Impact of the radiographic method on treatment decisions related to dental caries in primary molars: a before-after study

Estimated compared with actual plans of paediatric dental treatment performed under deep sedation: A retrospective cohort study

BACKGROUND

Planning the extent of paediatric dental treatment under deep sedation is highly important, as the duration of the sedation should be limited to approximately 1 h, and the amount of local anesthesia is limited by the children's body weight.

AIM

To compare treatment plans estimated at initial examinations with actual dental treatments under intravenous deep sedation. We examined factors that could affect the differences.

DESIGN

For this retrospective cohort study, data were collected from the medical records of all the children younger than 18 years who underwent dental treatment under intravenous deep sedation during 2019-2021 at the Department of Pediatric Dentistry.

RESULTS

In total, 108 children were included. During the actual versus the estimated treatment under deep sedation, more teeth were treated (p < .001), and the treatment was more complex (p < .001). A longer waiting period for dental treatment was found to be correlated with a greater number of treated teeth than was estimated (p = .003) and with greater complexity of the actual than the estimated treatment (p = .003).

CONCLUSION

Actual compared with estimated dental treatment under deep sedation involved more teeth and was of greater complexity. This suggests that referrals should include children with limited estimated treatment plans.

Performance of near-infrared light transillumination in the detection of occlusal caries lesions in deciduous teeth

BACKGROUND

This study compared the performance of near-infrared light transillumination (NILT; DIAGNOcam [DC]) in detecting occlusal caries lesions in deciduous molars with the performance of the International Caries Detection and Assessment System (ICDAS), digital radiographic method (RX) and laser fluorescence (DIAGNOdent pen [LFpen]).

METHODS

Fifty-seven extracted deciduous molars with no frank cavitation caries lesions were selected. One site per tooth was evaluated twice each by two examiners using all methods. Then, a histological examination was performed using a stereomicroscope. The performance of the methods was assessed with respect to two thresholds: D1 (all visible caries lesions affecting enamel) and D3 (caries lesions extended into dentin).

RESULTS

A weighted kappa and intraclass correlation coefficients were calculated for intra- and inter-observer reproducibilities, varying from 0.31 (RX) to 0.89 (LFpen). The intra-observer reproducibility at D1 and D3 thresholds varied from 0.51 (ICDAS) to 0.85 (DC) and from 0.30 (ICDAS) to 1.00 (RX), respectively. The inter-observer reproducibility varied from 0.28 (RX) to 0.47 (DC) and from 0.22 (LFpen) to 0.75 (DC), respectively. At the D1 threshold, higher sensitivity and accuracy were found for LFpen (0.76/0.71) and ICDAS (0.65/0.66); and higher specificities were found for RX (0.94), DC (0.79), and ICDAS (0.71). At the D3 threshold, all methods exhibited lower sensitivities (0.13-0.35) and higher specificity, accuracy, and area under the ROC curve values (0.70-1.00). All methods showed a correlation with histological results, especially for ICDAS and DC.

CONCLUSIONS

NILT technology (DC) and LFpen exhibited similar performance for the detection of occlusal caries lesions in deciduous molars when compared with ICDAS criteria.

The value of bitewing radiographs in the management of carious primary molars - the impact on treatment planning

Introduction Bitewing radiographs (BWs) with visual examination (VE) are critical for the early detection of caries in primary molars. However, their influence on treatment planning is not extensively studied. Given they involve exposure to ionising radiation, it is essential to understand their impact on treatment decisions.Aim To explore the impact of BWs in the management of carious primary molars.Design Cross-sectional study.Materials and methods A total of 30 children (mean age 6.2 years) referred for caries management in a dental hospital setting were recruited. One of six paediatric dental specialists performed VEs and scored pre-BW treatment needs (TN) for each primary molar, followed by reviewing the BWs, re-scoring TN and recording their opinion on treatment modality. Data were assessed using descriptive analyses. Five treatment planning descriptors detailing the reasons for change were identified.Results In total, 240 primary molars were examined. BWs resulted in an overall change in treatment plan for 24/30 (80.0%) children, with the majority (20/30; 66.7%) becoming more invasive. General anaesthesia was the commonest proposed modality (13/30; 43.3%) children), followed by inhalation sedation (10/30; 33.3%) and local anaesthesia (6/30; 20.0%), with only one child (3.3%) in the 'no analgesia' modality.Conclusion BWs play an important role in treatment planning carious primary molars.

Influence of two caries detection strategies on the quality of life of preschool children: An analysis of secondary outcomes of a 2-Year randomized clinical trial

OBJECTIVE

This randomized clinical trial aimed to evaluate the influence of two caries diagnosis strategies, and subsequent management, on oral health-related quality of life (OHRQoL) of preschoolers. Additionally, the association of the OHRQoL outcomes with the clinician-centred primary outcome used in the main study was also explored.

MATERIALS AND METHODS

This study refers to the OHRQoL secondary outcomes analyses of the so-called RCT 'CARDEC-1'. Three- to 6-year-old children were randomly allocated in two caries detection strategies in primary molars: visual inspection (VIS) or visual + radiographic (RAD) assessment. Participants were diagnosed and treated according to the allocated group and followed up for 2 years. Caregivers answered the Early Childhood Oral Health Impact Scale (ECOHIS) at baseline and after 2 years. Intention-to-treat analysis was performed. ECOHIS scores at baseline and 2 years later were compared using the Mann-Whitney test. Effect sizes, change scores and the minimally important difference (MID) were also compared between groups. Additional analysis was performed to assess if OHRQoL variables could reflect the primary clinical outcome (number of new operative interventions during the follow-up), observing if these met the Prentice criteria.

RESULTS

Two hundred and five children had the ECOHIS answered in both period times (18.7% attrition rate). There was a decrease in total ECOHIS scores, as well as for different domains for both trial groups, with effect sizes varying from 0.43 to 0.77. Comparisons between groups, however, did not show significant differences. In the additional analysis, the OHRQoL variables met the Prentice criteria and presented the same trends observed with the clinician-centred primary endpoint.

CONCLUSION

Caries detection performed by visual inspection alone or associated with radiographic method does not influence the long-term impact on OHRQoL. Furthermore, OHRQoL variables reflect clinical outcomes in this type of clinical trial.

CLINICALTRIALS

gov NCT02078453.

Radiation Exposure and Frequency of Dental, Bitewing and Occlusal Radiographs in Children and Adolescents

Dental radiographs are valuable diagnostic aids for oral healthcare, but exposure to ionizing radiation carries health risks, especially in children due to their high radio-sensitivity. Valid reference values for intraoral radiographs in children and adolescents are still missing. This study aimed to investigate the radiation dose values and underlying justifications of dental, bitewing and occlusal X-rays in children and adolescents. Data from routinely executed intraoral radiographs between 2002 and 2020 with conventional and digital tube-heads were extracted from the Radiology Information System. The effective exposure was calculated from technical parameters and statistical tests performed. A total number of 4455 intraoral (3128 dental, 903 bitewing and 424 occlusal) radiographs were investigated. For dental and bitewing radiographs, the dose area product (DAP) was 2.57 cGy × cm² and the effective dose (ED) 0.77 µSv. For occlusal radiographs, the DAP was 7.43 cGy × cm² and the ED 2.22 µSv. Overall, 70.2% of all intraoral radiographs were dental, 20.3% bitewing and 9.5% occlusal radiographs. The most frequent indication for intraoral radiographs was trauma (28.7%), followed by caries (22.7%) and apical diagnostics (22.7%). Moreover, 59.7% of all intraoral radiographs were taken in boys, especially for trauma (66.5%) and endodontics (67.2%) (p ≤ 0.00). Girls were significantly more frequently X-rayed for caries diagnostics than boys (28.1% vs. 19.1%, p ≤ 0.00). The average ED of 0.77 µSv for intraoral dental and bitewing radiographs in this study was within the range of other reported values. The technical parameters of the X-ray devices were found at the lowest recommended levels to best limit the radiation exposure and to assure acceptable diagnostic efficacy. Intraoral radiographs were performed predominantly for trauma, caries and apical diagnostics-reflecting general recommendations for the use of X-rays in children. For improved quality assurance and radiation protection, further studies are necessary to determine the meaningful dose reference level (DRL) for children.

Maternal Common Mental Disorders symptoms influence associated with early childhood dental caries: A cross-sectional study in a southern Brazilian city

BACKGROUND

Maternal mental problems can interfere with the overall health and care of the child; some oral health studies have been trying to elucidate whether there is a relationship between maternal common mental disorders (CMD) and children's oral health status.

AIM

The aim was to investigate the influence of mothers that present CMD symptoms on their child's dental caries status.

DESIGN

This cross-sectional study was carried out in Pelotas with 530 mother/child (aged 2-5 years old) dyads recruited from an epidemiological survey in August 2015 during the national vaccination campaign. A questionnaire was used to determine mother's CMD symptoms using the Self-Reporting Questionnaire (SRQ-20) and socioeconomic/demographic variables which were used for adjustment. Dental caries examination was performed. The outcome was obtained using the dmfs (decayed, missing, filled surfaces) index, based on OMS guidelines. Poisson regression with robust variance was used to estimate the risk ratio and 95% confidence interval (CI).

RESULTS

Maternal CMD was positively associated with dental caries prevalence in children; the adjusted relative risk for every 1 SRQ-20 score increase was 1.06 (95% CI 1.00-1.12).

CONCLUSIONS

Our findings suggest that maternal mental health can impair children's oral health in relation to dental caries.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Negligible therapeutic impact, false-positives, overdiagnosis and lead-time are the reasons why radiographs bring more harm than benefits in the caries diagnosis of preschool children

Background

To evaluate the clinical course and interventions required during two years of follow-up of dental surfaces of deciduous molars diagnosed, and consequently treated, by two different strategies: diagnosis made by clinical examination alone or associated with radiographs.

Methods

This is a secondary analysis of a two-arm randomized clinical trial with parallel groups related to the diagnostic strategy for caries detection in preschool children. 216 children (3–6 years old) were followed-up for two years. All dental surfaces were diagnosed by visual inspection and later, through radiographic assessment. Baseline treatment was made in accordance with the results obtained by visual inspection performed alone or combined with radiographic method, considering the allocated group. Dental surfaces with no restoration needs, or those restored at the beginning of the study were followed-up for two years. The treatment decision was made according to the allocated group. The outcome was the occurrence of failure (a new caries lesion or a restoration replacement) during the follow-up.

Results

4383 proximal and occlusal surfaces of deciduous molars in 216 preschool children were diagnosed and treated according to the abovementioned diagnostic strategies and followed-up for 24 months. The assessment of radiographs made change the initial decision reached by visual inspection in about 30% of the surfaces when all types of interventions were considered. However, most disagreements occurred for initial lesions, where radiographs tended to underestimate them. Discordances between methods occurred in less than 5% of all surfaces when considered lesions requiring operative treatment. For discrepancy cases, the placed interventions guided by following the radiographic results did not present less failures against those made following only visual inspection. As a matter of fact, the use of radiographs in the diagnostic strategy for caries detection in children brought more harms than benefits due to the occurrence of false-positives, overdiagnosis and lead-time bias.

Conclusions

Simultaneous association of visual inspection and radiographic assessment for caries detection in preschool children causes more harms than benefits, and therefore, visual inspection should be conducted alone in the regular clinical practice.

Trial registration Clinicaltrials.gov platform: NCT02078453, registered on 5th March 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01528-w.

Association of Dietary Fluoride Intake and Diet Variables with Dental Caries in Adolescents from the ELEMENT Cohort Study

To examine the association of dietary fluoride intake, total carbohydrate consumption and other key dietary variables with dental caries experience among adolescents, a cross-sectional analysis was conducted in a sample of 402 participants from the Early Life Exposures in Mexico to Environmental Toxicants cohort. The presence and severity of dental caries were assessed using the International Caries Detection and Assessment System (ICDAS) to calculate the number of decayed, missing, and filled teeth or surfaces (D1MFT/D4MFT). The dietary intake of fluoride, energy, carbohydrates, and food groups was estimated using a validated food frequency questionnaire (FFQ). Multivariate zero-inflated negative binomial regression models and negative binomial regression models were run to estimate the association of fluoride intake (mg/day) and total carbohydrate intake (g/day) with the D1MFT/D4MFT index. We found that 80% of the adolescents experienced dental caries (D1MFT >0), with 30% presenting cavitated lesions (D4MFT >0). The mean scores for D1MFT and D4MFT were 6.2 (SD 5.3) and 0.67 (SD 1.3), respectively. The median intake of fluoride estimated by the FFQ was 0.015 mg/kg/day. This intake was statistically higher in participants with a D4MFT = 0 compared to those with a D4MFT >0 (0.90 vs. 0.82 mg/day; 0.016 vs. 0.014 mg/kg/day; p < 0.05). For D1MFT, D1MFS, D4MFT, and D4MFS scores, a higher fluoride consumption (mg/day) from foods and beverages was associated with a statistically significant reduction in the number of lesions. The reported frequency of consumption of sugary foods in a whole day was statistically higher in those with D1MFT >0 than in those with D1MFT = 0 (p < 0.05). The total carbohydrate intake (g/day) was positively associated with dental caries experience. We conclude that a higher fluoride intake through foods and beverages is associated with a lower dental caries experience among adolescents; this effect was seen even when the dietary intake of fluoride was 0.015 mg/kg/day, which is lower than the average intake recommendation. In contrast, a higher total carbohydrate intake and the frequency of intake of sugary foods were associated with a higher dental caries experience, with no apparent threshold for the effects.

Reproducibility of subtraction radiography in monitoring changes in approximal carious lesions in children: An in vivo study

BACKGROUND

Laboratory studies have shown that digital subtraction radiography (DSR) can be a more effective tool, than conventional radiography, in monitoring changes in carious lesions. The clinical performance of the technique, however, has not been sufficiently researched.

AIM

To compare the reproducibility of DSR to that of bitewing radiographs, in monitoring changes in approximal caries in the mixed dentition. A secondary aim was to determine whether assessment outcomes differed as a function of the method used.

DESIGN

Six assessors evaluated 310 lesions first on bitewings, then with DSR. The overall reproducibility was evaluated via intra-class correlation coefficient (ICC). Intra- and inter-rater reproducibility were assessed using weighted Kappa. Paired t test was used to assess differences in the reproducibility across methods.

RESULTS

The overall reproducibility for DSR was (ICC = 0.47, 95% CI = 0.31-0.56). Intra- and inter-rater reproducibility were 0.65 and 0.44, respectively. The overall reproducibility for bitewings was ICC = 0.45, 95% CI = 0.42-0.57. Intra- and Inter-rater reproducibility were 0.71 and 0.46, respectively. Differences in the reproducibility across methods were not statistically significant. Significantly more lesions were scored as progressed using DSR.

CONCLUSIONS

The reproducibility of DSR in monitoring changes in approximal caries is comparable to that of bitewings. Additionally, DSR detected higher proportion of progression than bitewing assessments.

Impact of visual inspection and radiographs for caries detection in children through a 2-year randomized clinical trial: The Caries Detection in Children-1 study

BACKGROUND

Visual inspection (VIS) with radiographic examination (RAD) is the recommended diagnostic strategy for detecting caries in children; however, this recommendation is based on accuracy studies. The authors conducted a clinical trial to compare the detection and subsequent treatment of carious lesions in primary molars performed with VIS alone and with RAD.

METHODS

Children (3-6 years old) were randomly assigned to 2 groups according to the diagnostic strategy used for caries detection on primary molars: VIS or RAD. Participants were diagnosed and treated according to the management plan related to the allocated group. The primary outcome was the number of new operative interventions during the 2-year follow-up period. Other secondary outcomes were also compared. Comparisons were performed with Mann-Whitney test using an intention-to-treat approach.

RESULTS

Of the 252 children included and randomized, 216 were followed-up after 2 years (14.3% attrition rate). There was no difference between the groups for the primary outcome (P = .476). For the secondary outcomes, the RAD group had more restoration replacements (P = .038) and more restorations performed since the beginning of the study (P = .038) compared with the VIS group. In addition, the RAD group had a higher number of false-positive results than the VIS group (P < .001).

CONCLUSIONS

Simultaneous use of VIS and RAD for caries diagnosis in primary molars of children who seek dental treatment does not provide additional benefits compared with VIS alone.

PRACTICAL IMPLICATIONS

Dentists should perform VIS only, not RAD, for detecting carious lesions in preschool-aged children. ClinicalTrials.gov: NCT02078453.