Pharmacological treatment of oro-facial pain - health technology assessment including a systematic review with network meta-analysis.

This health technology assessment evaluated the efficacy of pharmacological treatment in patients with oro-facial pain. Randomised controlled trials were included if they reported pharmacological treatment in patients ≥18 years with chronic (≥3 months) oro-facial pain. Patients were divided into subgroups: TMD-muscle [temporomandibular disorders (TMD) mainly associated with myalgia]; TMD-joint (TMD mainly associated with temporomandibular joint pain); and burning mouth syndrome (BMS). The primary outcome was pain intensity reduction after pharmacological treatment. The scientific quality of the evidence was rated according to GRADE. An electronic search in PubMed, Cochrane Library, and EMBASE from database inception to 1 March 2017 combined with a handsearch identified 1552 articles. After screening of abstracts, 178 articles were reviewed in full text and 57 studies met the inclusion criteria. After risk of bias assessment, 41 articles remained: 15 studies on 790 patients classified as TMD-joint, nine on 375 patients classified as TMD-muscle and 17 on 868 patients with BMS. Of these, eight studies on TMD-muscle, and five on BMS were included in separate network meta-analysis. The narrative synthesis suggests that NSAIDs as well as corticosteroid and hyaluronate injections are effective treatments for TMD-joint pain. The network meta-analysis showed that clonazepam and capsaicin reduced pain intensity in BMS, and the muscle relaxant cyclobenzaprine, for the TMD-muscle group. In conclusion, based on a limited number of studies, evidence provided with network meta-analysis showed that clonazepam and capsaicin are effective in treatment of BMS and that the muscle relaxant cyclobenzaprine has a positive treatment effect for TMD-muscle pain.

Estimates of sensitivity and specificity of electric pulp testing depend on pulp disease spectrum: a modelling study.

AIM: To demonstrate how the spectrum of diseased pulps may influence sensitivity and specificity in diagnostic studies on pulp status. METHODOLOGY: An original sample from a previous study consisting of 59 teeth scheduled for root canal treatment was used where the relationship between the response to electric pulp testing and the visual status of the pulp was evaluated. To alter the spectrum of diseased pulps, a hypothetical sample of asymptomatic teeth with deep caries lesions was added to the original sample. Sensitivity and specificity were then compared for the two samples. RESULTS: In the original sample of 59 teeth, sensitivity was 72% and specificity 90%. When the spectrum of diseased pulps was altered, sensitivity decreased to 67% and specificity increased to 97%. The change in disease spectrum also decreased the prevalence of necrotic pulps. CONCLUSIONS: The spectrum of diseased pulps included in a diagnostic study on the accuracy of electric pulp testing, and indirectly also disease prevalence (here pulp necrosis), influences estimates of sensitivity and specificity. This implies that estimates of diagnostic accuracy from one study with a particular tooth population spectrum may not apply to another tooth population with a different disease spectrum.

Caries risk assessment. A systematic review.

OBJECTIVE: To assess the ability of multivariate models and single factors to correctly identify future caries development in pre-school children and schoolchildren/adolescents. STUDY DESIGN: A systematic literature search for relevant papers was conducted with pre-determined inclusion criteria. Abstracts and full-text articles were assessed independently by two reviewers. The quality of studies was graded according to the QUADAS tool. The quality of evidence of models and single predictors was assessed using the GRADE approach. RESULTS: Ninety original articles fulfilled the inclusion criteria. Seven studies had high quality, 35 moderate and the rest poor quality. The accuracy of multivariate models was higher for pre-school children than for schoolchildren/adolescents. However, the models had seldom been validated in independent populations, making their accuracy uncertain. Of the single predictors, baseline caries experience had moderate/good accuracy in pre-school children and limited accuracy in schoolchildren/adolescents. The period of highest risk for caries incidence in permanent teeth was the first few years after tooth eruption. In general, the quality of evidence was limited. CONCLUSIONS: Multivariate models and baseline caries prevalence performed better in pre-school children than in schoolchildren/adolescents. Baseline caries prevalence was the most accurate single predictor in all age groups. The heterogeneity of populations, models, outcome criteria, measures and reporting hampered the synthesis of results. There is a great need to standardize study design, outcome measures and reporting of data in studies on caries risk assessment. The accuracy of prediction models should be validated in at least one independent population.

Approximal Caries Detection by DIFOTI: In Vitro Comparison of Diagnostic Accuracy/Efficacy with Film and Digital Radiography.

The aim of the present study was to compare the diagnostic accuracy/efficacy of digital imaging fiber-optic transillumination (DIFOTI) with film and digital radiography, in detection of approximal caries lesions. One hundred and twelve approximal surfaces were scored for caries, using DIFOTI images film and digital radiographs. All three sets of images were examined twice by 8 observers, with a minimal interval of one week between examinations. Validation of histological sections served as a reference standard. Reproducibility, based on intra- and interobserver agreement, was similar for all three methods. At diagnostic threshold D1 (enamel and dentin caries), DIFOTI showed significantly higher sensitivity, but differences in specificity between methods were nonsignificant. Diagnostic accuracy in the form of area under the receiver operating characteristic curve (AUC) was significantly higher for DIFOTI. At diagnostic threshold D3 (dentin caries), the differences in sensitivity and AUC among methods were nonsignificant, but DIFOTI showed significantly lower specificity. Compared with the radiographs, DIFOTI showed closer agreement, expressed as weighted kappa values, with the reference standard. The results show that under in vitro conditions, the diagnostic accuracy of DIFOTI in detecting early approximal enamel lesions is greater than that of film and digital radiography, while the potential for detecting lesions in dentin is similar for all three methods.

Radiological diagnosis of periapical bone tissue lesions in endodontics: a systematic review.

This systematic review evaluates the diagnostic accuracy of radiographic methods employed to indicate presence/absence and changes over time of periapical bone lesions. Also investigated were the leads radiographic images may give about the nature of the process and the condition of the pulp in nonendodontically treated teeth. Electronic literature search included the databases PubMed, Embase and CENTRAL from January 1950 to June 2011. All languages were accepted provided there was an abstract in English. The MeSH terms were 'Cone beam computed tomography (CBCT)', 'Radiography, panoramic', 'Periapical diseases', 'Dental pulp diseases', 'Sensitivity and specificity', 'receiver operating characteristics (ROC) curve', 'Cadaver', 'Endodontics' and 'Radiography dental'. Two reviewers independently assessed abstracts and full text articles. An article was read in full text if at least one of the two reviewers considered an abstract to be potentially relevant. Altogether, 181 articles were read in full text. The GRADE approach was used to assess the quality of evidence of each radiographic method based on studies of high or moderate quality. Twenty-six studies fulfilled criteria set for inclusion. None was of high quality; 11 were of moderate quality. There is insufficient evidence that the digital intraoral radiographic technique is diagnostically as accurate as the conventional film technique. The same applies to CBCT. No conclusions can be drawn regarding the accuracy of radiological examination in identifying various forms of periapical bone tissue changes or about the pulpal condition.

Diagnosis of the condition of the dental pulp: a systematic review.

The aim of this systematic review was to appraise the diagnostic accuracy of signs/symptoms and tests used to determine the condition of the pulp in teeth affected by deep caries, trauma or other types of injury. Radiographic methods were not included. The electronic literature search included the databases PubMed, EMBASE, The Cochrane Central Register of Controlled Trials and Cochrane Reviews from January 1950 to June 2011. The complete search strategy is given in an Appendix S1 (available online as Supporting Information). In addition, hand searches were made. Two reviewers independently assessed abstracts and full-text articles. An article was read in full text if at least one of the two reviewers considered an abstract to be potentially relevant. Altogether, 155 articles were read in full text. Of these, 18 studies fulfilled pre-specified inclusion criteria. The quality of included articles was assessed using the QUADAS tool. Based on studies of high or moderate quality, the quality of evidence of each diagnostic method/test was rated in four levels according to GRADE. No study reached high quality; two were of moderate quality. The overall evidence was insufficient to assess the value of toothache or abnormal reaction to heat/cold stimulation for determining the pulp condition. The same applies to methods for establishing pulp status, including electric or thermal pulp testing, or methods for measuring pulpal blood circulation. In general, there are major shortcomings in the design, conduct and reporting of studies in this domain of dental research.

Perspectives on being a mentor for undergraduate dental students.

As part of the new study programme in Dentistry, an obligatory mentor programme was introduced during autumn 2005 for all student dentists at Karolinska Institutet, Sweden. The aim of the programme is to provide support and guidance for the students in their professional role as dentists. All mentors in the programme are licenced dentists and lecturers at the Department of Dental Medicine. The mentors follow three to five mentees throughout the entire 5 year programme. This study aims to evaluate the programme from the mentors' perspective and to explore the perceived effects of being a mentor. Following an exploratory focus group, questionnaires were distributed to all mentors (n = 66, response rate 83%). The results of the evaluation of the programme show that being a mentor is perceived to be rewarding in many different ways, including an increased understanding of the students' situation and some professional development as a teacher.

Comparison of visual inspection and different radiographic methods for dentin caries detection on occlusal surfaces.

OBJECTIVES: The aim of the present study was to assess the validity of the digital phosphor plate radiographic technique (Gendex Dental Systems) on occlusal surfaces in comparison with visual examination and conventional E- and F-speed films. METHODS: The study material consisted of 54 non-cavitated third molars with a range of appearances, including apparently sound surfaces. Each surface was visually examined (VI) according to the criteria established by Ekstrand et al. Three radiographic images (E-speed, F-speed, digital phosphor plate film) were taken of each molar. The standardized radiograph technique used an alignment fixture to reproduce the focus-to-object distance as well as the object-to-film distance. Afterwards each tooth was cut into sections in the buccolingual direction with a microtome saw, and caries extension was assessed using light microscopy (LM) and microradiography (MR). The statistical analysis included the calculation of sensitivity (SE), specificity (SP) and A(z) values. RESULTS: The following validity parameters were found for the tested diagnostic methods on the dentin caries level: VI/LM, 68.0 SE/93.1 SP/0.698 A(z); VI/MR, 68.2/87.5/0.751; E-speed/LM, 76.0/78.6/0.637; E-speed/MR, 77.3/74.2/0.681; F-speed/LM, 64.0/67.9/0.507; F-speed/MR, 68.2/67.7/0.594; Gendex/LM, 60.0/85.7/0.629; and Gendex/MR, 59.1/80.6/0.586. CONCLUSION: The methods used showed different levels of validity: E- and F-speed films were linked to higher sensitivity values, whereas a higher specificity was recorded for the tested imaging plate system. In accordance with the diagnostic performance, the digital system can be recommended for practical use and potentially help prevent overtreatment thanks to its high SP.

Validity and reliability of laser-induced fluorescence measurements on carious root surfaces in vitro.

The aim was to assess the validity of laser fluorescence (LF), visual inspection and surface texture on root caries lesions in vitro, related to histological lesion depths. Agreement on interdevice, interexaminer and intra-examiner levels as well as the influence of discolouration and surface texture on LF readings were investigated. Calibrated examiners assessed lesion colour and surface texture and performed measurements with 2 LF devices in 3 separate series at intervals of 1 week. Sections (300 mum thick) of 64 out of 93 teeth were obtained and examined under the microscope. Lesion depth was assessed with 2 references: from the delineated borderline of the original exposed root surface (ref. I), or if loss of surface continuity, the absolute lesion depth (ref. II). The correlation (Spearman rho) between LF readings and histological depth was low with values ranging from 0.22 (p > 0.05) to 0.31 (p < 0.05). LF 1 and LF 2 were significantly correlated with discolouration (rho = 0.52 and 0.46, respectively) and with surface texture denoted as hard (rho = 0.34 and 0.33, respectively). A significant correlation between colour and histological depth ref. I (rho = 0.51) and ref. II (rho = 0.56) was found. No significant correlation between surface texture and histological depth was found. The reliability, evaluated as intraclass correlation coefficient was for intra-examiner 0.99, interexaminer 0.97 and interdevice level 0.98. Large differences were found between 2 consecutive measurements, and high measurement errors indicated considerable deviation of individual measurements. Based on these findings, the LF device is not suitable as a diagnostic tool for root caries.

DIAGNOdent--an adjunctive diagnostic method for caries diagnosis in epidemiology.

UNLABELLED: The DIAGNOdent system is intended as an aid to caries detection and has undergone extensive investigation in experimental and clinical studies. Its applicability for epidemiological purposes has yet to be evaluated. The Objective of the present study was to evaluate the DIAGNOdent system under field conditions. BASIC RESEARCH DESIGN: The subjects comprised a sub-sample from an on-going epidemiological study. PARTICIPANTS AND CLINICAL SETTING: In 39 individuals, 97 sites were visually identified as possibly carious: 42 occlusal, 13 lingual, 19 buccal and 23 approximal sites. MAIN OUTCOME MEASURES: Three DIAGNOdent measurements were taken at each site under varying conditions: (1) naturally wet, (2) dried, and (3) polished and dried surfaces. Three sets of measurements were obtained and compared by intra-class correlation and paired sample t-tests. RESULTS: All correlation coefficients were > 0.9. There was a systematic difference between mean scores from naturally wet sites (without cleaning) and from either dried, or polished and dried sites. The difference was marginal and did not impact on the threshold for recording sites as carious. In two subjects, high unexpected values were recorded on sound sites prior to actual measurements, i.e. during establishment of a standard value for a sound site. The overall findings were not affected by these values, as they were consistently high in all three measurements. CONCLUSIONS: The DIAGNOdent system performed satisfactorily under different measurement conditions. The present study indicates that the DIAGNOdent system would be applicable in field studies, provided consistent study conditions are maintained and unexpected values are interpreted with caution.

A new in vivo method for measuring caries activity using quantitative light-induced fluorescence.

The aim of this in vivo study was to assess the association between caries prevalence and activity parameters and the properties of etched sites measured with quantitative light-induced fluorescence (QLF). In a clinical method, two areas of a deciduous tooth were etched in each of 44 children (mean age 8.23 years+/-1.45) with 36% phosphoric acid gel for 1 min and 4 min, respectively. DeltaQ of the etched site was measured immediately after the etching (DeltaQ1) and 24 h later (DeltaQ2) with QLF. In addition, deft/DMFT, approximal plaque (API), bleeding on probing (mod. PBI), active carious lesions and currently used fluorides were recorded. In a regression analysis for the deft, the use of fluoridated salt (standardized coefficient SC=-0.25) and fluoride gel (SC=-0.37) showed the greatest effect, as did the fluoride gel (SC=-0.26) and gingival bleeding (SC=0.50) for the number of active carious lesions. The deft and the number of active carious lesions correlated significantly (r=0.70, p<0.001). DeltaQ1 and DeltaQ2 showed a significant statistical correlation with the age-adjusted deft (0.39

Application of quantitative light-induced fluorescence to monitor incipient lesions in caries-active children. A comparative study of remineralisation by fluoride varnish and professional cleaning.

The aim of this study was to apply the quantitative light-induced fluorescence (QLF) method in a randomised controlled study, comparing treatment with fluoride varnish and professional tooth cleaning for remineralisation of white spot lesions in caries-active adolescents. In the fluoride varnish group (n = 13; 32 lesions), professional tooth-cleaning was followed by application of fluoride varnish at the beginning of the study, after 1 wk, and then once every 6 wk for 6 months. The other group (n = 18; 30 lesions) underwent professional tooth-cleaning once every 6 wk for 6 months. Enamel fluorescence was measured at baseline and at each visit. In the fluoride varnish group there was a significant change over time (baseline: 6 months) for both lesion area: and average change in fluorescence (decreased lesion area and increased fluorescence radiance). The corresponding changes in the professional tooth-cleaning group were not significant. There was a significant difference in average change in fluorescence between the two test groups. For lesion area, there was no significant difference, but a tendency towards a difference between the test groups. It was concluded that (a) the QLF method is a sensitive method, suitable for longitudinal quantification of incipient caries lesions on smooth surfaces; and (b) that repeated fluoride applications had a favourable effect on the remineralisation of white spot lesions as measured after 6 months.

Validation of DIAGNOdent for quantification of smooth-surface caries: an in vitro study.

The aims were 1) to validate a laser-based device, KaVo DIAGNOdent, for quantification of caries lesions on smooth surfaces, using histopathologic and microradiographic analyses as the gold standard, and 2) to test inter- and intra-observer agreements. We also investigated the influence on DIAGNOdent readings of the storage medium used for extracted teeth. Two observers measured independently the tooth surfaces of 40 extracted premolars that had been stored in thymol-saturated saline. After subsequent storage in neutral-buffered formalin for 14 days they were re-measured. The teeth were then sectioned for histopathologic and microradiographic analysis. The Spearman rank correlation coefficients between lesion depth and DIAGNOdent readings were 0.78-0.83 and 0.85 for teeth stored in thymol-saturated saline and formalin, respectively. Inter- and intra-observer agreements were 0.94 and 0.95 when the teeth were stored in thymol-saturated saline. The DIAGNOdent reading was almost 1.5 times higher for teeth stored in formalin than for those stored in thymol saline. The Spearman rank correlation coefficient between mineral loss in enamel (deltaZ) and DIAGNOdent readings ranged from 0.64 to 0.68. It was concluded that DIAGNOdent may be helpful for assessing smooth-surface caries, but the cut-off points need to be assessed under clinical conditions. The increase in fluorescence associated with storage of teeth in formalin warrants further investigation.

Comparison of QLF and DIAGNOdent for quantification of smooth surface caries.

The aim was to compare the detection and quantification of smooth surface caries by KaVo DIAGNOdent and quantitative laser/light-induced fluorescence (QLF) using a laser and a lamp as two different light sources. On 40 premolar teeth extracted from adolescents, 71 non-cavitated approximal surfaces were assessed. For QLF, both mean and maximum fluorescence losses were registered. To provide a gold standard for verification, the teeth were then sectioned and lesion depth, stratified on a five-point scale, was determined by histopathology and microradiography. The correlation between the gold standard and the two methods was assessed by Spearman's rank correlation coefficient. The sensitivity and specificity of the methods for detection of smooth surface caries at D(3) level were also assessed. For lesion depth, correlation with the gold standard was similar for QLF and DIAGNOdent: about 0.85. With respect to dentinal caries detection, sensitivity for DIAGNOdent was 0.75 and specificity 0.96, with a cut-off point of 9. The corresponding values for QLF were 0.94 and 1, with a cut-off value of 20% of fluorescence loss. Spearman's rank correlation coefficients for enamel mineral loss and QLF and DIAGNOdent, respectively, were 0.76 and 0.67. It was concluded that for quantification of smooth surface caries, the methods are of equal merit, but for scientific purposes, QLF offers the advantage of closer correlation with changes in mineral content.

Quantitative diagnosis of small approximal caries lesions utilizing wavelength-dependent fiber-optic transillumination.

The instruments clinically available for the diagnosis of approximal caries lesions are inadequate to detect lesions early and quantitatively. The aim of this study was to investigate whether wavelength-dependent light scattering and absorption of carious tissues may be utilized for the quantitative diagnosis of these small approximal caries lesions. Seventeen extracted premolar teeth were transilluminated at an approximal surface with a glass fiber, which transported the light from a halogen light bulb. Seven approximal surfaces contained a naturally developed small white-spot lesion, and 5 surfaces a small discolored lesion. Five teeth were sound. The occlusal surface was imaged with a CCD camera. Light in the blue and red portions of the electromagnetic spectrum was selected by means of Schott glass filters. From the obtained images, average effective decadic optical thickness differences were determined. These were plotted as a function of average mineral loss assessed by means of wavelength-independent microradiography. The correlation coefficient between the average effective decadic optical thickness difference and average mineral loss was r = 0.79 (95% CI: 0.47 ... 0.93). Different sources of variation that influence the observed correlation were defined and quantified. From these measurements, the correlation coefficient between average effective decadic optical thickness difference and "true' average mineral loss was estimated to be r = 0.92 (95% CI: 0.77 ... 0.97). The results indicate that early and, in principle, also quantitative diagnosis of approximal caries lesions is feasible when wavelength-dependent light propagation through carious tissues is utilized.

Monitoring the caries process. Optical methods for clinical diagnosis and quantification of enamel caries.

Early detection of a caries lesion would enable the dentist, by using effective prophylactic measures, to enhance remineralization and conservation of the tooth substance rather than restoration of the dentition. The presently-used diagnostic methods of detecting early lesions require visual observation. Reflected light is used to detect changes in color, texture, and translucency of the tooth substance. Attempts to improve the traditional methods or to develop new ones have been numerous. For clinical use, only 2 quantitative methods are presently available: (i) a method based on the scattering of light by enamel crystals in relation to their surrounding environment, and (ii) a method that uses visible laser light within the blue-green region as the light source to excite the autofluorescence of enamel. The possibilities and limitations of these methods are evaluated, and clinical applications are presented and discussed.

A new method for in vivo quantification of changes in initial enamel caries with laser fluorescence.

A new method for the in vivo assessment of changes in initial enamel caries lesions was developed and tested. A CCD camera equipped with a high-pass filter (lambda > 520 nm) collects the fluorescence image of carious teeth, illuminated intraorally with diffuse laser light (lambda = 488 nm). Incipient lesions show a loss in fluorescence to be expressed as a percentage of fluorescence radiance of sound tissue. A PC program (Inspektor, model QLF 1.0) is used for display, storage, and subsequent analysis of images. To enable the calculation of fluorescence loss, the fluorescence of sound tissue at the lesion site is reconstructed from the radiances of sound tissue bordering the lesion. This method was tested on 19 visually sound buccal surfaces in vivo. The differences between actual and reconstructed radiance was -1.6 +/- (SD) 1.1%, over areas varying between 8 and 14 mm2. The repeatability of the caries quantification was tested by measuring one arrested initial caries lesion 25 times in vivo. The lesion area was 0.56 +/- 0.20 mm2, and the loss of fluorescence was 17.6 +/- 0.7%, corresponding to a lesion depth of 17 +/- 2 microns. The new quantitative method was applied for the testing of an in vivo caries model using plaque-accumulating brackets on premolars scheduled for extraction. Videoimages were recorded in vivo before bracketing and 0, 2, 3, and 5 weeks after debracketing. Clear changes between the different time points were recorded for both lesion size and mineral content.(ABSTRACT TRUNCATED AT 250 WORDS)