Impact of the radiographic examination on diagnosis and treatment decision of caries lesions in primary teeth--the Caries Detection in Children (CARDEC-01) trial: study protocol for a randomized controlled trial

Challenges in conducting clinical research in primary care dentistry

The integration of dentistry into primary health care is crucial for promoting patient well-being. However, clinical studies in dentistry face challenges, including issues with study design, transparency, and relevance to primary care. Clinical trials in dentistry often focus on specific issues with strict eligibility criteria, limiting the generalizability of findings. Randomized clinical trials (RCTs) face challenges in reflecting real-world conditions and using clinically relevant outcomes. The need for more pragmatic approaches and the inclusion of clinically relevant outcomes (CROs) is discussed, such as tooth loss or implant success. Solutions proposed include well-controlled observational studies, optimized data collection tools, and the integration of artificial intelligence (AI) for predictive modelling, computer-aided diagnostics and automated diagnosis. In this position paper advocates for more efficient trials with a focus on patient-centred outcomes, as well as the adoption of pragmatic study designs reflecting real-world conditions. Collaborative research networks, increased funding, enhanced data retrieval, and open science practices are also recommended. Technology, including intraoral scanners and AI, is highlighted for improving efficiency in dental research. AI is seen as a key tool for participant recruitment, predictive modelling, and outcome evaluation. However, ethical considerations and ongoing validation are emphasized to ensure the reliability and trustworthiness of AI-driven solutions in dental research. In conclusion, the efficient conduct of clinical research in primary care dentistry requires a comprehensive approach, including changes in study design, data collection, and analytical methods. The integration of AI is seen as pivotal in achieving these objectives in a meaningful and efficient way.

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.

Survival rate of primary molar restorations is not influenced by hand mixed or encapsulated GIC: 24 months RCT

BACKGROUND

Glass ionomer cements (GIC) have been considered the top option to restore primary teeth by dentists. The most common supply forms are hand mixed and encapsulated GIC. There is a lack of information about the impact of different GIC supply forms on restoration survival.

METHODS

This randomized clinical trial compared the survival rate of occlusal and occlusoproximal restorations in primary molars using two glass ionomer cements versions: hand-mixed (H/M) and encapsulated (ENC) after 24 months. Children aged 3-10 years who presented dentin caries lesions in primary molars were selected at School of Dentistry, University of São Paulo, Brazil. They were randomly assigned to groups: H /M (Fuji IX^®, GC Europe) or ENC (Equia Fill^®, GC Europe). The occurrence of restoration failure was evaluated by two blinded and calibrated examiners. The analyses were performed in Stata 13 (StataCorp, USA). To evaluate the primary outcome (restoration survival), we  performed a survival analysis. Additionally an intention to treat (ITT) analysis were done at 24 months of follow-up. Cox Regression with shared frailty was performed to assess association between restoration failure and independent variables (α = 5%).

RESULTS

A total of 324 restorations were performed in 145 children. The survival for H/M group was 58.2% and 60.1% for ENC, with no difference (p = 0.738). Occlusoproximal restorations had lower survival rate when compared to occlusal ones (HR = 3.83; p < 0.001).

CONCLUSIONS

The survival rate in primary molars is not influenced by the different supply forms of GIC. Also, occlusoproximal restorations present reduced performances when compared to occlusal cavities.

TRIAL REGISTRATION

This randomized clinical trial was registered on ClinicalTrials.Gov on 10/15/2014 under protocol (NCT02274142).

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.

Pulp liner materials in selective caries removal: study protocol for a randomised controlled trial

INTRODUCTION

The literature shows that selective carious tissue removal (SCTR) decreases the number and diversity of bacteria, stops the caries process and reduces the risk of pulp exposure. However, no consensus exists on which pulp liner would be suitable for teeth undergoing SCTR. So, this study will verify the in vivo response of dentine-pulp complex after SCTR in primary teeth with or without pulp liner material.

METHODS AND ANALYSIS

A randomised clinical trial, double-blinded, parallel-group and allocation concealment will be conducted with the enrolment of 384 patients from 5 to 9 years, with one maxillary/mandibular first/second primary molars with deep occlusal/occlusoproximal cavities. The remaining dentine will be lined with calcium hydroxide cement-group 1; mineral trioxide aggregate-group 2 and without liner-group 3. The primary outcome will be success of the of dentine-pulp complex evaluated clinically and radiographically at 6, 12 and 24 months, while the secondary outcomes will be the measurement of the dentine barrier on periapical radiographs. During all study, two trained and calibrated examiners will evaluate the treated teeth clinically and radiographically. Interexaminer and intraexaminer reliability will be verified by casual and systematic error. The Kolmogorov-Smirnov test will be adopted to test the normality of continuous variables. Comparisons among groups will be performed by using the χ² test and anaylsis of variance, followed by Tukey test (p<0.05). The logistic regression will be applied, and the degrees of this association will be measured using the OR and 95% CI.

ETHICS AND DISSEMINATION

The present protocol was submitted and approved by the Ethical Committee of the University of São Paulo, Bauru, São Paulo, Brazil (CAAE: 79123517.0.0000.5417). Consent for publication will be obtained from all parents or legal guardians. Results of this study will be reported in full through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

RBR-9fsxnn.

What diagnostic strategy performs better for caries lesion detection on proximal surfaces of adolescents?

OBJECTIVE

To evaluate the performance of visual inspection alone and associated to radiographic and laser fluorescence (LF) methods in detecting non-evident caries lesions at adolescents' proximal surfaces.

MATERIALS AND METHODS

Adolescents (12 to 17 years old) were assessed for the presence of caries lesions through visual inspection, radiographic examination, and LF method (DIAGNOdent pen), at non-cavitated (NC) and cavitated lesion (CAV) thresholds. Temporary separation with orthodontic rubbers followed by direct visual inspection was the reference standard method. Two examiners conducted the examinations, and the first examiner reassessed around 20% of the sample, to evaluate inter- and intra-examiner reproducibility, respectively. Sensitivity, specificity, accuracy, and utility values were calculated for the methods alone and combined with visual inspection using two different strategies: simultaneous and sequential combination.

RESULTS

A total of 834 proximal surfaces (51 adolescents) were included. Visual inspection presented higher reproducibility values (higher than 0.98). Moreover, visual inspection presented higher sensitivity (around 0.51) than those obtained with other diagnostic strategies (varying from 0.09 to 0.20) at the NC threshold. For CAV, visual inspection presented higher specificity (0.996) than the sequential association with adjunct methods (around 0.97), but with lower sensitivity. Accuracy and utility values for combined strategies were similar or lower than those achieved with the visual inspection performed alone.

CONCLUSION

Visual inspection alone performs better for detecting caries lesions in premolars and molars of adolescents than other diagnostic strategies.

CLINICAL RELEVANCE

The best diagnostic strategy for caries detection of proximal caries lesions in adolescents is the visual inspection alone.

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.

Study protocol for a diagnostic randomized clinical trial to evaluate the effect of the use of two clinical criteria in the assessment of caries lesions around restorations in adults: the Caries Cognition and Identification in Adults (CaCIA) trial

Background

The assessment of restored teeth in dentistry remains a challenge, mainly related to the detection of caries around restorations. There is a diversity of clinical criteria available to assess the caries lesions, resulting in differences in the dentists’ diagnosis and treatment decisions. In addition, there is a lack of evidence regarding the best criteria to detect caries lesions around the restorations. Thus, the present protocol aims to evaluate the effect of using 2 visual criteria to assess restored teeth on the outcomes related to oral health in adults.

Methods

The design protocol of the Caries Cognition and Identification in Adults trial correspond to a triple-blind randomized, controlled clinical trial with parallel-groups. Two groups will be compared: patients who will receive the diagnosis and treatment decision according to FDI (World Dental Federation) criteria—FDI group; and patients who will receive diagnosis and treatment decision according to the “Caries Associated with Restorations or Sealants” criteria defined by the International Caries Classification and Management System (ICCMS group). The participants will be followed up after 6, 12, 18, 24, and 60 months, and the restoration failure will be the primary outcome. The analysis will be conducted through Cox regression with shared frailty. The impact of oral health on quality of life and the cost-effectiveness of the methods used will be the secondary outcomes. Two-tailed analyzes will be used, considering a level of significance of 5%.

Discussion

This is the first clinical trial to assess the effect of using two visual methods to detect caries lesions around restorations on the outcomes related to oral health in adults. The findings of this study will define what is the best diagnostic strategy for the assessment of caries around restorations in permanent teeth.

Trial registration NCT03108586 (registered 11 April 2017).

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.

An In Vivo Investigation of Diagnostic Performance of DIAGNOdent Pen and the Canary System for Assessment and Monitoring Enamel Caries under Fissure Sealants

Aim and Objectives

The aim of this study was to evaluate and compare the diagnostic performance of a quantitative light-induced fluorescence (DIAGNOdent pen [DP]) and a photothermal radiometry (Canary System [CS]) for assessment and monitoring occlusal enamel caries under fissure sealants placed on young permanent teeth.

Materials and Methods

Forty-five patients of mean age 9.96 (1.4) years, having at least two occlusal surface sites of non-cavitated lesions (International Caries Detection and Assessment System [ICDAS], 1-3 at baseline), were assigned for this clinical study as per specific inclusion/exclusion criteria. A total of 90 permanent teeth were examined using a visual examination method (ICDAS), a quantitative light-induced fluorescence (DP), and a photothermal radiometry (CS). Teeth were randomly divided into two groups based on the type of fissure sealants: a resin sealant and a glass-ionomer sealant. Sealants were placed over the study sites, and caries assessment was performed with each caries detection method at 3- and 6-month recall appointments. Numerical data were presented as mean, standard deviation, median, and interquartile range values. Qualitative data were presented as frequencies and percentages. Receiver operating characteristic (ROC) curve was constructed to determine the diagnostic accuracy measures of the two modalities and compared using z-statistic. ROC curve analysis was performed with MedCalc software, Ostend, Belgium, version 11.3 for Windows (MedCalc Software). Changes by time in caries progression were analyzed using McNemar test and Cochran Q test. The significance level was set at P ≤ 0.05. Statistical analysis was performed with the IBM Statistical Package for the Social Sciences (SPSS) software for Windows, version 23.0 (IBM, Armonk, New York).

Results

The CS and DP were able to distinguish between sound and carious tissue beneath fully and partially retained sealants at 6-month follow-up with an accuracy of 46.7% and 33.4%, respectively.

Conclusion

The diagnostic performance of the CS and DP are acceptable and can be considered as useful adjunct tools in the clinical evaluation and monitoring the changes in enamel due to lesion progression under fissure sealants. However, in the clinical setting, sensitivity and specificity of these devices may be influenced by the sealant type, thickness, retention, and the differences in the lesion characteristics over time.

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

OBJECTIVES

To evaluate the impact of radiographic examination on changes of treatment decision related to dental caries compared to decisions guided by visual inspection alone in primary molars.

MATERIALS AND METHODS

A total of 126 children aged 3-6 years who had sought dental assistance were randomly selected and examined by two calibrated examiners using visual inspection. A treatment plan regarding dental caries was generated based on this assessment. The same examiners then evaluated two bitewing radiographs, creating an additional treatment plan guided by concurrent assessment of both visual and radiographic methods. Occlusal and proximal surfaces of primary molars received a treatment decision as follows: (i) no treatment, (ii) non-operative treatment, and (iii) operative treatment. The frequency of changes in the treatment decision after radiographic examination was calculated, with subsequent Poisson multilevel regression analysis to evaluate variables influencing such changes.

RESULTS

Changes from "no treatment" decided with visual inspection to "non-operative treatment" after radiographic evaluation occurred in 52 surfaces (3.2%), and changes to "operative treatment" were observed in 46 dental surfaces (2.8%). Furthermore, 50 surfaces (6.2%) had their treatment decision changed from non-operative to operative treatment after radiographic assessment. In addition, changes were significantly more frequent in children with higher caries experience, on proximal surfaces and in 1st primary molars.

CONCLUSIONS

The impact of radiographic examination on changes in the treatment decision of primary molars made with visual inspection is modest. Changes are more frequent in children with higher caries experience and in proximal surfaces.

CLINICAL RELEVANCE

The benefits of the radiographic method for detecting caries in children, as a protocol in the diagnostic process, seem to be overestimated; the impact of this method on changes in treatment decision made by visual examination alone is low. Radiographs could be, however, useful in particular conditions, such as in children with high caries experience.

The effect of bitewing radiography on estimates of dental caries experience among children differs according to their disease experience

BACKGROUND

Radiography is a regularly used and accepted adjunct to visual examination in the diagnosis of dental caries. It is assumed that not using radiographs can lead to underestimation of dental caries experience with most reports having involved studies of young adults or adolescents, and been focused on the permanent dentition. The aim of this study was to determine the relative contributions of bitewing radiography and clinical examination in the detection of dental caries in primary molars and to determine whether those contributions differ according to caries experience.

METHODS

A cross-sectional study was conducted, involving examinations undertaken in dental clinics. Bitewing radiographs taken at the time of the clinical examination were developed and read later, with the data from those used at the analysis stage to adjust the caries diagnosis for the mesial, occlusal and distal surfaces of the primary molar teeth. Children's clinically determined dmfs score was used to allocate them to one of three caries experience groups (0 dmfs, 1-8 dmfs, or 9+ dmfs).

RESULTS

Of the 501 three-to-eight-year-old children examined, nearly three-quarters were younger than six. Caries prevalence and mean dmfs after clinical examination alone and following radiographs were 63.1% and 4.6 (sd, 6.2), and 74.7% and 5.8 (sd, 6.5) respectively. Among children with a dmfs of 1-8, the number of lesions missed during the clinical examination was greater than the number of 106 (25.6%) in children with a dmfs of 9+. In the 185 children with no apparent caries at clinical examination, 124 lesions were detected radiographically, among 58 (46.8%) of those.

CONCLUSIONS

Taking bitewing radiographs in young children is not without challenges or risks, and it must be undertaken with these in mind. Diagnostic yields from bitewing radiographs are greater for children with greater caries experience. The findings of this study further support the need to consider using bitewing radiographs in young children to enhance the management of lesions not detected by a simple visual examination alone.

TRIAL REGISTRATION

ACTRN12614000844640 .

The Influence of Cognitive Bias on Caries Lesion Detection in Preschool Children

We aimed to evaluate whether children’s caries experience exerts an influence on the performance of visual and radiographic methods in detecting nonevident proximal caries lesions in primary molars. Eighty children (3–6 years old) were selected and classified as having a lower (≤3 decayed, missing, or filled surfaces; dmf-s) or higher (> 3 dmf-s) caries experience. Two calibrated examiners then assessed 526 proximal surfaces for caries lesions using visual and radiographic methods. As a reference standard, 2 other examiners checked the surfaces after temporary separation. Noncavitated and cavitated lesion thresholds were considered and Poisson multilevel regression analyses were conducted to evaluate the influence of caries experience on the performance of diagnostic strategies. Accuracy parameters stratified by caries experience were also derived. A statistically significant influence of caries experience was observed only for visual inspection, with more false-positive results in children with a higher caries experience at the noncavitated lesion threshold, and more false results at the cavitated threshold. The detection of noncavitated caries lesions in children with a higher caries experience was overestimated (specificity = 0.696), compared to children with a lower caries experience (specificity = 0.918), probably due to confirmation bias. However, the examiners underestimated the detection of cavitated lesions in children with a higher caries experience (sensitivity = 0.143) compared to lower-caries-experience children (sensitivity = 0.222), possibly because of representativeness bias. The radiographic method was not influenced by children’s caries experience. In conclusion, children’s caries experience influences the performance of visual inspection in detecting proximal caries lesions in primary teeth, evidencing the occurrence of cognitive biases.

Responsiveness of the Early Childhood Oral Health Impact Scale (ECOHIS) is related to dental treatment complexity

BACKGROUND

The responsiveness of the Early Childhood Oral Health Impact Scale (ECOHIS) has varied greatly across studies; hence, we hypothesized that this discrepancy could be related to the complexity of dental treatment received. Thus, we aimed to evaluate the responsiveness of the ECOHIS to changes in oral health-related quality of life (OHRQoL) following dental treatments of varying complexity in preschool children.

METHODS

Preschool children aged 3 to 6 years were selected; their parents responded to the ECOHIS at baseline. The parents responded to the ECOHIS again and a global transition question 30 days after the children were treated. The type of treatment received by the children was categorized according to complexity, as follows: 1) non-operative treatment only, 2) restorative treatment, and 3) endodontic treatment and/or tooth extraction. Change scores and effect sizes (ES) were calculated for total scores, as well as considering the different treatment types and global transition question responses.

RESULTS

Of the 152 children who completed the study, the ECOHIS yielded large ES for total scores (0.89). The children showed increasing ES values associated with better perception of improvement, assessed by the global transition question. The magnitude of ES after treatment was related to treatment complexity (0.53, 0.92 and 1.43, for children who received non-operative treatment only, restorative treatment, and endodontic treatment and/or tooth extraction, respectively).

CONCLUSIONS

Parents whose children required more complex dental treatment are more likely to perceive treatment-related changes to OHRQoL assessed with the ECOHIS.