Edwina Kidd

Reproducibility and Accuracy of Three Methods for Assessment of Demineralization Depth on the Occlusal Surface: An in vitro Examination

This laboratory study of 100 occlusal surfaces investigated the reproducibility and accuracy of a visual ranked caries scoring system, an electronic caries scoring system (ECM) using a continuous conductance scale, and a radiographic ranked caries scoring system. Histological examination of the teeth served as a gold standard to validate the ability of each system to assess lesion depth and predict softened, demineralized dentine. After training, 3 examiners carried out each scoring system on two separate occasions. Kappa values for visual, ECM and radiographic ranked scoring systems showed good inter- and intra-examiner reproducibility levels and acceptable limits of agreement for ECM readings. When scoring systems were tabulated against histological scores there was a high correlation between the visual and ECM methods and lesion depth in both enamel and dentine, but radiographic examination could not detect enamel caries. When compared to the histological scoring, the Spearman correlation coefficients for the visual scoring ranged between 0.87 and 0.93, for the ECM between 0.80 and 0.85 and for the radiographic scoring system between 0.76 and 0.78. No tooth scored as visually sound had histological evidence of dentine caries. Soft dentine corresponded to demineralization involving the middle third of the dentine or more which was related to visual cavity formation or an ECM reading above 9 (score 3 or 4). The radiograph was an excellent predictor of soft dentine. In conclusion, the new visual system appears promising, but takes time to learn. The reproducibility and accuracy for the ECM is acceptable while radiographs miss early occlusal lesions.

Microleakage : a review

Abstract Microleakage may be defined as the passage of bacteria, fluids, molecules or ions between a cavity wall and the restorative material applied to it. Many techniques have been devised to test the cavity-sealing properties of restorations both in vitro and in vivo . These techniques include the use of dyes, radioactive isotopes, air pressure, bacteria, neutron activation analysis, artificial caries and scanning electron microscopy. Some form of thermal stressing has frequently been included in the experimental protocol. Research has shown that freshly packed amalgam restorations leak but that this leakage tends to decrease as fillings age. Cavity varnishes and liners reduce initial leakage of the material. Many of the tooth-coloured restorative materials in common use have been shown to leak. Acrylic restorations appear particularly susceptible to leakage after thermal stressing. There is some evidence that the newer composite materials may form a good cavity seal.

How ‘Clean’ Must a Cavity Be before Restoration?

The metabolic activity in dental plaque, the biofilm at the tooth surface, is the driving force behind any loss of mineral from the tooth or cavity surface. The symptoms of the process (the lesion) reflect this activity and can be modified by altering the biofilm, most conveniently by disturbing it by brushing with a fluoride-containing toothpaste. The role of operative dentistry in caries management is to restore the integrity of the tooth surface so that the patient can clean. Thus, the question, ‘how clean must a cavity be before restoration?’ may be irrelevant. There is little evidence that infected dentine must be removed prior to sealing the tooth. Leaving infected dentine does not seem to result in caries progression, pulpitis or pulp death. However, some of the bacteria survive. What is their fate and if they are not damaging, why is this?

Detection, Diagnosing, Monitoring and Logical Treatment of Occlusal Caries in Relation to Lesion Activity and Severity: An in vivo Examination with Histological Validation

The aims of the present study were to investigate the ability of 3 experienced clinicians to detect occlusal carious lesions, assess their depth, diagnose their activity and define a logical management for each lesion. The material consisted of 35 third molars scheduled for extraction or surgical removal making it possible to validate the accuracy of the clinical recordings histologically. Examinations were carried out at baseline and after 4 months in order to monitor lesion progression. At the first visit a radiograph was taken; the number of filled surfaces was counted and the oral hygiene assessed generally and by disclosing occlusal plaque of the tooth under examination. After cleaning the occlusal surface caries was recorded in a selected investigation site using a visual ranked caries scoring system, as well as an electrical conductance recording (ECM). Apart from counting fillings and taking new radiographs the same procedure was performed at the second visit, which then was followed by extraction of the tooth. After sectioning the tooth lesion depth was recorded, and lesion activity, based on acid production, was assessed using methyl red dye. Lesion activity was also judged by means of polarized light microscopic examinations of the sections. Results showed strong relationships between the visual, ECM and radiographic assessments and both lesion depth and lesion activity. In contrast, all other parameters were poorly related to lesion activity. Changes in visual assessments and in conductance readings from first to second examination were poorly associated with lesion activity. In conclusion, clinicians are able to detect lesions, predict activity and severity and define a logical management of occlusal caries on the basis of a single examination.

In vitro Evaluation of Five Alternative Methods of Carious Dentine Excavation

This in vitro, split–tooth study aimed to evaluate the efficiency (time taken) and effectiveness (quantity of dentine removed) of four techniques of carious dentine excavation (bur, air–abrasion, sono–abrasion and Carisolv™ gel) compared to conventional hand excavation. Eighty freshly extracted human molars were assigned to four experimental groups (n = 20), sectioned longitudinally through occlusal lesions and pre–excavation colour photomicrographs obtained. Using the natural autofluorescence of carious dentine (detected using confocal laser scanning microscopy) as an objective and reproducible guide, carious dentine removal was assessed in each half of the split tooth sample, comparing hand excavation to the test method. The time taken to reach a cavity floor that was hard to a dental probe was noted and final colour photomicrographs were taken. From the results, it was concluded that bur excavation was quickest but overprepared cavities relative to the autofluorescent signature, whereas Carisolv excavation was slowest but removed adequate quantities of tissue. Sono–abrasion tended to underprepare whereas air–abrasion was more comparable to hand excavation in both the time and amounts of dentine removed. Conventional hand excavation appeared to offer the best combination of efficiency and effectiveness for carious dentine excavation within the parameters used in this study.

A reappraisal of the value of the bitewing radiograph in the diagnosis of posterior approximal caries

The aim of this paper was to re-assess the available literature examining the value of the bitewing radiograph in the diagnosis of approximal caries and to compare the relative values of radiographic and clinical examinations. To this end, results from 29 research studies have been re-presented and tabulated. These results show that the use of the bitewing radiograph is essential if much approximal caries is not to be missed. It is particularly important in the detection of the small lesion which may be managed preventively rather than operatively. Although there is a proper need to ensure that radiographic exposures are minimised, the evidence suggests that both clinicians and epidemiologists must balance this need with the ethical issues associated with failing to employ an established diagnostic aid

Microbiological validation of assessments of caries activity during cavity preparation.

The operative management of primary and secondary caries assumes that all discoloured tissue at the enamel-dentine junction (EDJ) represents active disease and this is removed to arrest the carious process. This study aims to establish clinical criteria to differentiate between active and arrested caries at the EDJ using microbiological assessment of dentine samples to verify its clinical status. Radiographs were available for posterior teeth. Cavities (n = 205) were prepared under rubber dam. After gaining access, areas of the EDJ were chosen and assessments made of consistency (soft, medium, hard), colour (dark brown, mid-brown, pale) and moisture content (wet, dry). Dentine was removed by using a No. 3 round burr and placed in 1 ml of bacteriological culture broth. This sampling procedure was repeated at the same site once during cavity preparation and again when the cavity was judged as fully prepared. Samples were vortexed, diluted and cultured to give viable counts of the total anaerobic microflora, mutans streptococci and lactobacilli; viable counts were expressed as log10 (CFU per sample +1). Results showed no significant differences between the microflora of primary and secondary caries. The number of bacteria recovered diminished significantly as cavities were completed. Initial samples from soft and wet lesions harboured significantly more bacteria, lactobacilli and mutans streptococci than samples from medium, hard or dry lesions. Lesions visible on radiographs harboured more bacteria, including lactobacilli and mutans streptococci, while dentine colour was not discriminatory.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between Visual Examination and a Laser Fluorescence System for in vivo Diagnosis of Occlusal Caries

This study compared a laser fluorescence (LF) system (DIAGNOdent) with a visual caries scoring system for in vivo detection and diagnosis of occlusal caries under the conditions of an epidemiological study, in 132 mandibular and 38 maxillary first permanent molars in 170 children (mean age: 6.85 ± 0.58 years). The teeth were cleaned and occlusal caries status in a selected investigation site recorded using both visual and LF systems. The LF readings were interpreted both according to the cut–off points recommended by the manufacturers and those based on laboratory research with histological validation. The percentage agreement of the LF and visual scoring system was better using the cut–off limits recommended by the manufacturer. Histological validation was not possible in this clinical study, but it appeared that either the LF method was overscoring some lesions or the visual method was underscoring them. Since the LF instrument cannot be expected to differentiate caries from hypomineralisation, it should probably be used as an adjunct to a clinical examination.

Marginal Ditching and Staining as a Predictor of Secondary Caries Around Amalgam Restorations: A Clinical and Microbiological Study

Caries at the margins of restorations is difficult to diagnose. In particular, the relevance of both marginal ditching and staining around amalgam restorations is unclear. This clinical study questions the relevance of marginal ditching and color change to the level of infection of the dentin beneath the margins of amalgam restorations. Clinically visible sites (330) on the tooth/restoration margin were selected on 175 teeth. The enamel adjacent to each site was noted as stained (a grey discoloration) or stain-free. One hundred and seventy-eight sites were clinically intact, 83 sites had narrow ditches (< 0.4 mm), and at 49 sites, wide ditches were present (> 0.4 mm). Twenty sites with frankly carious lesions were also included. Plaque was sampled at the tooth-restoration margin, and the dentin was sampled at the enamel-dentin junction below each site. Samples were vortexed, diluted, and cultured for total anaerobic counts, mutans streptococci, lactobacilli, and yeasts. Plaque samples showed that margins with wide ditches (> 0.4 mm) harbored significantly more bacteria, mutans streptococci, and lactobacilli than did clinically intact margins and margins with narrow ditches. There were no significant differences in the degree of infection of the dentin beneath clinically intact restorations and those with narrow ditches, but samples associated with wide ditches and carious lesions yielded significantly more bacteria, mutans streptococci, and lactobacilli. The color of the enamel adjacent to the sample site was irrelevant to the level of infection of the dentin beneath the filling margin, provided a frankly carious lesion was not present. The results suggest that amalgam fillings where margins show wide ditches or carious lesions should be replaced. Narrow ditches and color change alone should not trigger the replacement of a filling.

Prediction of Secondary Caries around Tooth-colored Restorations: A Clinical and Microbiological Study

Caries at the margins of restorations is difficult to diagnose, and the relevance of staining and ditching around tooth-colored fillings is unclear. This clinical study questions the relevance of marginal color change and marginal ditching to the level of infection of the dentin beneath the margins of tooth-colored restorations. Clinically visible sites (197) on the tooth/restoration margin were selected in 113 teeth. The filling margin and the enamel adjacent to each site were noted as stained or stain-free, and sites were graded as intact, having a narrow ditch, or having a wide ditch. Thirty sites with frankly carious lesions were also included. Plaque was sampled at the toothrestoration margin and the filling removed. The enamel-dentin junction (EDJ) at each sample site was noted as hard or soft when probed, and the dentin was sampled. Samples were vortexed, diluted, and cultured for total anaerobic counts, mutans streptococci, and lactobacilli. There were more bacteria in the plaque over frankly carious cavities, and the dentin was soft and heavily infected. Only 38 out of 167 sites without frankly carious cavities had soft dentin at the EDJ. Both the plaque and dentin in these sites harbored more micro-organisms. However, none of the clinical criteria chosen would reliably predict the presence of this soft dentin. In this study, only a frankly carious lesion at the margin of the filling constituted a reliable diagnosis of secondary caries.