Characteristics, detection methods and treatment of questionable occlusal carious lesions: findings from the national dental practice-based research network.

Questionable occlusal carious lesions (QOC) can be defined as an occlusal tooth surface with no cavitation and no radiographic radiolucencies, but caries is suspected due to roughness, surface opacities or staining. An earlier analysis of data from this study indicates 1/3 of patients have a QOC. The objective of this report has been to quantify the characteristics of these common lesions, the diagnostic aids used and the treatment of QOC. A total of 82 dentist and hygienist practitioner-investigators from the USA and Denmark in the National Dental Practice-Based Research Network participated. When consenting patients presented with a QOC, information was recorded about the patient, tooth, lesion and treatments. A total of 2,603 QOC from 1,732 patients were analyzed. The lesions were usually associated with a fissure, on molars, and varied from yellow to black in color. Half presented with a chalky luster and had a rough surface when examined with an explorer. There was an association between color and luster: 10% were chalky-light, 47% were shiny-dark and 42% were mixtures. A higher proportion of chalky than of shiny lesions were light (22 vs. 9%; p < 0.001). Lesions light in color were less common in adults than in pediatric patients (9 vs. 32%; p < 0.001). Lesions that were chalky and light were more common among pediatric than among adult patients (22 vs. 6%; p < 0.001). This is the first study to investigate characteristics of QOC in routine clinical practice. Clinicians commonly face this diagnostic uncertainty. Determining the characteristics of these lesions is relevant when making diagnostic and treatment decisions.

Casein phosphopeptide-amorphous calcium phosphate shows promise for preventing caries.

DATA SOURCES: To find studies to include in the review, searches were made using Biomed Central, Cochrane Oral Health Reviews, Cochrane Library, the Directory of Open Access Journals, PubMed, Science Direct and the Research Findings Electronic Register. STUDY SELECTION: English language clinical trials [randomised clinical trials (RCT) or quasi-RCT; in situ or in vivo] or systematic reviews (with or without meta-analysis) of published trials were selected that reported on the efficacy of phosphopeptide-amorphous calcium phosphate (CPP-ACP) using any mode of delivery. Studies were reviewed and their quality assessed independently. DATA EXTRACTION AND SYNTHESIS: Data was extracted by two reviewers independently. Trials that were considered clinically and methodologically homogenous and that reported on similar outcomes were pooled for meta-analyses. RESULTS: Twelve articles were included of which five in-situ RCT could be pooled for meta-analyses. The pooled in-situ results showed a weighted mean difference (WMD) of the percentage remineralisation scores in favour of chewing gum with 18.8 mg CPP-ACP, compared with chewing gum without CPP-ACP of -8.01 [95% confidence interval (CI), -10.54- -5.48; P 0.00001], and compared with no intervention of -13.56 (95% CI, -16.49- -10.62; P 0.00001). A significantly higher remineralisation effect was also observed after exposure to 10.0 mg CPP-ACP (WMD, -7.75; 95% CI, -9.84- -5.66; P 0.00001). One long-term in vivo RCT (24 months) with a large sample size (N = 2720) found that the odds of a tooth surface's progressing to caries was 18% less in subjects who chewed sugar-free gum containing 54 mg CPP-ACP than in control subjects who chewed gum without CPP-ACP (P 0.03). CONCLUSIONS: Within the limitations of this systematic review with meta-analysis, the results of the clinical in-situ trials indicate a short-term remineralisation effect of CPP-ACP. Additionally, the promising in-vivo RCT results suggest a caries-preventing effect for long-term clinical CPP-ACP use. Further RCT are needed in order to confirm these initial results in vivo.

Agreement among dentists' recommendations for restorative treatment.

Differences among dentists in their decisions to recommend treatment have been studied principally at a "macro" level by examinations of variations in dentists' treatment recommendations for individual patients, or for patients aggregated to the practice level. If reasons for these differences are to be understood, however, a "micro" level examination of differences in dentists' decisions to recommend treatment for individual teeth is necessary. Extent of agreement to recommend treatment among dentists was explored for 1187 teeth in 43 patients. Each tooth was examined by a mean of 6.6 general practitioners. A modified reliability index and distributions of raw levels of agreement were used for quantification of agreement rates across an incomplete cross-classification for practitioners and patients. Overall inter-dentist reliability in recommending individual teeth for treatment was moderate, p = 0.62. Among unrestored teeth with no clinically evident caries, as judged by an independent experienced evident caries, as judged by an independent experienced examiner, reliability in treatment recommendations due to caries was fair, p = 0.51. Reliability was lowest for recommendations concerning previously restored teeth, p = 0.43. Among all teeth receiving at least one recommendation for treatment, only 22% received a unanimous recommendation. Over one-half of all instances of lack of agreement resulted from a single dentist's recommendation differing from those of all other dentists examining the tooth. The results suggest that much of the variation in dentists' practice profiles is due to basic differences in decisions to recommend treatment for individual teeth with specific conditions, and that the presence of previous restorations seems to magnify these differences.

Movement of teeth adjacent to posterior bounded edentulous spaces.

Bounded edentulous spaces (BES)-a missing posterior tooth with intact adjacent teeth-are thought to lead to arch collapse resulting from the movement of adjacent teeth. To determine the rate of change in distance between teeth adjacent to a BES, we examined three successive measurable radiographs of 116 untreated posterior BES cases. The distance between the teeth (DBT) adjacent to the space was measured, and change in DBT (delta DBT) between pre-extraction and follow-up radiographs was calculated. We used linear spline regression to construct models for tooth movement and to identify factors associated with delta DBT. The mean delta DBT was < 1 mm during the first year post-extraction, and the DBT continued to decrease at a successively slower rate each following year. Overall and for each tooth type, the greatest rates of decrease in DBT were seen in the zero to two-year period. In a multivariable model, time since extraction and tooth type were significantly associated with delta DBT. These findings suggest that movement of teeth adjacent to a posterior BES after the first two years is usually gradual and minor within the time frame of this study.

Six-month effects of a sanguinarine dentifrice on plaque and gingivitis.

A six-month, double-blind clinical trial was conducted to determine the effectiveness of a sanguinarine-containing dentifrice in reducing plaque and gingival inflammation. One hundred twenty adult volunteers were randomly assigned to a control or experimental group. The test dentifrice contained 750 mcg/g of sanguinaria extract. A dentifrice of similar composition without sanguinarine was used as the placebo. Plaque and gingival inflammation scores were recorded for four surfaces on each of 12 index teeth at baseline, one-, three, and six-months. Matched pair t-test analyses showed no significant differences between experimental and control groups for mean six-month changes in plaque and gingival inflammation scores in analyses using all 48 sites per subject or in analyses of only the 24 interproximal sites. No long-term reduction was demonstrated in plaque or gingival inflammation with the use of a sanguinarine-containing dentifrice.

Presence of periodontal data in patient records of general practitioners.

It has been reported that little diagnostic information concerning periodontal conditions is entered in patient records of general practitioners, but actual rates for such chart entries are unknown. Records of regular patients, seen at least annually, were randomly selected from the offices of 36 general practitioners in two North Carolina counties. In each office 80 records were selected for audit. After adjustment, the final sample consisted of 2488 audited records. Entries noting the presence or absence of 14 diagnostic conditions were identified for the five previous years and for the patient's most recent examination. The presence of a periodontal diagnosis or periodontal treatment plan was noted. The number of radiographic sets exposed in the previous five years and the age of the most recent set were determined for complete series/panoramic films and for bitewings. Across practices, the most frequent notations (20.5% within the past five years) concerned the presence of probing depths and calculus. Gingival bleeding (13%) and plaque (12%) were noted less frequently. A periodontal diagnosis was recorded in only 16.3% of the records. Annualized rates for radiographic sets were 0.09 for complete series/panoramic films and 0.50 for bitewings. These data suggest that, except for radiographs, the majority of patient records do not contain sufficient diagnostic information to describe patients' periodontal health.

Clinical periodontal status of regularly attending patients in general dental practices.

Periodontal status of regular patients of general practitioners in the United States is unknown. A project assessing the effectiveness of continuing professional education in altering provider behavior and patient periodontal health provided the opportunity to clinically examine 1092 patients in the offices of 36 general practitioners. These regularly attending patients were selected by a random start systematic sample of patient records. The examination included recording missing teeth and assessing plaque, gingivitis, calculus, probing depth, and attachment loss on the facial and facial-mesial surfaces of the Ramfjord teeth (PDI). The mean patient age was 48 years, and 63% were female. The mean number of missing teeth, not including third molars, was 3.9. Almost 78% of the patients had no sites with a P1I score greater than 1, but 52% of the patients had at least one site with bleeding. Calculus was present in 62% of the patients. Deepest pocket depth was 4 mm or greater in 9% of patients and 3.8% had sites with 4 mm or greater attachment loss. Mean attachment loss was 1.6 mm across all sites. Although the majority of these regular patients had plaque, calculus, and gingivitis, only a minority exhibited periodontitis at the index sites.

What do we know about how dentists make caries-related treatment decisions?

A conceptual model of dentists' treatment decision-making is discussed. The model suggests that dentists do not use a hypothetico-deductive process for the diagnosis of caries. Rather, caries is identified through a process of pattern recognition that in most instances is inextricably linked to intervention decisions. Individual dentists have inventories of caries scripts that, when matched by a particular clinical presentation, lead to decisions to treat. The scripts comprise salient factors that are dependent on individual dentist's characteristics and biases, and thus vary substantially across dentists. The scripts tend to be complex, highly visual, and difficult to describe. All of these characteristics suggest that efforts to improve dentists' caries-related treatment decisions should acknowledge this knowledge structure and be designed to change the salient factors or interpretations of salient factors within the context of the caries script.

Relationship between epidemiologic coronal caries assessments and practitioners' treatment recommendations in adults.

Caries incidence determinations in adults reflect dentists' treatment decisions as well as epidemiologists' caries assessments because many patients receive treatment between the two assessments that are required to determine incidence. Yet knowledge of the relationship between epidemiologically assessed caries and practitioners' treatment recommendations is poor. In this study, the proportions of practitioners recommending treatment for a tooth, and the reasons for those recommendations, were compared across teeth grouped by their caries status as determined from an epidemiologic assessment. On average, for a tooth deemed carious by epidemiologic assessment, a mean of almost 90% of examining practitioners recommended treatment. Most but not all of these recommendations for treatment of teeth with epidemiologically determined caries were for caries-related reasons. Among teeth classified as sound by epidemiological assessment, the mean proportion of dentists recommending treatment was 11%. For restored, non-carious teeth a mean of 35% of examining dentists recommended treatment. Across all noncarious teeth, 25% of all treatment recommendations were related to caries. The mean patient F increment (number of newly filled surfaces) that would result from treatment recommendations practitioners indicated as being associated with caries was slightly less than one-half of the total F increment. Thus, F increments may substantially overestimate caries incidence.

A systematic review of selected caries prevention and management methods.

A systematic review of the periodic scientific literature was undertaken to determine the strength of the evidence for the efficacy of professional caries preventive methods applied to high risk individuals, and the efficacy of professionally applied methods to arrest or reverse non-cavitated carious lesions. An initial search identified 1435 articles, of which 27 were eventually included in the review. Among the 22 studies addressing the prevention of carious lesions in caries-active or high risk individuals, the strength of the evidence was judged to be fair for fluoride varnishes and insufficient for all other methods. Among the seven studies addressing the management of non-cavitated carious lesions, the strength of the evidence for efficacy was judged to be insufficient for all methods. The results do not indicate that the preventive and management methods reviewed are not efficacious; rather, they demonstrate that not enough is known to determine the efficacy of the methods. Suggestions for strengthening the limited evidence base involve the following: i) increasing the number of studies that examine prevention among high risk individuals and non-surgical management of non-cavitated lesions, ii) including a wider variety of subject ages, iii) targeting aspects of the efficacy questions not yet addressed, iv) strengthening research methods employed in the studies, and v) reporting methods and outcomes more completely.

Incidence rates for complete cusp fracture.

OBJECTIVES: Although complete cusp fracture is acknowledged to occur frequently, incidence rates have been reported rarely. This study determined incidence rates for complete coronal cusp fracture per person and per tooth type. METHODS: All fractures presenting among enrollees in a dental health maintenance organization using two geographically isolated clinics were noted for 105 days. For a sample of these enrollees, likelihood of attending the clinic in the event of a fracture was assessed through a telephone survey, and the at-risk status of all teeth was determined through a record survey. Incidence rates were calculated for persons, and for individual tooth types for all complete fractures and for non-carious complete fractures. In addition, for posterior teeth the distribution of fractured cusps, and the severity of fractures were examined. RESULTS: Per-person incidence rates for complete coronal fractures for all teeth were 89.0 and 72.7 per 1000 person years, respectively, for all fractures and for non-carious fractures. The rates for all anterior and all posterior teeth were 10.2 and 69.9, respectively, for all non-carious fractures. In mandibular posterior teeth, lingual cusps fractured twice as frequently as facial cusps, while the opposite was true for maxillary premolars. Among maxillary molars, the mesiofacial and distolingual cusps fractured most frequently. The large majority of fractures exposed dentin (95%), while pulpal exposure occurred infrequently (3%). A minority of fractures extended below the gingival crest (24%) or the DEJ (25%). CONCLUSIONS: This is the first report of fracture incidence rates for enumerated persons and teeth at risk and as such helps define the magnitude of the problem for dentists and their patients.

Using crowns to prevent tooth fracture.

Placing crowns to prevent tooth fracture is thought to be a common but infrequently documented treatment procedure. Two studies are described that provide information about dentists' use of crowns to prevent tooth fracture. North Carolina general dentists indicated that 44% of the crowns they placed were for the principal reason of fracture prevention. However, when groups of dentists examined the same patients, there was little agreement about which teeth should be crowned due to risk of fracture. These results suggest that the placing of crowns to prevent fracture merits a careful determination of effectiveness and appropriateness.

Case-control study of non-carious cervical lesions.

An exploratory case-control study of non-carious cervical lesions was undertaken to examine the effects of a variety of risk factors. Candidate exposure variables were related to erosion, abrasion, and tooth flexure, the three principal putative causal mechanisms for cervical lesions. Because previous studies have tended to focus on specific causal mechanisms, evidence for a multifactorial etiology is inconclusive. Data describing exposure factors were obtained through clinical examination, dietary and behavioral questionnaires, and analysis of study casts from 264 subjects (137 cases, 127 control). Salivary data were also obtained for a subset of these subjects. Patient and tooth-level logistic regression models were constructed for the full subject group, and the subset with salivary data. For the two patient-level models, only exposures related to brushing entered. For tooth-level models, multiple exposures representing all three causal mechanisms were included in both models. The results suggest that non-carious cervical lesions do have a multifactorial etiology, and that multiple causal mechanisms may operate in the initiation and progression of individual lesions.

Dental patients' knowledge and beliefs about periodontal disease.

The knowledge and beliefs about periodontal disease of 1093 regularly attending patients in 36 North Carolina general dental practices were examined. Patients had a strong positive orientation toward keeping their teeth. Correct information concerning the signs, causes, prevention, and treatment of periodontal disease was widely held. Older patients were more knowledgeable about treatment and signs of periodontal disease, while younger patients expressed more positive beliefs about keeping their teeth for a lifetime. Although patients' knowledge was not perfect, it included few misperceptions that could threaten oral health. Additional education was most needed with respect to the significance of bleeding gums.

Association of dental health knowledge with periodontal conditions among regular patients.

Although routine patient education concerning periodontal disease is recommended as a means of improving oral health, strong associations between oral health knowledge and plaque or gingival inflammation scores have not been demonstrated. This study examined associations between four knowledge scales (likelihood of keeping teeth, signs of disease, role of diet, role of oral hygiene measures) and six periodontal status measures (plaque, gingivitis, calculus, probing depth, attachment loss, missing teeth) among 1088 regularly attending dental patients. In bivariate correlation analyses, there was a weak, direct association between stronger expectations of keeping teeth and better levels of periodontal health, while an inverse association between knowledge of signs of periodontal disease and better periodontal health was noted. Level of knowledge of the role of oral hygiene or of diet in periodontal disease was not associated with level of disease. When effects associated with age, sex, race, and different dental practices were held constant, these patient knowledge scales did not explain substantial proportions of variance in the periodontal disease measures. Among regular utilizers, the effects of receipt of dental care may be more determinative than level of patient knowledge.

Identifying children who will experience high caries increments.

An 18-month longitudinal study of 197 5 to 18-yr-old children was conducted to assess the performance of multiple baseline variables in predicting which children would experience high increments of caries. Nine predictors were assessed; DMFS and defs scores, number of permanent teeth, indices of fissure retentiveness and occlusal morphology, S. mutans and lactobacilli levels, and sex and race. Discriminant analyses were applied to data for children in five age groups to identify the 30% who would have the largest 18-month DMFS increments. Prediction performance was assessed by comparisons with the actual high increment group, defined as those children with increments in the upper quartiles of the DMFS distributions within age groups. The analyses predicted between 56% and 91% of actual high increment children depending on age group. The children identified in the analyses experienced between 59% and 91% of the disease experienced by the actual high increment groups.

Non-carious cervical lesions.

Non-carious cervical lesions are commonly encountered in clinical practice and present in a variety of forms. A knowledge of the aetiology of these lesions is important for preventing further lesions, halting progression of lesions already present, and determining appropriate treatment. The most commonly cited aetiological factors thought to lead to the development of cervical lesions are erosion, abrasion and tooth flexure. Evidence supports a multifactorial aetiology for non-carious cervical lesions. The purpose of this paper is to review the evidence for each of these aetiological factors as it relates to the development of non-carious cervical lesions. Specific features of cervical lesions linked to these factors, including their morphology, location, prevalence and distribution by age and sex will be discussed. Suggestions for future research into the cause and prevention of non-carious cervical lesions will be presented.

Descriptive models of restorative treatment decisions.

OBJECTIVES: This study developed descriptive models of dentists' restorative treatment decisions for individual teeth. Such models could be useful in personnel planning, in assessing the effects of dental treatment programs, and in furthering understanding of dentists' decision-making processes. METHODS: Logistic regression was used to construct models of the probability of individual teeth receiving a recommendation for restorative treatment. Independent variables for the models were data from epidemiologic oral examinations and self-administered questionnaires of subjects who were seeking treatment at a dental school. Data for the dependent variable, the probability of treatment, were collected from multiple dentists' treatment plans of these subjects. Separate models were constructed for molar, premolar, and anterior teeth. An assessment of the models' utilities in a different population consisted of comparing the treatment probabilities estimated by the models with those actually experienced by a community sample of 317 individuals who visited dentists in the 18 months following our examination. RESULTS: Constructed models for molar, premolar, and anterior teeth returned kappa values of 0.60, 0.62, and 0.65, respectively, for the original data set. The models were less accurate in identifying which teeth received treatment among subjects in the community sample, with kappas of 0.10, 0.18, and 0.20, respectively. CONCLUSIONS: Models of dentists' restorative treatment decision making based on clinical and nonclinical data can determine the probability of treatment for individual teeth with reasonable accuracy. Hence, the approach holds promise for developing measures of normative treatment need. However, the models are not accurate predictors of dichotomous decisions by individual dentists regarding treatment interventions. Both differences in the subject samples used to develop and assess the models and individual dentist idiosyncrasies may contribute to this inaccuracy.

Variation in dentists' clinical decisions.

OBJECTIVES: The first comprehensive review of the recent literature regarding variation in dentists' clinical treatment decisions is presented. METHODS: Variation among dentists in the clinical decisions they make as well as the methods used for assessing this variation are examined at three levels of aggregation of clinical decisions: the dental practice (or dentist), the patient, and the individual tooth. RESULTS: The extent to which differences in dentists' clinical decisions have been examined is limited. Studies are particularly sparse at the level of the dental practice, where the aggregate of dentists' treatment decisions is reflected. Further, the methods and measures used to assess variation tend to be different across studies, making quantification of variation difficult. Nevertheless, the available information reflects substantial variation in measures such as rates of provision of specific procedures; cost and numbers of procedures recommended for specific patients; and diagnoses, intervention decisions, and treatment selections for individual teeth. CONCLUSIONS: Even when differences in patients are controlled, variation in dentists' clinical decisions is ubiquitous. While its consequences remain undetermined, the variation in basic clinical decisions such as caries diagnosis signals the need to consider the extent to which the appropriateness of care is affected.

Cost implications of differences in dentists' restorative treatment decisions.

OBJECTIVES: This study sought to determine the effects of variation in both dentists' decisions to treat and choice of treatment on the costs of care. METHODS: Each of 37 patients was examined individually by several practicing dentists (between 3-22, mean = 6.2). For each dentist's recommended treatment for each patient, the total cost of restorative treatment was calculated first using the least expensive treatment possible for each tooth indicated as needing treatment, and second using the costs of specific treatment selected by each dentist RESULTS: Considerable variation was found among dentists in each patients cost of treatment using both methods. The mean of the median cost per patient of the specific treatment selected was three times larger than the cost per patient of basic treatment. Few dentists were found to consistently recommend higher or lower cost treatment plans. CONCLUSIONS: These findings suggest that inconsistencies in both dentists' decisions to intervene and dentists' selection of treatment can have a profound effect on cost. Further, focusing utilization review on "outlier dentists" is likely to be much less productive in containing costs and improving quality than comprehensive attempts to improve consistency across the profession.