Dental and Craniofacial Anomalies Associated with Axenfeld-Rieger Syndrome with PITX2 Mutation

Axenfeld-Rieger syndrome (ARS) (OMIM Nr.: 180500) is a rare autosomal dominant disorder (1  :  200000) with genetic and morphologic variability. Glaucoma is associated in 50% of the patients. Craniofacial and dental anomalies are frequently reported with ARS. The present study was designed as a multidisciplinary analysis of orthodontic, ophthalmologic, and genotypical features. A three-generation pedigree was ascertained through a family with ARS. Clinically, radiographic and genetic analyses were performed. Despite an identical genotype in all patients, the phenotype varies in expressivity of craniofacial and dental morphology. Screening for PITX2 and FOXC1 mutations by direct DNA-sequencing revealed a P64L missense mutation in PITX2 in all family members, supporting earlier reports that PITX2 is an essential factor in morphogenesis of teeth and craniofacial skeleton. Despite the fact that the family members had identical mutations, morphologic differences were evident. The concomitant occurrence of rare dental and craniofacial anomalies may be early diagnostic indications of ARS. Early detection of ARS and elevated intraocular pressure (IOP) helps to prevent visual field loss

CariesCare practice guide : consensus on evidence into practice

This CariesCare practice guide is derived from the International Caries Classification and Management System (ICCMS) and provides a structured update for dentists to help them deliver optimal caries care and outcomes for their patients. This '4D cycle' is a practice-building format, which both prevents and controls caries and can engage patients as long-term health partners with their practice. CariesCare International (CCI™) promotes a patient-centred, risk-based approach to caries management designed for dental practice. This comprises a health outcomes-focused system that aims to maintain oral health and preserve tooth structure in the long-term. It guides the dental team through a four-step process (4D system), leading to personalised interventions: 1st D: Determine Caries Risk; 2nd D: Detect lesions, stage their severity and assess their activity status; 3rd D: Decide on the most appropriate care plan for the specific patient at that time; and then, finally, 4th D: Do the preventive and tooth-preserving care which is needed (including risk-appropriate preventive care; control of initial non-cavitated lesions; and conservative restorative treatment of deep dentinal and cavitated caries lesions). CariesCare International has designed this practice-friendly consensus guide to summarise best practice as informed by the best available evidence. Following the guide should also increase patient satisfaction, involvement, wellbeing and value, by being less invasive and more health-focused. For the dentist it should also provide benefits at the professional and practice levels including improved medico-legal protection

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 (Chi(2) = 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

Caries associated with orthodontic care part 2: management

It is recognized that wearing an orthodontic appliance increases the caries risk of the individual. The prevalence of demineralization has been reported to be as high as 73%. When demineralization occurs a number of treatments exist: fluoride application, acid microabrasion, casein phosphopeptide-amorphous calcium phosphate (CCP-ACP), resin infiltration and self-assembling peptides. Of these, topical fluoride has the most evidence to support its use. CPD/Clinical Relevance: Demineralization is the most common complication of orthodontic care. The clinician should understand how to manage this when it occurs

ORCA-EFCD consensus report on clinical recommendation for caries diagnosis. Paper I:caries lesion detection and depth assessment

OBJECTIVES: The aim of the present consensus paper was to provide recommendations for clinical practice considering the use of visual examination, dental radiography and adjunct methods for primary caries detection.MATERIALS AND METHODS: The executive councils of the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) nominated ten experts each to join the expert panel. The steering committee formed three work groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity assessment and (3) forming individualised caries diagnoses. The experts responsible for "caries detection and diagnostic methods" searched and evaluated the relevant literature, drafted this manuscript and made provisional consensus recommendations. These recommendations were discussed and refined during the structured process in the whole work group. Finally, the agreement for each recommendation was determined using an anonymous Delphi survey.RESULTS: Recommendations (N = 8) were approved and agreed upon by the whole expert panel: visual examination (N = 3), dental radiography (N = 3) and additional diagnostic methods (N = 2). While the quality of evidence was found to be heterogeneous, all recommendations were agreed upon by the expert panel.CONCLUSION: Visual examination is recommended as the first-choice method for the detection and assessment of caries lesions on accessible surfaces. Intraoral radiography, preferably bitewing, is recommended as an additional method. Adjunct, non-ionising radiation methods might also be useful in certain clinical situations.CLINICAL RELEVANCE: The expert panel merged evidence from the scientific literature with practical considerations and provided recommendations for their use in daily dental practice.</p

ORCA-EFCD consensus report on clinical recommendation for caries diagnosis. Paper I:caries lesion detection and depth assessment

OBJECTIVES: The aim of the present consensus paper was to provide recommendations for clinical practice considering the use of visual examination, dental radiography and adjunct methods for primary caries detection.MATERIALS AND METHODS: The executive councils of the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) nominated ten experts each to join the expert panel. The steering committee formed three work groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity assessment and (3) forming individualised caries diagnoses. The experts responsible for "caries detection and diagnostic methods" searched and evaluated the relevant literature, drafted this manuscript and made provisional consensus recommendations. These recommendations were discussed and refined during the structured process in the whole work group. Finally, the agreement for each recommendation was determined using an anonymous Delphi survey.RESULTS: Recommendations (N = 8) were approved and agreed upon by the whole expert panel: visual examination (N = 3), dental radiography (N = 3) and additional diagnostic methods (N = 2). While the quality of evidence was found to be heterogeneous, all recommendations were agreed upon by the expert panel.CONCLUSION: Visual examination is recommended as the first-choice method for the detection and assessment of caries lesions on accessible surfaces. Intraoral radiography, preferably bitewing, is recommended as an additional method. Adjunct, non-ionising radiation methods might also be useful in certain clinical situations.CLINICAL RELEVANCE: The expert panel merged evidence from the scientific literature with practical considerations and provided recommendations for their use in daily dental practice.</p

Development, Methodology and Potential of the New Universal Visual Scoring System (UniViSS) for Caries Detection and Diagnosis

Given the limitations of adjunct caries detection and diagnostic tools, e.g., imperfect validity and reproducibility, as well as the difficulties in controlling all possible confounding factors, the need for an objective visual caries detection and diagnosis system has become evident. Our work has therefore aimed at systematizing caries lesions with the Universal Visual Scoring System (UniViSS) for occlusal and smooth surface lesions, which can be used for primary and permanent teeth, as well as under clinical, epidemiological, public health and laboratory conditions. Besides the description of the development and methodology of UniViSS, it is shown that UniViSS allows an accurate and reproducible classification of caries lesions on occlusal surfaces

How to Intervene in the Caries Process in Older Adults: A Joint ORCA and EFCD Expert Delphi Consensus Statement

Aim: To provide recommendations for dental clinicians for the management of dental caries in older adults with special emphasis on root caries lesions. Methods: A consensus workshop followed by a Delphi consensus process were conducted with an expert panel nominated by ORCA, EFCD, and DGZ boards. Based on a systematic review of the literature, as well as non-systematic literature search, recommendations for clinicians were developed and consented in a two-stage Delphi process. Results: Demographic and epidemiologic changes will significantly increase the need of management of older adults and root caries in the future. Ageing is associated with a decline of intrinsic capacities and an increased risk of general diseases. As oral and systemic health are linked, bidirectional consequences of diseases and interventions need to be considered. Caries prevention and treatment in older adults must respond to the patient’s individual abilities for self-care and cooperation and often involves the support of caregivers. Systemic interventions may involve dietary counselling, oral hygiene instruction, the use of fluoridated toothpastes, and the stimulation of salivary flow. Local interventions to manage root lesions may comprise local biofilm control, application of highly fluoridated toothpastes or varnishes as well as antimicrobial agents. Restorative treatment is often compromised by the accessibility of such root caries lesions as well as the ability of the senior patient to cooperate. If optimum restorative treatment is impossible or inappropriate, longterm stabilization, e.g., by using glass-ionomer cements, and palliative treatments that aim to maintain oral function as long and as well as possible may be the treatment of choice for the individual

Remineralization of natural early caries lesions in vitro by P₁₁-4 monitored with photothermal radiometry and luminescence.

Aim: The efficacy of self-assembling peptide P11 -4 to regenerate enamel in natural early caries lesions was evaluated over 50 days by photothermal radiometry and luminescence using The Canary System (CS) and The Canary Lab (CL). Methods: Baseline readings for sound and carious sites on smooth surfaces of extracted teeth were obtained by scanning with CS and CL. Teeth were then randomly assigned to a treatment group (TG, treated with P11 -4), a placebo group (PG, same vehicle as treatment group without P11 -4), or a control group (CG, no treatment). All the teeth were then placed in artificial saliva to facilitate natural remineralization, and the sites were rescanned with CS and CL at 7, 14, 30, and 50 days. Results: For carious sites in TG, mean canary numbers (CN) derived from CS decreased significantly (P<.01) from 44±3.8 at baseline to 24±4.9 at day 50; the mean CN for the TG derived from CL also decreased significantly (P<.05), from 65 at baseline to 45 at day 50. In contrast, no significant changes in CN were observed for carious sites in the CG or PG using either CS or CL. Conclusions: P11 -4 promoted the regeneration of early caries