Conventional bitewing radiography

Accurate detection and diagnosis of carious lesions is the prerequisite for application of the most effective caries management approach. However, the accuracy of proximal caries detection using visual-tactile assessment is limited. Additional diagnostic measures should therefore be performed to increase the validity of the diagnosis. Amongst various caries detection aids available, bitewing radiographs remain the gold standard for detection of proximal caries lesions. Here we describe a method for caries diagnosis using standardized bitewing holders. With this method the bitewing holders can be placed more precisely and reproducibly in the oral cavity. This approach increases accuracy of bitewing radiographs, which, due to the reproducible placement of the x-ray film, allows for monitoring of carious lesions long term

Outcomes in Trials for Management of Caries Lesions (OuTMaC):protocol

Background Clinical trials on caries lesion management use an abundance of outcomes, hampering comparison or combination of different study results and their efficient translation into clinical practice. Core outcome sets are an agreed standardized collection of outcomes which should be measured and reported in all trials for a specific clinical area. We aim to develop a core outcome set for trials investigating management of caries lesions in primary or permanent teeth conducted in primary or secondary care encompassing all stages of disease. Methods To identify existing outcomes, trials on prevention and trials on management of caries lesions will be screened systematically in four databases. Screening, extraction and deduplication will be performed by two researchers until consensus is reached. The definition of the core outcome set will by based on an e-Delhi consensus process involving key stakeholders namely patients, dentists, clinical researchers, health economists, statisticians, policy-makers and industry representatives. For the first stage of the Delphi process, a patient panel and a separate panel consisting of researchers, clinicians, teachers, industry affiliated researchers, policy-makers, and other interested parties will be held. An inclusive approach will be taken to involve panelists from a wide variety of socio-economic and geographic backgrounds. Results from the first round will be summarized and fed back to individuals for the second round, where panels will be combined and allowed to modify their scoring in light of the full panel’s opinion. Necessity for a third round will be dependent on the outcome of the first two. Agreement will be measured via defined consensus rules; up to a maximum of seven outcomes. If resources allow, we will investigate features that influence decision making for different groups. Discussion By using an explicit, transparent and inclusive multi-step consensus process, the planned core outcome set should be justifiable, relevant and comprehensive. The dissemination and application of this core outcome set should improve clinical trials on managing caries lesions and allow comparison, synthesis and implementation of scientific data. Trial registration Registered 12 April 2015 at COMET (http://www.comet-initiative.org

Managing carious lesions:why do we need consensus on terminology and clinical recommendations on carious tissue removal?

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Cariology Clinical Trials:What Are We-and What Should We Be-Looking At?

Randomized control trial (RCT) methodology has compared interventions for the prevention and management of dental caries since the late 1960s. Despite almost 50 years and evidence of significant wastage within the wider biomedical research field, there has been little investigation into what works well and where weaknesses lie. This paper aims to draw attention to areas for improvement within cariology clinical trial methodology by summarizing systematic reviews on interventions and outcomes, and using examples to illustrate some challenges with intervention delivery fidelity, outcome analyses, and intervention co-production. Trial design stage choices are critical to ensure that optimum information is obtained when testing interventions. Intervention choice, outcome choice, and analyses are particularly important, and cariology trials have specific issues associated with them. A systematic search and review of cariology RCTs found 650 RCT reports. Social Network Analysis of interventions revealed a high degree of separation between prevention and management trials, gaps in clinically important comparisons, and a tendency for there to be comparisons within groups; e.g., comparison of interventions within the same, rather than different, levels of invasiveness. Outcomes measured for the same trial reports show: a focus on restoration performance and individual/population caries burden; the growing use of carious lesion activity and economic-related outcomes; and sparse, although an increase in the use of, patient-reported/patient-centered outcomes. Fidelity of adherence to complex interventions can be challenging to measure but is important in interpreting trial findings. Involving target populations in intervention design, delivery, and relating it to the planned rollout, are opportunities to ensure intervention relevance and improved uptake. Outcomes analyses should consider the minimum clinically important differences and outcome relevance measures for the target population. Factors underlying trialists’ comparator and outcome choices need to be identified, and there is a need to ensure that a minimum dataset of outcomes allow for combination and comparisons of trial data for systematic review

To fill or not to fill: a qualitative cross-country study on dentists' decisions in managing non-cavitated proximal caries lesions

BACKGROUND: This study aimed to identify barriers and enablers for dentists managing non-cavitated proximal caries lesions using non- or micro-invasive (NI/MI) approaches rather than invasive and restorative methods in New Zealand, Germany and the USA. METHODS: Semi-structured interviews were conducted, focusing on non-cavitated proximal caries lesions (radiographically confined to enamel or the outer dentine). Twelve dentists from New Zealand, 12 from Germany and 20 from the state of Michigan (USA) were interviewed. Convenience and snowball sampling were used for participant recruitment. A diverse sample of dentists was recruited. Interviews were conducted by telephone, using an interview schedule based on the Theoretical Domains Framework (TDF). RESULTS: The following barriers to managing lesions non- or micro-invasively were identified: patients' lacking adherence to oral hygiene instructions or high-caries risk, financial pressures and a lack of reimbursement for NI/MI, unsupportive colleagues and practice leaders, not undertaking professional development and basing treatment on what had been learned during training, and a sense of anticipated regret (anxiety about not restoring a proximal lesion in its early stages before it progressed). The following enablers were identified: the professional belief that remineralisation can occur in early non-cavitated proximal lesions and that these lesions can be arrested, the understanding that placing restorations weakens the tooth and inflicts a cycle of re-restoration, having up-to-date information and supportive colleagues and work environments, working as part of a team of competent and skilled dental practitioners who perform NI/MI (such as cleaning or scaling), having the necessary resources, undertaking ongoing professional development and continued education, maintaining membership of professional groups and a sense of professional and personal satisfaction from working in the patient's best interest. Financial aspects were more commonly mentioned by the German and American participants, while continuing education was more of a focus for the New Zealand participants. CONCLUSIONS: Decisions on managing non-cavitated proximal lesions were influenced by numerous factors, some of which could be targeted by interventions for implementing evidence-based management strategies in practice

Contemporary operative caries management:consensus recommendations on minimally invasive caries removal

The International Caries Consensus Collaboration (ICCC) presented recommendations on terminology, on carious tissue removal and on managing cavitated carious lesions. It identified 'dental caries' as the name of the disease that dentists should manage, and the importance of controlling the activity of existing cavitated lesions to preserve hard tissues, maintain pulp sensibility and retain functional teeth in the long term. The ICCC recommended the level of hardness (soft, leathery, firm, and hard dentine) as the criterion for determining the clinical consequences of the disease and defined new strategies for carious tissue removal: 1) Selective removal of carious tissue - including selective removal to soft dentine and selective removal to firm dentine; 2) stepwise removal - including stage 1, selective removal to soft dentine, and stage 2, selective removal to firm dentine 6 to 12 months later; and 3) non-selective removal to hard dentine - formerly known as complete caries removal (a traditional approach no longer recommended). Adoption of these terms will facilitate improved understanding and communication among researchers, within dental educators and the wider clinical dentistry community. Controlling the disease in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal or control first. Only when cavitated carious dentine lesions are either non-cleansable or can no longer be sealed, are restorative interventions indicated. Carious tissue is removed purely to create conditions for long-lasting restorations. Bacterially contaminated or demineralised tissues close to the pulp do not need to be removed. The evidence and, therefore these recommendations, supports minimally invasive carious lesion management, delaying entry to, and slowing down, the destructive restorative cycle by preserving tooth tissue, maintaining pulp sensibility and retaining the functional tooth-restoration complex long-term

Restorative Thresholds for Carious Lesions:Systematic Review and Meta-analysis

Current evidence supports noninvasive/nonrestorative treatment of “early” carious lesions: those confined to enamel or reaching the enamel-dentin junction. The extent that dentists’ thresholds for intervening restoratively have changed with this evidence is unknown. This systematic review aimed to determine dentists’ and therapists’ current lesion threshold for carrying our restorative interventions in adults/children and primary/permanent teeth. Embase, Medline via PubMed, and Web of Science were searched for observational studies, without language, time, or quality restrictions. Screening and data extraction were independent and in duplicate. Random-effects meta-analyses with subgroup and meta-regression analysis were performed. Thirty studies, mainly involving dentists, met the inclusion criteria. There was heterogeneity in sampling frames, methods, and scales used to investigate thresholds. The studies spanned 30 y (1983–2014), and sample representativeness and response bias issues were likely to have affected the results. Studies measured what dentists said they would do rather than actually did. Studies represented 17 countries, focusing mainly on adults (n = 17) and permanentteeth (n = 24). For proximal carious lesions confined to enamel (not reaching the enamel-dentin junction), 21% (95% confidence interval [CI], 15%–28%) of dentists/therapists would intervene invasively. The likelihood of a restorative intervention almost doubled (risk ratio, 1.98; 95% CI, 1.68–2.33) in high caries risk patients. For proximal lesions extending up to the enamel-dentin junction, 47% (95% CI, 39%–55%) of dentists/therapists would intervene restoratively. For occlusal lesions with enamel discoloration/cavitation but no clinical/radiographic dentin involvement, 12% (95% CI, 6%–22%) of dentists/therapists stated they would intervene, increasing to 74% (95% CI,56%–86%) with dentin involvement. There was variance between countries but no significant temporal trend. A significant proportion of dentists/therapists said they would intervene invasively (restoratively) on carious lesions where evidence and clinical recommendations indicate less invasive therapies should be used. There is great need to understand decisions to intervene restoratively and to find implementation interventions that translate research evidence into clinical practice

Artificial Intelligence for Caries Detection: Value of Data and Information.

If increasing practitioners' diagnostic accuracy, medical artificial intelligence (AI) may lead to better treatment decisions at lower costs, while uncertainty remains around the resulting cost-effectiveness. In the present study, we assessed how enlarging the data set used for training an AI for caries detection on bitewings affects cost-effectiveness and also determined the value of information by reducing the uncertainty around other input parameters (namely, the costs of AI and the population's caries risk profile). We employed a convolutional neural network and trained it on 10%, 25%, 50%, or 100% of a labeled data set containing 29,011 teeth without and 19,760 teeth with caries lesions stemming from bitewing radiographs. We employed an established health economic modeling and analytical framework to quantify cost-effectiveness and value of information. We adopted a mixed public-private payer perspective in German health care; the health outcome was tooth retention years. A Markov model, allowing to follow posterior teeth over the lifetime of an initially 12-y-old individual, and Monte Carlo microsimulations were employed. With an increasing amount of data used to train the AI sensitivity and specificity increased nonlinearly, increasing the data set from 10% to 25% had the largest impact on accuracy and, consequently, cost-effectiveness. In the base-case scenario, AI was more effective (tooth retention for a mean [2.5%-97.5%] 62.8 [59.2-65.5] y) and less costly (378 [284-499] euros) than dentists without AI (60.4 [55.8-64.4] y; 419 [270-593] euros), with considerable uncertainty. The economic value of reducing the uncertainty around AI's accuracy or costs was limited, while information on the population's risk profile was more relevant. When developing dental AI, informed choices about the data set size may be recommended, and research toward individualized application of AI for caries detection seems warranted to optimize cost-effectiveness