Are direct restorations an effective treatment strategy in the management of root caries lesions?

Data sources PubMed, Cochrane Library/Embase and Web of science.Study selection Randomised controlled trials and non-randomised trials reporting success or failure rates of direct restorative materials for managing root caries lesions and in vitro studies assessing performance of restorations for root caries lesions published between September 1990 and October 2021 and written in English were included.Data extraction and synthesis Data was extracted by one reviewer and quality assessment of the included clinical studies performed using the Cochrane risk-of-bias in non-randomised studies of interventions tools. Restoration success, survival and failure rates were presented for each included study with no data synthesis.Results A total of 11 clinical studies and 31 in vitro studies were included. Restoration failure rates ranged from 14-55% at 24-60 months. Success rates of atraumatic restorative technique (ART) ranged from 65-87% at 12-60 months.Conclusion There is a lack of high-quality evidence to provide a recommendation on the most appropriate restorative material for restoring root caries lesions. The survival rate of ART and conventional techniques are comparable and ART could be an optional treatment where conventional treatment is challenging.

Development of a Root Caries Prediction Model in a Population of Dental Attenders.

Root caries prevalence is increasing as populations age and retain more of their natural dentition. However, there is generally no accepted practice to identify individuals at risk of disease. There is a need for the development of a root caries prediction model to support clinicians to guide targeted prevention strategies. The aim of this study was to develop a prediction model for root caries in a population of regular dental attenders. Clinical and patient-reported predictors were collected at baseline by routine clinical examination and patient questionnaires. Clinical examinations were conducted at the 4-year timepoint by trained outcome assessors blind to baseline data to record root caries data at two thresholds - root caries present on any teeth (RC > 0) and root caries present on three or more teeth (RC ≥ 3). Multiple logistic regression analyses were performed with the number of participants with root caries at each outcome threshold utilized as the outcome and baseline predictors as the candidate predictors. An automatic backwards elimination process was conducted to select predictors for the final model at each threshold. The sensitivity, specificity, and c-statistic of each model's performance was assessed. A total of 1,432 patient participants were included within this prediction model, with 324 (22.6%) presenting with at least one root caries lesion, and 97 (6.8%) with lesions on three or more teeth. The final prediction model at the RC >0 threshold included increasing age, having ≥9 restored teeth at baseline, smoking, lack of knowledge of spitting toothpaste without rinsing following toothbrushing, decreasing dental anxiety, and worsening OHRQoL. The model sensitivity was 71.4%, specificity 69.5%, and c-statistic 0.79 (95% CI: 0.76, 0.81). The predictors included in the final prediction model at the RC ≥ 3 threshold included increasing age, smoking, and lack of knowledge of spitting toothpaste without rinsing following toothbrushing. The model sensitivity was 76.5%, specificity 73.6%, and c-statistic 0.81 (95% CI: 0.77, 0.86). To the authors' knowledge, this is the largest published root caries prediction model, with statistics indicating good model fit and providing confidence in its robustness. The performance of the risk model indicates that adults at risk of developing root caries can be accurately identified, with superior performance in the identification of adults at risk of multiple lesions.

Sealants for preventing dental caries in primary teeth.

BACKGROUND: Pit and fissure sealants are plastic materials that are used to seal deep pits and fissures on the occlusal surfaces of teeth, where decay occurs most often in children and adolescents. Deep pits and fissures can retain food debris and bacteria, making them difficult to clean, thereby causing them to be more susceptible to dental caries. The application of a pit and fissure sealant, a non-invasive preventive approach, can prevent dental caries by forming a protective barrier that reduces food entrapment and bacterial growth. Though moderate-certainty evidence shows that sealants are effective in preventing caries in permanent teeth, the effectiveness of applying pit and fissure sealants to primary teeth has yet to be established. OBJECTIVES: To evaluate the effects of sealants compared to no sealant or a different sealant in preventing pit and fissure caries on the occlusal surfaces of primary molars in children and to report the adverse effects and the retention of different types of sealants. SEARCH METHODS: An information specialist searched four bibliographic databases up to 11 February 2021 and used additional search methods to identify published, unpublished and ongoing studies. Review authors scanned the reference lists of included studies and relevant systematic reviews for further studies. SELECTION CRITERIA: We included parallel-group and split-mouth randomised controlled trials (RCTs) that compared a sealant with no sealant, or different types of sealants, for the prevention of caries in primary molars, with no restriction on follow-up duration. We included studies in which co-interventions such as oral health preventive measures, oral health education or tooth brushing demonstrations were used, provided that the same adjunct was used with the intervention and comparator. We excluded studies with complex interventions for the prevention of dental caries in primary teeth such as preventive resin restorations, or studies that used sealants in cavitated carious lesions. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, extracted data and assessed risk of bias of included studies. We presented outcomes for the development of new carious lesions on occlusal surfaces of primary molars as odds ratios (OR) with 95% confidence intervals (CIs). Where studies were similar in clinical and methodological characteristics, we planned to pool effect estimates using a random-effects model where appropriate. We used GRADE methodology to assess the certainty of the evidence. MAIN RESULTS: We included nine studies that randomised 1120 children who ranged in age from 18 months to eight years at the start of the study. One study compared fluoride-releasing resin-based sealant with no sealant (139 tooth pairs in 90 children); two studies compared glass ionomer-based sealant with no sealant (619 children); two studies compared glass ionomer-based sealant with resin-based sealant (278 tooth pairs in 200 children); two studies compared fluoride-releasing resin-based sealant with resin-based sealant (113 tooth pairs in 69 children); one study compared composite with fluoride-releasing resin-based sealant (40 tooth pairs in 40 children); and one study compared autopolymerised sealant with light polymerised sealant (52 tooth pairs in 52 children). Three studies evaluated the effects of sealants versus no sealant and provided data for our primary outcome. Due to differences in study design such as age of participants and duration of follow-up, we elected not to pool the data. At 24 months, there was insufficient evidence of a difference in the development of new caries lesions for the fluoride-releasing sealants or no treatment groups (Becker Balagtas odds ratio (BB OR) 0.76, 95% CI 0.41 to 1.42; 1 study, 85 children, 255 tooth surfaces). For glass ionomer-based sealants, the evidence was equivocal; one study found insufficient evidence of a difference at follow-up between 12 and 30 months (OR 0.97, 95% CI 0.63 to 1.49; 449 children), while another with 12-month follow-up found a large, beneficial effect of sealants (OR 0.03, 95% CI 0.01 to 0.15; 107 children). We judged the certainty of the evidence to be low, downgrading two levels in total for study limitations, imprecision and inconsistency. We included six trials randomising 411 children that directly compared different sealant materials, four of which (221 children) provided data for our primary outcome. Differences in age of the participants and duration of follow-up precluded pooling of the data. The incidence of development of new caries lesions was typically low across the different sealant types evaluated. We judged the certainty of the evidence to be low or very low for the outcome of caries incidence. Only one study assessed and reported adverse events, the nature of which was gag reflex while placing the sealant material. AUTHORS' CONCLUSIONS: The certainty of the evidence for the comparisons and outcomes in this review was low or very low, reflecting the fragility and uncertainty of the evidence base. The volume of evidence for this review was limited, which typically included small studies where the number of events was low. The majority of studies in this review were of split-mouth design, an efficient study design for this research question; however, there were often shortcomings in the analysis and reporting of results that made synthesising the evidence difficult. An important omission from the included studies was the reporting of adverse events. Given the importance of prevention for maintaining good oral health, there exists an important evidence gap pertaining to the caries-preventive effect and retention of sealants in the primary dentition, which should be addressed through robust RCTs.

How do different levels of smoking affect dental implants?

Data sources PubMed, EMBASE, Web of Science and Scopus.Study selection Randomised controlled clinical trials, cohort studies, case-control studies and case series reporting data on dental implant failures related to smoking published up to January 2019 were included, with no language restrictions.Data extraction and synthesis Data was extracted by one reviewer and quality assessment of the included observational studies was performed using the Newcastle-Ottawa scale. Smoker subgroups were categorised by number of cigarettes smoked daily, and statistical heterogeneities were assessed using Cochran's Q statistics and quantified using the I² test.Results A higher implant failure rate was found in patients who smoked <10 cigarettes/day than in non-smokers (p = 0.046), 95% CI (1-1.64). Likewise, patients who smoked >10 cigarettes/day showed higher failure rates than those smoking <10 cigarettes/day (p <0.001), 95% CI (1.31-2.17).Conclusions Increase in smoking dose appears to correspond directly with increase in implant failure rate. Smoking <10 cigarettes/day can be recommended as a safe level for dental implant failure.

Examining the effectiveness of different dental recall strategies on maintenance of optimum oral health: the INTERVAL dental recalls randomised controlled trial.

Objective To compare the clinical effectiveness of different frequencies of dental recall over a four-year period.Design A multi-centre, parallel-group, randomised controlled trial with blinded clinical outcome assessment. Participants were randomised to receive a dental check-up at six-monthly, 24-monthly or risk-based recall intervals. A two-strata trial design was used, with participants randomised within the 24-month stratum if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or six-month recall interval.Setting UK primary dental care.Participants Practices providing NHS care and adults who had received regular dental check-ups.Main outcome measures The percentage of sites with gingival bleeding on probing, oral health-related quality of life (OHRQoL), cost-effectiveness.Results In total, 2,372 participants were recruited from 51 dental practices. Of those, 648 were eligible for the 24-month recall stratum and 1,724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding on probing between intervention arms in any comparison. For those eligible for 24-month recall stratum: the 24-month versus six-month group had an adjusted mean difference of -0.91%, 95% CI (-5.02%, 3.20%); the 24-month group versus risk-based group had an adjusted mean difference of 0.07%, 95% CI (-3.99%, 4.12%). For the overall sample, the risk-based versus six-month adjusted mean difference was 0.78%, 95% CI (-1.17%, 2.72%). There was no evidence of a difference in OHRQoL (0-56 scale, higher score for poorer OHRQoL) between intervention arms in any comparison. For the overall sample, the risk-based versus six-month effect size was -0.35, 95% CI (-1.02, 0.32). There was no evidence of a clinically meaningful difference between the groups in any comparison in either eligibility stratum for any of the secondary clinical or patient-reported outcomes.Conclusion Over a four-year period, we found no evidence of a difference in oral health for participants allocated to a six-month or a risk-based recall interval, nor between a 24-month, six-month or risk-based recall interval for participants eligible for a 24-month recall. However, patients greatly value and are willing to pay for frequent dental check-ups.

Fluorescence devices for the detection of dental caries.

BACKGROUND: Caries is one of the most prevalent and preventable conditions worldwide. If identified early enough then non-invasive techniques can be applied, and therefore this review focusses on early caries involving the enamel surface of the tooth. The cornerstone of caries detection is a visual and tactile dental examination, however alternative methods of detection are available, and these include fluorescence-based devices. There are three categories of fluorescence-based device each primarily defined by the different wavelengths they exploit; we have labelled these groups as red, blue, and green fluorescence. These devices could support the visual examination for the detection and diagnosis of caries at an early stage of decay. OBJECTIVES: Our primary objectives were to estimate the diagnostic test accuracy of fluorescence-based devices for the detection and diagnosis of enamel caries in children or adults. We planned to investigate the following potential sources of heterogeneity: tooth surface (occlusal, proximal, smooth surface or adjacent to a restoration); single point measurement devices versus imaging or surface assessment devices; and the prevalence of more severe disease in each study sample, at the level of caries into dentine. SEARCH METHODS: Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 30 May 2019); Embase Ovid (1980 to 30 May 2019); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 30 May 2019); and the World Health Organization International Clinical Trials Registry Platform (to 30 May 2019). We studied reference lists as well as published systematic review articles. SELECTION CRITERIA: We included diagnostic accuracy study designs that compared a fluorescence-based device with a reference standard. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. Studies that explicitly recruited participants with caries into dentine or frank cavitation were excluded. DATA COLLECTION AND ANALYSIS: Two review authors extracted data independently using a piloted study data extraction form based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Sensitivity and specificity with 95% confidence intervals (CIs) were reported for each study. This information has been displayed as coupled forest plots and summary receiver operating characteristic (SROC) plots, displaying the sensitivity-specificity points for each study. We estimated diagnostic accuracy using hierarchical summary receiver operating characteristic (HSROC) methods. We reported sensitivities at fixed values of specificity (median 0.78, upper quartile 0.90). MAIN RESULTS: We included a total of 133 studies, 55 did not report data in the 2 x 2 format and could not be included in the meta-analysis. 79 studies which provided 114 datasets and evaluated 21,283 tooth surfaces were included in the meta-analysis. There was a high risk of bias for the participant selection domain. The index test, reference standard, and flow and timing domains all showed a high proportion of studies to be at low risk of bias. Concerns regarding the applicability of the evidence were high or unclear for all domains, the highest proportion being seen in participant selection. Selective participant recruitment, poorly defined diagnostic thresholds, and in vitro studies being non-generalisable to the clinical scenario of a routine dental examination were the main reasons for these findings. The dominance of in vitro studies also means that the information on how the results of these devices are used to support diagnosis, as opposed to pure detection, was extremely limited. There was substantial variability in the results which could not be explained by the different devices or dentition or other sources of heterogeneity that we investigated. The diagnostic odds ratio (DOR) was 14.12 (95% CI 11.17 to 17.84). The estimated sensitivity, at a fixed median specificity of 0.78, was 0.70 (95% CI 0.64 to 0.75). In a hypothetical cohort of 1000 tooth sites or surfaces, with a prevalence of enamel caries of 57%, obtained from the included studies, the estimated sensitivity of 0.70 and specificity of 0.78 would result in 171 missed tooth sites or surfaces with enamel caries (false negatives) and 95 incorrectly classed as having early caries (false positives). We used meta-regression to compare the accuracy of the different devices for red fluorescence (84 datasets, 14,514 tooth sites), blue fluorescence (21 datasets, 3429 tooth sites), and green fluorescence (9 datasets, 3340 tooth sites) devices. Initially, we allowed threshold, shape, and accuracy to vary according to device type by including covariates in the model. Allowing consistency of shape, removal of the covariates for accuracy had only a negligible effect (Chi2 = 3.91, degrees of freedom (df) = 2, P = 0.14). Despite the relatively large volume of evidence we rated the certainty of the evidence as low, downgraded two levels in total, for risk of bias due to limitations in the design and conduct of the included studies, indirectness arising from the high number of in vitro studies, and inconsistency due to the substantial variability of results. AUTHORS' CONCLUSIONS: There is considerable variation in the performance of these fluorescence-based devices that could not be explained by the different wavelengths of the devices assessed, participant, or study characteristics. Blue and green fluorescence-based devices appeared to outperform red fluorescence-based devices but this difference was not supported by the results of a formal statistical comparison. The evidence base was considerable, but we were only able to include 79 studies out of 133 in the meta-analysis as estimates of sensitivity or specificity values or both could not be extracted or derived. In terms of applicability, any future studies should be carried out in a clinical setting, where difficulties of caries assessment within the oral cavity include plaque, staining, and restorations. Other considerations include the potential of fluorescence devices to be used in combination with other technologies and comparative diagnostic accuracy studies.

ANTECEDENTES: La caries es una de las afecciones más frecuentes y prevenibles en todo el mundo. Si se identifican con suficiente antelación, se pueden aplicar técnicas no invasivas y, por lo tanto, esta revisión se centra en las caries tempranas que afectan la superficie del esmalte del diente. La piedra angular de la detección de la caries es una exploración dental visual y táctil; sin embargo, existen métodos alternativos de detección, entre los que se incluyen los dispositivos basados en la fluorescencia. Hay tres categorías de dispositivos basados en la fluorescencia, cada una de ellas definida principalmente por las diferentes longitudes de onda que utilizan; estos grupos se han llamado fluorescencia roja, azul y verde. Estos dispositivos podrían apoyar la exploración visual para la detección y el diagnóstico de la caries en una etapa temprana de descomposición. OBJETIVOS: Los objetivos principales fueron determinar la exactitud de la prueba diagnóstica de dispositivos basados en la fluorescencia para la detección y el diagnóstico de la caries del esmalte en niños o adultos. Se planificó investigar las siguientes fuentes potenciales de heterogeneidad: superficie dental (oclusal, proximal, superficie lisa o adyacente a una restauración); dispositivos de medición de punto único frente a dispositivos de imagen o de evaluación de superficie; y la prevalencia de enfermedades más graves en cada muestra de estudio, a nivel de caries en la dentina. MÉTODOS DE BÚSQUEDA: El documentalista del Grupo Cochrane de Salud Oral (Cochrane Oral Health Group) realizó una búsqueda en las siguientes bases de datos: MEDLINE Ovid (1946 al 30 de mayo de 2019); Embase Ovid (1980 al 30 de mayo de 2019); Registro de ensayos en curso de los Institutos Nacionales de Salud de los Estados Unidos (ClinicalTrials.gov, hasta el 30 de mayo de 2019); y la Plataforma de Registro Internacional de Ensayos Clínicos de la Organización Mundial de la Salud (hasta el 30 de mayo de 2019). Se estudiaron las listas de referencias y las revisiones sistemáticas publicadas. CRITERIOS DE SELECCIÓN: Se incluyeron diseños de estudios de exactitud diagnóstica que compararon un dispositivo basado en la fluorescencia con un estándar de referencia. Esto incluyó estudios prospectivos que evaluaron la exactitud diagnóstica de una única prueba índice y estudios que compararon directamente dos o más pruebas índice. Se excluyeron los estudios que reclutaron explícitamente a participantes con caries en la dentina o en la cavitación franca. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Dos autores de la revisión extrajeron los datos de forma independiente mediante un formulario de extracción de datos de estudios piloto basado en la Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS­2). De cada estudio se informaron la sensibilidad y la especificidad con intervalos de confianza (IC) del 95%. Esta información se ha presentado en forma de diagramas de bosque (forest plot) emparejados y gráficos de curva resumen de rendimiento diagnóstico (SROC), que muestran los puntos de sensibilidad­especificidad de cada estudio. La exactitud diagnóstica se calculó mediante métodos de modelo jerárquico de curva resumen de rendimiento diagnóstico (HSROC). Se informaron sensibilidades a valores fijos de especificidad (mediana 0,78, cuartil superior 0,90). RESULTADOS PRINCIPALES: Se incluyeron un total de 133 estudios, 55 no informaron los datos en el formato 2 x 2 y no se pudieron incluir en el metanálisis. En el metanálisis se incluyeron 79 estudios que proporcionaron 114 conjuntos de datos y evaluaron 21 283 superficies dentales. Hubo alto riesgo de sesgo en el dominio de selección de los participantes. La prueba índice, el estándar de referencia y los dominios de flujo y tiempo mostraron que una alta proporción de los estudios tenían un bajo riesgo de sesgo. Las preocupaciones relacionadas con la aplicabilidad de la evidencia fueron altas o poco claras en todos los dominios, y la mayor proporción se observó en la selección de los participantes. El reclutamiento selectivo de los participantes, los umbrales diagnósticos mal definidos y el hecho de que los estudios in vitro no se puedan generalizar al escenario clínico de una exploración dental de rutina fueron las principales razones de estos hallazgos. El predominio de los estudios in vitro también hizo que la información sobre la forma en que se utilizan los resultados de esos dispositivos para apoyar el diagnóstico, en contraposición con la detección pura, fuera muy limitada. Hubo una variabilidad significativa en los resultados que no se pudo explicar por los diferentes dispositivos o dentición u otras fuentes de heterogeneidad que se investigaron. El odds ratio diagnóstico (ORD) fue 14,12 (IC del 95%: 11,17 a 17,84). La sensibilidad estimada, con una especificidad media fija de 0,78, fue 0,70 (IC del 95%: 0,64 a 0,75). En una cohorte hipotética de 1000 puntos o superficies dentales, con una prevalencia de caries del esmalte del 57%, obtenida de los estudios incluidos, la sensibilidad estimada de 0,70 y la especificidad de 0,78 daría lugar a 171 puntos o superficies dentales con caries del esmalte no detectados (falsos negativos) y 95 incorrectamente considerados con caries temprana (falsos positivos). Se utilizó la metarregresión para comparar la exactitud de los diferentes dispositivos para la fluorescencia roja (84 conjuntos de datos, 14 514 puntos dentales), la fluorescencia azul (21 conjuntos de datos, 3429 puntos dentales), y la fluorescencia verde (nueve conjuntos de datos, 3340 puntos dentales). Inicialmente, se permitió que el umbral, la forma y la exactitud variaran según el tipo de dispositivo, incluyendo covariables en el modelo. Permitiendo la homogeneidad de la forma, la eliminación de las covariables para la exactitud tuvo sólo un efecto insignificante (Ji2 = 3,91; grados de libertad [gl] = 2; p = 0,14). A pesar del volumen relativamente grande de evidencia, la certeza de las mismas se consideró baja, disminuyendo dos niveles en total, por el riesgo de sesgo debido a las limitaciones en el diseño y la realización de los estudios incluidos, los hallazgos indirectos derivados del elevado número de estudios in vitro y la incoherencia debida a la considerable variabilidad de los resultados. CONCLUSIONES DE LOS AUTORES: Existe una considerable variación en la ejecución de estos dispositivos basados en la fluorescencia que no se pudo explicar por las diferentes longitudes de onda de los dispositivos evaluados, los participantes ni las características de los estudios. Los dispositivos basados en la fluorescencia azul y verde parecieron superar a los basados en la fluorescencia roja, pero esta diferencia no estuvo respaldada por los resultados de una comparación estadística formal. La base de evidencia fue considerable, pero sólo fue posible incluir 79 estudios de 133 en el metanálisis, ya que no se pudieron extraer o derivar las estimaciones de los valores de sensibilidad o especificidad o ambos. En cuanto a la aplicabilidad, todo estudio futuro se debería realizar en un ámbito clínico, en el que las dificultades de la evaluación de la caries dentro de la cavidad oral incluyen la placa, la tinción y las restauraciones. Otras consideraciones son el potencial de los dispositivos de fluorescencia para ser utilizados en combinación con otras tecnologías y estudios comparativos de exactitud diagnóstica.

Tests to detect and inform the diagnosis of root caries.

BACKGROUND: Root caries is a well-recognised disease, with increasing prevalence as populations age and retain more of their natural teeth into later life. Like coronal caries, root caries can be associated with pain, discomfort, tooth loss, and contribute significantly to poorer oral health-related quality of life in the elderly. Supplementing the visual-tactile examination could prove beneficial in improving the accuracy of early detection and diagnosis. The detection of root caries lesions at an early stage in the disease continuum can inform diagnosis and lead to targeted preventive therapies and lesion arrest. OBJECTIVES: To assess the diagnostic test accuracy of index tests for the detection and diagnosis of root caries in adults, used alone or in combination with other tests. SEARCH METHODS: Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 31 December 2018); Embase Ovid (1980 to 31 December 2018); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 31 December 2018); and the World Health Organization International Clinical Trials Registry Platform (to 31 December 2018). We studied reference lists as well as published systematic review articles. SELECTION CRITERIA: We included diagnostic accuracy study designs that compared one or more index tests (laser fluorescence, radiographs, visual examination, electronic caries monitor (ECM), transillumination), either independently or in combination, with a reference standard. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. In vitro and in vivo studies were eligible for inclusion but studies that artificially created carious lesions were excluded. DATA COLLECTION AND ANALYSIS: Two review authors extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) specific to the review context. Estimates of diagnostic test accuracy were expressed as sensitivity and specificity with 95% confidence intervals (CI) for each dataset. We planned to use hierarchical models for data synthesis and explore potential sources of heterogeneity through meta-regression. MAIN RESULTS: Four cross-sectional diagnostic test accuracy studies providing eight datasets with data from 4997 root surfaces were analysed. Two in vitro studies evaluated secondary root caries lesions on extracted teeth and two in vivo studies evaluated primary root caries lesions within the oral cavity. Four studies evaluated laser fluorescence and reported estimates of sensitivity ranging from 0.50 to 0.81 and specificity ranging from 0.40 to 0.80. Two studies evaluated radiographs and reported estimates of sensitivity ranging from 0.40 to 0.63 and specificity ranging from 0.31 to 0.80. One study evaluated visual examination and reported sensitivity of 0.75 (95% CI 0.48 to 0.93) and specificity of 0.38 (95% CI 0.14 to 0.68). One study evaluated the accuracy of radiograph and visual examination in combination and reported sensitivity of 0.81 (95% CI 0.54 to 0.96) and specificity of 0.54 (95% CI 0.25 to 0.81). Given the small number of studies and important differences in the clinical and methodological characteristics of the studies we were unable to pool the results. Consequently, we were unable to formally evaluate the comparative accuracy of the different tests considered in this review. Using QUADAS-2 we judged all four studies to be at overall high risk of bias, but only two to have applicability concerns (patient selection domain). Reasons included bias in the selection process, use of post hoc (data driven) positivity thresholds, use of an imperfect reference standard, and use of extracted teeth. We downgraded the certainty of the evidence due to study limitations and serious imprecision of the results (downgraded two levels), and judged the certainty of the evidence to be very low. AUTHORS' CONCLUSIONS: Visual-tactile examination is the mainstay of root caries detection and diagnosis; however, due to the paucity of the evidence base and the very low certainty of the evidence we were unable to determine the additional benefit of adjunctive diagnostic tests for the detection and diagnosis of root caries.

Risk-based, 6-monthly and 24-monthly dental check-ups for adults: the INTERVAL three-arm RCT.

BACKGROUND: Traditionally, patients are encouraged to attend dental recall appointments at regular 6-month intervals, irrespective of their risk of developing dental disease. Stakeholders lack evidence of the relative effectiveness and cost-effectiveness of different recall strategies and the optimal recall interval for maintenance of oral health. OBJECTIVES: To test effectiveness and assess the cost-benefit of different dental recall intervals over a 4-year period. DESIGN: Multicentre, parallel-group, randomised controlled trial with blinded clinical outcome assessment at 4 years and a within-trial cost-benefit analysis. NHS and participant perspective costs were combined with benefits estimated from a general population discrete choice experiment. A two-stratum trial design was used, with participants randomised to the 24-month interval if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or 6-month recall interval. SETTING: UK primary care dental practices. PARTICIPANTS: Adult, dentate, NHS patients who had visited their dentist in the previous 2 years. INTERVENTIONS: Participants were randomised to attend for a dental check-up at one of three dental recall intervals: 6-month, risk-based or 24-month recall. MAIN OUTCOMES: Clinical - gingival bleeding on probing; patient - oral health-related quality of life; economic - three analysis frameworks: (1) incremental cost per quality-adjusted life-year gained, (2) incremental net (societal) benefit and (3) incremental net (dental health) benefit. RESULTS: A total of 2372 participants were recruited from 51 dental practices; 648 participants were eligible for the 24-month recall stratum and 1724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding between intervention arms in any comparison. For the eligible for 24-month recall stratum: the 24-month (n = 138) versus 6-month group (n = 135) had an adjusted mean difference of -0.91 (95% confidence interval -5.02 to 3.20); the risk-based (n = 143) versus 6-month group had an adjusted mean difference of -0.98 (95% confidence interval -5.05 to 3.09); the 24-month versus risk-based group had an adjusted mean difference of 0.07 (95% confidence interval -3.99 to 4.12). For the overall sample, the risk-based (n = 749) versus 6-month (n = 737) adjusted mean difference was 0.78 (95% confidence interval -1.17 to 2.72). There was no evidence of a difference in oral health-related quality of life between intervention arms in any comparison. For the economic evaluation, under framework 1 (cost per quality-adjusted life-year) the results were highly uncertain, and it was not possible to identify the optimal recall strategy. Under framework 2 (net societal benefit), 6-month recalls were the most efficient strategy with a probability of positive net benefit ranging from 78% to 100% across the eligible and combined strata, with findings driven by the high value placed on more frequent recall services in the discrete choice experiment. Under framework 3 (net dental health benefit), 24-month recalls were the most likely strategy to deliver positive net (dental health) benefit among those eligible for 24-month recall, with a probability of positive net benefit ranging from 65% to 99%. For the combined group, the optimal strategy was less clear. Risk-based recalls were more likely to be the most efficient recall strategy in scenarios where the costing perspective was widened to include participant-incurred costs, and in the Scottish subgroup. LIMITATIONS: Information regarding factors considered by dentists to inform the risk-based interval and the interaction with patients to determine risk and agree the interval were not collected. CONCLUSIONS: Over a 4-year period, we found no evidence of a difference in oral health for participants allocated to a 6-month or a risk-based recall interval, nor between a 24-month, 6-month or risk-based recall interval for participants eligible for a 24-month recall. However, people greatly value and are willing to pay for frequent dental check-ups; therefore, the most efficient recall strategy depends on the scope of the cost and benefit valuation that decision-makers wish to consider. FUTURE WORK: Assessment of the impact of risk assessment tools in informing risk-based interval decision-making and techniques for communicating a variable recall interval to patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95933794. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme [project numbers 06/35/05 (Phase I) and 06/35/99 (Phase II)] and will be published in full in Health Technology Assessment; Vol. 24, No. 60. See the NIHR Journals Library website for further project information.

Traditionally, dentists have encouraged both patients at low risk and patients at high risk of developing dental disease to attend their dental practices for regular 6-month 'check-ups'. There is, however, little evidence available for either patients or dentists to use when deciding on the best dental recall interval (i.e. time between dental check-ups) for maintaining oral health. In this study, we wanted to find out, for adult patients who regularly attend the dentist, what interval of time between dental check-ups maintains optimum oral health and represents value for money. A total of 2372 adults who regularly attended 51 different dental practices across Scotland, Northern Ireland, England and Wales were involved. Patients aged 18 years or over who received all or part of their care as NHS patients were randomly allocated to groups to receive a check-up either every 6 months, at an individualised recall interval based on their own risk of oral disease (risk-based recall), or every 24 months (if considered at low risk by their dentist). The recruited adults completed questionnaires at their first trial appointment and then every year of the 4-year study. Their attendance at recall appointments was recorded and they received a clinical assessment taken by study staff at the end of their involvement at year 4. After 4 years, there was no evidence of a difference in the oral health of patients allocated to a 6-month or variable risk-based recall interval. For patients considered by their dentists to be suitable for a 24-month recall interval, there was no difference between those in the 24-month, 6-month or risk-based recall intervals. However, people greatly value and are willing to pay for frequent dental check-ups. The recall strategy that offers the best value for money to patients and the NHS, therefore, depends on what people and decision-makers wish to value within a health-care system.

Recall intervals for oral health in primary care patients.

BACKGROUND: There is ongoing debate about the frequency with which patients should attend for a dental check-up and the effects on oral health of the interval between check-ups. Recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, but 6-month dental check-ups have traditionally been advocated by general dental practitioners in many high-income countries. This review updates a version first published in 2005, and updated in 2007 and 2013. OBJECTIVES: To determine the optimal recall interval of dental check-up for oral health in a primary care setting. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 17 January 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; in the Cochrane Library, 2019, Issue 12), MEDLINE Ovid (1946 to 17 January 2020), and Embase Ovid (1980 to 17 January 2020). We also searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching. SELECTION CRITERIA: We included randomised controlled trials (RCTs) assessing the effects of different dental recall intervals in a primary care setting. DATA COLLECTION AND ANALYSIS: Two review authors screened search results against inclusion criteria, extracted data and assessed risk of bias, independently and in duplicate. We contacted study authors for clarification or further information where necessary and feasible. We expressed the estimate of effect as mean difference (MD) with 95% confidence intervals (CIs) for continuous outcomes and risk ratios (RR) with 95% CIs for dichotomous outcomes. We assessed the certainty of the evidence using GRADE. MAIN RESULTS: We included two studies with data from 1736 participants. One study was conducted in a public dental service clinic in Norway and involved participants under 20 years of age who were regular attenders at dental appointments. It compared 12-month with 24-month recall intervals and measured outcomes at two years. The other study was conducted in UK general dental practices and involved adults who were regular attenders, which was defined as having attended the dentist at least once in the previous two years. It compared the effects of 6-month, 24-month and risk-based recall intervals, and measured outcomes at four years. The main outcomes we considered were dental caries, gingival bleeding and oral-health-related quality of life. Neither study measured other potential adverse effects. 24-month versus 12-month recall at 2 years' follow-up Due to the very low certainty of evidence from one trial, it is unclear if there is an important difference in caries experience between assignment to a 24-month or a 12-month recall. For 3- to 5-year-olds with primary teeth, the mean difference (MD) in dmfs (decayed, missing, and filled tooth surfaces) increment was 0.90 (95% CI -0.16 to 1.96; 58 participants). For 16- to 20-year-olds with permanent teeth, the MD in DMFS increment was 0.86 (95% CI -0.03 to 1.75; 127 participants). The trial did not assess other clinical outcomes of relevance to this review. Risk-based recall versus 6-month recall at 4 years' follow-up We found high-certainty evidence from one trial of adults that there is little to no difference between risk-based and 6-month recall intervals for the outcomes: number of tooth surfaces with any caries (ICDAS 1 to 6; MD 0.15, 95% CI -0.77 to 1.08; 1478 participants); proportion of sites with gingival bleeding (MD 0.78%, 95% CI -1.17% to 2.73%; 1472 participants); oral-health-related quality of life (MD in OHIP-14 scores -0.35, 95% CI -1.02 to 0.32; 1551 participants). There is probably little to no difference in the prevalence of moderate to extensive caries (ICDAS 3 to 6) between the groups (RR 1.04, 95% CI 0.99 to 1.09; 1478 participants; moderate-certainty evidence). 24-month recall versus 6-month recall at 4 years' follow-up We found moderate-certainty evidence from one trial of adults that there is probably little to no difference between 24-month and 6-month recall intervals for the outcomes: number of tooth surfaces with any caries (MD -0.60, 95% CI -2.54 to 1.34; 271 participants); percentage of sites with gingival bleeding (MD -0.91%, 95% CI -5.02% to 3.20%; 271 participants). There may be little to no difference between the groups in the prevalence of moderate to extensive caries (RR 1.05, 95% CI 0.92 to 1.20; 271 participants; low-certainty evidence). We found high-certainty evidence that there is little to no difference in oral-health-related quality of life between the groups (MD in OHIP-14 scores -0.24, 95% CI -1.55 to 1.07; 305 participants). Risk-based recall versus 24-month recall at 4 years' follow-up We found moderate-certainty evidence from one trial of adults that there is probably little to no difference between risk-based and 24-month recall intervals for the outcomes: prevalence of moderate to extensive caries (RR 1.06, 95% CI 0.95 to 1.19; 279 participants); number of tooth surfaces with any caries (MD 1.40, 95% CI -0.69 to 3.49; 279 participants). We found high-certainty evidence that there is no important difference between the groups in the percentage of sites with gingival bleeding (MD -0.07%, 95% CI -4.10% to 3.96%; 279 participants); or in oral-health-related quality of life (MD in OHIP-14 scores -0.37, 95% CI -1.69 to 0.95; 298 participants). AUTHORS' CONCLUSIONS: For adults attending dental check-ups in primary care settings, there is little to no difference between risk-based and 6-month recall intervals in the number of tooth surfaces with any caries, gingival bleeding and oral-health-related quality of life over a 4-year period (high-certainty evidence). There is probably little to no difference between the recall strategies in the prevalence of moderate to extensive caries (moderate-certainty evidence). When comparing 24-month with either 6-month or risk-based recall intervals for adults, there is moderate- to high-certainty evidence that there is little to no difference in the number of tooth surfaces with any caries, gingival bleeding and oral-health-related quality of life over a 4-year period. The available evidence on recall intervals between dental check-ups for children and adolescents is uncertain. The two trials we included in the review did not assess adverse effects of different recall strategies.

Is personal oral hygiene advice effective in preventing coronal dental caries?

Data sources PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials databases.Study selection PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials databases were searched for studies published in English between January 1950 and February 2017.Data extraction and synthesis Data were extracted independently by two reviewers and risk of bias assessed using a modified Jadad scale. Heterogeneity was evaluated using the chi-squared statistic and meta-analysis performed.Results Three randomised trials were included, involving 681 participants; all children 10-13 years old. Two trials were conducted in the USA and one in the UK. Two studies tested school-based, daily supervised oral hygiene (including plaque staining and removal and supervised flossing) against control groups; one study tested the same intervention every two weeks against controls. Two studies measured decayed, missing or filled surfaces (DMFS) scores at three years and one trial at 29 months. Personal oral hygiene interventions failed to influence the incidence of dental caries, (DMFS = -0.11; 95% CI -0.91, 0.69: P value <0.79). Four non-randomised trials were retained to conduct sensitivity analyses.Conclusions Personal oral hygiene interventions delivered to school children failed to show a reduction in coronal dental carious lesion incidence over three years when compared to control groups.

INTERVAL (investigation of NICE technologies for enabling risk-variable-adjusted-length) dental recalls trial: a multicentre randomised controlled trial investigating the best dental recall interval for optimum, cost-effective maintenance of oral health in dentate adults attending dental primary care.

BACKGROUND: Traditionally, patients at low risk and high risk of developing dental disease have been encouraged to attend dental recall appointments at regular intervals of six months between appointments. The lack of evidence for the effect that different recall intervals between dental check-ups have on patient outcomes, provider workload and healthcare costs is causing considerable uncertainty for the profession and patients, despite the publication of the NICE Guideline on dental recall. The need for primary research has been highlighted in the Health Technology Assessment Group's systematic review of routine dental check-ups, which found little evidence to support or refute the practice of encouraging 6-monthly dental check-ups in adults. The more recent Cochrane review on recall interval concluded there was insufficient evidence to draw any conclusions regarding the potential beneficial or harmful effects of altering the recall interval between dental check-ups. There is therefore an urgent need to assess the relative effectiveness and cost-benefit of different dental recall intervals in a robust, sufficiently powered randomised control trial (RCT) in primary dental care. METHODS: This is a four year multi-centre, parallel-group, randomised controlled trial with blinded outcome assessment based in dental primary care in the UK. Practitioners will recruit 2372 dentate adult patients. Patient participants will be randomised to one of three groups: fixed-period six month recall, risk-based recall, or fixed-period twenty-four month recall. Outcome data will be assessed through clinical examination, patient questionnaires and NHS databases. The primary outcomes measure gingival inflammation/bleeding on probing and oral health-related quality of life. DISCUSSION: INTERVAL will provide evidence for the most clinically-effective and cost-beneficial recall interval for maintaining optimum oral health in dentate adults attending general dental practice. TRIAL REGISTRATION: ISRCTN95933794 (Date assigned 20/08/2008).

Cone beam computed tomography in pre-surgical assessment of mandibular third molars.

DesignMulticentre, randomised controlled clinical trial.InterventionPatients referred for third molar removal received a digital panoramic radiograph(PR). Adults with one or more lower third molars in a close relationship with the mandibular canal were eligible for the study. Patients randomised to the cone beam computed tomography (CBCT) group received a high resolution CBCT scan in addition to the PR. All lower third molar extractions were performed under local anaesthesia without sedation and without antibiotic prophylaxis. Information on variables such as experience of the surgeon, duration of surgery and technique for third molar removal were recorded.Outcome measureThe primary outcome measure was the number of patient-reported altered sensations one week after surgery. Secondary outcomes included the number of patients with an objective IAN injury; permanent IAN injury (>6 months); occurrence of other postoperative complications (wound infection, alveolar osteitis); Oral Health Related Quality of Life-14, questionnaire responses; pain (VAS score); duration of surgery; number of emergency visits; and number of missed days of work or study.ResultsThree hundred and forty-one patients with 477 lower third molars were randomised from three centres. Two hundred and sixty-eight patients with 320 mandibular third molars were analysed according to the intention-to-treat principle for the primary and secondary outcomes. The overall incidence of patient-reported altered sensations one week after surgery was 6.3%. At one week there was no difference in subjective IAN injury between the CBCT and PR group. No significant differences were noted between the two groups for any of the secondary outcomes recorded.ConclusionsAlthough CBCT is a valuable diagnostic adjunct for identification of an increased risk for IAN injury, the use of CBCT does not translate into a reduction of IAN injury and other postoperative complications, after removal of the complete mandibular third molar. In these selected cases with a high risk for IAN injury, an alternative strategy, such as monitoring or a coronectomy, might be more appropriate.