The current referral patterns for temporomandibular joint disorders (TMD) in Greater Manchester.

BACKGROUND: Temporomandibular joint disorders (TMD) affect up to 50% of the population. Chronic TMD may have a significant impact on patients' quality of life and is associated with a significant cost burden to health services. AIMS: The aim of this study was to investigate the incidence of TMD in Greater Manchester and to determine the most appropriate setting for its management. METHODS: Data were retrospectively collected on the demographics, symptoms and management provided to patients referred for TMD. RESULTS: There were 789 referrals analysed; 616 to a Tertiary Centre and 173 to a District General Hospital (DGH). The most common reason for referral was pain (82%), followed by limitation in opening (55%) and clicks or sounds (44%). 27% of referrals were managed with a splint and 12% were provided with advice or a patient information leaflet prior to referral. DISCUSSION: The effect of chronic pain on patients' quality of life and the cost burden of its management compels us to review current practices in referral and management of TMD. Barriers to provision of treatment in primary care may include a lack of training, remuneration or confidence. These may be overcome with the development of self-care plans for patients and a care pathway for practitioners. CONCLUSION: Based on existing evidence, timely and conservative management of TMD should be encouraged in primary care, enabling better outcomes to be achieved for patients and the maintenance of the experience and skill level of specialist services in secondary care.

Protocol for a Randomised controlled trial to Evaluate the effectiveness and cost benefit of prescribing high dose FLuoride toothpaste in preventing and treating dEntal Caries in high-risk older adulTs (reflect trial).

BACKGROUND: Dental caries in the expanding elderly, predominantly-dentate population is an emerging public health concern. Elderly individuals with heavily restored dentitions represent a clinical challenge and significant financial burden for healthcare systems, especially when their physical and cognitive abilities are in decline. Prescription of higher concentration fluoride toothpaste to prevent caries in older populations is expanding in the UK, significantly increasing costs for the National Health Services (NHS) but the effectiveness and cost benefit of this intervention are uncertain. The Reflect trial will evaluate the effectiveness and cost benefit of General Dental Practitioner (GDP) prescribing of 5000 ppm fluoride toothpaste and usual care compared to usual care alone in individuals 50 years and over with high-risk of caries. METHODS/DESIGN: A pragmatic, open-label, randomised controlled trial involving adults aged 50 years and above attending NHS dental practices identified by their dentist as having high risk of dental caries. Participants will be randomised to prescription of 5000 ppm fluoride toothpaste (frequency, amount and duration decided by GDP) and usual care only. 1200 participants will be recruited from approximately 60 dental practices in England, Scotland and Northern Ireland and followed up for 3 years. The primary outcome will be the proportion of participants receiving any dental treatment due to caries. Secondary outcomes will include coronal and root caries increments measured by independent, blinded examiners, patient reported quality of life measures, and economic outcomes; NHS and patient perspective costs, willingness to pay, net benefit (analysed over the trial follow-up period and modelled lifetime horizon). A parallel qualitative study will investigate GDPs' practises of and beliefs about prescribing the toothpaste and patients' beliefs and experiences of the toothpaste and perceived impacts on their oral health-related behaviours. DISCUSSION: The Reflect trial will provide valuable information to patients, policy makers and clinicians on the costs and benefits of an expensive, but evidence-deficient caries prevention intervention delivered to older adults in general dental practice. TRIAL REGISTRATION: ISRCTN: 2017-002402-13 registered 02/06/2017, first participant recruited 03/05/2018. Ethics Reference No: 17/NE/0329/233335. Funding Body: Health Technology Assessment funding stream of National Institute for Health Research. Funder number: HTA project 16/23/01. Trial Sponsor: Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL. The Trial was prospectively registered.

Sugar before bed: a simple dietary risk factor for caries experience.

Clinical care pathways have placed renewed emphasis on caries risk assessment and the ability to predict and prevent further disease. With diet considered a key factor in the development of caries, the level of caries risk posed by dietary habits, such as the frequency of intake and timing of free sugars is questioned. OBJECTIVE: To identify reliable and simple dietary risk factors for caries experience. RESEARCH DESIGN: A cross-sectional observational study of a convenience sample with data gained from clinical examinations, questionnaire and a 24 hour dietary-recall interview. PARTICIPANTS: 128 subjects aged 11-12 from comprehensive schools in Greater Manchester and Newcastle upon-Tyne, UK. OUTCOME MEASURES: free sugars consumed between meals, before bed and total % of total free sugars consumed were assessed from dietary assessments led by a dietitian. D4-6MFT was generated with a caries threshold of ICDAS stage 4 from clinical examinations. RESULTS: Analysis revealed no significant differences in caries experience when looking specifically at caries into dentine, referred to as the cavity group (split at D4-6MFT), between high and low deprivation, consumption of free sugars between meals and free sugars (%). The consumption of free sugars within the hour before bed revealed a statistically significant difference between the cavity/no cavity groups (p=0.002). Logistic regression analysis on the cavity/no cavity groups revealed an odds ratio of 2.4 (95%CI 1.3,4.4) for free sugars consumption before bedtime. CONCLUSIONS: The study suggests that the consumption of free sugars before bedtime may be an important risk factor for adolescent caries into dentine experience.

Prevalence and severity of dental fluorosis in four English cities.

OBJECTIVE: To assess the prevalence and severity of dental fluorosis in four city-based populations using a robust photographic method with TF index reporting; and to record the aesthetic satisfaction scores of children in all four cities. BASIC RESEARCH DESIGN: Cross sectional epidemiological survey (surveillance). PARTICIPANTS: 1,904 children aged 11-14 years, in four English cities. INTERVENTIONS: Two cities were served by community water fluoridation schemes supplying water at 1mg/l F. The other two cities did not have water fluoridation schemes and had low levels of fluoride naturally present. MAIN OUTCOME MEASURES: The prevalence and severity of dental fluorosis. Scoring was undertaken using high quality digital images by a single calibrated examiner. RESULTS: Data suggest that the prevalence of fluorosis at levels greater than TF2 are broadly similar to previous studies (F 10%, NF 2%), with an apparent increase in the total number of TF1 cases across both fluoridated (41%) and non-fluoridated cities (32%) with a commensurate decrease in TF0 (F 39%, NF 63%). Data suggest that the proportion of children expressing dissatisfaction with the appearance of their teeth is the same in fluoridated and non-fluoridated communities although the reasons for this may differ. CONCLUSIONS: The levels of fluorosis that might be considered of aesthetic concern are low and stable while the increase in TF1 may be due to an increase in self- and professionally-applied fluoride products or the increased sensitivity afforded by the digital imaging system. It is not however a public health problem or concern. Further monitoring appears justified.

Detection and monitoring of early caries lesions: a review.

AIM: To review the current evidence base of detecting and monitoring early carious lesions in children and adolescents and a rationale proposed to ensure that such lesions are identified and appropriately managed. METHODS: The systematic literature search identified initially a review by Gomez and co-workers from 2013 and this still represents the current state of the science in relation to caries detection and monitoring. The review described among others, visible detection systems, image-based detection systems and point-measurement approaches. RESULTS: The current evidence base suggests that while there are numerous devices or technology-enabled detection systems, the use of a careful, methodical visual inspection of clean, dry teeth, supplemented where indicated by radiographic views, remains the standard of care in caries detection and diagnostics. Further, it is possible by means of existing visible and radiographical systems to monitor lesions over time. Using low-cost intra-oral cameras facilitates the recording of lesion appearance in the patient record and may be of significant benefit in monitoring early lesions over time following their detection. This benefit extends to the clinician and the patient for whom it may be a useful educational and motivational tool. CONCLUSIONS: Recommendations are presented that can be adopted and adapted to local circumstances and that are both substantiated by evidence and promote a clear, simple and consistent approach to caries detection, diagnosis and monitoring in children and adolescents. The diagnoses (initial, active; moderate, active and extensive, active) are linked to appropriate management options within primary care.

Dentists' perspectives on caries-related treatment decisions.

OBJECTIVE: To assess the impact of patient risk status on Colombian dentists' caries related treatment decisions for early to intermediate caries lesions (ICDAS code 2 to 4). METHODS: A web-based questionnaire assessed dentists' views on the management of early/intermediate lesions. The questionnaire included questions on demographic characteristics, five clinical scenarios with randomised levels of caries risk, and two questions on different clinical and radiographic sets of images with different thresholds of caries. RESULTS: Questionnaires were completed by 439 dentists. For the two scenarios describing occlusal lesions ICDAS code 2, dentists chose to provide a preventive option in 63% and 60% of the cases. For the approximal lesion ICDAS code 2, 81% of the dentists chose to restore. The main findings of the binary logistic regression analysis for the clinical scenarios suggest that for the ICDAS code 2 occlusal lesions, the odds of a high caries risk patient having restorations is higher than for a low caries risk patient. For the questions describing different clinical thresholds of caries, most dentists would restore at ICDAS code 2 (55%) and for the question showing different radiographic thresholds images, 65% of dentists would intervene operatively at the inner half of enamel. No significant differences with respect to risk were found for these questions with the logistic regression. CONCLUSION: The results of this study indicate that Colombian dentists have not yet fully adopted non-invasive treatment for early caries lesions.

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

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

Measuring initial enamel erosion with quantitative light-induced fluorescence and optical coherence tomography: an in vitro validation study.

BACKGROUND: Measurement of initial enamel erosion is currently limited to in vitro methods. Optical coherence tomography (OCT) and quantitative light-induced fluorescence (QLF) have been used clinically to study advanced erosion. Little is known about their potential on initial enamel erosion. OBJECTIVES: To evaluate the sensitivity of QLF and OCT in detecting initial dental erosion in vitro. METHODS: 12 human incisors were embedded in resin except for a window on the buccal surface. Bonding agent was applied to half of the window, creating an exposed and non-exposed area. Baseline measurements were taken with QLF, OCT and surface microhardness. Samples were immersed in orange juice for 60 min and measurements taken stepwise every 10 min. QLF was used to compare the loss of fluorescence between the two areas. The OCT system, OCS1300SS (Thorlabs Ltd.), was used to record the intensity of backscattered light of both areas. Multiple linear regression and paired t test were used to compare the change of the outcome measures. RESULTS: All 3 instruments demonstrated significant dose responses with the erosive challenge interval (p < 0.05) and a detection threshold of 10 min from baseline. Thereafter, surface microhardness demonstrated significant changes after every 10 min of erosion, QLF at 4 erosive intervals (20, 40, 50 and 60 min) while OCT at only 2 (50 and 60 min). CONCLUSION: It can be concluded that OCT and QLF were able to detect demineralization after 10 min of erosive challenge and could be used to monitor the progression of demineralization of initial enamel erosion in vitro.

A clinical investigation using quantitative light-induced fluorescence (QLF) of the anticaries efficacy of a dentifrice containing 1.5% arginine and 1450 ppm fluoride as sodium monofluorophosphate.

OBJECTIVE: The purpose of this study was to assess the ability of a new dentifrice containing arginine, an insoluble calcium compound, and fluoride to arrest or reverse naturally occurring buccal caries lesions measured using Quantitative Light-induced Fluorescence (QLF). METHODS: Three study groups used dentifrices which contained 1) 1.5% arginine and 1450 ppm fluoride as sodium monofluorophosphate (experimental), 2) 1450 ppm fluoride as sodium monofluorophosphate (positive control), and 3) no fluoride (negative control). All three dentifrices were formulated in the same calcium base. The study participants were from three schools in the city of Chengdu, Sichuan Province, China. A total of 446 of 450 recruited subjects completed the study. Of these, 147 were in the experimental, 148 in the positive control, and 151 in the negative control groups. The initial age of the children was 10-12 years (mean 11.4 +/- 0.54); 47.5% were female. RESULTS: Using QLF, assessments of buccal caries lesions were made at baseline and after three and six months of product use. For AQ, representing lesion volume, the baseline mean value for the three groups was 27.30, and at the three-month examination the mean values were 16.76, 19.25, and 25.89 for the experimental, positive, and negative control dentifrices, respectively. This represents improvements from baseline of 38.6%, 29.5%, and 5.2%. At six months, the deltaQ values for the three groups were 13.46, 18.47, and 24.18, representing improvements from baseline of 50.7%, 32.3%, and 11.4%. For all QLF metrics, deltaF (loss of fluorescence), area, and deltaQ, the differences between the negative control and both the experimental and positive control groups were statistically significant (p < or = 0.01). The differences between the experimental and positive control groups attained statistical significance for deltaQ (p < or = 0.003) at the six-month examination. CONCLUSION: It is concluded that both of the fluoride-containing toothpastes are significantly better at arresting and reversing buccal caries lesions than the non-fluoride toothpaste. Furthermore, it is concluded that the new dentifrice containing arginine, an insoluble calcium compound, and fluoride provides significantly greater anticaries benefit than a dentifrice containing fluoride alone.

The caries continuum: opportunities to detect, treat and monitor the re-mineralization of early caries lesions.

The aim of this review is to discuss dental caries as a dynamic process of de-mineralization and re-mineralization with progression, arrest or reversal of lesions reflecting the balance between them. The need for new clinical trial designs to assess oral care products which reflect and monitor these processes is highlighted and discussed. The research evidence to support the use of two state-of-the-art methods that focus on re-mineralization of natural root caries lesions and natural enamel lesions is described. The use of the Electrical Caries Monitor (ECM) in combination with clinical scoring of lesions to assess the hardness of root dentin and the use of Quantitative Light-induced Fluorescence (QLF) to measure enamel lesions are described together with a number of studies that have employed the methods to assess the efficacy of oral care products. It can be concluded that quantification of the re-mineralization provided by oral care products assessed using both buccal caries and root caries study designs is a valid approach to developing understanding of the mechanism of action of a new technology and to establishing its clinical efficacy in respect of arresting and reversing early caries lesions, and it complements, enhances and may ultimately supplant the information from a conventional two- to three-year clinical trial measuring effects at the cavitation level.

The anti-caries efficacy of a dentifrice containing 1.5% arginine and 1450 ppm fluoride as sodium monofluorophosphate assessed using Quantitative Light-induced Fluorescence (QLF).

OBJECTIVE: To compare the efficacy of a new dentifrice containing 1.5% arginine, an insoluble calcium compound and 1450 ppm fluoride to arrest and reverse naturally occurring buccal caries lesions in children relative to a positive control dentifrice containing 1450 ppm fluoride alone. STUDY DESIGN: Participants from Chengdu, Sichuan Province, China tested three dentifrices: a new dentifrice containing 1.5% arginine, an insoluble calcium compound, and 1450 ppm fluoride, as sodium monofluorophosphate, a positive control dentifrice containing 1450 ppm fluoride, as sodium fluoride, in a silica base, and a matched negative control dentifrice without arginine and fluoride. Quantitative Light-induced Fluorescence (QLF) was used to assess buccal caries lesions at baseline and after 3 and 6 months of product use. RESULTS: 438 participants (initial age 9-13 years (mean 11.1±0.78) and 48.6% female) completed the study. No adverse events attributable to the products were reported during the course of the study. The subject mean ΔQ (mm(2)%), representing lesion volume, was 27.26 at baseline. After 6 months of product use, the ΔQ values for the arginine-containing, positive and negative control dentifrices were 13.46, 17.99 and 23.70 representing improvements from baseline of 50.6%, 34.0% and 13.1%. After 6 months product use, the differences between the pair wise comparisons for all three groups were statistically significant (p<0.01). The arginine-containing dentifrice demonstrated an improvement after only 3 months that was almost identical to that achieved by the conventional 1450 ppm fluoride dentifrice after 6 months. CONCLUSION: The new dentifrice containing 1.5% arginine, an insoluble calcium compound, and 1450 ppm fluoride provides statistically significantly superior efficacy in arresting and reversing buccal caries lesions to a conventional dentifrice containing 1450 ppm fluoride alone.

Estimating the need for dental sedation: evaluating the threshold of the IOSN tool in an adult population.

AIM: The aim of this study was, through a service evaluation, to assess the use of the IOSN tool in determining whether threshold values were appropriate for identification of IV sedation and general anaesthetic (GA) cases from a referral population. METHODS: A total of 105 patients were taken from a dental minor oral surgery referral service within a north west primary care trust over the course of six months. The IOSN tool was completed to assess: treatment complexity, medical and behavioural factors and patient anxiety levels. Each patient was then followed through to treatment. The type of sedation modality they received was compared to their IOSN score previously calculated and these results evaluated. RESULTS: The findings suggest that 94% of patients were treated within primary care by the MOS service, of which 58% received local anaesthetic (LA) alone and 42% were treated by LA with IV sedation. There was a general marked trend as the IOSN score increased so did the treatment modality from LA, through sedation to GA. Logistic regression using the components of the IOSN tool to predict sedation use indicated the IOSN predictors distinguished between those who required sedation and those who didn't (chi-square = 56.411, p <0.0001, df = 3) with treatment complexity (Exp B = 10.836, p <0.0001) and anxiety (Exp B = 4.319, p <0.0001) shown to be significant factors in determining sedation need. CONCLUSIONS: The data collected have shown that there is a positive relationship between the IOSN score and the type of treatment modality the patient received, suggesting that the threshold values are correctly set. It is concluded that IOSN tool is a useful means of aiding the clinician in both assessing and referring patients for that sedation need.

The views of examiners on the use of intra-oral photographs to detect dental caries in epidemiological studies.

AIM: The aim of the study was to obtain the views of examiners on their experience of using intra-oral photographs as a means of detecting caries in epidemiological studies compared to an established visual examination method. METHOD: A focus group discussion was conducted with five examiners experienced in an established visual examination method after they had performed visual dental examinations of a sample of children as well as assessed intra-oral photographs of the same children. RESULTS: The time taken by examiners to assess intraoral photographs becomes extended when compared to performing a visual examination. The ability to assess intra-oral photographs on a screen at a convenient time and place was considered advantageous. The examiners found it easier to make caries detection decisions on intra-oral photographs of primary teeth than permanent teeth. Adequate removal of debris and moisture control prior to obtaining the photographs were considered important. CONCLUSION: The views of examiners in this study suggest that to improve the utility of photographic method, further research is needed to determine adequate drying methods for use in the field. Consideration should be given to a time-limited, standardised presentation of the photographs including the size and resolution. Specific training on caries detection from photographs is also required.

Non-cavitated carious lesions detection methods: a systematic review.

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

In vitro performance of different methods in detecting occlusal caries lesions.

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

Effect of post-brushing mouthwash solutions on salivary fluoride retention--study 2.

OBJECTIVE: This study evaluated the effects of three post-brushing mouthwashes containing 0 ppm F, 225 ppm F, and 500 ppm F, respectively, on salivary fluoride retention after brushing with 1450 ppm fluoride (as NaF) toothpaste and rinsing with water immediately after brushing. METHODS: In this three-phase, randomized, cross-over study, an ion-specific electrode was used to measure salivary F levels in thirty trial participants before brushing (Time 0), and after brushing, rinsing with water, and then rinsing with one of the three mouthwashes. Time points evaluated after brushing were one, three, five, 10, 20, 30, 45, and 60 minutes. For saliva sample collections, subjects were asked to pool saliva in their mouths for 10 seconds before spitting out into a container for each of the time points. RESULTS: The AUC0-60 means for F in saliva were 554, 252, and 20 for the 500, 225, and 0 ppm F mouthwash groups, respectively. The 500 ppm F mouthwash resulted in a 2660% increase in total fluoride salivary retention over 60 minutes when compared with the 0 ppm F group, and a 120% increase when compared with the 225 ppm F group. A significant difference (p < 0.001) in the AUC0-60 means between the three groups was observed using analysis of variance (ANOVA). Paired t-tests also showed significant differences in the mean fluoride retention over 60 minutes for all three pair-wise group comparisons (p < 0.001). CONCLUSION: Use of a fluoride mouthwash containing 225 ppm F or 500 ppm F produced a significant increase in salivary fluoride retention following brushing with a 1450 ppm F toothpaste and rinsing with water compared to rinsing without fluoride. The use of the 500 ppm F mouthwash may be of particular benefit to those at high caries risk.

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

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

Estimating the need for dental sedation. 4. Using IOSN as a referral tool.

OBJECTIVE: In this article we report on the use of the IOSN as a referral tool in primary care and the need for sedation in the referred patient population (as determined by the IOSN score). SETTING: Four centres in the North West of England (primary care) accepting referrals for treatment with the aid of sedation participated in this study. DESIGN: A service evaluation. SUBJECTS (MATERIALS) AND METHODS: The four were provided with IOSN referral forms, operator and patient questionnaires. The centres distributed IOSN forms to referrers as a means of recommending patients for sedation. All patients receiving treatment under sedation (having been referred for treatment through the IOSN form) were asked to complete the patient questionnaire. The individual operator who undertook the treatment under sedation was asked to complete the operator questionnaire. Data were entered into SPSS and the IOSN score noted. Statistical analyses of the data utilised descriptives and comparisons between groups using the Chi Squared test. RESULTS: Seventy-eight percent of the patients (n = 140) in this study were receiving treatment with sedation appropriately according to the principals of the IOSN. Patients deemed by the IOSN tool to have a low need for sedation were less likely to cancel their appointment if sedation had not been given. The majority of patients were female (70%) and the majority of operators and patients reported the IOSN forms acceptable for use. CONCLUSIONS: This study provides support for using the IOSN as a tool for organising sedation referral. The majority of operators and patients reported the IOSN forms acceptable for use.