Juliana Gomez

Evidence on existing caries risk assessment systems: are they predictive of future caries?

AIM To critically appraise evidence for the prediction of caries using four caries risk assessment (CRA) systems/guidelines (Cariogram, Caries Management by Risk Assessment (CAMBRA), American Dental Association (ADA), and American Academy of Pediatric Dentistry (AAPD)). This review focused on prospective cohort studies or randomized controlled trials. METHODS A systematic search strategy was developed to locate papers published in Medline Ovid and Cochrane databases. The search identified 539 scientific reports, and after title and abstract review, 137 were selected for full review and 14 met the following inclusion criteria: (i) used as validating criterion caries incidence/increment, (ii) involved human subjects and natural carious lesions, and (iii) published in peer-reviewed journals. In addition, papers were excluded if they met one or more of the following criteria: (i) incomplete description of sample selection, outcomes, or small sample size and (ii) not meeting the criteria for best evidence under the prognosis category of the Oxford Centre for Evidence-Based Medicine. RESULTS There are wide variations among the systems in terms of definitions of caries risk categories, type and number of risk factors/markers, and disease indicators. The Cariogram combined sensitivity and specificity for predicting caries in permanent dentition ranges from 110 to 139 and is the only system for which prospective studies have been conducted to assess its validity. The Cariogram had limited prediction utility in preschool children, and a moderate to good performance for sorting out elderly individuals into caries risk groups. One retrospective analysis on CAMBRAs CRA reported higher incidence of cavitated lesions among those assessed as extreme-risk patients when compared with those at low risk. CONCLUSION The evidence on the validity for existing systems for CRA is limited. It is unknown if the identification of high-risk individuals can lead to more effective long-term patient management that prevents caries initiation and arrests or reverses the progression of lesions. There is an urgent need to develop valid and reliable methods for caries risk assessment that are based on best evidence for prediction and disease management rather than opinions of experts.

In vitro performance of different methods in detecting occlusal caries lesions

UNLABELLED Early caries detection is essential for the implementation of preventive, therapeutic and intervention strategies within general dental practice. OBJECTIVE The aim of this study was to compare the in vitro performance of the International Caries Detection and Assessment System (ICDAS), digital photographs scored with ICDAS (ICDAS photographs), fibre-optic transillumination (FOTI), optical coherence tomography (OCT), SoproLife(®) camera and two implementations of quantitative light-induced fluorescence a commercial (QLF-Inspektor Research systems) and a custom (QLF-Custom) system, to detect early and intermediate occlusal lesions. METHODS One hundred and twelve permanent extracted teeth were selected and assessed with each detection method. Histological validation was used as a gold standard. The detection methods were compared by means of sensitivity, specificity, areas under receiver operating characteristic (AUROC) curves for enamel and dentine levels and with the Spearmans rank correlation coefficient against histology. RESULTS For any enamel or dentine caries detection, the AUROC curves ranged from 0.86 (OCT) to 0.98 (ICDAS and ICDAS photographs, SoproLife(®) camera) and at the dentine level from 0.83 (OCT) to 0.96 for FOTI. The correlations with histology ranged between 0.65 (OCT) and 0.88 (ICDAS and FOTI). Under in vitro conditions, the assessed detection methods showed excellent intra-examiner reproducibility. All the methods were strongly correlated with histology (p<0.01) except OCT which showed a moderate correlation (0.65). CONCLUSION Even though all methods present similar performance in detecting occlusal caries lesions, visual inspection seems to be sufficient to be used in clinical practice for detection and assessment of lesion depth. Other methods may be useful in monitoring caries lesion behaviour.

Non-Cavitated Carious Lesions detection methods: a systematic review

The aim of this study was to critically appraise the performance of detection methods for non-cavitated carious lesions (NCCLs). A detailed search of Medline (via OVID), the Cochrane Collaboration, Scielo and EMBASE identified 2054 publications. After title and abstract review by three investigators (JG, MT, AI), 124 publications were selected for further review. The final publications evaluated the following methods: Visual (V), Caries Lesion Activity Assessment (CLAA), Laser Fluorescence (LF), Radiographic (R), Fibre-optic Transillumination (FOTI), Electrical Conductance (EC) and Quantitative Light-induced Fluorescence (QLF). All included studies used histological assessment as a gold standard for in vitro studies or clinical/visual validation for the in vivo designs. They reported outcomes measures such as sensitivity (SE), specificity (SP), area under the receiver operating characteristic curve (AUROC) and reliability. Data were extracted from the selected studies independently by two reviewers and checked for errors. The quality of the studies was evaluated as described by Bader et al. (2002). Of the 124 articles, 42 were included that described 85 clinical assessments. Overall, the quality of evidence on detection methods was rated ‘poor’, except for EC that was rated ‘fair’. The SE rates were as follows: V (0.17–0.96), LF or DIAGNOdent (DD) (0.16–0.96), R (0.12–0.84), FOTI (0.21–0.96), EC (0.61–0.92) and QLF (0.82). The SP rates were as follows: V (0.46–1.0), LF (0.25–1.00), R (0.55–0.99), FOTI (0.74-0.88), EC (0.73–1.0) and QLF (0.92). There is a large variation in SE and SP values for methods and a lack of consistency in definition of disease and analytical methods. EC and QLF seem to be promising for detection of early lesions. For both cost and practicality considerations, visual methods should remain the standard for clinical assessment in dental practice.

Detection and diagnosis of the early caries lesion

The purpose of this manuscript is to discuss the current available methods to detect early lesions amenable to prevention. The current evidence-based caries understanding, based on biological concepts, involves new approaches in caries detection, assessment, and management that should include non-cavitated lesions.Even though the importance of management of non-cavitated (NC) lesions has been recognized since the early 1900s, dental caries have been traditionally detected at the cavitation stage, and their management has focused strongly on operative treatment. Methods of detection of early carious lesions have received significant research attention over the last 20 years. The most common method of caries detection is visual-tactile. Other non-invasive techniques for detection of early caries have been developed and investigated such as Quantitative Light-induced Fluorescence (QLF), DIAGNOdent (DD), Fibre-optic Transillumination (FOTI) and Electrical Conductance (EC). Based on previous systematic reviews, the diagnosis of NCCLs might be more accurately achieved in combination of the visual method and the use of other methods such as electrical methods and QLF for monitoring purposes.

Caries clinical trial methods for the assessment of oral care products in the 21st century.

Traditionally, caries clinical trials of oral care products have focused on the prevention of caries in children and adolescents at the “cavitation” level. Because of a general reduction in caries incidence and the use of positive control comparators, studies have grown both in size and duration to improve statistical power. Currently, they tend to be of 2 to 3 years’ duration, with up to 2,000 high-risk individuals per group. During the past decade, there has been a shift in emphasis from a restorative approach to the treatment of dental caries to a therapeutic approach focused on the remineralization of early caries lesions. However, caries clinical trials of oral care products have not often reflected this paradigm change. This manuscript reviews alternative caries clinical trial methods for oral care products. It is concluded that methods focused on the detection and monitoring of enamel caries and root caries, by visual approaches such as ICDAS and instrumental methods such as QLF, Diagnodent, and Electrical Caries Monitors, provide viable alternatives to traditional methods. In particular, such approaches more accurately reflect the modes of action of many therapeutic agents and formulations and may reduce the cost and duration of product innovation.

Quantitative light-induced fluorescence to measure enamel remineralization in vitro.

The aim of this study was to compare the ability of quantitative light-induced fluorescence (QLF) and surface microhardness (SMH) to measure the remineralization of enamel subsurface lesions, using a pH-cycling model including treatment with 0-ppm, 550-ppm or 1,100-ppm sodium fluoride (NaF) dentifrices. Methods: Subsurface lesions were created in human enamel specimens (n = 36) and exposed to a remineralization pH-cycling model for 14 days. The pH-cycling model was performed in an automated system where specimens were subjected to a demineralizing solution for 20 min and treatment for 1 min and were then remineralized for 7 h 39 min, 3 times daily. The treatments consisted of 3 NaF, silica-containing dentifrices (0 ppm F; 550 ppm F; 1,100 ppm F). The outcome variables were: change from baseline in surface hardness and percentage change from baseline in fluorescence. An ANCOVA explored differences between different treatment groups (at the p < 0.05 level). Associations between QLF and SMH were evaluated using Spearmans correlation coefficient. Results: The percentage SMH changes were 14.9 ± 2.1%, 56.6 ± 9.6% and 103.9 ± 14.6% for the 0-, 550- and 1,100-ppm F dentifrices, respectively. The percentage fluorescence changes were 15.6 ± 7.1%, 59.8 ± 11.9% and 85 ± 13.2%, respectively. The differences between all pairwise comparisons were statistically significant for both methods (p = 0.001). QLF correlated with SMH (r = 0.67). Conclusions: Both the SMH and QLF methods demonstrated a significant F dose response for toothpaste in this in vitro remineralization model, and both methods were able to distinguish treatments with different F levels.

Histological validation of near-infrared reflectance multispectral imaging technique for caries detection and quantification

Near infrared (NIR) multispectral imaging is a novel noninvasive technique that maps and quantifies dental caries. The technique has the ability to reduce the confounding effect of stain present on teeth. The aim of this study was to develop and validate a quantitative NIR multispectral imaging system for caries detection and assessment against a histological reference standard. The proposed technique is based on spectral imaging at specific wavelengths in the range from 1000 to 1700 nm. A total of 112 extracted teeth (molars and premolars) were used and images of occlusal surfaces at different wavelengths were acquired. Three spectral reflectance images were combined to generate a quantitative lesion map of the tooth. The maximum value of the map at the corresponding histological section was used as the NIR caries score. The NIR caries score significantly correlated with the histological reference standard (Spearmans Coefficient=0.774, p<0.01). Caries detection sensitivities and specificities of 72% and 91% for sound areas, 36% and 79% for lesions on the enamel, and 82% and 69% for lesions in dentin were found. These results suggest that NIR spectral imaging is a novel and promising method for the detection, quantification, and mapping of dental caries.

Prevention in practice--a summary.

BackgroundThis paper is a summary document of the Prevention in Practice Conference and Special Supplement of BMC Oral Health. It represents the consensus view of the presenters and captures the questions, comments and suggestions of the assembled audience.MethodsUsing the prepared manuscripts for the conference, collected materials from scribes during the conference and additional resources collated in advance of the meeting, authors agreed on the summary document.ResultsThe Prevention in Practice conference aimed to collate information about which diseases could be prevented in practice, how diseases could be identified early enough to facilitate prevention, what evidence based therapies and treatments were available and how, given the collective evidence, could these be introduced in general dental practice within different reimbursement models.ConclusionsWhile examples of best practice were provided from both social care and insurance models it was clear that further work was required on both provider and payer side to ensure that evidence based prevention was both implemented properly but also reimbursed sufficiently. It is clear that savings can be made but these must not be overstated and that the use of effective skill mix would be key to realizing efficiencies. The evidence base for prevention of caries and periodontal disease has been available for many years, as have the tools and techniques to detect, diagnose and stage the diseases appropriately. Dentistry finds itself in a enviable position with respect to its ability to prevent, arrest and reverse much of the burden of disease, however, it is clear that the infrastructure within primary care must be changed, and practitioners and their teams appropriately supported to deliver this paradigm shift from a surgical to a medical model.

DESEMPEÑO CLINICO DE TRES TECNICAS OPERATORIAS EN PREESCOLARES DE BOGOTA: ESTUDIO CLINICO ALEATORIZADO

Objetivo. Evaluar El Comportamiento A 12 Meses De Tres Tecnicas De Restauracion Aplicadas A Ninos De 3 A 5 Anos De Edad De Localidades De Bajos Recursos Economicos En Bogota. Metodos. 477 Sujetos Con Una Lesion De Caries Cavitacional En Un Molar Primario Fueron Incluidos En Este Estudio Clinico Aleatorizado Con Tres Brazos: Grupo tecnica Convencional De Amalgama ; Grupo tecnica Combinada De Ionomero De Vidrio Y, Grupo tecnica Simplificada De Corona De Acero . En Linea Base Se Valoro Caries Dental (ceo-d, ICDAS) Y Riesgo Individual De Caries Y Adicionalmente En Los Casos Seleccionados, Actividad De Caries Y Profundidad De La Preparacion Cavitaria. El Desenlace A Evaluar Fue El Porcentaje De Fallas Para Cada Tecnica, Con Base En Criterios Clinicos De Presencia De Caries, Estado De La Restauracion Y De La Estructura Dental Asociada. Resultados. En Linea Base (n=477) El Ceo-d Fue De 4.6, El Promedio De Superficies Con Criterios ICDAS 1-6 Fue De 26.4 Y, 95% De Los Sujetos Fueron Clasificados Como Riesgo Individual Muy Alto-alto De Caries Dental. En El Seguimiento A 12 Meses (n=258) Los Porcentajes De Fallas Fueron De 53% Para La tecnica Combinada De Ionomero De Vidrio , 18% Para La tecnica Convencional De Amalgama y, De 15% Para La tecnica Simplificada De Corona De Acero . Conclusiones. A Pesar De La Alta Perdida De Muestra (46%), La Corona De Acero Mostro Mejor Desempeno Clinico Despues De Un Ano.

Preclinical Local Anesthesia Education in Dental Schools: A Systematic Review

The aim of this systematic review was to evaluate the published literature on current educational techniques used to teach local anesthesia administration in U.S. dental schools to determine the methods by which potential complications may be minimized and efficacy maximized. A PubMed search was performed in June 2017 on the following terms: (local anesthesia, education, dental) AND (Humans[Mesh]). Out of 136 articles identified, 13 met the study criteria and were included for review. Of those, the nine with outcome measures were included in the qualitative synthesis. With a quality assessment tool designed for this study, the quality of each included article was assessed independently by three of the authors. Three main pedagogies were identified: didactic instruction based on textbooks and lectures, student-to-student injections, and use of anatomic models. However, the effects of these pedagogies on local anesthesia administration efficacy, patient satisfaction, and student confidence in administering local anesthesia were largely not assessed in these studies. Quality assessment of the reviewed articles yielded a mean score of 62% (range 44-83%) for the observational studies and a mean score of 56% (range 47-63%) for the interventional studies. Due to the heterogeneity of the studies assessed, no meta-analysis could be performed. While the experimental and observational studies reviewed provided some insight into the efficacy of current educational techniques, they had numerous methodological inconsistencies. The inconsistency of the available evidence made it difficult to make fully informed curriculum recommendations based on the existing literature.