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Transcript of Caries Diagosis
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Structured Abstract
Objectives
Dental caries is a widespread chronic infectious disease, experienced by almost 80
percent of children by the age of 18 and over 90 percent of adults. Substantial
variation exists in dentists' diagnoses of carious lesions as well as in the methods
dentists use to prevent and manage carious lesions. In addition, new methods for
identifying carious lesions are beginning to appear, and new approaches for the
management of individual carious lesions and for the management of individuals
deemed to be at elevated risk for experiencing carious lesions are emerging. A
systematic review of the literature was conducted to address three related questions
concerning the diagnosis and management of dental caries: (1) the performance
(sensitivity, specificity) of currently available diagnostic methods for carious lesions,
(2) the efficacy of approaches to the management of noncavitated, or initial carious
lesions, and (3) the efficacy of preventive methods in individuals who have
experienced or are expected to experience elevated incidence of carious lesions.
Search Strategy
We conducted two detailed searches of the relevant English language literature from
1966 to October 1999 using MEDLINE, EMBASE, and the Cochrane Controlled Trials
Register. We did not pursue reports in the gray literature, i.e., information not
appearing in the periodic scientific literature. We did hand-search current journals up
to the end of 1999. One search focused on six diagnostic methods (visual and
visual/tactile inspection, radiography, fiberoptic transillumination, electrical
conductance, laser fluorescence) and combinations of these methods. A second
search focused on preventive or management methods for carious lesions, including
fluorides, pit and fissure sealants, health education, dental prophylaxis, oral hygiene,
dental plaque, chlorhexidine, dental sealants, and cariostatic agents.
Selection Criteria
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We included studies in the diagnostic review that used histologic validation of caries
status and either reported results as sensitivity and specificity of the diagnosis or
reported data from which these measures could be calculated. We excluded reports of
diagnostic methods not commercially available. For the review of the dental caries
management literature, we included only reports concerning methods applied or
prescribed in a professional setting. Also, we included only studies performed in vivo
and having a comparison group. In the literature describing the management of
noncavitated carious lesions, we included only studies where the lesion was the unit
of analysis. In the literature describing the management of subjects at elevated risk
for dental caries, we included only studies where such determinations had been made
on an individual subject level based on carious lesion experience and/or bacteriologic
testing.
Data Collection and Analysis
We selected studies for inclusion from among 1,407 diagnostic and 1,478
management reports through independent duplicate reviews of titles, abstracts, and,
where necessary, full papers. We abstracted data (single abstraction, subsequent
independent review) on 39 diagnostic studies and 27 management studies using
different forms for the diagnostic and management studies. Similarly, a separate
quality rating form was completed by the scientific director for the each study.
Different rating forms were employed for the two types of studies.
Main Results
We judged the strength of the evidence describing the validity of all diagnostic
methods evaluated to bepoor. There were almost no reports of diagnostic
performance of any method applied to primary teeth, anterior teeth, and root
surfaces. For posterior occlusal and proximal surfaces of permanent teeth, the
number of available studies was sufficient for some but not all methods. However,
where numbers of studies were sufficient, their quality and/or the variation among
studies precluded establishing unambiguous assessments of sensitivity and specificity.
The variation in sensitivity among methods was generally similar to the variation
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reported within methods. With the exception of electrical conductance, dental caries
diagnostic methods featured criteria that maximized specificity at the expense of
sensitivity: false positive diagnoses were proportionally infrequent compared with
false negative diagnoses. In addition to the limited numbers of studies for certain
teeth and methods, the literature on diagnosis displayed a variety of serious
limitations, including the predominance of in vitro studies, small numbers of
examiners, high prevalences of lesions, and inadequate descriptions of subject
selection, examiner training and reliability, and criteria for diagnoses.
The literature on the management of noncavitated carious lesions consisted of five
studies describing seven experimental interventions. Because these interventions
varied extensively in terms of management methods tested as well as other study
characteristics, no conclusions about the efficacy of these methods were possible. We
rated the evidence for efficacy of methods for the management of noncavitated
lesions as incomplete. Standardization for the determination of noncavitated status is
needed for future studies.
The literature on the management of individuals at elevated risk of carious lesions
consisted of 22 studies describing 29 experimental interventions. We rated the
evidence for the efficacy of fluoride varnish for prevention of dental caries in high-risk
subjects as fairand the evidence for all other methods as incomplete. Because the
evidence for efficacy for some methods, including chlorhexidine, sucrose-free and
xylitol-containing gum, and combined chlorhexidine-fluoride methods, is suggestive
but not conclusive, these interventions represent fruitful areas for further research.
Conclusions
The strength of the evidence available to estimate the validity of diagnostic methods
for carious lesions dental caries is insufficient to the task. For many applications,
there are few studies, and when sufficient numbers of studies are available,
substantial variation among studies and/or the quality of the studies is problematic.
The literature describing the management of two specific dental caries-related
conditions, nonsurgical interventions for noncavitated lesions and prevention of
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lesions in persons at elevated risk for new lesions, is inadequate to permit conclusions
about the efficacy of most methods. Only for two specific applications, fluoride
varnishes in caries-active, high-risk individuals and fluoride-based interventions for
individuals receiving radiotherapy was the evidence rated as fair. For all other
management methods, the evidence was judged to be incomplete. The need for
efficacy determinations is acute as much of modern preventive dental practice is
predicated on the efficacy of management methods for these conditions.
This document is in the public domain and may be used and reprinted without
permission except those copyrighted materials noted for which further reproduction is
prohibited without the specific permission of copyright holders.
Suggested Citation
Bader JD, Shugars DA, Rozier G, et al. Diagnosis and Management of Dental Caries.
Evidence Report/Technology Assessment No. 36 (prepared by Research Triangle
Institute and University of North Carolina at Chapel Hill Evidence-based Practice
Center under Contract No. 290-97-0011). AHRQ Publication No. 01-E056. Rockville,
MD: Agency for Healthcare Research and Quality. June 2001.
Summary
Overview
Dental caries, or cavities, is a chronic infectious disease experienced by more than 90
percent of all adults in the United States. Recent changes in the epidemiology of
dental caries have altered the presentation of the disease so that among children age
5 to 17 years, about 75 percent of the disease is now experienced in 25 percent of the
population. Also, as understanding of the disease process has matured, the range of
management strategies for dental caries has broadened.
Interventions to arrest or reverse the demineralization process that characterizes the
development of a carious lesion are available, and several strategies for identifying
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those persons representing the quarter of the population who will experience an
elevated incidence of dental caries have been reported.
The growing sophistication in available interventions for prevention and nonsurgical
treatment of dental caries is matched by a similar increase in the available methods
for diagnosis of carious lesions. The diagnosis of carious lesions has been primarily a
visual process, based principally on clinical inspection and review of radiographs.
Tactile information obtained through use of the dental explorer or "probe" has also
been used in the diagnostic process. The development of some alternative diagnostic
methods, such as fiberoptic transillumination (FOTI) and direct digital imaging
continue to rely on the dentist's interpretation of visual cues, while other emerging
methods, such as electrical conductance (EC) and computer analysis of digitized
radiographic images, offer the first "objective" assessments, where visual and tactile
cues are either supplemented or supplanted by quantitative measurements.
This relatively recent growth in alternatives available for both diagnosis and
management of dental caries has yet to be fully assimilated by dental practice.
Thorough reviews of methods for diagnosis and management of dental caries should
assist in that assimilation process.
Reporting the Evidence
The clinical questions in this report were developed in conjunction with the planning
committee for the Dental Caries Consensus Development Conference on the Diagnosis
and Management of Dental Caries Through Life (to be held in 2001). The questions
reflect three aspects of the diagnosis and management of dental caries where the
committee perceived either that current clinical practice might not reflect current
knowledge regarding efficacy and effectiveness, or that a review of current evidence
might help stimulate new research.
The first question addresses methods used in caries diagnosis asking what the validity
of each diagnostic technique is. Diagnoses of carious lesions must be made in a
variety of sites -- primary and permanent teeth, occlusal and smooth surfaces, and
coronal and root surfaces.
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Several diagnostic techniques are available, and the ability of these different
techniques to detect carious lesions on specific sites is not widely understood.
The second question concerns the efficacy of nonsurgical strategies to arrest or
reverse the progress of carious lesions before tooth tissue is irreversibly lost. The
relative effectiveness of these conservative treatments is not well identified.
The third question addresses the efficacy of preventive methods among those
individuals who have experienced, or are expected to experience, an elevated
incidence of carious lesions. Dentists are now being urged to identify individuals with
elevated caries activity, but this risk assessment strategy has not been complemented
by the identification of the most effective interventions to mitigate the expected caries
attack.
Methodology
Search Process and Inclusion Criteria
The Evidence-based Practice Center (EPC) review and investigative team conducted
two detailed searches of the relevant English language literature from 1966 to
October 1999 using MEDLINE, EMBASE, and the Cochrane Controlled Trials Register.
The team did not pursue reports in the gray literature (i.e., information not reported
in the periodic scientific literature). The team hand-searched current journals up to
the end of 1999.
One search focused on the following diagnostic methods -- visual and visual tactile
inspection, radiography, fiberoptic transillumination, electrical conductance, laser
fluorescence, and combinations of these methods -- using keywords for the disease
(dental caries, tooth demineralization), diagnostic concepts (oral diagnosis, oral
pathology, dental radiography), and study characteristics and design.
A second search focused on dental caries preventive or management methods, using
keywords for methods (fluorides, pit and fissure sealants, health education, dental
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prophylaxis, oral hygiene, dental plaque, chlorhexidine dental sealants, cariostatic
agents) and study characteristics and design in addition to the disease keywords.
The EPC team applied several inclusion and exclusion criteria to the reports identified
in our literature search. The team included studies in the diagnostic review that used
histological validation of caries status, and either reported results as sensitivity and
specificity of the diagnosis or reported data from which these measures could be
calculated. The team excluded reports of diagnostic methods not commercially
available. For the review of the dental caries management literature, the team
included only reports concerning methods applied or prescribed in a professional
setting, and only studies performed in vivo and having a comparison group.
The two disease management questions that were addressed by the team used the
results of the management review and featured additional inclusion criteria. For the
management of non-cavitated carious lesions, the team included only studies where
the lesion was the unit of analysis. The team accepted several different descriptions of
noncavitated lesions (including the terms "incipient" and "initial)." From the literature
describing the management of subjects at elevated risk for dental caries, the team
included only studies where the classification of elevated risk had been made for
individual subjects and was based on carious lesion experience and/or bacteriological
testing. The team accepted the elevated risk classification described in the paper.
The EPC team selected studies for inclusion from among 1,407 diagnostic and 1,478
management reports through independent duplicate reviews of titles, abstracts, and,
where necessary, full papers, with discussion leading to consensus where
disagreement occurred. Two team reviewers agreed on inclusion status for 97 percent
of the reports at this stage. In addition, the reviewers separately identified six studies
evaluating preventive methods in patients who had received radiotherapy for head
and neck neoplasms (a special high-risk group) and seven studies evaluating
preventive methods in patients with orthodontic bands or brackets (another special
high-risk group). The team believed that these studies should be included in the
review, but not combined with the main group of studies due to substantial
differences in lesions and study methods.
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The team abstracted data (single abstraction, subsequent independent review) on 39
diagnostic studies and 27 management studies, using different forms for the
diagnostic and management studies. Four reviewers were involved in the abstraction
process, with reviewer agreement rates of 100 percent for results and 88 percent for
other study descriptors. Separate quality rating forms were completed by the EPC
team's scientific director for the two types of studies. The quality rating scales
assessed several elements of internal validity, including study design, duration,
sample size, blinding, baseline assessments of differences among groups, loss to
followup, and examiner reliability. Two items also requested the reviewer's subjective
assessment of both the internal and external validity of the study.
The team compiled the abstracted data in a series of six evidence tables, one each for
in vivo and in vitro radiographic studies, studies of management of noncavitated
carious lesions and individuals at elevated risk for carious lesions, and studies of
special populations of orthodontic patients and patients who received head and neck
radiotherapy. The team then graded the evidence summarized in the tables.
For the diagnostic question, the strength of the evidence was judged in terms of the
extent to which it offered a clear, unambiguous assessment of the validity of a
particular method for identifying a specific type of lesion on a specific type of surface.
The three possible ratings were:
Good (A): The number of studies is large, the quality of
the studies is generally high, and the results of the studies
represent narrow ranges of observed sensitivity and specificity.
Fair (B): There are at least three studies, the quality of
the studies is at least average, and the results represent
moderate ranges of observed sensitivity and specificity.
Poor (C): There are fewer than three studies, or the
quality of the available studies is generally lower than average,
and/or the results represent wide ranges of observed
sensitivities and/or specificities.
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For purposes of this question, a narrow range is defined as no more than 0.15 on a
scale of 0.0 to 1.00, a moderate range is no more than 0.35, and a wide range is
more than 0.35. High quality is defined as most study scores at or above 60, and
average quality is defined as most study scores at or above 45.
For the management studies, the team used a scheme based on several
considerations, including the magnitude of the results reported, the quality rating
scores of the studies, the number of studies, and the consistency of the results across
studies. The EPC team's scientific and clinical directors independently rated the
interventions and developed an adjudicated final rating. The four possible ratings
were:
Good (A): Data are sufficient for evaluating efficacy.
The sample size is substantial, the data are consistent, and the
findings indicate that the intervention is clearly superior to the
placebo/usual care alternative.
Fair (B): Data are sufficient for evaluating efficacy. The
sample size is substantial, but the data show some
inconsistencies in outcomes between intervention and
placebo/usual care groups such that efficacy is not clearly
established.
Poor (C): Data are sufficient for evaluating efficacy. The
sample size is sufficient, but the data show that the
intervention is no more efficacious than placebo or usual care.
Incomplete Evidence (I) Data are insufficient for
assessing the efficacy of the intervention, based on limited
sample size and/or poor methodology.
Findings
Diagnostic Methods
The EPC team evaluated the strength of the evidence describing the performance of
diagnostic methods separately for cavitated lesions, lesions involving dentin, enamel
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lesions, and any lesions. The team also separated the evaluations by the surface and
tooth type involved. The team found 39 studies reporting 126 histologically validated
assessments of diagnostic methods.
There are few assessments of the performance of any
diagnostic methods for primary or anterior teeth and no
assessments of performance on root surfaces. The strength of
the evidence describing the performance of any method for
these teeth and surfaces ispoor.
Among studies assessing diagnostic performance for
proximal and occlusal surfaces in posterior teeth, the team
rated the strength of the evidence describing the performance
of visual/tactile, FOTI, and laser fluorescence methods aspoor
due to the small numbers of studies available.
The team also rated the strength of the evidence for
radiographic, visual, and EC methods aspoorfor all types of
lesions on posterior proximal and occlusal surfaces. However,
these ratings were due less to inadequate numbers of
assessments than to variation among reported results. In one
instance, the quality of the available studies was the principal
reason for the rating.
For all but EC assessments, specificity of a diagnostic
method was generally higher than sensitivity. Thus, false
negative diagnoses are proportionally more apt to occur in the
presence of disease than are false positive diagnoses in the
absence of disease.
The evidence did not support the superiority of either
visual or visual/tactile methods. The number of available
assessments was small and there was substantial variation
among reports for each method.
The evidence suggests, but is not conclusive, that some
digital radiographic methods offer small gains in sensitivity
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compared with conventional film radiography on both proximal
and occlusal surfaces.
The evidence also suggests, but is not conclusive, that
EC methods may offer heightened sensitivity on occlusal
surfaces, but at the expense of specificity.
The diagnostic performance literature is limited in terms
of numbers of available assessments for most diagnostic
techniques overall, and especially for primary teeth, anterior
teeth, and root surfaces and for visual/tactile and FOTI
methods. The literature is further limited by threats to both
internal and external validity represented by incomplete
descriptions of selection and diagnostic criteria and examiner
reliability, the use of small numbers of examiners,
nonrepresentative teeth, samples with high lesion prevalence,
and a variety of reference standards of unknown reliability.
Management of Noncavitated Carious Lesions
We found only five studies addressing this topic. The evidence was rated as
incomplete.
This literature is limited by:
Differences in treatment provided to comparison groups
and in how noncavitated lesions are defined.
Problems in the identification and control of patient
exposure to community-based and individual preventive dental
procedures.
High loss to followup due in part to limiting analyses
only to full participants.
All of these limitations make drawing conclusions difficult.
Management of Caries-Active Individuals
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The EPC team evaluated the evidence for nine management methods: fluoride
varnishes, fluoride topical solutions, fluoride rinses, chlorhexidine varnishes,
chlorhexidine topicals, chlorhexidine rinses, combined chlorhexidine-fluoride
applications, sealants, and other approaches. The team based its review on 22 studies
that described 29 experimental interventions evaluating these. The team also
examined 13 studies of special at-risk populations (orthodontic and head and neck
radiotherapy patients).
The team rated the evidence for the efficacy of fluoride
varnishes as fair, and the evidence for all other methods as
incomplete.
The evidence for efficacy was suggestive for
chlorhexidine varnishes and gels, for combination treatments
including chlorhexidine, and for sucrose-free gum, but in each
instance the number of studies was too small or the results
were too variable to be conclusive.
Among subjects undergoing orthodontic treatment with
attached bands or brackets, the team found the evidence for
efficacy of fluoride interventions to be suggestive but
incomplete. Evidence was also incomplete for all other
prevention methods for these subjects.
Among patients receiving head and neck radiotherapy,
the literature offers fairevidence of the efficacy of fluoride-
based interventions. The evidence was incomplete for any other
types of preventive interventions among these patients.
The team found no reports of substantive harms
associated with any interventions.
The team found the number of available studies for any
specific method to be a serious limitation. Among studies
addressing a method, the variety of experimental protocols,
comparison groups, and other community and individual
preventive dentistry exposures further restricted the
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opportunity to draw conclusions about the efficacy of the
method. Finally, generalization from the studies to the broader
U.S. population is problematic, as nearly all studies included
only children and evaluated changes only in the permanent
dentition.
Future Research
Research is needed to evaluate the performance of all diagnostic methods currently
available to dental practitioners. Such research should focus on in vivo settings to the
extent possible, despite difficulties imposed by the requirement for histological
validation in that environment. Methods for histological validation should be
standardized, and a standard reporting format for evaluation of diagnostic
performance should be formulated. Several aspects of study designs in this literature
should be strengthened, including using samples with representative lesion
prevalences and presentations, increasing the numbers of examiners whose
performance is assessed, and ensuring examiner blinding for determinations of both
experimental diagnoses and reference standards. Finally, research is needed to
evaluate the "downstream" performance of diagnostic methods; i.e., the
appropriateness of treatment provided in response to the diagnosis and diagnostic
performance in detection of changes in lesion volume.
Additional clinical studies examining outcomes of management strategies for
noncavitated lesions and for caries-active patients are clearly needed. Here
investigators must be encouraged to contribute studies that fill identified gaps, that
build upon existing findings, and that use methods that facilitate comparison across
studies. Funders and editors are important gatekeepers in this respect.
Whenever possible, studies should use comparison groups representing the most
common alternative treatment, and they should document all professional,
community, and individual preventive dentistry exposures for all subjects. Intention to
treat analyses, where all outcomes of all subjects enrolled at baseline are included in
the analyses, are to be encouraged as well.
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Secondary analyses of existing studies of preventive agents might be exploited in the
short-term to augment the meager store of knowledge for both noncavitated lesions
and caries-active individuals. However, some additional efforts need to be extended
for the development of valid standard criteria for these classifications.
Chapter 1. Introduction
Primary Objectives and Scope of this Evidence Report
The National Institute of Dental and Craniofacial Research (NIDCR) is collaborating
with the Agency for Healthcare Research and Quality (AHRQ) in supporting a series of
systematic analyses of oral health topics at the beginning of the new century. NIDCR
selected dental caries as the inaugural topic in the series partly because current
approaches to diagnosis, treatment, and prevention of this most widespread of
chronic diseases have become subjects of increased interest as the expression of the
disease in the population has changed.
NIDCR has scheduled a National Institutes of Health (NIH) NIDCR Consensus
Development Conference (CDC) on Diagnosis and Management of Dental Caries
Through Life. The conference will address most aspects of the diagnosis and
prevention of dental caries. The Evidence-based Practice Center (EPC) was asked to
"anchor" the conference through the preparation and presentation of evidence-based
reviews for selected aspects of conference topics. An objective of the CDC, and the
principal objective of the evidence report, is to identify valid diagnostic methods for
various lesions and effective professional preventive strategies for specific types of
lesions and patients.
The treatment of dental caries has long claimed the majority of dentists' efforts, and
until the last three decades, much of that effort was devoted to repairing teeth that
had suffered irreversible loss of tissue and removing teeth deemed unsalvageable.1
With the advent of water fluoridation, fluoridated dentifrices, and both community-
based and professional fluoride treatments, the nature of the disease has gradually
changed for the majority of the population, who now experience what can be
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characterized as a more gradual and limited caries onset, with fewer lesions
manifesting and progression of these lesions seemingly occurring more slowly.2 For a
minority of individuals, however, caries incidence continues unabated, with the result
that although caries is still ubiquitous, a relatively small proportion of the population
now bears a large majority of the disease in terms of the number of lesions
experienced.3 Thus, dentists now routinely encounter a distribution of disease among
their patients that was uncommon two decades ago.
Concomitantly, as knowledge of the carious process is progressively refined, dentists
are increasingly urged to view dental caries as a chronic infection, and more attention
is being paid to the elimination of the infection as a key step in treatment.4
Also,
nonsurgical treatment interventions are gaining in popularity as alternatives to
mechanical replacement of damaged tooth tissue with artificial materials. Thus, at the
same time that differences among patients in caries activity and perceived caries risk
are raising new questions about the appropriate preventive and treatment strategies
for individual patients, the range of possible strategies that can be applied to these
patients is increasing.
This growing complexity in methods for caries management is matched by a similar
increase in the complexity in methods for caries diagnosis. The diagnosis of carious
lesions has been primarily a visual process, based principally on clinical inspection and
review of radiographs. Tactile information obtained through use of the dental explorer
or probe has also been used in the diagnostic process. Chiefly because these methods
depend on subjective interpretation of subtle visual and tactile cues, variation among
dentists' diagnoses had tended to be extensive.5
Some developing alternative
diagnostic methods, such as fiberoptic transillumination (FOTI) and direct digital
imaging, continue to rely on dentists' interpretation of visual cues, whereas other
emerging methods, such as electrical conductance (EC) and computer analysis of
digitized radiographic images, offer the first "objective" assessments, where visual
and tactile cues are either supplemented or supplanted by quantitative
measurements.
Key Clinical Questions
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51883%23A51883http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51884%23A51884http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51885%23A51885http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51886%23A51886http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51883%23A51883http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51884%23A51884http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51885%23A51885http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51886%23A51886 -
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The clinical questions in this report were developed in conjunction with the planning
committee for the CDC. They reflect three aspects of the diagnosis and management
of dental caries where the committee perceived either that current clinical practice
might not reflect current knowledge regarding efficacy and effectiveness or that a
review of current evidence might help stimulate new research.
The first question addresses methods used for identifying carious lesions. At issue is
the validity of each diagnostic technique. Lesions must be identified in a variety of
sites -- primary and permanent teeth, occlusal and smooth surfaces, and coronal and
root surfaces. Several diagnostic techniques are available, and the ability of these
different techniques to detect carious lesions on specific sites may not be completely
appreciated.
The second question concerns the effectiveness of strategies to arrest or reverse the
progress of carious lesions before tooth tissue is irreversibly lost. Early stages of
dental decay involve demineralization of tooth tissues with minimal loss of the organic
matrix. In some instances, dentists can promote remineralization of the matrix, thus
effectively reversing the caries process.6 In other instances, the affected area can be
covered with a protective material without any surgical removal of tooth tissue. The
efficacy of these conservative, nonsurgical caries treatments is not well identified.
The third question addresses the effectiveness of preventive methods in those
individuals who have experienced, are experiencing, or are expected to experience an
elevated incidence of carious lesions. Dentists are now being urged to identify
individuals with elevated caries activity,7but this "risk assessment" strategy has not
been complemented by the identification of the most effective interventions to
mitigate the caries attack in these high-risk individuals.
Technical Expert Advisory Group Involvement
Guidelines from AHRQ require identification of technical experts in diagnosis and
management of dental caries. The Technical Expert Advisory Group (TEAG) (see
Appendix B for its composition) was expected to contribute to (a) advancing AHRQ's
broader goals of creating and maintaining "science partnerships" and "public-private
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51887%23A51887http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51888%23A51888http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51888%23A51888http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51660%23A51660http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51887%23A51887http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51888%23A51888http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hserta&part=A51525#A51660%23A51660 -
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partnerships" and (b) meeting the needs of a broad array of potential users of its
products. Thus, it was both a resource and a sounding board throughout the project.
The TEAG included seven members, three technical experts, two individuals
representing the public health perspective of the population at large, and two
potential users of the final evidence report or other materials.
To ensure scientifically robust work, the TEAG was called upon to provide reactions to
work in progress and advice on substantive issues or possibly overlooked areas of
research. TEAG members participated in conference calls and e-mail solicitations:
At the beginning of the project to discuss the key
clinical questions, initial drafts of causal pathways, and
proposed inclusion and exclusion criteria for research articles.
During the development of abstracting forms to provide
comments concerning the forms, the content proposed for
inclusion in the evidence tables, and the final versions of the
key clinical questions and causal pathways.
When the draft evidence tables were produced to
discuss the content of the tables and the completeness of the
search.
Because of their extensive knowledge of the caries literature and their active
involvement in professional societies, TEAG members were also asked to participate in
the peer review process by commenting on the draft report. In addition to the
contribution of the TEAG, the preparation of the evidence report also benefited from
the contributions of three consultants whose advice was sought informally during all
phases of the project. Subject to their availability, the consultants also participated in
the conference calls.
Dental Caries: Background and Significance
Dental caries is a chronic infectious disease that results in the destruction of tooth
tissue. It is caused by a complex interaction of oral microorganisms in dental plaque,
diet, and a broad array of host factors ranging from societal and environmental
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factors to genetic and biochemical/immunologic host responses.8 Dental caries is also
site specific as each tooth and each site have different susceptibilities because of their
unique anatomical, physiologic, and environmental characteristics. The crown or
coronal portion of a tooth is covered by a layer of enamel. The occlusal surfaces of
posterior crowns have invaginations termed pits and fissures, whereas the facial,
lingual, and proximal aspects of tooth crowns typically are smooth. In contrast, the
tooth root consists of dentin covered by only a thin layer of cementum. These
anatomical variations provide different environmental niches that permit very
different forms of plaque to flourish.
Dental tissues are in a constant state of mineralization and demineralization because
the acidogenic plaque adjacent to enamel surfaces. When this dynamic balance is
disrupted, the caries process can proceed and can result in the destruction of tooth
tissue. Initially there is a diffusion of acids into the enamel and subsurface
demineralization begins to occur. Loss of subsurface enamel can result in a
noncavitated lesion, or white spot lesion. If the balance of the equilibrium shifts to
remineralization, the subsurface layer of enamel can be reformed by deposition of
calcium and phosphate. However, when demineralization dominates, the subsurface
lesion becomes so large that the surface layer of enamel collapses causing cavitation.
Cavitated and noncavitated lesions can progress through the enamel to the
dentoenamel junction (DEJ). Once in dentin, the lesion progresses by following the
dentinal tubules and spreads laterally in a saucer-shape fashion. Root surfaces, which
are composed of a thin layer of cementum over dentin, are much rougher than
coronal (enamel) surfaces, facilitating plaque formation. Compared with coronal
lesions, root lesions have less well-defined margins and exhibit a broad pattern of
progression through the dentin.
Prevalence of Carious Lesions
The Third National Health and Nutrition Examination Survey-Phase I (NHANES III),
conducted from 1988 to 1991, provides the most recent estimates of the prevalence
of carious lesions in the United States.9,10 This survey, which produced nationally
representative estimates for the civilian noninstitutionalized U.S. population, found
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that the mean decayed and filled surfaces (dfs) of primary teeth score in children age
2 to 9 was 3.1. The score varied among racial-ethnic categories: non-Hispanic whites
(2.5), non-Hispanic blacks (2.7), and Mexican-Americans (4.8). Overall, 83 percent of
children age 2 to 4 years had experienced no lesions in the primary dentition, with
this percentage dropping to 50 percent in children 5 to 9 years of age.
Table 1. Mean DS, DMFS, and % DS/DMFS per person by race-ethnicity (more...)
Table 1. Mean DS, DMFS, and % DS/DMFS per person by race-ethnicity in
U.S. children and adolescents age 5 to 17, 1988-91
Race/Ethnicity DS (SE) DMFS (SE) % DS/DMFS (SE) 1
Total 0.4 (0.1) 2.5 (0.2) 19.7 (1.5)
Non-Hispanic Whites 0.3 (0.0) 2.4 (0.3) 14.6 (2.2)
Non-Hispanic Blacks 0.8 (0.1) 2.5 (0.2) 37.9 (3.1)
Mexican-Americans 0.7 (0.1) 2.7 (0.1) 36.4 (2.8)
The overall mean decayed, missing, and filled surfaces (DMFS) of permanent teeth
scores for children age 5 to 17 in various racial-ethnic categories are shown in Table
1, together with the D component scores and the D/DMF proportion, which represents
the relative proportion of an individual's disease experience that has not received
treatment. In this age group, overall DMFS was similar across race-ethnicity
categories, but the proportion of DS in the DMFS varied substantially by race-ethnicity
categories, which may be more of a reflection of access or utilization issues rather
than disease patterns.
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In children age 5 to 11, 74 percent had no carious lesions in the permanent dentition,
whereas for children age 12 to 17, the proportion falls to 33 percent. Overall, carious
lesions in children are not evenly distributed; 75 percent of overall caries experience
in permanent teeth occurred in approximately 25 percent of the population.3 Thus,
although the majority of children have moderate decay or less, carious lesions are a
recurring problem for a substantial minority. Carious lesions are also not equally
distributed across tooth surfaces in this population, as occlusal surfaces experience
lesions five times more frequently than the mesial and distal (smooth) surfaces.
Table 2. Mean DS, DFS, and %DS/DFS per person by race-ethnicity in (more...)
Table 2. Mean DS, DFS, and %DS/DFS per person by race-ethnicity in U.S.
dentate adults, ages 18 Years and older, 1988-91
Race/Ethnicity DS (SE) DFS (SE) %DS/DFS (SE) 1
Total 1.8 (0.0) 22.2 (0.9) 14.2 (0.8)
Non-Hispanic Whites 1.5 (0.1) 24.3 (1.5) 10.6 (0.8)
Non-Hispanic Blacks 3.4 (0.3) 11.9 (3.4) 35.4 (2.8)
Mexican-Americans 2.8 (0.3) 14.1 (2.8) 31.0 (2.6)
In adults 18 and older, evidence of past or present coronal carious lesions was found
in 94 percent of the population. The mean DFS score for dentate adults (those with
one or more teeth) was 22.2. Females exhibited a higher mean number of treated and
untreated surfaces per person. Coronal DFS scores, shown in Table 2, varied by race-
ethnicity, and the proportion of decayed surfaces in the DFS score varied as well.
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Carious root lesions were found in 23 percent of the dentate population overall and in
more than 47 percent of individuals 65 or older. The average number of treated and
untreated root surfaces ranged from a low in non-Hispanic whites of 1.1 to 1.4 in
Mexican-Americans and 1.6 in non-Hispanic blacks.
Burden of Illness from Dental Caries
Because treatment and/or prevention of carious lesions is one of several reasons for
visiting a dentist, and because accurate information describing reasons for dental
visits is not available, the extent to which carious lesions necessitate dental visits is
not known. However, from the preceding section on the prevalence of carious lesions
and filled tooth surfaces, it would seem that racial and ethnic minorities receive
proportionally less treatment for carious lesions than do white non-Hispanics. This
observation is supported from existing data on dental visits. The Surgeon General's
report on oral health11 has assembled data from a number of Federal agencies that
paint a clear picture of differences in the receipt of oral health care by race/ethnicity,
income, and insurance status. In white, non-Hispanic adults, 64 percent reported a
dental visit in 1993 compared with 47 percent of black, non-Hispanic adults and 46
percent of Hispanic adults. For individuals with incomes at or above poverty level, 64
percent reported a dental visit in the previous year compared with 36 percent for
those with incomes below poverty level. In 1989, 70 percent of individuals 2 years
and older with private dental insurance reported a dental visit within the preceding
year compared with 51 percent for those without private dental insurance. Finally,
those individuals who rate their oral health as very good or excellent are more likely
to have visited a dentist in the preceding year (61 percent) than were those assessing
their health as fair or poor (45 percent).
The economic cost of dental caries is also difficult to assess precisely. In 1998,
Americans spent more than $53 billion on dental services.11 From an analysis of
insurance claims, approximately 40 percent of charges are related to restorative
dental services, which are usually, but not always, performed to repair teeth damaged
by carious lesions.12 Thus, even without adding in the cost of more complex services
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necessary to restore function lost as a result of the sequalae of the dental caries
process, expenditures related to caries were more than $20 billion.
Beyond the direct economic costs of dental treatment, there are the less directly
calculable costs associated with the loss of working time, missed school, and reduced
levels of social functioning. The National Health Interview Survey (NHIS) indicates
that 2.9 million acute dental conditions occurred in the U.S. population during 1994.
These dental conditions accounted for an estimated 3.9 million days of missed work in
persons 18 years of age and over, 1.2 million days of missed school in youth 5 to 17
years of age, and 12.2 million days of restricted activity across all ages (e.g.,
nonperformance of usual family role activities).13
The NHIS methods may
underestimate the actual amount of missed time from school and work and restricted
activity days for dental conditions.14,15
Studies of how dental caries affects quality of life are much less empirically
compelling, but experts agree on what the potential effects of dental caries are likely
to be in the short and long term.16 In the short term, physical discomfort and pain are
the most likely consequences of untreated lesions. Physical impacts can be felt
directly as through the pain of toothaches, infections, and temporomandibular joint
disorder resulting in part from a loss of posterior teeth and the failure to replace them
when necessary. The possible eventual inability to eat -- both bite and chew --
because of tooth loss can lead to unnecessary dietary restrictions and nutritional
deficiencies as well as complicate the dietary management of other chronic health
conditions.
The psychological pain of self-consciousness and social isolation may also accompany
the embarrassment of the unsightly deterioration of anterior teeth caused by dental
caries. The same psychological distress can result from the embarrassment of missing
anterior teeth, the communication dysfunction associated with not being able to be
easily understood by others, and the isolation or withdrawal from social intercourse
because of missing teeth. In the long term, left untreated, carious lesions may lead to
the loss of such teeth, the replacement of which may be needed for functional, social,
cosmetic, and physical and mental health reasons.
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Caries Diagnosis
The local result of the dental caries infection is a process of demineralization of tooth
tissue (enamel, dentin, cementum). Acid produced by bacteria as a product of
carbohydrate fermentation causes the demineralization. The diagnosis of dental caries
at a particular site on a tooth is based on either direct or indirect detection of the
demineralized tooth structure.
The principal methods dentists use to diagnose carious lesions -- visual and
visual/tactile examinations and radiographic assessment -- have been employed with
little change for decades. Refinement in techniques, rather than development of new
technology, has characterized these methods over the years. Illumination has
improved and magnification is more easily employed for visual examinations, whereas
radiation doses have decreased for radiographic assessment as both equipment and
film have been improved.
Visual inspection is based on a search for signs of demineralization, which include
changes in color and in surface consistency and contour. Tactile inspection is usually
accomplished with a fine-tipped dental explorer or probe that is passed over smooth
surfaces of teeth as well as pits and fissures. On smooth surfaces, the surface texture
is assessed for roughness as well as breaks in contour. In pits and fissures, the probe
is usually pressed with differing levels of force into depressed areas to assess whether
any penetration is possible and whether there is any resistance to withdrawal of the
probe. Radiographic assessment is based on identification of demineralization of tooth
tissue through differential exposure of film. Demineralized tooth tissue is less
resistant to the passage of ionizing radiation and thus appears darker on film images.
More recently, new technologies have begun to appear that further refine radiographic
diagnosis of carious lesions and offer alternatives to this technology. Digital
radiographic techniques eliminate film by capturing radiographic images on phosphor
storage plates or charge-coupled devices. The images can then be manipulated to
enhance diagnostic features. Fiberoptic transillumination, passing a narrow beam of
light through tooth tissue, has become an adjunctive diagnostic method now used for
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both anterior and posterior teeth, principally on proximal surfaces. Demineralized
tooth tissue appears dark when transilluminated because of its decreased
transmission of light. This method represents refinement of the traditional technique
of transilluminating the anterior proximal surfaces using a mouth mirror and the
operatory light. Measuring the resistance of tooth tissue to an electrical current
passed through it is another approach to caries diagnosis, especially of occlusal
fissure caries. First demonstrated in the 1950s, the technique has been progressively
refined, with devices available commercially since the 1980s. The technique depends
on the fact that when enamel becomes demineralized, it loses much of its resistance
to electrical charges, hence its conductance increases.
The extent of variation in the diagnosis of dental caries is substantial among dental
practitioners using the traditional techniques. Typically agreement among several
dentists is poor to moderate, with kappa values ranging from 0.30 to 0.60 in several
studies.5 The range of positive diagnoses (proportion of teeth diagnosed as carious) is
typically wide for any given sample, often spanning 30 to 40 percentage points.5 The
problem of calibrating dental practitioners to an objective standard for caries
diagnosis results to a large extent from the absence of objective criteria for the
diagnosis;17,18 consequently, dentists tend to develop widely different subjective
patterns or "scripts" that they then use for identification of carious lesions.19This
variation in the diagnosis of carious lesions is a principal contributor to the still
greater variation in the decision to restore teeth through irreversible surgical
intervention20,21 and the concomitant variation in associated costs of those decisions.22
Professionally Administered Methods of Caries Prevention
Caries prevention as accomplished in dental practice has traditionally been viewed as
a combination of several procedures, including oral prophylaxis, topical application of
fluoride, oral self-care instruction, sealants for fissured surfaces, and restoration of
existing carious lesions. Although oral self-care instruction and oral prophylaxis
methods have not changed appreciably over the years, application of topical fluoride
has seen continuing modifications, both in delivery vehicles and in solutions and
concentrations used. Dental sealant technology has similarly become refined, with
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changes in materials and in etching and polymerization techniques. In recent years,
an additional intervention has become available: prescription antimicrobial
mouthrinses. Also, the number of "over-the-counter" (OTC) products that dentists can
specifically recommend for home use has increased, such as remineralization rinses,
salivary substitutes for persons with decreased salivary flow, and candies and gums
with nonfermentable sugars. Finally, simplified testing for mutans streptococci (mS),
the putative pathogen for dental caries, has become commercially available.
As the incidence of carious lesions experienced by most children has decreased in the
past three decades, available approaches to prevention in both children and adults
have become more specific to individual clinical circumstances. The two circumstances
on which this review is focused involve the management of noncavitated carious
lesions and the prevention of carious lesions in caries-active individuals. Noncavitated
carious lesions are areas where demineralization has started, but is not extensive. In
theselesions, no tissue has been lost and no loss of contour or break in continuity of
the enamel surface is detectable. Strategies for preventing these lesions from
progressing to irreversible tissue loss, or cavitation, can include all of the traditional
and more recently developed preventive techniques. The prevention of new carious
lesions in caries-active individuals also can involve the full gamut of professionally
applied preventive procedures.
Variation in Methods to Control Noncavitated Lesions
Little is known about dentists' strategies to reduce or eliminate progression of
noncavitated carious lesions and hence the necessity for surgical intervention. The
previously cited literature on variation in dentists' decisions to initiate treatment
includes some studies of dentists' treatment thresholds. These studies suggest there
is variation in the extent of progression of a carious lesion that individual dentists are
willing to tolerate before they intervene surgically. Unfortunately, these types of
studies must be done using patient vignettes, and there is some suggestion that what
dentists say they do with respect to intervention is often different than what they
actually do in practice.23-26 These studies show that a sizable proportion of dentists
routinely intervene when radiographic evidence of dental caries manifests itself in the
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enamel prior to cavitation. No recent studies are available to document circumstances
surrounding application of nonsurgical means of control, although the continuing
controversy about "sealing over caries"27 suggests that dentists vary in their
willingness to use sealants as a method for the control of unidentified occlusal lesions.
Variation in Methods to Control Caries in Caries-Active
Individuals
Knowledge of dentists' practices in addressing caries control in caries-active
individuals is exceedingly limited. Only recently have the concepts of "caries risk" and
"medical management" emerged in the clinical dental literature.4,7,28,29 These
discussions suggest that practitioners' preventive approaches may not be routinely
based on a careful assessment of the magnitude of the caries challenge. Information
from insurance claims suggests that topical fluoride applications tend to vary by
practitioner, but not by patients within a practice, who all receive the same preventive
care even though they have different rates for restoration receipt.30 Also, a survey of
practitioners shows that commonly used clinical protocols are not congruent with
current recommendations for low-risk individuals.31 Clearly, there is a potential for
both over use and under use of prevention and control methods in a caries-active
population; but studies that examine dentists' preventive treatment behaviors are
rare, and none differentiate treatment by an individual's caries activity.
Organization of this Report
The remainder of this report is organized in the following sections. Chapter 2 provides
details about the literature search and review methods describes the causal pathway
for key questions and approaches to establishing inclusion and exclusion criteria,
conducting the systematic review, abstracting data from articles, maintaining quality
control, assigning quality scores to individual articles, and similar details. Chapter 3
presents the results for the three key clinical questions -- diagnostic methods,
management of noncavitated lesions, and management of caries-active individuals.
Chapter 4 provides conclusions, and Chapter 5 offers recommendations concerning
research on diagnosis and management of dental caries. References cited in the body
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of the report, the six evidence tables, and a list of all literature reviewed for the
preparation of the tables follow. The appendixes contain acknowledgments (Appendix
A), information on the TEAG (Appendix B) and the peer reviewers (Appendix C), data
extraction forms (Appendix D), and acronyms and abbreviations used in this report
(Appendix E).
Chapter 2. Methodology
Overview
This chapter of the report documents the procedures that the Research Triangle
Institute-University of North Carolina at Chapel Hill Evidence-based Practice Center
(RTI-UNC EPC) used to develop a comprehensive evidence report that describes and
contrasts the approaches currently used in the diagnosis of dental caries and in
management of two specific clinical presentations of dental caries. To set the
framework for review, the key questions and their underlying causal pathway are
presented first. This is followed by a detailed description of the literature search,
which includes descriptions of the Medical Subject Headings (MeSH terms) used in the
principal search, other search sources, the inclusion and exclusion criteria, and the
application of these criteria to the results of the searches. Once the RTI-UNC EPC
team determined that studies met the inclusion/exclusion criteria and were eligible for
inclusion, the team abstracted data onto Data Extraction Forms and then transferred
critical information to evidence tables; these forms are also described in this chapter.
The chapter also discusses quality issues, i.e., the RTI-UNC EPC's quality control
procedures with regard to determining the eligibility for inclusion, carrying out the
data abstraction, and developing a quality rating scheme for individual studies. An
evidence report requires an extensive search of all types of literature. Because the
criteria for quality ratings will vary by type of study design, the RTI-UNC EPC
developed quality rating forms specific to the two types of studies included in the
diagnosis and management reviews. This section describes the development of the
rating system and its use in the analysis.
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Key Questions and Causal Pathways
This report addresses three questions. The first concerns diagnosing carious lesions,
the second examines strategies for treatment of early carious lesions, and the third
focuses on management of patients who have multiple carious lesions or are
perceived to be at high risk for developing lesions. All the questions were put in final
form with input from the TEAG and the consultants after an original set of questions
was identified in initial discussions with the planning committee for the CDC on the
Diagnosis and Management of Dental Caries Throughout Life.
Final Key Questions
The key questions address issues of caries diagnosis and management that arise in
the professional treatment of dental caries, i.e., those procedures that are provided
by dentists and allied dental personnel in dental practices and clinics. Thus, the
procedures are limited to those commercially available at the time of this review.
Further, the caries management questions focus on issues that accompany the
"modern" view of dental caries as an oral infection that, at specific sites, initially leads
to demineralization and ultimately destruction of tooth tissue. The key questions,
stated in final form, are as follows:
Question 1.
What are the validities of the available diagnostic
methods for detecting carious lesions in primary and
permanent teeth?
Question 2.
What are the efficacies of the nonsurgical methods
available for stopping or reversing the progression of a
noncavitated coronal carious lesion in a primary or a permanent
tooth?
Question 3.
What are the efficacies of the methods available for
reducing the incidence of new coronal carious lesions in primary
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and permanent teeth in individuals who are deemed to be
"caries active" or at "high caries risk"?
The first question addresses only the diagnosis of primary caries, i.e., the first carious
lesion on a tooth surface. Both coronal and root surfaces are included in the review,
and for coronal surfaces, both primary and permanent teeth are included. Following
discussion with the TEAG, assessment of test validity was operationalized as the
sensitivity and specificity of a diagnostic test. The methods to be assessed included all
those diagnostic methods that are commercially available, including visual and visual-
tactile inspection, radiography, FOTI, EC, laser fluorescence, and combinations of
those methods.
The second question focuses on individual early carious lesions, where
demineralization has occurred but cavitation has not yet occurred. In the past, this
type of lesion was either removed surgically and replaced with a restoration or
monitored or "watched." Dentists generally assumed that many noncavitated lesions
would progress to cavitation, and based treatment decisions on this assumption. More
recently, the possibility of remineralizing or at least arresting the demineralization of
these noncavitated lesions has been considered as an alternative to surgical removal
and restoration. Another nonsurgical technique, placing dental sealants, is also
available for noncavitated lesions on fissured surfaces. The question includes
consideration of a still wider range of potentially useful methods, including
professional fluoride applications and prescribed supplements, other remineralization
agents, professional oral hygiene and plaque control programs, and combinations of
these methods.
The third question focuses on patients rather than individual carious lesions. It
reflects the need for information about how to manage patients who have active
carious lesions or who are at risk of developing such lesions. Recommendations for
the "medical management" of such patients have appeared; yet the methods to be
included in such an approach are not well defined. This question includes
consideration of professional fluoride applications and prescribed supplements,
sealants, antimicrobial therapy, salivary enhancements, nutritional/diet counseling,
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professional oral hygiene/plaque control programs, and combinations of these
methods.
Causal Pathways
Figure 1. Causal pathways for the diagnosis, nonsurgical management, (more...)
Figure 1. Causal pathways for the diagnosis, nonsurgical management, and
prevention of carious lesions
Because the questions are closely linked in the typical examination and treatment
sequence that occurs in dental practice, the RTI-UNC EPC team chose to construct a
single causal pathway that defines the relationship of the three questions (Figure 1
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). The diagnosis of carious lesions is, in reality, an exhaustive search for signs of
disease on all surfaces of all teeth, using a variety of search techniques. The results of
the search will drive subsequent treatment decisions. Information from the search will
include the presence or absence of carious lesions and their pattern of occurrence, the
degree of penetration of each identified lesion, and whether a lesion is cavitated, i.e.,
has lost organic material to the extent that the enamel surface has lost its contour.
The first question examines the accuracy with which the presence or absence (i.e.,
"any caries") and the depth of penetration (caries affecting the dentin or inner
structure of the tooth) are identified, as well as the accuracy with which cavitation can
be detected.
The degree of penetration of the lesion is thought to be the principal criterion that
most dentists use in making treatment decisions, with penetration to the dentin
seemingly the threshold for restoration reported most often. In view of caries
progression, whether a lesion is cavitated or not may represent a more logical
criterion for differentiating between opportunities to arrest or reverse caries
progression nonsurgically and the necessity for removal of the lesion and replacement
of the lost tissue. The use of dentin penetration as the surgical intervention criterion
may result in the treatment of noncavitated, potentially reversible lesions. The causal
pathway reflects the lack of a cavitation criterion for nonsurgical intervention.
For those patients found to have one or more carious lesions, in addition to surgical or
nonsurgical treatment directed specifically at the lesion(s), there is an opportunity to
provide treatment for the purpose of reducing the likelihood for the development of
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further lesions. As noted, although dentists have long provided professional
preventive procedures, linking the provision of these procedures to a patient's caries
activity status, when it has been done, usually has been done informally, with little
knowledge of the effectiveness of such preventive procedures in patients with high
rates of disease. Extending this type of targeted intensified prevention to patients
identified as being at risk for the development of carious lesions is less common.
Caries risk assessment is a relatively recent development in dentistry; and even
though a number of risk assessment instruments have been described, the approach
has not been validated when applied to individual patients.
Literature Search
This portion ofChapter 2 documents the literature search process, specifying the
terms used for each of the literature database searches conducted, as well as
describing other search strategies and listing the inclusion/exclusion criteria used for
the initial search and the review of identified studies. It also documents the steps
taken to identify the relevant studies from among those identified in the searches to
be included in the evidence report.
Search Terms
Table 3. Strategy and results of MEDLINE caries diagnosis search (more...)
Table 3. Strategy and results of MEDLINE caries diagnosis search
Wide search of early caries literature
1 exp dental caries/pa,di.ra 2,846
2 limit to human, English, 1966-75 219
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Defining studies of caries
3 exp tooth demineralization/pa,di,ra 2,928
4 exp dental caries/ 21,830
5 3 or 4 21,904
Limiting 5 to diagnostic methods
6 exp diagnosis/, oral diagnosis/ 2,420
7 exp radiography/, dental radiography/, digital dental
radiology/816
8 exp pathology/, oral pathology/ 4
9 1 or 6 or 7 or 8 2,539
10 limit to human, English 1,776
Limiting 10 to various study types
11 controlled clinical trial 21
12 meta analysis 4
13 randomized controlled trial 50
14 epidemiologic study characteristics 244
15 epidemiologic research design 333
16 comparative study 457
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Combining results of 1966-75 "wide" search and searches for
specific study types
17 2 or 11 or 12 or 13 or 14 or 15 or 16 1,266
Adding all root caries studies
18 exp root caries/pa,di,ra 62
Total 1,328
Table 4. Strategy and results of MEDLINE caries management search (more...)
Table 4. Strategy and results of MEDLINE caries management search
Identifying management methods
1 exp fluorides, topical/tu 2,061
2 exp tooth remineralization/ 445
3 exp pit and fissure sealants/tu 667
4 exp health education, dental/ 4,287
5 exp dental prophylaxis/ 3,699
6 exp oral hygiene/ 8,624
8 exp dental plaque/pc,dh,dt,th 3,423
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9 exp chlorhexidine/tu 1,126
10 exp xylitol/tu 162
11 exp tooth demineralization/pc,dt,th 10,162
12 exp cariostatic agents/tu 3,994
13 fluoride supplements 60
14 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or12 or 13
26,902
Identifying caries management methods
15 exp dental caries/pc,dh,dt,th 10,064
16 14 and 15 10,058
17 limit to human, English 5,057
Limiting 17 to various study types
18 controlled clinical trial 122
19 randomized clinical trial 177
20 epidemiologic study characteristics 762
21 epidemiologic research design 266
22 comparative study 758
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Total of 18 or 19 or 20 or 21 or 22 1,435
Two separate literature searches were conducted for this evidence report -- one for
the caries diagnosis question and the other for the two caries management questions.
Tables 3 and 4 show the MeSH terms used for searching MEDLINE, the principal
database for each of these two searches, as well as the results of the searches. The
searches were run in October 1999. Although detailed sets of inclusion and exclusion
criteria had been developed prior to the searches (see following section), few of the
criteria are evident in the search strategies. Indexing for the dental literature is
sketchy and unreliable in the first 10 years covered by MEDLINE, and problems exist
well into the 1980s for some terms of interest in these searches (e.g.,
demineralization and remineralization). Thus, the search strategies tended to be
inclusive rather than exclusive. Only at the broadest level could either search be
limited to human studies, reports in English (because resource constraints), and a
rather wide variety of study types listed in the tables.
In the absence of effective exclusion criteria available in MEDLINE, it still might have
been possible to design relatively "tight" search strategies if certain critical keywords
were available to narrow the search focus. Unfortunately, this was not the case for
either search. The diagnosis search returned a large number of potentially eligible
studies (1,328) because preliminary searches had demonstrated that a key term,
"sensitivity and specificity," could not be assumed to identify accurately all eligible
studies.
In the management search, two critical features of eligible studies could not be
isolated through use of indexing terms. Neither noncavitated lesions nor caries-active
or "at-risk" patients are identifiable through the keyword structure. Thus, the
management search had to be designed to identify all possible evaluations of the
eligible preventive methods, with subsequent inspection of the abstract or full paper
required for a final determination of eligibility for either of the systematic reviews
based on patient sample or type of lesion included. The result was the identification of
1,435 citations.
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Additional Searching
Table 5. Strategy and results for EMBASE caries diagnosis search (more...)
Table 5. Strategy and results for EMBASE caries diagnosis search
1. dental adjacent to caries 1,554
2. diagnosis 248,652
3. dental radiography 121
4. 2 and 3 248,677
5. 1 and 4 87
6. New citations added (not duplicates with MEDLINE) 79
Table 6. Strategy and results for EMBASE caries management search (more...)
Table 6. Strategy and results for EMBASE caries management search
1. dental adjacent to caries 1,554
2. topical fluorides 6
3. remineralizaion 79
4. dental sealants 13
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5. sealants 96
6. chlorhexidine 0
7. cariostatic agents 0
8. 2 or 3 or 4 or 5 or 6 or 7 181
9. 1 and 8 48
10. New citations added (not duplicates with MEDLINE) 43Subsequent to the principal literature searches in MEDLINE, the team completed
followup searches in EMBASE and the Cochrane Controlled Trials Register. The search
terms and results for the EMBASE searches are shown in Tables 5 and 6. The studies
not duplicated in the MEDLINE searches were added to the two groups of studies
included in the review. No new studies were found in the Cochrane Library.
A valuable supplemental search strategy was perusal of the reference sections of
papers identified in the searches. Again, the reason for the seeming inefficiency of the
MEDLINE searches is in large measure the imprecise indexing characteristics of dental
studies in the 1970s and 1980s. Not only are descriptors of study design
characteristics inexact or missing, but descriptors related to the condition or process
of interest are also often tangential in nature. This forces the search to be less
exclusive and at the same time increases the likelihood that some studies will be
missed, even with a fairly broad search strategy such as the one employed.
The team had elected at the outset not to complete a detailed search of the gray
literature. This is information not appearing in the periodic scientific literature, such as
dissertations, theses, industry reports, unpublished studies, abstracts, and other
nontraditional sources. The team made this decision because of both limited resources
and the prevailing experience opinion among RTI-UNC EPC staff that in the absence of
known sources for such literature, searches were unlikely to yield useful information.
The team did query NIDCR to identify any in-progress studies that might have
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recently reported relevant data. The team did not identify other po