reproducibility and accuracy (correlation with histology, summary ROC curves [SROC], and diagnostic odds ratio [DOR]). The latter 2 were expressed at D1/D3 levels. The heterogeneity of the studies was also assessed. Reproducibility values (pooled) were > 0.65. The ICDAS mostly presented a good overall performance as most areas under SROC were > 0.75 at D1 and > 0.90 at D3; DOR ≥6. For the second objective, we selected studies investigating activity assessment associated with the ICDAS. The meta-analyses pooled results based on the same methodology and parameters as above. Longitudinal findings regarding caries progression were described to estimate the validity of these systems. On average, the systems for activity assessment of caries lesions showed moderate values concerning reproducibility and overall performance. Active caries lesions were more prone to progress than inactive ones after 2 years. In conclusion, the ICDAS presented a substantial level of reproducibility and accuracy for assessing primary coronal caries lesions. Additional systems associated with the ICDAS that classify caries lesion activity can be useful as they are moderately reproducible and accurate.

Nyvad Criteria for Caries Lesion Activity and Severity Assessment: A Validated Approach for Clinical Management and Research

The Nyvad classification is a visual-tactile caries classification system devised to enable the detection of the activity and severity of caries lesions with special focus on low-caries populations. The criteria behind the classification reflect the entire continuum of caries, ranging from clinically sound surfaces through noncavitated and microcavitated caries lesions in enamel, to frank cavitation into the dentin. Lesion activity at each severity stage is discriminated by differences in surface topography and lesion texture. The reliability of the Nyvad criteria is high to excellent when used by trained examiners in the primary and permanent dentitions. The Nyvad criteria have construct validity for lesion activity assessments because of their ability to reflect the well-known caries-controlling effect of fluoride. Predictive validity was demonstrated by showing that active noncavitated lesions are at higher risk of progressing to a cavity or filled state than do inactive noncavitated lesions. Lesion activity assessment performed successfully as a screening tool to identify individuals with a poor caries prognosis. Because of their predictive validity, the Nyvad criteria are superior to other current caries lesion descriptors for the detection of changes in the lesion activity status over time. The Nyvad criteria fulfill all the formal requirements for a robust caries lesion classification and are recommended for evidence-based caries management in clinical practice and in research.

Correlation between ICDAS and histology: Differences between stereomicroscopy and microradiography with contrast solution as histological techniques

Detection of occlusal caries with visual examination using ICDAS correlates strongly with histology under stereomicroscopy (SM), but dentin aspects under SM are ambiguous regarding mineral content. Thus, our aim was to test two null hypotheses: SM and microradiography result in similar correlations between ICDAS and histology; SM and microradiography result in similar positive (PPV) and negative predictive values (NPV) of ICDAS cut-off 1–2 (scores 0–2 as sound) with histological threshold D3 (demineralization in the inner third of dentin). Occlusal surfaces of extracted permanent teeth (n = 115) were scored using ICDAS. Undemineralized ground sections were histologically scored using both SM without contrast solution and microradiography after immersion in Thoulet’s solution 1.47 for 24 h (MRC). Correlation between ICDAS and histology differed from SM (0.782) to MRC (0.511) (p = 0.0002), with a large effect size “q” of 0.49 (95% CI: 0.638/0.338). For ICDAS cut-off 1–2 and D3, PPV from MRC (0.56) was higher than that from SM (0.28) (p< 0.00001; effect size h = 0.81), and NPV from MRC (0.72) was lower than that from SM (1,00) (p < 0.00001; effect size h = 1.58). In conclusion, SM overestimated the correlation between ICDAS and lesion depth, and underestimated the number of occlusal surfaces with ICDAS cut-off 1–2 and deep dentin demineralization.

First Detection and Characterization of Streptococcus dentapri from Caries Active Subject

INTRODUCTION

Mutans streptococci (MS) are a group of oral bacteria generally regarded as the principal agents in the pathogenesis of dental caries.

AIM

The study aimed was characterize S. dentapri based on phylogenetic analysis and phenotypic methods from Caries Active Subject.

MATERIALS AND METHODS

While sequencing MS species which were isolated from 65 caries active subjects, one strain of S. dentapri was detected. Dental plaque samples were processed and cultured on mitis salivarius bacitracin agar. S. dentapri was characterized using phylogenetic analysis, colony morphology characterization and biotyping.

RESULTS

Among the study population, one strain designated as H14 was identified as S. dentapri by 16S rDNA sequencing. Morphologically, S. dentapri could not differentiate from other species of MS. S. dentapri H14 demonstrated biotype II biochemical characteristics of MS. The phylogenetic analysis showed S. dentapri is closely related to S. macacae.

CONCLUSION

The study concludes that S. dentapri can inhabit the human oral cavity and therefore further investigations are warranted to determine its role in caries.

A Contemporary Examination of First and Second Permanent Molar Emergence

The emergence of first permanent molars (FPMs) and second permanent molars (SPMs) is an important developmental milestone influencing caries risk and the timing of sealant placement. Emergence times have been shown to vary by sex and race/ethnicity, while recent reports suggest a positive association with adiposity. Amid the changing demographics of the US population and the rising rates of pediatric overweight/obesity, we sought to examine the association of body mass index (BMI) with FPM/SPM emergence in a representative sample of US children and adolescents. We used cross-sectional data from 3 consecutive cycles of the National Health and Nutrition Examination Survey (2009 to 2014). The FPM analysis included ages 4 to 8 y ( n = 3,102 representing ~20 million children), and the SPM analysis included ages 9 to 13 y ( n = 2,774 representing ~19 million children/adolescents). The Centers for Disease Control and Prevention's growth chart data were used to calculate age- and sex-specific BMI percentiles, as measures of adiposity. Initial data analyses relied on descriptive statistics and stratified analyses. We used multivariate methods, including survey linear and ordinal logistic regression and marginal effects estimation to quantify the association between pediatric overweight/obesity and FPM/SPM emergence, adjusting for age, sex, and race/ethnicity. Forty-eight percent of 6-y-olds and 98% of 8-y-olds had all FPMs emerged, whereas SPM emergence varied more. Blacks (vs. whites) and females (vs. males) experienced earlier emergence of FPMs and SPMs. Overweight/obesity was associated with earlier FPM emergence, particularly among black females. Obesity but not overweight was associated with earlier SPM emergence. Overall, overweight/obesity accounted for 6 to 12 mo of dental acceleration. This study's results emanate from the most recent US-representative data and affirm that FPM/SPM emergence varies by race/ethnicity and sex and is positively influenced by BMI. Future research should further elucidate these associations with detailed eruption data and examine the implications of this variation for clinical care.

Caries Incidence in a Healthy Young Adult Population in Relation to Diet

In the past, epidemiological studies focused on cavitated stages of caries. The arrival of the International Caries Detection and Assessment System (ICDAS) in 2004 allowed for clinical measurements of the initial stages of enamel caries. However, since the introduction, most studies applying the ICDAS still have studied the diseased population. The objective of this cross-sectional observational study was to describe early enamel caries in a large healthy young adult population and determine the relationship with diet and oral hygiene measures. The study population consisted of 268 healthy participants without frank cavitation. The examinations were done visually and radiographically using ICDAS on all tooth surfaces. In total, 8.6% of the surfaces (occlusal > approximal > smooth) had caries, of which 92.0% were confined to enamel (28.5% ICDAS score 1, 54.0% score 2, 8.6% score 3). Thirteen percent of the occlusal and 63% of the approximal caries were found with radiography. Thus, radiography is quintessential for the diagnosis of approximal enamel lesions. We found a positive correlation between enamel caries (ICDAS 1 to 3) and the consumption of mono- and disaccharides and carbohydrates ( r = 0.226 and r = 0.188, respectively, both P < 0.01), as well as a negative correlation with alcohol consumption ( r = -0.202, P < 0.01). There was also a positive correlation between enamel caries and the energy intake from mono- and disaccharides (sugar kJ, r = 0.206, P < 0.01), which was independent of body mass index. Only 11 participants consumed less than 10% of total energy as sugar kJ, which is the recommended percentage of kJ from free sugar by the World Health Organization. No clear correlation was found with oral hygiene. In conclusion, in this healthy young adult population, caries was found in 97.8% of the subjects, mostly initial enamel caries (ICDAS 1 to 2) in the occlusal surface of molars, and was related with dietary factors.

Relationship between body mass index and dental caries in children, and the influence of socio-economic status

OBJECTIVES

To determine the association of body mass index (BMI) with dental caries in Indian schoolchildren, and to analyse the influence of socio-economic status (SES).

METHODS

The study population consisted of 11- to 14-year-old children from Medak District in Telangana State, India. The Indian Academy of Paediatrics 2015 growth charts were used to categorise children as underweight, overweight, normal or obese, based on their BMI. Data on the SES of the family were collected through questionnaires. Clinical examination for dental caries was performed by a single examiner.

RESULTS

A total of 1,092 subjects returned questionnaires and were clinically examined (giving a response rate of 85%). There were no significant differences in caries prevalence and experience across the categories of BMI. However, caries prevalence and experience in overweight children were 24.8% and 0.69 ± 1.51, respectively, while the corresponding values in normal-weight children were 35% and 0.85 ± 1.50, respectively. Among children of high-SES families, overweight children had approximately 71% fewer caries than did those who were normal weight [incidence rate ratio (IRR) = 0.29; 95% CI: 0.11-0.78)].

CONCLUSIONS

BMI was not associated with dental caries prevalence and experience in this population. The association of BMI with dental caries varied across SES categories. In the high-SES category, overweight children experienced fewer caries than did normal-weight children.

Occlusal Caries: Biological Approach for Its Diagnosis and Management

The management of occlusal caries still remains a major challenge for researchers as well as for general practitioners. The present paper reviews and discusses the most up-to-date knowledge and evidence of the biological principles guiding diagnosis, risk assessment, and management of the caries process on occlusal surfaces. In addition, it considers the whole spectrum of the caries process on occlusal surfaces, ranging from the molecular ecology of occlusal biofilms to the management of deep occlusal caries lesions. Studies using molecular methods with focus on biofilms in relation to occlusal caries should explore the relationship between the function and the structural composition of these biofilms to understand the role of occlusal biofilms in caries development. State-of-the-art measures to evaluate risk for occlusal caries lesion activity, caries incidence, and progression should include the assessment of the occlusal biofilm and the stage of tooth eruption. Careful clinical examination of non-cavitated lesions, including assessment of the lesion activity status, remains the major tool to determine the immediate treatment need and to follow on the non-operative treatment outcome. Even medium occlusal caries lesions in the permanent dentition may be treated by non-invasive fissure sealing. By extending the criteria for non-invasive treatments, traditional restoration of occlusal surfaces can be postponed or even avoided, and the dental health in children and adolescents can be improved. Selective removal (incomplete) to soft dentin in deep carious lesions has greater success rates than stepwise excavation. Selective (complete) removal to firm dentin has a lower success rate due to increased pulp exposure.

Comparison of two visual methods for detecting caries among obese and non-obese children

OBJECTIVE

The study aimed to compare two visual methods for detecting caries among obese and non-obese children in Salvador, Brazil.

MATERIALS AND METHODS

A cross-sectional study was conducted from 2011-2012, which evaluated 180 paediatric patients, 6-14 years old, girls and boys, categorized into two groups: obese and non-obese (healthy weight), according to the body mass index. For the evaluation of dental caries, the decayed, missing or filled teeth index (DMFT/dmft) and International Caries Detection and Assessment System II (ICDAS II) visual criteria were used.

RESULTS

The mean DMFT value was 0.98 in obese children and 0.57 in the non-obese children, without significant differences between groups (p = 0.206). The mean dmft value in the non-obese children (1.66) was higher than in obese children (0.95), with significant differences between groups (p = 0.021). According to ICDAS II criteria, there was a higher prevalence of non-cavitated enamel lesions (D1-3) in obese children (n = 156, 10.5%) compared to the non-obese children (n = 55, 1.9%), with significant differences between the groups (p < 0.001).

CONCLUSIONS

The inclusion of non-cavitated lesions during the caries evaluation represents a challenge in diagnosis, which allows for control of this process before the evolution of these lesions to cavitation.

Orange/Red Fluorescence of Active Caries by Retrospective Quantitative Light-Induced Fluorescence Image Analysis

This retrospective clinical study determined the association of caries activity and orange/red fluorescence on quantitative light-induced fluorescence (QLF) images of surfaces that progressed to cavitation, as determined by clinical visual examination. A random sample of QLF images from 565 children (5-13 years) previously enrolled in a longitudinal study was selected. Buccal, lingual and occlusal surface images obtained after professional brushing at baseline and every 4 months over a 4-year period were analyzed for red fluorescence. Surfaces that progressed (n = 224) to cavitation according to the International Caries Detection and Assessment System (ICDAS 0/1/2/3/4 to 5/6 or filling), and surfaces that did not progress (n = 486) were included. QA2 image analysis software outputs the percentage increase of the red/green components as x0394;R and area of x0394;R (areax0394;R) at different thresholds. Mixed-model ANOVA was used to compare progressive and nonprogressive surfaces to account for correlations of red fluorescence (x0394;R and areax0394;R) between surfaces within a subject. The first analysis used the first observation for each surface or the first available visit if the surface was unerupted (baseline), while the second analysis used the last observation prior to cavitation for surfaces that progressed and the last observation for surfaces that did not progress (final). There was a significant (p < 0.05) association between red fluorescence and progression to cavitation at thresholds x0394;R0, x0394;R10, x0394;R20, x0394;R60, x0394;R70, x0394;R80, x0394;R90 and x0394;Rmax at baseline and for x0394;R0 and x0394;R10 at the final observation. Quantification of orange/red fluorescence may help to identify lesions that progress to cavitation. Future studies identifying microbiological factors causing orange/ red fluorescence and its caries activity are indicated.

Natural history of dental caries in very young Australian children

BACKGROUND

Whilst the global burden of caries is increasing, the trajectory of decay in young children and the point at which prevention should occur has not been well established.

AIM

To identify the 'natural history' of dental caries in early childhood.

DESIGN

A birth cohort study was established with 467 mother/child dyads followed at 1, 6, 12, 18, and 36 months of age. Parent-completed surveys captured demographic, social, and behavioural data, and oral examinations provided clinical and data.

RESULTS

Eight per cent of children (95% confidence interval (CI): 5-12%) at 18 months and 23% (95% CI: 18-28%) at 36 months experienced decay. Interesting lesion behaviour was found between 18 and 36 months, with rapid development of new lesions on sound teeth (70% of teeth, 95% CI: 63-76%) and regression of many lesions from non-cavitated lesions to sound (23% of teeth, 95% CI: 17-30%). Significant associations were found between soft drink consumption and lesion progression.

CONCLUSIONS

Findings suggest optimal time periods for screening and prevention of a disease which significantly impacts multiple health and well-being outcomes across the life course.

Clinical relevance of studies on the accuracy of visual inspection for detecting caries lesions: a systematic review

Although visual inspection is the most commonly used method for caries detection, and consequently the most investigated, studies have not been concerned about the clinical relevance of this procedure. Therefore, we conducted a systematic review in order to perform a critical evaluation considering the clinical relevance and methodological quality of studies on the accuracy of visual inspection for assessing caries lesions. Two independent reviewers searched several databases through July 2013 to identify papers/articles published in English. Other sources were checked to identify unpublished literature. The eligible studies were those which (1) assessed the accuracy of the visual method for detecting caries lesions on occlusal, approximal or smooth surfaces, in primary or permanent teeth, (2) used a reference standard, and (3) reported data about sample size and accuracy of the methods. Aspects related to clinical relevance and the methodological quality of the studies were evaluated. 96 of the 5,578 articles initially identified met the inclusion criteria. In general, most studies failed in considering some clinically relevant aspects: only 1 included study validated activity status of lesions, no study considered its prognosis, 79 studies did not consider a clinically relevant outcome, and only 1 evaluated a patient-centred outcome. Concerning methodological quality, the majority of the studies presented a high risk of bias in sample selection. In conclusion, studies on the accuracy of the visual method for caries detection should consider clinically relevant outcomes besides accuracy; moreover, they should be conducted with higher methodological quality, mainly regarding sample selection.

Risk of initial and moderate caries lesions in primary teeth to progress to dentine cavitation: a 2-year cohort study

AIM

To investigate the risk of sound surfaces, and initial and moderate caries lesions to progress to dentine cavitation in preschool children.

DESIGN

A cohort study was designed with 639 children (12-59 months old) who had been examined by visual inspection during a survey in 2010. After 2 years, 469 children were re-examined regarding the presence of dentine cavitations. The probability of progression was calculated for sound and carious (initial and moderate lesions) surfaces. Relative risk of progression and 95% confidence intervals for each condition compared with sound surfaces were calculated using multilevel Poisson regression analysis. Association with explanatory variables, including caries experience of the children, was also investigated.

RESULTS

The higher the initial score attributed to the dental surface, the more likely was the progression. Moreover, children with severe lesions at baseline had higher risk of having a sound surface or a non-cavitated caries lesion progressing to cavitation when compared with caries-free children; however, this increased risk was not observed in children with only initial caries lesions.

CONCLUSIONS

Initial caries lesions present a low frequency of progression. Moreover, sound surfaces and initial caries lesions in children already presenting cavitations are more likely to progress to more severe conditions.

Longitudinal study of caries progression in 2- and 3-year-old German children

OBJECTIVE

This 2-year longitudinal study in 2- and 3-year-old kindergarten children investigated lesion progression on different surfaces of primary teeth.

METHODS

The study was conducted between September 2008 and September 2010 on a sample of 400 children from the Kyffhäuser district (Thuringia, Germany). A calibrated investigator recorded (non)cavitated caries lesions according to World Health Organization (WHO), International Caries Detection and Assessment System (ICDAS) and Universal Visual Scoring System (UniViSS) criteria. Nonparametric methods and linear regression using a mixed-effects model with an unbalanced design were used for data analysis.

RESULTS

There was a significant increase in the prevalence of noncavitated caries lesions during the 2-year period, with the highest chance for change on all surfaces compared to cavitated lesions. First visible sign lesions on occlusal surfaces had the highest chance for change (estimate 0.38), whereas established lesions revealed the highest chance for change on proximal (estimate 1.05) and smooth surfaces (estimate 0.62). Proximal lesions exhibited the greatest chance for change irrespective of severity level.

CONCLUSION

Our study demonstrated that each type of carious lesion had different changing rates. Greater lesion severity correlated with greater chances to change and receive treatment. This information is crucial for dental practitioners in decision-making processes.

Ex vivo evaluation of new 2D and 3D dental radiographic technology for detecting caries

OBJECTIVES

Proximal dental caries remains a prevalent disease with only modest detection rates by current diagnostic systems. Many new systems are available without controlled validation of diagnostic efficacy. The objective of this study was to evaluate the diagnostic efficacy of three potentially promising new imaging systems.

METHODS

This study evaluated the caries detection efficacy of Schick 33 (Sirona Dental, Salzburg, Austria) intraoral digital detector images employing an advanced sharpening filter, Planmeca ProMax(®) (Planmeca Inc., Helsinki, Finland) extraoral "panoramic bitewing" images and Sirona Orthophos XG3D (Sirona Dental) CBCT images with advanced artefact reduction. Conventional photostimulable phosphor images served as the control modality. An ex vivo study design using extracted human teeth, ten expert observers and micro-CT ground truth was employed.

RESULTS

Receiver operating characteristic analysis indicated similar diagnostic efficacy of all systems (ANOVA p > 0.05). The sensitivity of the Schick 33 images (0.48) was significantly lower than the other modalities (0.53-0.62). The specificity of the Planmeca images (0.86) was significantly lower than Schick 33 (0.96) and XG3D (0.97). The XG3D showed significantly better cavitation detection sensitivity (0.62) than the other modalities (0.48-0.57).

CONCLUSIONS

The Schick 33 images demonstrated reduced caries sensitivity, whereas the Planmeca panoramic bitewing images demonstrated reduced specificity. XG3D with artefact reduction demonstrated elevated sensitivity and specificity for caries detection, improved depth accuracy and substantially improved cavitation detection. Care must be taken to recognize potential false-positive caries lesions with Planmeca panoramic bitewing images. Use of CBCT for caries detection must be carefully balanced with the presence of metal artefacts, time commitment, financial cost and radiation dose.

Detection and proportion of very early dental caries in independent living older adults

BACKGROUND AND OBJECTIVES

Dental caries is an important healthcare challenge in adults over 65 years of age. Integration of oral health screening into non-dental primary care practice may improve access to preventive dental care for vulnerable populations such as the elderly. Such integration would require easy, fast, and accurate early caries detection tools. Primary goal of this study was to evaluate the diagnostic performance of optical coherence tomography (OCT) imaging for detecting very early caries in the elderly living in community-based settings. The International Caries Detection and Assessment System (ICDAS) served as gold standard. Secondary goal of this study was to provide baseline prevalence data of very early caries lesions in independent living adults aged 65+ years.

MATERIALS AND METHODS

Seventy-two subjects were recruited from three sites in Southern California: a retirement community, a senior health fair, and a convalescent hospital. Clinical examination was performed using the ICDAS visual criteria and this was followed by OCT imaging. The two-dimensional OCT images (B-scan) were analyzed with simple software. Locations with a log of back-scattered light intensity (BSLI) below 2.9 were scored as sound, and areas equaling or exceeding 2.9 BSLI were considered carious. Diagnostic performance of OCT imaging was compared with ICDAS score.

RESULTS

OCT-based diagnosis demonstrated very good sensitivity (95.1%) and good specificity (85.8%). 54.7% of dentate subjects had at least one tooth with very early coronal caries.

CONCLUSIONS

Early coronal decay is prevalent in the unrestored pits and fissures of coronal surfaces of teeth in independent living adults aged 65+ years. Though OCT imaging coupled with a simple diagnostic algorithm can accurately detect areas of very early caries in community-based settings, existing devices are expensive and not well-suited for use by non-dental health care providers. Simple, inexpensive, fast, and accurate tools for early caries detection by field health care providers working in non-traditional settings are urgently needed to support inter-professional dental health management.

Detection and monitoring of early caries lesions: a review

AIM

To review the current evidence base of detecting and monitoring early carious lesions in children and adolescents and a rationale proposed to ensure that such lesions are identified and appropriately managed.

METHODS

The systematic literature search identified initially a review by Gomez and co-workers from 2013 and this still represents the current state of the science in relation to caries detection and monitoring. The review described among others, visible detection systems, image-based detection systems and point-measurement approaches.

RESULTS

The current evidence base suggests that while there are numerous devices or technology-enabled detection systems, the use of a careful, methodical visual inspection of clean, dry teeth, supplemented where indicated by radiographic views, remains the standard of care in caries detection and diagnostics. Further, it is possible by means of existing visible and radiographical systems to monitor lesions over time. Using low-cost intra-oral cameras facilitates the recording of lesion appearance in the patient record and may be of significant benefit in monitoring early lesions over time following their detection. This benefit extends to the clinician and the patient for whom it may be a useful educational and motivational tool.

CONCLUSIONS

Recommendations are presented that can be adopted and adapted to local circumstances and that are both substantiated by evidence and promote a clear, simple and consistent approach to caries detection, diagnosis and monitoring in children and adolescents. The diagnoses (initial, active; moderate, active and extensive, active) are linked to appropriate management options within primary care.

Icdas II criteria (international caries detection and assessment system)

The International Caries Detection and Assessment System (ICDAS) is a clinical scoring system which allows detection and assessment of caries activity. ICDAS was developed for use in clinical research, clinical practice and for epidemiological purposes. A recent review of caries detection criteria systems found that there were inconsistencies among the research criteria for caries measuring systems. There is a need to an uniform system which allows comparison of data collected in different researches. ICDAS allows detection of caries process at every stage and characterization of the caries activity status of lesion. Later, the criteria were modified and ICDAS II created. The aim of this review is to inform about the ICDAS II and make a comparison between ICDAS II criteria and other caries detection systems.

Detecting Short-Term Changes in the Activity of Caries Lesions with the Aid of New Technologies

This paper discusses the use of new technologies for the assessment of caries and more in particular changes in caries activity. Over the past decades, we have seen a shift from restorative treatment caries to a prevention-driven approach. Also there is a need for shorter and less expensive caries clinical trials. These demand earlier detection of lesions and the monitoring of lesion changes longitudinally in time, which has led to the development of new technologies to aid clinical visual examination. Also clinical visual inspection indices have been refined to fit this purpose. There is a constant flow of technologies emerging and disappearing. This review discusses the merits of recent developments regarding their respective uses for research purposes in testing new caries prevention strategies as well as in clinical caries management in dental private practice. Which technique to choose highly depends on the needed resolution of information.

In vitro Detection of Occlusal Caries on Permanent Teeth by a Visual, Light-Induced Fluorescence and Photothermal Radiometry and Modulated Luminescence Methods

Background: The paradigm shift towards the nonsurgical management of dental caries relies on the early detection of the disease. Detection of caries at an early stage is of unequivocal importance for early preventive intervention. Objective: The aim of this in vitro study is to evaluate the performance of a visual examination using the International Caries Detection and Assessment System (ICDAS) criteria, two quantitative light-induced fluorescence (QLF) systems - Inspektor™ Pro and QLF-D Biluminator™ 2 (Inspektor Research Systems B.V., Amsterdam, The Netherlands) - and a photothermal radiometry and modulated luminescence, The Canary System® (Quantum Dental Technologies, Toronto, Ont., Canada) on the detection of primary occlusal caries on permanent teeth. Methods: A total of 60 teeth with occlusal surface sites ranging from sound to noncavitated lesions (ICDAS 0-4) were assessed with each detection method twice in a random order. Histological validation was used to compare methods for sensitivity, specificity, percent correct, and the area under the receiver operating characteristic curve (AUC), at standard and optimum sound thresholds. Interexaminer agreement and intraexaminer repeatability were measured using intraclass correlation coefficients. Results: Interexaminer agreement ranged between 0.48 (The Canary System®) and 0.96 (QLF-D Biluminator™ 2). Intraexaminer repeatability ranges were 0.33-0.63 (The Canary System®) and 0.96-0.99 (QLF-D Biluminator™ 2). The sensitivity range was 0.75-0.96 while that of specificity was 0.43-0.89. The AUC were 0.79 (The Canary System®), 0.87 (ICDAS), 0.90 (Inspektor™ Pro), and 0.94 (QLF-D Biluminator™ 2). Conclusion: ICDAS had the best combination of sensitivity and specificity followed by QLF-D Biluminator™ 2 at optimum threshold.

White spot lesions after orthodontic treatment assessed by clinical photographs and by quantitative light-induced fluorescence imaging; a retrospective study

OBJECTIVE

White spot lesions (WSL) are an important side-effect of orthodontic multi-bracket (MB) treatment. Standardized monitoring of such WSL may help in caries management.

MATERIALS AND METHODS

In this retrospective study the discriminatory power of caries assessment on routine digital oral photographs was compared to quantitative light-induced fluorescence (QLF) imaging in monitoring WSL development after debonding of orthodontic appliances. Oral and QLF photographs captured directly after debond (T1) and 1 year thereafter (T2) of 51 subjects, treated with full MB orthodontic appliances were used. Oral photographs were assessed by use of The International Caries Detection and Assessment System (ICDAS) at both time points independently and by side-by-side comparison to assess visual transition (VT). QLF photographs were categorized based on integrated fluorescence loss at T1 and T2.

RESULTS

At T1 433 and 384 lesions on 918 buccal surfaces were detected using ICDAS and QLF, respectively. For both methods these numbers were reduced at T2. Changes within ICDAS scores were recorded by VT and showed mainly lesion improvement within ICDAS score 2.

CONCLUSION

The oral and QLF photographs both showed regression of WSL after debonding of MB orthodontic appliances. The VT evaluation was found to have higher discriminatory power in comparison to ICDAS.

The dynamic behavior of the early dental caries lesion in caries-active adults and implications

OBJECTIVE

To describe the full range of behavior of the visible, noncavitated, early caries lesion in caries-active adults with substantial fluoride exposure, and to consider implications.

METHODS

The data were from the Xylitol for Adult Caries Trial (X-ACT) collected annually for 33 months using condensed ICDAS caries threshold criteria. Individual tooth surfaces having a noncavitated caries lesion were included, and the patterns of transition to each subsequent annual clinical examination to sound, noncavitated or cavitated, filled or crowned were determined. The resulting sets of patterns for an individual tooth surface, looking forward from its first appearance as a noncavitated lesion, were combined into one of four behavior profiles classified as reversing, stable, oscillating, or continuously progressing, or were excluded if not part of the caries continuum. The distributions of profile types were assessed using the Rao-Scott chi-square test, which adjusts for clustering of tooth surfaces within teeth.

RESULTS

Inter- and intra-examiner kappa scores demonstrated acceptable calibration at baseline and annually. 8084 tooth surfaces from 543 subjects were included. The distribution of profile types differed significantly between coronal and root surfaces. Overall, two-thirds of all coronal noncavitated lesions were first seen at baseline, half reversed, over a fifth were stable, 15% oscillated, and only 8.3% progressed to cavitation, filled, or crowned in 33 months or less (6.3% consistently Progressed plus 2.0% inconsistently, a subset of oscillating, which oscillated before progressing to cavitation). Approximal, smooth, and occlusal coronal surfaces each were significantly different in their individual distributions of profile types. Xylitol showed no significant and consistent effect on this distribution by tooth surface type. This was in keeping with the X-ACT's lack of effect of xylitol at the noncavitated plus cavitated lesion thresholds combined.

CONCLUSIONS

This study demonstrated the full dynamic range of early caries lesion behavior. The great majority were not progressive, and few (8.3%) became cavitated over 33 months in caries-active adults using fluorides. Important caries management implications favoring recorded longitudinal monitoring, prevention of active risks, and minimal restoration only after direct visual determination of cavitation are discussed.

One-year evaluation of inactive occlusal enamel lesions in children and adolescents

OBJECTIVES

The aims of this study were to compare caries incidence and progression on sound occlusal surfaces and on surfaces presenting inactive enamel lesions in children and adolescents over 1 year and to estimate the risk of caries incidence and progression on these surfaces.

METHODS

This prospective cohort study followed 200 7-15-year-old caries-inactive schoolchildren over 1 year. Stage of eruption, occlusal plaque, and occlusal caries were recorded on permanent molars. Statistical analysis was performed using generalized estimating equations with a logistic link function.

RESULTS

Twenty-two children (11 %) presented "caries progression" (at least one active lesion on molar teeth). At site level, no difference was observed in caries incidence and progression between sites classified either sound (2.6 %) or with inactive enamel lesion (3.9 %) at the baseline examination (χ (2) test, p = 0.48). Adjusted for plaque, stage of eruption, type of molar and dental arch, inactive enamel lesions presented a similar risk for caries progression than sound occlusal surfaces (OR = 0.98, 95 % CI = 0.40-2.38).

CONCLUSION

Within the limitations of this study, no difference was observed in caries incidence, progression, and risk on sound occlusal sites in comparison with sites presenting inactive enamel lesions.

CLINICAL RELEVANCE

Occlusal surfaces harboring inactive caries lesions did not require additional attention than the one normally given to sound occlusal surfaces over a 1-year period.

A Potential Biofilm Metabolite Signature for Caries Activity - A Pilot Clinical Study

BACKGROUND

This study's aim was to compare the dental biofilm metabolite-profile of caries-active (N=11) or caries-free (N=4) children by gas chromatography-mass spectrometry (GC/MS) analyses.

METHODS

Samples collected after overnight fasting, with or without a previous glucose rinse, were combined for each child based on the caries status of the site, re-suspended in ethanol and analyzed by GC/MS.

RESULTS

Biofilm from caries-active sites exhibited a different chromatographic profile compared to caries-free sites. Qualitative and quantitative analysis suggested a special cluster of branched alcohols and esters present at substantially higher intensity in biofilms of caries-active sites.

CONCLUSIONS

This pilot study indicates that there are metabolites present in the biofilm which have the potential to provide a characteristic metabolomics signature for caries activity.

Caries process on occlusal surfaces: evolving evidence and understanding

Management of the caries process on occlusal surfaces of permanent molars has proven a major challenge. The onset of caries on these surfaces takes place soon after their eruption, and the permanent first molars, followed by the second molars, remain the sites in the dentition which show the highest caries prevalence. This paper is structured in the form of questions and answers in which traditional concepts of caries susceptibility of occlusal surfaces are appraised and confronted with the current evidence. Then, research studies examining the role of biological determinants on the development and arrest of occlusal caries in young permanent teeth are discussed. Finally, the contribution of these studies in terms of developing the available scientific evidence and our understanding of the caries process on occlusal surfaces is analyzed. The current evidence does not support the concept that the early onset and high prevalence of occlusal caries in young permanent teeth are due to a particularly low inherent resistance of the occlusal surface or due to the presence of inaccessible fissure-like structures on these surfaces. Evidence is provided to show that the most influential biological determinants of the development and arrest of occlusal caries are thick plaque accumulation on the groove-fossa system and the stage of tooth eruption limiting mechanical oral function. Consequently, active occlusal lesions are significantly more prevalent in erupting than in fully erupted teeth. The major contribution of this review is to provide updated knowledge about the biological principles determining the development and arrest of caries on occlusal surfaces of erupting teeth.

Tridimensional surface roughness analysis after resin infiltration of (deproteinized) natural subsurface carious lesions

OBJECTIVES

The objectives of this study were to evaluate ex vivo the effects of resin infiltration on the areal surface roughness of natural non-cavitated proximal subsurface lesions with or without previous deproteinization and to determine differences between E2 and D1 lesions or between premolars and molars.

MATERIALS AND METHODS

Forty premolars and 40 molars with proximal carious lesions and macroscopically intact surfaces (International Caries Detection and Assessment System (ICDAS) II; code 2) were radiologically assessed and randomly allocated to four groups (with 20 E2 and 20 D1 lesions, respectively). In each group, 10 lesions were deproteinized (NaOCl; 1%) before etching (HCl; 15%) and resin infiltration (Icon). Areal surface roughness (Sa) at the most demineralized lesion part (DIAGNOdent) was evaluated topometrically before and after deproteinization, after etching, and after infiltration using focus variation 3D scanning microscopy.

RESULTS

Pretreatment with NaOCl (n = 40) had no significant effects on Sa (p = 0.208), but resulted in significantly differing Sa values between premolars and molars after etching (p = 0.011). Regarding the effects between etching and baseline, significantly differing Sa values (p = 0.0498) were found for premolars and molars (n = 40/40); Sa after resin infiltration (compared to etching) differed significantly between premolars and molars (p = 0.009). No treatment regimen lead to differences among the radiological grades (E2 vs. D1; p > 0.106).

CONCLUSIONS

Resin infiltration showed only minor effects on Sa values of etched subsurface lesions (p < 0.170) and did neither equal nor improve baseline surface roughness (p > 0.401) of the different tooth types.

CLINICAL RELEVANCE

Deproteinization should be recommended before etching and infiltration, even if surface roughness of infiltrated advanced (pre-)molar lesions will not be improved.

Doxycycline-encapsulated nanotube-modified dentin adhesives

This article presents details of fabrication, biological activity (i.e., anti-matrix metalloproteinase [anti-MMP] inhibition), cytocompatibility, and bonding characteristics to dentin of a unique doxycycline (DOX)-encapsulated halloysite nanotube (HNT)-modified adhesive. We tested the hypothesis that the release of DOX from the DOX-encapsulated nanotube-modified adhesive can effectively inhibit MMP activity. We incorporated nanotubes, encapsulated or not with DOX, into the adhesive resin of a commercially available bonding system (Scotchbond Multi-Purpose [SBMP]). The following groups were tested: unmodified SBMP (control), SBMP with nanotubes (HNT), and DOX-encapsulated nanotube-modified adhesive (HNT+DOX). Changes in degree of conversion (DC) and microtensile bond strength were evaluated. Cytotoxicity was examined on human dental pulp stem cells (hDPSCs). To prove the successful encapsulation of DOX within the adhesives-but, more important, to support the hypothesis that the HNT+DOX adhesive would release DOX at subantimicrobial levels-we tested the antimicrobial activity of synthesized adhesives and the DOX-containing eluates against Streptococcus mutans through agar diffusion assays. Anti-MMP properties were assessed via β-casein cleavage assays. Increasing curing times (10, 20, 40 sec) led to increased DC values. There were no statistically significant differences (p > .05) in DC within each increasing curing time between the modified adhesives compared to SBMP. No statistically significant differences in microtensile bond strength were noted. None of the adhesives eluates were cytotoxic to the human dental pulp stem cells. A significant growth inhibition of S. mutans by direct contact illustrates successful encapsulation of DOX into the experimental adhesive. More important, DOX-containing eluates promoted inhibition of MMP-1 activity when compared to the control. Collectively, our findings provide a solid background for further testing of encapsulated MMP inhibitors into the synthesis of therapeutic adhesives that may enhance the longevity of hybrid layers and the overall clinical performance of adhesively bonded resin composite restorations.

Pulpal status of human primary molars with coexisting caries and physiological root resorption

AIM

This study sought to investigate the effect of caries, in association with physiological root resorption, on the pulpal status of human primary molars.

DESIGN

Fifty-three mandibular primary molars were obtained from children requiring extractions under general anaesthesia. Following extraction, teeth were split longitudinally and placed in Zamboni's fixative. Teeth were categorised according to i) the depth of caries (less than or greater than halfway through dentine thickness) and ii) the degree of physiological root resorption (<33%, 34-66% or >67% of the root length). Ten-micrometre pulp sections were subject to indirect immunofluorescence using a combination of PGP 9.5 (a general neuronal marker), CD45 (a general neuronal marker), and Ulex europaeus agglutinin I (a marker of vascular endothelium). Image analysis was used to determine the percentage area of staining (PAS) for innervation and immune cells.

RESULTS

Marked differences were seen between different samples, but there were no significant differences in mean PAS for PGP 9.5 or CD45 according to the degree of caries or extent of physiological root resorption (two-way anova, P > 0.05).

CONCLUSION

Findings suggest that even if primary molars are undergoing exfoliation, they show comparable caries-induced changes to teeth without physiological root resorption, thus retaining potential for healing and repair.

Frequency and distribution of early tooth loss and endodontic treatment needs of permanent first molars in a Turkish pediatric population

Objectives:

The objective of this study is to evaluate the frequency and distribution of early tooth loss and endodontic treatment needs of permanent first molars in a Turkish pediatric population.

Materials and Methods:

A total of 7,895 panoramic radiographs taken for routine dental examination at the Department of Oral Maxillofacial Radiology between 2008 and 2012 years were investigated. Two independent specialists evaluated early tooth loss and endodontic treatment needs of permanent first molars using panoramic radiography and patient anamnesis forms. The teeth were classified according to the following data: (a) Missing teeth, (b) teeth requiring extraction, (c) endodontically treated teeth (ETT), (d) teeth requiring endodontic therapy. The data also classified according to four factors: Age group (6-12 and 13-16), gender (boy and girl), jaw (mandible and maxilla) and side (right and left). A Chi-square test was used for statistical analyses.

Results:

A total of 19,488 and 12,092 teeth were evaluated in the child group and adolescent group respectively. All data were higher in adolescents than children (P < 0.001). For gender factor, only ETT was higher in girls than it was in boys (P < 0.001). For the jaw factor, all data were higher (P < 0.001) in mandible than in the maxilla. For the side factor, no statistical difference existed between right and left.

Conclusions:

Early tooth loss and endodontic treatment needs of permanent first molars showed variability according to age groups and jaws. When the results were compared according to the side and gender factors, no statistical difference was found (P > 0.05) except with the data of ETT in gender groups.

Radiographic display of carious lesions and cavitation in approximal surfaces: Advantages and drawbacks of conventional and advanced modalities

BACKGROUND

Treatment strategies have changed with efforts on arresting carious lesions suspected to have an intact surface sparing operative treatment for cavitated lesions. Radiography is still the most recommended adjunct method in the diagnosis of clinically inaccessible approximal surfaces. BITEWING RADIOGRAPHY: The major drawback of bitewing radiography for caries diagnosis is that the clinical state of the surface cannot be determined; i.e. if cavitation has developed or the demineralized surface is still intact. Based on studies of the relationship between radiographic lesion depth and clinical cavitation in approximal surfaces, a threshold for operative treatment decision has been suggested when a lesion is observed radiographically more than one-third into dentine. However, the results from previous studies are contradictory and the majority of studies are ~25 years old. In addition, there are few longitudinal observational studies on the behaviour of dentinal carious lesions, particularly in adults. CONE BEAM COMPUTED TOMOGRAPHY: Cone beam CT is an advanced 3-dimensional radiographic modality, which seems much more accurate than intra-oral modalities for displaying cavitation in approximal surfaces. Nonetheless, there are several drawbacks with CBCT, such as radiation dose, costs and imaging artefacts. Therefore, CBCT cannot be advocated at current as a primary radiographic examination with the aim of diagnosing cavitated carious lesions.

CONCLUSIONS

Bitewing radiography is, thus, still state-of-the-art as an adjunct in diagnosing carious lesions in clinically inaccessible approximal surfaces. The risk for cavitation is related to lesion depth, but new studies are needed in both child and adult populations to validate current thresholds for the operative treatment decision based on the radiographic lesion depth.

Assessment of early occlusal caries pre- and post-sealant application--an imaging approach

BACKGROUND AND OBJECTIVE

Clinicians have difficulty assessing and monitoring early occlusal caries. Traditional clinical exam and radiographs are unable to detect the subtle alterations in enamel indicative of de- or re-mineralization, particularly under dental sealants. Although clinicians have used laser fluorescence (LF) to address this gap, this modality has demonstrated weak correlation with histology. The International Caries Detection and Assessment System (ICDAS-II) has demonstrated high sensitivity and specificity for caries detection, but since it is based on visual assessment, it is of no use in areas beneath the most commonly used dental sealants which are opaque. Optical coherence tomography (OCT) is an emergent assessment tool which has demonstrated great promise in detecting and quantifying caries, including areas beneath commonly used dental sealants and composites. However, OCT has not yet been widely integrated into clinical dental practice, perhaps because OCT imaging does not provide an easily accessible diagnostic outcome for clinicians. The objective of this ex vivo study was to use OCT-images of sound and carious occlusal surfaces in combination with a simple algorithm to compare the caries detection ability of OCT with tools clinicians may be more familiar with (LF and radiography), and with an established valid and reliable clinical assessment tool (ICDAS-II).

STUDY DESIGN/MATERIALS AND METHODS

One hundred twenty extracted teeth with sound or naturally carious occlusal surfaces were imaged with OCT, LF, radiography, and examined clinically with the ICDAS-II. Teeth were randomized to one of two dental sealants recommended for use with LF. A novel simple algorithm was used to interpret OCT-based images. The accuracy of caries severity assessments of the OCT-based diagnosis, LF, ICDAS-II, and digital radiography were compared to the 4-point histological analysis gold standard.

RESULTS

OCT and ICDAS-II caries severity assessments demonstrated high sensitivity (94.0%; 92.3%) and specificity (85.0%; 83.3%), LF demonstrated low sensitivity (65.2%) but high specificity (97.6%), and digital radiography demonstrated low sensitivity (67.1%) with moderate specificity (79.5%) on unsealed occlusal surfaces. OCT-based caries severity assessments of sealed teeth demonstrated high specificity (97.6%), sensitivity (89.9%), excellent positive predictive value (98.6%), and negative predictive value (83.3%). Despite our use of LF recommended dental sealants, in the presence of sealants, LF assessment of caries severity demonstrated high sensitivity (95.1%), but extremely low specificity (10.3%), positive predictive value (68.8%), and negative predictive value (50.0%).

CONCLUSION

This study found that OCT-based imaging combined with a simple diagnostic algorithm accurately assessed the severity of natural early caries on occlusal surfaces in extracted teeth both in the absence and presence of dental sealant. The findings of this study support the clinical use of OCT imaging for assessment and monitoring progression of early non-cavitated caries lesions on occlusal surfaces including areas under dental sealants.

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.

Direct composite resin fillings versus amalgam fillings for permanent or adult posterior teeth

BACKGROUND

Amalgam has been the traditional material for filling cavities in posterior teeth for the last 150 years and, due to its effectiveness and cost, amalgam is still the restorative material of choice in certain parts of the world. In recent times, however, there have been concerns over the use of amalgam restorations (fillings), relating to the mercury release in the body and the environmental impact following its disposal. Resin composites have become an esthetic alternative to amalgam restorations and there has been a remarkable improvement of its mechanical properties to restore posterior teeth.There is need to review new evidence comparing the effectiveness of both restorations.

OBJECTIVES

To examine the effects of direct composite resin fillings versus amalgam fillings for permanent posterior teeth, primarily on restoration failure.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 22 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 22 October 2013), EMBASE via OVID (1980 to 22 October 2013), and LILACs via BIREME Virtual Health Library (1980 to 22 October 2013). We applied no restrictions on language or date of publication when searching the electronic databases. We contacted manufacturers of dental materials to obtain any unpublished studies.

SELECTION CRITERIA

Randomized controlled trials comparing dental resin composites with dental amalgams in permanent posterior teeth. We excluded studies having a follow-up period of less than three years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Of the 2205 retrieved references, we included seven trials (10 articles) in the systematic review. Two trials were parallel group studies involving 1645 composite restorations and 1365 amalgam restorations (921 children) in the analysis. The other five trials were split-mouth studies involving 1620 composite restorations and 570 amalgam restorations in an unclear number of children. Due to major problems with the reporting of the data for the five split-mouth trials, the primary analysis is based on the two parallel group trials. We judged all seven trials to be at high risk of bias and we analyzed 3265 composite restorations and 1935 amalgam restorations.The parallel group trials indicated that resin restorations had a significantly higher risk of failure than amalgam restorations (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.52 to 2.35, P value < 0.001 (fixed-effect model) (low-quality evidence)) and increased risk of secondary caries (RR 2.14, 95% CI 1.67 to 2.74, P value < 0.001 (low-quality evidence)) but no evidence of an increased risk of restoration fracture (RR 0.87, 95% CI 0.46 to 1.64, P value = 0.66 (moderate-quality evidence)). The results from the split-mouth trials were consistent with those of the parallel group trials.Adverse effects of dental restorations were reported in two trials. The outcomes considered were neurobehavioral function, renal function, psychosocial function, and physical development. The investigators found no difference in adverse effects between composite and amalgam restorations. However, the results should be interpreted with caution as none of the outcomes were reported in more than one trial.

AUTHORS' CONCLUSIONS

There is low-quality evidence to suggest that resin composites lead to higher failure rates and risk of secondary caries than amalgam restorations. This review reinforces the benefit of amalgam restorations and the results are particularly useful in parts of the world where amalgam is still the material of choice to restore posterior teeth with proximal caries. Though the review found insufficient evidence to support or refute any adverse effects amalgam may have on patients, new research is unlikely to change opinion on its safety and due to the decision for a global phase-down of amalgam (Minamata Convention on Mercury) general opinion on its safety is unlikely to change.

Longitudinal analyses of early lesions by fluorescence: an observational study

Previous caries experience correlates to future caries risk; thus, early identification of lesions has importance for risk assessment and management. In this study, we aimed to determine if Quantitative Light-induced Fluorescence (QLF) parameters--area (A [mm(2)]), fluorescence loss (F [%]), and Q [% × mm(2)]--obtained by image analyses can predict lesion progression. We secured consent from 565 children (from 5-13 years old) and their parents/guardians and examined them at baseline and regular intervals over 48 months according to the International Caries Detection Assessment System (ICDAS), yearly radiographs, and QLF. QLF images from surfaces with ICDAS 0/1/2/3/4 at baseline that progressed (N = 2,191) to cavitation (ICDAS 5/6) or fillings and surfaces that did not progress to cavitation/fillings (N = 4,141) were analyzed independently for A, F, and Q. Linear mixed-effects models were used to compare means and slopes (changes over time) between surfaces that progressed and those that did not. QLF A, F, and Q increased at a faster rate for surfaces that progressed than for surfaces that did not progress (p = .0001), regardless of type of surface or baseline ICDAS score. AUC for ICDAS ranged from 0.65 to 0.80, but adding QLF information improved AUC (0.82-0.87, p < .0005). We concluded that faster changes in QLF variables can indicate lesion progression toward cavitation and be more clinically relevant than actual QLF values.

The impact of gender on caries prevalence and risk assessment

Dental caries remains a common disease worldwide. There is evidence indicating that many caries risk factors provide a gender bias, placing women at a higher caries risk. Generally, dental caries disproportionally affects the poor and racial or ethnic minorities worldwide, with women suffering more from the disease. Differences in access to care as reflected by untreated caries rates also reflect gender disparities. There is a lack of evidence in regard to gender differences and dental caries. Therefore, there is an urgent need to develop the evidence necessary to meet the oral health needs of both women and men worldwide.