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This chapter considers the main principles guiding diagnosis of the disease dental caries in clinical practice by means of clinical examination and radiographs as adjunct method. Dental professionals have been trained to diagnose caries disease by assessing clinical symptoms and signs of caries lesions complemented by radiographic examination as an adjunct method. Clinical examination is the foundation of the diagnosis and should be performed after removal of dental biofilm of tooth surfaces, air-drying, and under good illumination. Clinical diagnostic methods categorize caries lesions according to their severity and in some methods according to their activity. Caries lesion activity has been determined by surface reflection and texture. The detection of thick or heavy biofilm on tooth surfaces is an additional diagnostic clinical tool to estimate caries lesion activity. Patients with no caries experience, that is, without clinical and/or radiographic signs of caries lesions in the dentition, are considered caries inactive. Other caries-inactive patients may present inactive caries lesions/restorations in their dentition. In contrast, patients are considered caries active when presenting any active caries lesion at clinical level and/or any progressing lesion as demonstrated by at least two bitewing radiographs taken at different points in time. The main concern about caries-active patients is that caries lesions are likely to progress unless effective measures are implemented to interfere with its progression. Prescribed according to individual needs, bitewing radiographs provide additional information for clinical examination in the detection of approximal enamel and outer third dentine lesions that can be inactivated by nonoperative treatment., (© 2023 S. Karger AG, Basel.)

The aim of this prospective cohort study was to assess the radiographic progression of underlying dentin shadows (UDS) on the occlusal surfaces of permanent posterior teeth of adolescents and young adults over 1-2 years and to identify possible risk factors. A total of 149 UDS lesions (from 101 individuals) were included at baseline. Each participant had to present at least one UDS to be considered eligible for the study. Data collection included the application of a questionnaire, clinical examination, and bilateral bitewing radiographs, performed at baseline and after 1-2 years. The association between possible predictors and UDS progression (defined radiographically as an increase in the radiographic score from baseline to follow-up) was assessed using Weibull regression models. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were estimated. A total of 81 individuals (mean age: 24.0, standard deviation: 8.03) were reexamined after 1-2 years (742 occlusal surfaces, of which 118 were UDS). The overall progression rate was 8.6% after 1-2 years, being 12.6% for UDS without baseline radiolucency and 20% for UDS with baseline radiolucency. The risk analysis showed that UDS without radiolucency at baseline had a similar likelihood of progression (adjusted HR = 1.71, 95% CI = 0.68-4.32, p = 0.26) while UDS with radiolucency at baseline were more likely to progress (adjusted HR = 2.96, 95% CI = 1.06-8.26, p = 0.04) than the reference category (sound occlusal surfaces without radiolucency). These estimates were adjusted for caries prevalence, tooth type, and arch. This study showed low progression rates of UDS after 1-2 years. The presence of radiolucency at baseline was found to predict UDS progression., (© 2023 S. Karger AG, Basel.)

This two-arm, parallel, randomized controlled trial aimed to assess the effect of augmented vision (AV, using interactive color overlays) on the education of dental students in detecting proximal carious lesions on bitewing radiographs compared to black-and-white textbook-like illustrations. Forty-eight preclinical third-year dental students were randomized using a random number generator into two learning groups: test (AV, allowing interaction with color-highlighted carious lesions, n = 24) and control (showing the native radiograph and a black-and-white illustration displaying the carious lesion, n = 24). First, students had 2 weeks to assess 50 bitewings (lesion prevalence on the tooth level: 54.5%) in the test or control. Due to the nature of the intervention, participants could not be blinded toward the intervention. After that, they were asked to detect lesions on 10 independent bitewings and to assess lesion extent (outer/inner enamel; outer/middle/inner dentin). The reference test was constituted by two experienced dentists. No significant differences in accuracy (test 0.84 [95% CI: 0.79, 0.88]; control 0.83 [0.78, 0.87]), AUC (test 0.82 [0.81, 0.84]; control 0.81 [0.80, 0.83]) and F1 score (test 0.79 [0.75, 0.82]; control 0.77 [0.72, 0.81]) were observed between groups. Students of both groups showed difficulties in differentiating enamel from dentin carious lesions. While AV was reported to be motivating by students, it did not increase their accuracy., (© 2022 S. Karger AG, Basel.)

This prospective cohort study investigated the distribution pattern of carious lesions diagnosed by visual tactile and radiographic examinations, assessed the radiographic yield for clinical caries diagnosis, and estimated how accurately commonly used indicators for caries identified young adults who would benefit from radiographs at different thresholds. Overall, 576 patients aged 16-32 years seeking a first consultation were included. Patients were examined for caries and answered a validated questionnaire on sociodemographics and oral health behavior. Almost 10% of clinically sound approximal surfaces presented radiolucency in enamel/dentine. Of the clinically diagnosed noncavitated approximal and occlusal lesions, 22.5 and 17.7%, respectively, presented radiolucency reaching dentine at the radiographic examination. Noncavitated/enamel lesions detected radiographically were mainly at approximal surfaces (73.2%), while at occlusal surfaces these were negligible (0.7%). More than half of approximal dentine lesions were only detected radiographically (61.3%), while more than half of occlusal dentine lesions were only clinically diagnosed (57.1%). The hierarchical logistic regression analysis showed that patient's caries activity, D1MFS scores ≥17, and frequent consumption of soft drinks were significantly associated with detection of approximal enamel/dentine lesions. Also, patient's caries activity and frequent consumption of soft drinks were significantly associated with occlusal dentine caries (p ≤ 0.05). The indicator power of grouping these indicators as a predictor for the presence of radiographically detected lesions showed high sensitivity (0.84-0.91) and moderate specificity (0.64-0.73) for all surfaces and thresholds tested. In conclusion, radiographs increased significantly the number of approximal enamel/dentine and occlusal dentine lesions diagnosed. The ability to identify young adults with approximal lesions from the predictor was satisfactory. Bearing in mind that an essential contribution of bitewing radiographs to clinical examination is the detection of approximal noncavitated/enamel lesions that can be inactivated by nonoperative interventions, our results support the prescription of radiographs in young adults seeking a first consultation. Updating of current guidelines' recommendation of radiographs is warranted., (© 2020 S. Karger AG, Basel.)

Objectives: In December 2008, artificial water fluoridation was introduced for the first time to the Logan-Beaudesert district in the state of Queensland, Australia. The aim of this study was to evaluate the effects of water fluoridation in the primary dentition in this community after a period of 36 months., Methods: Children aged 4-9 years with clinical examinations and bitewing radiographs (BWs) taken before water fluoridation (pre-F) were randomly selected as comparison controls for age matched children who had been exposed to a mean period of 36 months of water fluoridation (post-F). A total of 201 sets of pre-F BWs from children (mean age 6.95 ± 1.05 years) and 256 sets of post-F BWs from children (mean age 7.19 ± 1.23 years) attending schools in the district were randomly selected. Caries experience in the primary dentition was determined as decayed, missing or filled teeth/surfaces (dmft/dmfs)., Results: The caries prevalence for the pre-F group was 87% compared to 75% in the post-F group (Odds ratio (OR): 0.44, 95% CI: 0.27-0.72). Overall, there was a 19 percent reduction of mean dmft from 4.54 in the pre-F group to 3.66 in the post-F group (p = 0.005). After fluoridation, the dmfs was reduced from 6.68 to 5.17 (p = 0.0056). The distal surfaces of maxillary first primary molars experienced the greatest reduction (26%) in caries experience after water fluoridation (p < 0.001)., Conclusions: After only 36 months of water fluoridation there was a significant drop in caries prevalence from 87 to 75% and a 19% reduction in caries experience in a community with one of the highest caries rates in Australia.

Low viscosity resins (infiltrants) have been shown to penetrate the lesion body of natural caries lesions almost completely in vitro. However, penetration depths (PD) have not been evaluated in vivo. Therefore, the aim of the present study was to evaluate the penetration of an infiltrant into proximal caries lesions in primary molars after different application times using an ex vivo model. 59 proximal lesions from 34 children were randomly allocated to one of the application times and were infiltrated under clinical conditions for 1, 3, or 5 min. After extraction or exfoliation (n = 48), teeth were sectioned perpendicular to their surfaces and lesion depths (LD) as well as lesion areas (LA) were evaluated using polarized light microscopy. PD and penetration areas (PA) were measured on scanning electron microscopic images. Percentage penetration depth (PPD) and percentage penetration area (PPA) were calculated. The mean (±SD) LD and LA were 596 ± 203 µm and 4.03 ± 2.75 × 10(5) µm(2), respectively. PPD ranged from 70 to 80% and PPA from 54 to 60%. Longer application times did not result in significantly deeper or more complete penetration (p > 0.05; ANOVA). In conclusion, proximal caries lesions in primary molars can be infiltrated in vivo to a similar extent as observed previously in vitro. Moreover, 1-min application of the infiltrant led to PD and homogeneity similar to those observed with longer application times up to 5 min., (Copyright © 2012 S. Karger AG, Basel.)

This split-mouth study aimed to assess the efficacy of resin-infiltrated lesions covered by fluoride varnish (FV) versus FV treatment only of proximal lesions on deciduous molar teeth. The study lasted for 1 year. Children with 2 or more superficial proximal lesions on deciduous molar teeth detected on bitewing radiographs were included. After written parental consent, two lesions in each of 50 children were randomly allocated to one of two treatments: resin infiltration followed by FV (2.26% F) application (test lesion) versus only FV (control lesion). The ICDAS scores of the selected lesions were recorded by 2 clinicians before the treatments (weighted kappa for inter- and intra-examiner agreement >0.79). FV was applied to both test and control lesions 6 and 12 months after the first treatment. After 1 year ICDAS scores were obtained for 42 children and radiographs for 39. One external examiner not familiar with the study scored the radiographs twice (weighted kappa 0.88). Baseline mean age of the children was 7.17 +/- (SD) 0.68 and mean def-s was 8.1 +/- (SD) 6.9. After 1 year the ICDAS scores of 31% of the test lesions and 67% of the control lesions had progressed (p < 0.01). Radiographically, 23% of the test lesions and 62% of the control lesions had progressed (p < 0.01). Thus, the clinical and radiographic therapeutic effect of both resin infiltration/FV over FV alone was >35% and significant. To conclude, resin infiltration in conjunction with fluoride varnish seems promising for controlling proximal lesion progression on deciduous molar teeth., (Copyright 2010 S. Karger AG, Basel.)

There is a lack of clinical studies comparing dentifrices with high fluoride (F) concentration. The aim was to evaluate a dentifrice containing 5,000 ppm F compared to a dentifrice containing 1,450 ppm F in caries-active adolescents. The design was a 2-year, single-blind randomized controlled trial and 211 adolescents of 279 (76%) completed the trial. The subjects were divided into two groups and were given one of the assigned F dentifrices for daily unsupervised toothbrushing: (1) Duraphat 5,000 ppm F and (2) Pepsodent Superfluor 1,450 ppm F, both as NaF. The outcome variables were caries incidence and progression of proximal and occlusal caries. The subjects were asked to fill in a questionnaire to evaluate their compliance and they were divided into two subgroups: subgroup A, excellent compliance, and subgroup B, poor compliance. The latter group (28%) comprised the subjects who did not brush twice a day or did not use the dentifrice regularly. Adolescents using 5,000 ppm F toothpaste had significantly lower progression of caries compared to those using 1,450 ppm F toothpaste (A: p < 0.01, B: p < 0.001), with a prevented fraction of 40%. Subjects using 5,000 ppm F toothpaste had significantly lower caries incidence for compliance B compared to those using 1,450 ppm F toothpaste (p < 0.05); the prevented fraction was 42%. This may indicate that 5,000 ppm F toothpaste has a greater impact on individuals who do not use toothpaste regularly or do not brush twice a day. Thus, 5,000 ppm F toothpaste appears to be an important vehicle for caries prevention and treatment of adolescents with a high caries risk., (Copyright 2010 S. Karger AG, Basel.)

This in vivo study aimed to compare the performance of different methods of approximal caries detection in primary molars. Fifty children (aged 5-12 years) were selected, and 2 examiners evaluated 621 approximal surfaces of primary molars using: (a) visual inspection, (b) the radiographic method and (c) a pen-type laser fluorescence device (LFpen). As reference standard method, the teeth were separated using orthodontic rubbers during 7 days, and the surfaces were evaluated by 2 examiners for the presence of white spots or cavitations. The area under the receiver-operating characteristics curve (A(z)) as well as sensitivity, specificity and accuracy (percentage of correct diagnosis) were calculated and compared with the McNemar test at both thresholds. The interexaminer reproducibility was calculated using the intraclass correlation coefficient (ICC-absolute values) and the kappa test (dichotomizing for both thresholds). The ICC value of the reference standard procedure was 0.94. At white-spot threshold, no methods tested presented good performance (sensitivity: visual 0.20-0.21; radiographic 0.16-0.23; LFpen 0.16; specificity: visual 0.95; radiographic 0.99-1.00; LFpen 0.94-0.96). At cavitation threshold, both LFpen and radiographic methods demonstrated higher sensitivity (0.55-0.65 and 0.65-0.70, respectively) and A(z) (0.92 and 0.88-0.89, respectively) than visual inspection sensitivity (0.30) and A(z) (0.69-0.76). All methods presented high specificities (around 0.99) and similar ICCs, but the kappa value for LFpen at white-spot threshold was lower (0.44). In conclusion, both LFpen and radiographic methods present similar performance in detecting the presence of cavitations on approximal surfaces of primary molars., (Copyright 2009 S. Karger AG, Basel.)

Lesion detection aids ideally aim at increasing the sensitivity of visual caries detection without trading off too much in terms of specificity. The use of a dental probe (explorer), bitewing radiography and fibre-optic transillumination (FOTI) have long been recommended for this purpose. Today, probing of suspected lesions in the sense of checking the 'stickiness' is regarded as obsolete, since it achieves no gain of sensitivity and might cause irreversible tooth damage. Bitewing radiography helps to detect lesions that are otherwise hidden from visual examination, and it should therefore be applied to a new patient. The diagnostic performance of radiography at approximal and occlusal sites is different, as this relates to the 3-dimensional anatomy of the tooth at these sites. However, treatment decisions have to take more into account than just lesion extension. Bitewing radiography provides additional information for the decision-making process that mainly relies on the visual and clinical findings. FOTI is a quick and inexpensive method which can enhance visual examination of all tooth surfaces. Both radiography and FOTI can improve the sensitivity of caries detection, but require sufficient training and experience to interpret information correctly. Radiography also carries the burden of the risks and legislation associated with using ionizing radiation in a health setting and should be repeated at intervals guided by the individual patient's caries risk. Lesion detection aids can assist in the longitudinal monitoring of the behaviour of initial lesions., (Copyright 2009 S. Karger AG, Basel)

The objectives of this longitudinal study were to assess: (a) the prevalence of unrestored dentin caries among 15-year-olds, (b) the proportion of these lesions that had progressed to deep dentin lesions (inner half of dentin) since the immediately preceding examination at the age of 14 and (c) the frequency of deep restorations (extending into the inner half of the dentin). The sample consisted of all 15-year-olds (n = 2,487) born in 1990 and included in the Public Dental Service in Malmo, Sweden. Bitewing radiographs taken during 2005-2007 and the immediately preceding radiographs were analysed and scored by two examiners. The main radiographic scores were: sound; radiolucency in the outer or inner half of dentin; restored surface. The results showed that 22% of the individuals had 1 or more dentin lesions left unrestored from the time of the examination at the age of 14 until the next recall examination at the age of 15. During the observation period (median time 1.2 years), 9% of the unrestored outer dentin lesions progressed to deep dentin lesions. The majority of these (93%) were in molars. One or more deep restorations were found in 22% of the 15-year-olds; the majority involved occlusal surfaces of first molars. In conclusion, unrestored dentin lesions were common in 15-year-olds. Progression to deep dentin lesions occurred in 9% of these lesions and was most common in first molars. Occlusal surfaces of first molars had the highest frequency of deep restorations., ((c) 2008 S. Karger AG, Basel)

This study investigated, using digital bitewing radiography, the progression and regression of approximal caries in adolescent subjects chewing a sugar-free gum containing 54 mg CPP-ACP relative to the identical gum without CPP-ACP. 2,720 subjects from 29 schools were randomly assigned to one of the two gums and were instructed to chew their assigned gum for 3 x 10 min/day, with one session supervised on school days, over the 24-month study period. Standardized digital bitewing radiographs were taken at the baseline and 24-month clinical examinations for each subject. The radiographs, scored by a single examiner, were assessed for approximal surface dental caries at both the enamel and dentine level. Surface level transitions were scored using a transition matrix. Caries progression or regression was analysed using proportional-odds ordered logistic regression modelling of the transition scores at the tooth surface level. There was a statistically significant difference in the frequency distributions of the transition scores between the two gum groups (OR = 0.82, p = 0.03). For subjects chewing the CPP-ACP gum the odds of a surface experiencing caries progression were 18% less than those of a surface experiencing caries progression for subjects chewing the control gum. In conclusion, the 54 mg CPP-ACP sugar-free gum significantly slowed progression and enhanced regression of approximal caries relative to a control sugar-free gum in a 24-month clinical trial., ((c) 2008 S. Karger AG, Basel)

The aims were to determine caries prevalence in 9-year-olds belonging to a low-caries prevalence population and to assess how accurately some commonly used risk factors/risk markers (predictors) can identify additional approximal caries as judged from bitewing examination (BW). One calibrated dentist examined 117 consecutive 9-year-olds from the inner city of Stockholm. The predictors were the number of clinically detected dfs and DFS, visible plaque, salivary mutans streptococci, tooth brushing habits, consumption of sugary products, parents' education, and (before BW) an overall clinical judgement by the examiner. Analyses of the data included sensitivity and specificity and a multiple logistic regression model. When BW was included, the mean DFS was 0.27 and the mean dfs 1.74. For approximal enamel and dentin lesions, the average gain from BW was 0.20 lesions for permanent first molars and 1.23 lesions for primary molars. Altogether, 48% of the children benefited from BW. The best predictors of additional approximal caries from BW were presence of caries (cavitation/dentin level) on occlusal surfaces of permanent first molars and the dentist's judgement based on clinical findings, both with a combined sensitivity and specificity of 134%. The only statistically significant variables in a logistic regression model were the dentist's judgement and the child's statement about regular tooth brushing. It is concluded that a sizeable proportion of 9-year-olds, representing a low-caries prevalence population, benefited from BW. However, the ability to identify these children from the predictors was limited., (Copyright 2007 S. Karger AG, Basel.)

The laser device DIAGNOdent developed for the detection of occlusal caries has limited value on approximal surfaces. The aim of this study was to develop and to test a new laser fluorescence (LF) device for the detection of approximal caries. Light with a wavelength of 655 nm was transported to the approximal surface using two different sapphire fibre tips. Seventy-five teeth were selected from a pool of extracted permanent human molars, frozen at -20 degrees C until use. Before being measured, they were defrosted, cleaned and calculus was removed with a scaler. The molars were set in blocks simulating the contact area of adults. Bitewing radiographs were obtained using Kodak Insight films. After two independent assessments with the new LF device, the teeth were histologically prepared, and assessed for caries extension. Using the laser, specificity values for D1 threshold (outer half of enamel), D2 threshold (inner half of enamel), D3 threshold (dentine) ranged between 0.81 and 0.93, sensitivity between 0.84 and 0.92 with no difference between the two tips. Bitewing radiography showed an inferior performance compared to LF (p<0.05). Intraex aminer reproducibility was high (kappa>.74). The new LF system might be a useful additional tool in detecting approximal caries. Because of its good reproducibility, it could be used to monitor caries regression or progression on approximal surfaces., (Copyright (c) 2006 S. Karger AG, Basel.)

The aim of this in vivo study was to compare a laser fluorescence (LF) device with Ekstrand's visual scoring system and radiographic assessment for detection of occlusal caries. Thirty-eight adults aged 19-35 years participated in the study; a total of 57 third molars with macroscopically intact occlusal surfaces were selected. Two examiners assessed 110 sites by visual inspection (VI), bitewing radiography (BW) and LF. Teeth were then extracted and caries extent assessed by histology. The detection methods were compared by means of sensitivity, specificity, inter-examiner reproducibility (kappa statistics) and area under the ROC curve. VI and LF had similar (p > 0.05) and superior sensitivities than BW (p < 0.05). VI and BW showed similar specificities, which was superior to LF. The inter-examiner reproducibility was good for VI and BW and moderate for LF. The area under ROC curves showed that VI was better than LF. It was concluded that Ekstrand's visual scoring system is the most valid method for caries diagnosis. LF should be considered an adjunct to caries diagnosis., (Copyright 2005 S. Karger AG, Basel.)

The aim was to evaluate, in a 3-year RCT study, school-based fluoride varnish programme on approximal caries incidence and approximal caries progression in 13- to 16-year-olds in high, medium and low caries risk areas on the Swedish west coast. Seven hundred and fifty-eight (89%) fulfilled the trial. Using a simple mobile unit, 2 dental nurses treated the adolescents with F varnish: (1) twice a year at 6-month intervals, (2) 3 times a year within 1 week, (3) 8 times per year during the semesters with 1-month intervals, and (4) no treatment (control). Radiographic caries recording was performed blindly by one of the authors. Concerning total approximal caries incidence, control groups in all areas developed more caries than F varnish groups, with the largest difference in the high risk area: 3.05 +/- 3.37 new approximal caries lesions (mean +/- SD) compared to 0.54 +/- 1.26 for group 3, 0.95 +/- 1.67 for group 1 and 1.40 +/- 1.89 for group 2 (p < 0.001). More than 90% of the new approximal lesions in all the groups and in all areas consisted of new enamel lesions. Regarding progression of enamel lesions, there were only significant differences between groups 1-3 and group 4 in the high caries risk area. Prevented fraction for fluoride varnish treatment twice a year at 6-month intervals was 69% in high, 66% in medium and 20% in low risk areas. To conclude, school-based F varnish treatment every 6 months in 13- to 16-year-olds is excellent to prevent approximal caries in medium and high caries risk areas., (Copyright 2005 S. Karger AG, Basel.)

The aim was to assess how accurately some commonly used risk factors/risk markers (predictors) for caries development could identify children with and without approximal caries as judged from bitewing radiography. Two hundred and sixty-seven consecutive 5-year-old children from two Swedish cities participated. Three experienced dentists examined the children. The predictors were the overall dmfs (decayed, missing and filled surfaces) value (canines and molars), the number of occlusal dmfs, the frequency of intake of between-meal sugary products, visible plaque on free smooth surfaces of second primary molars, toothbrushing habits and (before bitewing examination) an overall judgement by the examining dentist. The mean dmfs value without bitewing examination was 0.40 (SD = 1.22). Twelve percent of the children had at least one dentin lesion and 33% at least one enamel lesion that were detected from bitewing examination only. The gain from adding bitewing examination to clinical examination amounted to a mean of 1.2 approximal enamel and/or dentin lesions. The ability to correctly identify children with approximal caries from the predictors was limited; sensitivity ranged from 0.27 to 0.75 and specificity ranged from 0.41 to 0.93. The single best predictor was the dentist's overall judgement with an average precision of 73%; average sensitivity for the presence of enamel and dentin lesions was 0.48 and for the presence of dentin lesions 0.66. The rest of the predictors added little to the predictive power. It is concluded that 33% of the 5-year-olds, representing a low caries prevalence population, benefited from bitewing examination. The ability to identify these children from the predictors was, however, limited., (Copyright (c) 2005 S. Karger AG, Basel.)

The purpose of this study was to evaluate the in vivo effectiveness of laser fluorescence compared to visual inspection and radiography for the detection of occlusal caries in primary teeth. Fifty sites from 30 molars in 29 patients were selected and evaluated under standardized conditions by 2 previously trained examiners according to the 3 diagnostic methods. Histological examination served as gold standard after exfoliation or extraction. Values obtained for sensitivity, specificity and accuracy were 0.60, 0.90 and 0.73 for laser fluorescence, 0.82, 0.85 and 0.84 for visual inspection and 0.62, 0.73 and 0.67 for radiography, respectively. Considering only dentinal caries, values were 0.73, 0.95 and 0.90 for laser fluorescence, 0.61, 1.00 and 0.90 for visual inspection and 0.96, 0.81 and 0.85 for radiography, respectively. We conclude that for the detection of occlusal caries in primary molars laser fluorescence presents a similar accuracy when compared to visual inspection and radiography, although visual inspection showed better values for sensitivities for both enamel and dentin lesions., (Copyright 2003 S. Karger AG, Basel)

Diagnosis of non-cavitated occlusal caries is generally considered problematic. The aim of this study was to evaluate the utility of the laser fluorescence device DIAGNOdent as part of routine dental check-ups in children. A total of 613 occlusal surfaces on permanent molars and 436 surfaces on primary molars in children aged 7-8 (n = 55) and 13-14 years (n = 54) were examined visually, using DIAGNOdent and for most 13- to 14-year-olds also using radiographs. The teeth were not cleaned professionally before examination. To provide a gold standard for carious teeth, the depth of the caries lesion was determined in those lesions that were judged visually to need opening by drilling (51 teeth). The higher the visual score, the higher were the mean DIAGNOdent values, but in each visual category the variation among values was large. The presence of a clear sealant did not affect DIAGNOdent measurements. The values for permanent and primary molars differed slightly. For permanent teeth, Youden's index value was highest (60%) at a cut-off value of 30, which indicates that the overall performance for DIAGNOdent in detecting dentinal caries was best at this point. Using this cut-off, sensitivity was 92% and specificity 69% with visual examination for validation, while sensitivity was 92% and specificity 82% with validation by fissure opening. Of the three methods, radiographic examination was the least accurate. In routine dental check-ups of children, DIAGNOdent appears to be useful as an adjunct to visual examination., (Copyright 2003 S. Karger AG, Basel)

In this study, the status of 705 occlusal surfaces of first and second molars of 90 17-year-olds was analysed longitudinally in a 6-year follow-up, using a combination of clinical and radiographic information. Clinical data were derived from an epidemiological project. Each of two examiners judged all bitewing radiographs. The overall Cohen's kappa for interexaminer agreement of radiographic assessments was 0.77. Between the age of 17 and 23 years, about one third of sound occlusal surfaces developed a new dentinal radiolucency, and over 70% of existing radiolucencies showed progression, both irrespective of the presence of a sealant. In both examination years, almost 20% of the restored surfaces showed signs of a dentinal radiolucency. It was concluded that at the age of 17 occlusal surfaces are still highly susceptible to new dentine caries and further progression of dentinal radiolucencies already present., (Copyright 2003 S. Karger AG, Basel)

The aim of this study was to compare, in vitro, the performance of different conventional diagnostic techniques with the laser-based device, DIAGNOdent, for diagnosis of occlusal caries in deciduous teeth. 95 deciduous teeth with macroscopically intact occlusal surfaces were selected. All teeth were assessed by the following techniques: visual inspection (VI), visual inspection with magnification (VIM), visual inspection combined with light pressure probing (VIP), bitewing radiography (BW) and the DIAGNOdent (DD). Caries extension was assessed by histology. DIAGNOdent showed, in comparison with the conventional clinical methods, a significantly improved ability (p < 0.05) to detect dentinal lesions (D(3) or D(4)) in deciduous teeth and an overall performance similar to that obtained in previous studies on permanent teeth. There was no statistically significant difference between VIM and DD in detecting caries confined to enamel (D(2)). DD performed better at D(2) level than the other methods. The intraexaminer kappa scores for DIAGNOdent were 0.76-0.86 (D(2)) and 0.77-0.85 (D(3)), respectively. It was concluded that DIAGNOdent could be used as an additional tool in the detection of occlusal caries in deciduous teeth and its good reproducibility should enable the laser device to monitor the caries process over time., (Copyright 2003 S. Karger AG, Basel)

The 'Cariogram' is an interactive PC program for caries risk evaluation. It takes into account the interactions between caries-related factors and expresses a graphic assessment of the risk. The aim of this study was to assess the caries risk in schoolchildren using the Cariogram and to evaluate the program by comparing the caries risk assessments with the actual change in DMF. A 2-year prospective study on 446 schoolchildren, 10-11 years old, was conducted. At baseline, data on general health, diet, oral hygiene and use of fluoride were obtained. Saliva analyses included mutans streptococci and lactobacilli counts, buffer capacity and secretion rate. DMFT and DMFS were calculated from records and bitewing radiographs. Scores were entered and caries risk was assessed. Re-examination for caries was done after 2 years. The children were divided into 5 groups according to the assessed caries risk at baseline. Where the Cariogram predicted a 0-20% (high risk), 21-40%, 41-60%, 61-80% and 81-100% (low risk) chance of avoiding new lesions, 8, 35, 42, 73 and 83%, respectively, had no new lesions 2 years later. Logistic regression analyses were carried out. When the Cariogram was included, only two factors, the Cariogram (p < 0.001) and the DMFS at baseline, i.e. past caries experience (p = 0.001), turned out to be significantly associated with caries increment. The Cariogram was the most powerful explanatory variable. When the Cariogram was excluded, lactobacillus count, mutans streptococci, diet intake frequency and DMFS at baseline were significantly associated with caries increment. The Cariogram predicted caries increment more accurately than any included single-factor model. How this finding can be translated into daily practice in the best and most practical way is a matter for future research., (Copyright 2002 S. Karger AG, Basel)

The aim of this study was to evaluate the caries incidence in a group of young patients with type 1 diabetes mellitus over a 3-year period from the onset of the disease in relation to metabolic control and to caries-associated risk factors. Sixty-four children and adolescents (8-15 years of age) had their diabetes treated and monitored according to a standard medical protocol and received extensive preventive oral health care based on individual needs. Data on blood glucose and glycosylated haemoglobin (Hb A(Ic)) were collected from the medical records. Whole saliva was collected every 3rd month and secretion rate, buffer capacity, glucose concentration, mutans streptococci and lactobacilli counts were determined. Dental examinations, including radiographs, were carried out once a year. Patients with less good metabolic control (>8.0% Hb A(Ic)) exhibited higher glucose levels in resting saliva (p < 0.05) and a significantly higher caries incidence (p < 0.05) compared to those with good metabolic control. The most influential determinants for high caries development during the 3-year follow-up period were metabolic control (odds ratio, OR = 5.7), poor oral hygiene (OR = 6.5), previous caries experience (OR = 5.3) and high levels of salivary lactobacilli (OR = 5.0). The findings suggest that the level of metabolic control and traditional caries risk markers are important factors for caries development in children and adolescents with type 1 diabetes mellitus., (Copyright 2002 S. Karger AG, Basel)

The objective was to assess the influence on the caries rate for the mesial surface of the first permanent molar (6m) of the caries status of the distal surface of the second primary molar (05d) in children from 6 to 12 years of age. The study design was retrospective and included 374 children with an average of 5 sets of bite-wing radiographs. The mean age of the children was 6.7 years when the first bite-wing radiographs were taken and 11.5 years at the time of the latest radiographs included in the study. The approximal surfaces were classified according to a scoring system: 0 = no visible radiolucency, 1= radiolucency in the outer half of the enamel, 2 = radiolucency in the inner half up to the enamel-dentin border, 3 = radiolucency with a broken enamel-dentin border but with no obvious involvement of the dentin, 4 = radiolucency with obvious spread in the outer half of the dentin, and score 5 = radiolucency in the inner half of the dentin. The influence of the status of 05d on the caries rate for 6m (state > or =2) was assessed by using a model for dependence between the two neighbouring surfaces. Presence or absence of approximal caries in the distal surface of the first primary molars (04d) and/or the mesial surface of the second primary molars (05m) at the time of eruption of 6m was also related to the caries rate for 6m. The caries rate for 6m was 15 times higher if 05d had developed enamel/enamel-dentin border caries (state 2 or 3) compared to a radiographically sound 05d (state 0 or 1). No significant increase in the caries rate for 6m was found when 05d had deeper unrestored dentin caries than when 05d had superficial caries (state 2 or 3). Furthermore, for preventing caries in 6m, no benefit could be found from restoring an 05d with dentin caries with amalgam as opposed to leaving the carious lesion unrestored until exfoliation. The caries rates for 6m and 05d were 3.4 and 2.7 times higher, respectively, in the presence of dentin caries/restoration in 04d/05m compared to absence of dentin caries in these molar surfaces at the time of eruption of 6m. In conclusion, the caries rate for 6m depended on the status of 05d and increased 15 times if 05d had enamel/enamel-dentin border caries compared to a sound 05d. Deeper unrestored or restored dentin lesions in 05d did not result in a higher caries rate for 6m compared with more shallow carious lesions in 05d.

Water fluoridation in Kuopio, Finland, was stopped at the end of 1992. In our previous study, no increase in caries was found in Kuopio 3 years after the discontinuation of water fluoridation. The aim of the present study was to further observe the occurrence and distribution of caries in Kuopio and Jyväskylä, which was used as the reference town for Kuopio. In 1992, 1995 and 1998 independent random samples of all children aged 3, 6, 9, 12 and 15 years were drawn in Kuopio and Jyväskylä. The total numbers of subjects examined were 688, 1,484 and 1,530 in 1992, 1995 and 1998, respectively. Calibrated dentists registered caries clinically and radiographically. No indication of increasing caries could be found in the previously fluoridated town during 1992-1998. In both towns the mean dmfs and DMFS values either decreased or remained about the same during the observation period. When all study years and both towns were pooled, 25% of the 12- and 15-year-olds with the highest DMFS counts accounted for 79 and 67%, respectively, of all affected surfaces. The mean numbers of fluoride varnish and sealant applications had markedly decreased in 1993-1998 compared to 1990-1992. The fact that no increase in caries was found in Kuopio despite discontinuation of water fluoridation and decrease in preventive procedures suggests that not all of these measures were necessary for each child.

The aim of this study was to compare the performance of fibre-optic transillumination (FOTI), visual inspection and bite-wing radiographs to detect occlusal caries and estimate the lesion depth. Fifty-nine extracted molars were assessed using FOTI and visual examination by 4 trained examiners and 1 examiner evaluated the bite-wing radiographs. Histological validation was performed using 250-microm sections examined with a stereomicroscope. For the three methods, the correlation between the lesion depth and the histological scores varied from 0.65 to 0.73. For dentinal caries detection, the areas under ROC curves ranged from 0.83 to 0.87. The radiographic method was poor at detecting lesions confined to enamel. FOTI, visual inspection and radiographs showed a good correlation with the histology but had difficulty in distinguishing lesions located deep in enamel or in the outer third of dentine. FOTI was shown to be as accurate as a detailed visual inspection in detecting occlusal caries.

The purpose of this study was to compare reproducibility in the assessment of caries lesion behaviour in digital subtraction images and conventional radiographs. Ninety-seven pairs of conventional film bite-wings were included. The radiographs had been taken with a Kwik-Bite filmholder without further standardisation. The selection criterion was that at least one surface imaged in a bite-wing pair should show progresssion of a caries lesion from the first exposure to the second. The time interval between the bite-wings was 1-2 years. The radiographs were scanned into a personal computer and the two images from the same patient subtracted. Seven observers scored the subtraction images and the conventional films. The scale was based on no change/ change in surface appearance scored in the following categories: 0 = no change; 1 = development of a new caries lesion in enamel; 2 = development of caries lesion in enamel and dentine/progression of an existing enamel lesion into dentine/progression of a dentinal lesion further into dentine; 3 = development of secondary caries; 4 = new filling/change of filling/extension of filling. Cohen's kappa coefficients were calculated for intra- and inter-observer agreement for the two radiographic methods separately. The kappa value served as the statistical sampling unit for testing differences between the two methods (Wilcoxon's test for ranked pairs). The average intra-observer kappa value was 0.875 (range 0.775-0.958) for the subtraction images and 0.758 (range 0.560-0.890) for the conventional radiographs. The difference was statistically significant (p<0.05). For inter-observer agreement, the kappa values were lower than for intra-observer agreement. The average value was 0.678 (range 0.485-0.754) for the subtraction images and 0.701 (range 0.497-0.817) for the conventional radiographs (p>0.1). This study suggests a new way of comparing reproducibility in terms of kappa values between diagnostic methods in clinical studies where accuracy cannot be evaluated. The subtraction method may be useful in the assessment of caries lesion behaviour in the clinic.

Ultrasound has been used in industrial business as one of the nondestructive measurement methods. It was hypothesized that nondestructiveness of the ultrasonics could be useful in determination of demineralization of noncavitated carious lesions on human enamel. This investigation was designed to determine the presence of natural carious lesions on proximal surfaces of human molar teeth using an ultrasonic system compared to radiography and histology as the gold standards. Measurements were made directly from proximal surfaces of 20 mandible molar teeth with white spot carious lesion by 2 examiners independently with the ultrasonic system. Ultrasonic evaluation of each natural white spot lesion had a sensitivity of 88%, specificity of 86%, positive predictive value of 88% and a negative predictive value of 86%, and the chance-corrected agreement was also satisfactory (kappa=0.74) compared to histology. The radiograph demonstrated chance-corrected agreement of 0.41:0.38 for the first and second examiners, respectively. Duncan test analysis of the numerical values was significantly different for the intact and the noncavitated carious surfaces (p<0.05). The results indicated that the ultrasonic evaluation is a sensitive method for the detection of the natural white spot carious lesions and can differentiate the changes in elastic properties of enamel numerically.

The aim of this study was to compare the effect of two different dental varnishes on approximal caries incidence in teenagers with proven caries susceptibility during a 3-year period. Two hundred 13- to 14-year-old subjects exhibiting at least two approximal enamel caries lesions were selected to take part in the study. One hundred and eighty subjects participated after informed consent and were randomly assigned to two equally sized groups. One group was treated with a fluoride varnish (FV, Fluor Protector) containing 0.1% F every 3rd month and the participants of the other group were treated in the same mode with a chlorhexidine varnish (CV, Cervitec((R))) containing 1% chlorhexidine and 1% thymol. In total, each subject was treated 12 times during the experimental period. Approximal caries including enamel lesions (DMFS(appr)) were recorded from four bitewing radiographs exposed at the start and end of the study. The mean (+/-SD) caries prevalence at baseline was 2.2+/-3.4 in the FV group and 2.5+/-4.0 in the CV group. After 3 years, the average approximal caries incidence was 2.7+/-3.1 and 3.1+/-3.5 in the FV and CV groups, respectively. The differences at baseline and after 3 years were not statistically significant. In conclusion, treatments every 3rd month with either a fluoride- or a chlorhexidine/thymol-containing varnish showed a promising effect with low approximal caries incidence and progression in teenagers with proven caries susceptibility.

This study aimed to record and monitor over a 2.5-year period the occurrence of cavitation and lesion depth progression in approximal surfaces with radiographic caries at baseline. In total, 66 approximal sites (in 29 students), where at least one of the contacting surfaces had radiographic caries, were selected to take part in the study. A clinical examination undertaken before and after tooth separation in order to assess the presence/absence of cavitation was repeated every sixth month. To monitor lesion progression bite-wing radiographs were taken every sixth month, too. After each series of examinations, surfaces judged to be prone for disease progression were referred to operative caries treatment. In surfaces with radiographic dentinal caries at baseline the cavitation prevalence following tooth separation found at the various recall examinations ranged from 20 to 44%. In surfaces with radiographic enamel caries at baseline this prevalence ranged from 4 to 8% at the various recall examinations. In dentinal lesions found with an intact surface at baseline, the risk of cavitation development during the first 1.5-year period was assessed to be up to 22%. After this period no new cavitations were found in previously intact dentinal lesions. In intact enamel lesions the risk of cavitation formation was found to be 3% during the first 1-year period. After this period no new cavitations developed in previously intact enamel lesions. Three of 7 lesions, which showed radiographic caries progression from the outer one third to the inner two thirds of the dentine during the observation period, had intact surfaces at baseline. On the basis of these results it is recommended to re-examine carefully intact, dentinal lesions by repeated clinical examination after tooth separation and by radiography about 1-1.5 years after baseline.

Using annual bite-wing radiographs, the incidence and progression of approximal caries (4d-7m) were assessed longitudinally in teenagers and adolescents whose treatment had been based on remineralizing rather than restorative strategies. A closed cohort of 536 children initially was followed from 11 to 22 years of age. The scoring system was: 0 = no visible radiolucency; 1-2 = radiolucency in the enamel up to the enamel-dentin border; 3 = radiolucency with a broken enamel-dentin border but with no obvious progression in the dentin; 4 = radiolucency with obvious spread in the outer half of the dentin, and 5 = radiolucency in the inner half of the dentin. Caries rates were estimated as the number of new lesions/100 tooth surface-years, and the Kaplan-Meier estimate was used to calculate the cumulative survival time of each approximal surface. Three events were used: the transitions from states 0 to 2, 2 to 4 and 3 to 4. The results showed a considerable variation between the surfaces in both caries rates and survival time. For all surfaces combined, the median caries rate from state 0 to 2 was 3.9 new lesions/100 tooth surface-years; from state 2 to 4, the rate was 5.4, and from state 3 to 4 it was 20.3. Of the sound surfaces (state 0), 75% survived 6.3 years without reaching state 2. Given state 2, 75% survived 4.8 years without reaching the outer half of the dentin (state 4), while given a lesion at the enamel-dentin border (state 3), 75% survived 1.3 years without doing the same. The median survival time of lesions from state 3 to 4 was 3.1 years. The group with DMFSappr>1 at the age of 11-12 years had a risk of new approximal enamel lesions (state 0-2) that was 2.5 times greater than that of the group with DMFSappr = 0-1.

This study aimed to determine whether incidence density (ID) calculations of caries incidence rates would provide a more sensitive means of detecting caries-preventive effects than would traditional techniques. A secondary analysis was conducted using data from a 1981 study in which three dentifrices were compared in a double-blind randomized clinical trial. Subjects were examined at baseline and 1, 2 and 3 years after baseline. Three-year DMFS increments were calculated for 1,754 subjects attending the baseline and 3-year examinations. Caries ID rates then were calculated for 2, 661 subjects who had at least two examinations, using each surface's net increment (-1, 0 or +1) as the numerator and the surface's time at risk as the denominator. Despite theoretical advantages, the ID method did not alter the conclusions drawn using DMFS increments, apparently because (a) subjects lost to follow-up were similar to those completing the study, and (b) loss to follow-up was similar among treatment groups.

This study aimed to (1) record the plaque and gingival status on sound and carious approximal surfaces and (2) investigate whether the two parameters could predict approximal lesion progression. For this purpose two samples were selected among 18- to 25-year-old patients at the Dental Faculty in Copenhagen. Sample 1 consisted of 45 patients, each having an approximal posterior surface requiring operative treatment and a contralateral approximal space, where both surfaces were radiographically sound. Sample 2 consisted of 25 patients, each having a posterior approximal tooth surface with an enamel/initial dentinal lesion recorded on a bitewing. Plaque and gingival status were classified using 4-point ranked scales. The recordings were performed once on each participant in sample 1. The recordings in sample 2 were repeated 5 times during a 15-month period. In order to assess lesion progression in sample 2, two serial intraoral examinations were performed, i.e. at the beginning and end of the study. Less than 10% of the sound and carious surfaces were recorded as plaque-free, while about 40% had a thick or heavy plaque accumulation. No significant difference was observed between plaque scores on sound and carious surfaces (p = 0.5), in contrast to findings representing the gingival status (p < 0.001). Tooth surfaces requiring operative treatment were associated with bleeding of the gingiva after probing. In sample 2, 3 of the 25 participants did not finish the study. On the remaining participants caries progression was observed in 9 cases (41%), while no progression was observed in 13 cases. Analyses showed that there were no significant differences between plaque scores in cases with caries progression, as compared with no caries progression (p > 0.05). Similar analyses concerning gingival status showed that bleeding of the gingiva was related to cases with progressing caries. Analyses also disclosed no direct association between plaque and gingival status (Spearman correlation coefficient 0.39). Thus, the occurrence of plaque does not have the same predictive power as bleeding after probing in decision-making as to whether or not a lesion progresses.

The aim was to assess the distribution and pattern of caries development longitudinally in teenagers and adolescents whose treatment had been based on remineralizing rather than restorative strategies. A baseline cohort of 536 children was studied, using bite-wing radiographs, from 11 to 22 years of age. The results showed a slow but continuous increase in both enamel and dentin caries of approximal surfaces. At 21, 29% of all posterior approximal surfaces had enamel caries according to the radiographic diagnoses, 14% had dentin caries and another 5% were restored. At the age of 20 21, the skewed distribution of DMFS(appr) apparent at 12 and 15 had given way to a more uniform picture and the percentage of individuals with no decayed approximal surfaces (DMFS(appr) = 0) decreased from 71 at 12-13 to 28 at 20-21 years of age. The proportion of DFS(occl) in relation to all DFS decreased from 83% at 12 to 52% at 21. The occlusal, mesial and distal surfaces of the first molar accounted for 60% of all restored surfaces at 21.

The aim of this study was to evaluate the diagnostic accuracy of visual, fibreoptic transillumination (FOTI), and bite-wing radiographic examination performed by 4 observers for the identification of cavitated carious lesions in contacting approximal surfaces, and to assess the inter-observer agreement with these methods and with direct visual examination conducted after tooth separation, the method used as validation for definitive determination of cavitation. A total of 338 unrestored approximal surfaces in 53 students were examined independently by 4 dentists using the diagnostic methods under study. The results from the diagnostic methods were compared with the results from the validation method for each observer. The sensitivities for identification of cavitated lesions using visual examination ranged from 0.12 to 0.50. For FOTI and radiography, the sensitivities ranged from 0.00 to 0.08 and from 0.56 to 0.69, respectively. The specificities exceeded 0.90 for all observers with all methods. Kappa values expressing inter-observer reproducibility were lowest for FOTI, followed by visual and radiographic examination. On the basis of these results, it was concluded that FOTI was the least reliable of the diagnostic methods tested. For the validation method, the inter-observer agreement was only 'substantial'. This implies that the method cannot be used as a validation for other diagnostic methods applied for the identification of cavitated carious lesions in contacting approximal surfaces. However, visual inspection after tooth separation may serve as a supplementary diagnostic tool to conventional visual and radiographic examination for clinical management of aproximal carious lesions.

This study compared the diagnostic efficacy of four imaging modalities for the detection of artificially induced recurrent caries: intraoral film, direct digital bitewing images, tuned apertuce computed tomography (TACT) slices and iteratively restored TACT images using an in vitro model. Twenty-four posterior teeth were prepared for MOD inlay restorations. These were then restored with different restorative materials (amalgam, Herculite and Durafill). Lesions were simulated in half the number of surfaces studied. These lesions were created either at the intersection of the facial or lingual walls and the gingival floor or on the gingival floor midway between the facial and lingual walls in the proximal boxes of the MOD restorations. Analysis of observations from 8 observers using ROC curve reveal the superior diagnostic efficacy with TACT iteratively restored images (Az for TACT iteratively restored images = 0.9171, TACT slices = 0.7052, Film = 0.6608, direct digital images = 0.5979). ANOVA revealed significance with respect to the imaging modality used (p < 0.0001). The results suggest that TACT images hold promise as a more effective imaging modality than film or direct digital systems for detection of recurrent caries.

The aim of this study was to compare in vitro diagnostic performance of three electrical methods for occlusal caries diagnosis with that of visual inspection and bite-wing radiography. One hundred and seven extracted molar and premolar teeth were subjected to the diagnostic methods by 2 operators and subsequently sectioned for histological validation. Electrical measurements were made at site level and at surface level using two different instruments. The diagnostic parameters calculated from the results were: sensitivity, specificity, diagnostic accuracy at a theoretical caries prevalence of 10% and area under the ROC curve. The electrical methods and bite-wing radiography showed higher sensitivity and lower specificity than visual inspection. Diagnostic accuracy was significantly lower for bite-wing radiography and one electrical method than for visual inspection. Overall diagnostic performance of two electrical methods was superior.

It has been suggested that the diagnosis of occlusal dentine carious lesions has become more difficult due to the influence of fluoride on the character of pit and fissure surfaces. The issue pertains to the occurrence of hidden caries exemplified by occlusal surfaces judged as clinically sound but showing a radiolucency on the bite-wing radiograph. The aim of this study was to investigate the influence of water fluoridation on the occurrence of hidden caries in clinically sound occlusal surfaces in young people. The data of 515 persons (15 years of age) collected in 1968/1969 as part of the Dutch longitudinal epidemiological Tiel/Culemborg study were used. The participants in Tiel (F) were exposed to artificially fluoridated drinking water (F-concentration 1.1 ppm F) from birth until the end of the data collection. The participants in Culemborg (NF) were not exposed to extra fluoride (F-concentration 0.1 ppm F). In 1994 the status of occlusal surfaces of the first and second molars, as read from bite-wings made in 1968/1969, were judged by 2 investigators. (Cohen's Kappa intra- and inter-examiner agreement 0.90, 0.83 and 0.85, respectively). The original clinical data of 270 inhabitants of Tiel (F) and 245 of Culemborg (NF) were compared with the radiographic judgements. The children examined in Tiel (F) had a mean of 2.54 clinically sound occlusal surfaces in first and second molars (including surfaces with an enamel demineralization only) of which bite-wing radiographs detected 0.43 surfaces (16.9%) with a radiolucency into dentine. In Culemborg (NF) the children had a mean 0.65 clinically sound judged surfaces of which 0.16 (24.6%) showed a radiolucency on the bite-wing films. The results of the investigation show a proportional reduction of surfaces with hidden caries among clinically sound surfaces in the fluoridated area compared to the control.

A field trial is in progress in which 14 community clinical dental officers and 19 general dental practitioners were asked to record the actual extent of fissure lesions and how this compared with the cavity size they expected. Participating operators worked under their normal conditions of daily practice. Forty-eight to fifty-seven percent of 644 prepared cavities were of the expected size upon investigation, depending on the diagnostic technique used. Greater accuracy was achieved among the smaller cavities (58-75% as expected) than with the larger (52-69% larger than expected). More difficulty with cavity size prediction occurred with the lower right first molar than with the other first molar teeth and with both mandibular second molars compared to the maxillary molars. Comparisons between the accuracy of cavity size prediction achieved using a visual inspection in combination with the probe and a visual inspection alone showed no significant difference. Under the conditions of this field trial, considerable difficulties were experienced in predicting cavity size accurately.

In the present in vitro study, the validity was determined of bite-wing radiographs for the diagnosis of secondary caries in approximal parts of teeth with class II amalgam restorations in vitro. The study was performed on 47 molars and 49 premolars providing 68 and 69 filled approximal surfaces, respectively. The teeth were radiographed in a buccolingual direction to obtain images comparable to bite-wings. Radiolucencies and radio-opacities were scored as caries. Subsequently the teeth were sectioned (700 microns) in transverse or sagittal direction and then the sections were radiographed. Validation was performed against these radiographs of sections, on which also radiolucencies and radio-opacities were scored. Statistical analysis of the results revealed significant differences between the validity parameters for molars and premolars, being for sensitivity 73 and 80%, respectively, for specificity 90 and 95%, for positive predictive value 95 and 92%, and for negative predictive value 58 and 86%. For molars, the results did not differ significantly from the results of our previous study on caries diagnosis in teeth with occlusal fillings. The present experiment showed that bite-wing radiographs are useful for the diagnosis of secondary caries under approximal parts of class II amalgam restorations, just as for secondary caries diagnosis adjacent to class I restorations.

Radiolucent and radiopaque areas in the dentine under amalgam fillings represent demineralized tissue. The aim of this study was to investigate whether caries progresses in radiolucent and radiopaque areas under amalgam fillings, by assessing their enlargement longitudinally on bite-wing radiographs. Bite-wings from dentitions of persons aged 17, 20 and 23 years were compared. For a 3-year evaluation, 365 teeth with class I and class II amalgam restorations were available on bite-wings; 16 radiopacities, 46 radiolucencies and 28 combinations could be followed longitudinally. All radiopacities remained the same size, 14 radiolucencies enlarged and 8 combinations enlarged. For a 6-year evaluation, 236 filled teeth were available; 10 radiopacities, 30 radiolucencies and 11 combinations could be compared longitudinally. All radiopacities remained the same size, 12 radiolucencies enlarged and 6 combinations enlarged. Because the radiopaque areas had not enlarged visibly on bite-wing radiographs over 3 or even 6 years, it was concluded that radiopacities may be non-progressing caries. A substantial number of radiolucent areas, with or without concomitant radiopacities, did not enlarge while radiolucent areas are considered as progressing caries.

The mere detection of caries lesions is insufficient for optimal treatment decision-making. Hence, the aim of this study was to investigate whether quantitative information about approximal lesion depth can be obtained from a technique based on the wavelength dependency of light propagation and additional use of a dye. Another aim was to compare the diagnostic performance of the optical technique and bitewing radiography. Measurements were performed on 33 extracted premolar teeth. Twelve proximal surfaces had white-spot, and 17 had discoloured small lesions. Four surfaces were sound. The teeth were transilluminated with a single glass fibre at the approximal surface before and after dye application. The occlusal surface was imaged with a CCD camera. Light in the blue and red part of the electromagnetic spectrum was selected using Schott glass filters. Average decadic optical thickness differences, delta bl-rd tau eff, were estimated and plotted as a function of normalised lesion depth, dhist, established from histological validation by two observers. The Spearman rank correlation was rs (delta bl-rd tau eff, dhist) = 0.87 (95% confidence interval, CI: 0.74-0.94). A marked increase in average decadic optical thickness in the blue part of the electromagnetic spectrum, delta dye tau eff, was observed for those lesion that, upon direct visual inspection of the approximal surface, clearly showed dye uptake. Bitewing radiographic depth ratings of two observers were plotted as a function of dhist. The correlations were rs (dRA,1, dhist) = 0.62 (95% CI: 0.34-0.80), rs (dRA,2, dhist) = 0.75 (95% CI: 0.54-0.87), and between the observers rs (dRA,1, dRA,2) = 0.44 (95% CI: 0.10-0.69). The p values of rs (delta bl-rd tau eff, dhist) -rs (dRA1,1, dhist) and rs (delta bl-rd tau eff, dhist) -rs (dRA,2, dhist) were p1 = 0.01 and p2 = 0.08, respectively. It was concluded that quantitative information about lesion depth can be obtained optically. The dye penetrates into only a limited number of caries lesions, in which cases dye uptake is detectable in transillumination geometry. Under laboratory circumstances the optical technique performs as well as bitewing radiography in the diagnosis of small approximal caries lesions.

To investigate the factors that influence the probability of clinical cavitation at radiolucent areas of proximal surfaces of posterior teeth, 108 molars and premolars with varying depths of proximal radiolucency were examined clinically, after cavity preparation on the carious contiguous tooth surfaces. The data obtained were subjected to logistic regression analysis with cavitation as the dependent variable, while age, tooth type and past caries experience (DMFT and DFS) were independent variables. When proximal radiolucency was confined to the outer half of enamel, there was no cavitation, but when it extended to the amelodentinal junction and the outer and inner half of dentine, there was cavitation in 19.3, 79.1 and 100% of cases, respectively. Moreover, there was a statistically significant relationship between the probability of cavitation, depth of radiolucency and age, suggesting that these should be among the main factors considered when restorative management of a radiolucent proximal surface of a posterior tooth is contemplated.

The aim of the study was to examine the relationship between oral hygiene level and caries experience in 14-year-olds using fluoride dentifrices on a regular basis. Oral hygiene expressed as Gingival Bleeding Points (GBP) was recorded in 267 individuals in the county of Lillehammer in Norway. Total caries experience as DMFS and approximal carious lesions in the outer half of the enamel (D1), in the inner half of the enamel (D2), in dentin (D3), and filled approximal surfaces were registered clinically and on standardized bite-wing radiographs. Using multiple regression analysis, oral hygiene level expressed as GBI was the only factor that could account for variation in caries experience (DMFS). Any significant effect of consumption of sweets on caries experience could not be demonstrated with the multivariate analysis. The average percentage of GBP (+/- SD) was 35.7 +/- 10.0%. The individuals were divided into one group with good oral hygiene (GBP < 35.7%) and one group with poor oral hygiene (GBP > or = 35.7%). Significantly fewer carious lesions and filled approximal surfaces were demonstrated in the group with good oral hygiene compared with the group with poor oral hygiene. About 16% of the study population used fluoride tablets or fluoride mouthrinses in addition to a fluoride toothpaste. Only in the good oral hygiene group, additional fluoride resulted in a lower caries experience compared with those using only a fluoride toothpaste. In the group with poor oral hygiene, additional fluoride did not result in lower caries experience. The study thus supported the view that during regular fluoride exposure oral hygiene level is an important variable to explain caries risk.

The aim of this study was to assess different methods for the diagnosis of fissure caries when employed on 37 extracted teeth with cavitated occlusal surfaces. A further aim was to compare these results with a previous assessment of the same diagnostic methods on 63 non-cavitated teeth [Lussi, 1993]. The examinations were performed under standard conditions in a professional dental unit. The methods employed were: visual inspection (VI, 26 dentists), VI with magnification (VIM, x2, 26 dentists), bite-wing radiography (BW, 24 dentists), VI combined with BW (VI + BW, 10 dentists) and VI combined with light-pressure probing (VI + P, 23 dentists). For information about the reproducibility, the VI and the VI + BW were repeated. After the last inspection, the teeth were histologically prepared, serially sectioned perpendicular to the occlusal surface and diagnosed for the presence of caries. The agreement between histological and clinical diagnosis was assessed. Sensitivities were VI = 62%, VIM = 75%, BW = 79%, VI + BW = 90%, and VI + P = 82%. The sensitivities found by the same dentists diagnosing non-cavitated teeth were VI = 12%, VIM = 20%, BW = 45%, VI + BW = 49%, VI + P = 14%. The differences between these sensitivities have a direct impact on the DMFS reported for fissure caries. It was concluded that the significant influence of the surface status (cavitated/non-cavitated) should be taken into account when comparing different methods for the diagnosis of occlusal caries.

Cavitation of enamel lesions probably represents a significant step regarding further progression of the caries process. The primary objective of this study was to examine in adolescents the macroscopical appearance of approximal surfaces with radiographic lesions and relate this to the caries activity of the individual. A second objective was to establish the clinical feasibility of a modified technique for inspection of approximal contact surfaces. The material consisted of 46 enamel lesions selected on the basis of routine bite-wing radiographs of 140 patients aged 17-18 years, available from the Public Dental Service of Lillehammer, a non-fluoridated town. Lesions close to or approaching the AD junction were classified as D2 lesions, whereas those demonstrating a shadow not more than 1 mm into the dentine were designated D3 lesions. Based on recorded treatment during the last 3 years, patients were dichotomised as caries-active (CA) if they had more than 6 new lesions involving the dentine. The remainder with little or no activity were designated modestly active (MA). A small orthodontic rubber ring was placed around the contact point of the approximal surface of interest 1 day before an impression was taken. A separation of 0.5 mm facilitated cleansing and injection of low viscosity impression material (Xantopren(R) L, Blue, Bayer Dental). Discontinuity in the approximal enamel surface, determined by visual inspection of stone dyes, prepared from the impressions, was classified as cavitation. The results demonstrated that in MA patients D2 lesions seldom had cavities while in CA patients cavitation was usually found both in D2 and D3 lesions. The feasibility of the impression/inspection method seems established. It is easily performed and should be considered as a diagnostic tool in borderline cases.

The purpose of this study was to investigate what effect differing levels of didactic education and clinical experience have on the ability to diagnose occlusal caries from radiographs. Freshman and senior dental students and dental school faculty were asked to evaluate bitewing radiographs for the presence of occlusal caries and for a recommendation for restorative treatment. The agreement between histologic and radiographic diagnosis was assessed by calculating sensitivity, specificity, accuracy, and interexaminer agreement. It was concluded that dental students and faculty did differ in their abilities to evaluate radiographs for occlusal caries, and that education and clinical experience especially affected interexaminer agreement.