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Objectives To evaluate overall image quality and visibility of anatomic structures on low-dose cone beam computed tomography (CBCT) scans and the effect of a noise reduction filter for assessment of the anterior maxilla. Methods We obtained 48 CBCT volumes on eight skull-phantoms using six protocols: two clinical default protocols [standard definition (SD) and high definition (HD)] and four low-dose protocols, two with a noise reduction filter [ultra-low-dose with high definition (ULDHD) and ultra-low-dose (ULD)] and two without [low-dose with high definition (LDHD) and low-dose (LD)]. Overall image quality and visibility of eight anatomic structures were assessed by five observers and statistically analyzed using the Wilcoxon signed rank test. Intra- and interobserver agreement was measured using Cohen's weighted kappa. Results HD provided higher overall image quality than diagnostically required; LD scored lower than diagnostically acceptable. ULDHD, ULD, and LDHD were acceptable. For anatomic structures, ULDHD and ULD were acceptable. LDHD and LD showed significantly inferior visibility for one and four structures, respectively. Mean values of intra- and interobserver agreement were 0.395-0.547 and 0.350 -0.370, respectively. Conclusions ULDHD, ULD, and LDHD may be recommended for assessment of impacted maxillary canines. The noise reduction filter affects image quality positively only at low exposure.

Objective: To investigate how cone beam computed tomography (CBCT) affects the therapeutic planning of impacted maxillary canines. Study Design: A total of 132 impacted canines from 89 pediatric patients were collected from 3 specialist clinics in Stockholm, Sweden. An interdisciplinary therapy planning team consisting of 5 dental specialists evaluated each case and chose their preferred treatment alternative, initially without and later with CBCT images, to decide whether CBCT was justified for therapy planning. Predefined variables measurable using only 2-dimensional (2D) assessments were analyzed using stepwise logistic regression analyses. Results: The CBCT was considered indicated in 47% of the cases. Additional information from CBCT led to a treatment decision change in 9.8%. Significant 2D predictors for CBCT justification were horizontal canine angulation compared with vertical angulation (odds ratio [OR] = 10.9), extraction strategy involvement (OR = 6.7), and buccally positioned canines compared with palatal (OR = 5.3), central (OR = 25.0), and distal or uncertain positions (OR = 7.7). Conclusions: The benefit-risk assessment of CBCT for impacted canines may be reinforced by performing and applying justification decisions for CBCT acquisition at the therapeutic thinking level. If preliminary treatment planning motivates further in-depth investigation of either root status or tooth location, a CBCT is indicated. publishedVersion

Objective - To explore whether plaque and gingival bleeding are more frequently experienced by adolescents with juvenile idiopathic arthritis (JIA) compared to matched controls without JIA; explore whether surface- and site-specific periodontal outcomes vary between the two groups; and for participants with JIA, investigate associations between disease-specific features and periodontal outcomes. Material and methods - In this comparative cross-sectional study, selected surfaces, and sites of index teeth in 10–16-year-olds with JIA and matched controls were examined by modified versions of Simplified Oral Hygiene Index (OHI-S) and Gingival Bleeding Index (GBI). Mixed-effects logistic regressions, reporting odds ratios (OR) with 95% confidence interval (CI), were applied. Intra-class correlation coefficients (ICCs) were calculated to quantify the degree of dependency of measures within the same individual. Results - 144 and 159 adolescents with JIA were evaluated according to OHI-S and GBI; corresponding numbers of controls were 154 and 161. Plaque and gingival bleeding were more frequent in individuals with JIA than controls. Adjusted analyses showed association between JIA status and OHI-S > 0 (OR = 2.33, 95% CI: 1.47 − 3.67, ICC = 0.45) and GBI > 0 (OR = 1.54, 95% CI: 1.10 − 2.16, ICC = 0.41 and 0.30). Surface-specific distribution of plaque varied among the two groups. Conclusions - Our results highlight the importance of increased awareness of oral health care in patients with JIA and that surface- and site-specific differences in periodontal outcomes exist between individuals with JIA and controls. Few JIA disease-specific variables associated with plaque or gingival bleeding.

Background Children and adolescents with juvenile idiopathic arthritis (JIA) may suffer pain from temporomandibular disorder (TMD). Still, routines for the assessment of temporomandibular joint (TMJ) pain in health and dental care are lacking. The aims of this study were to examine the prevalence of TMD in children and adolescents with JIA compared to their healthy peers and to investigate potential associations between JIA and TMD. Methods This comparative cross-sectional study is part of a longitudinal multicentre study performed during 2015–2020, including 228 children and adolescents aged 4–16 years with a diagnosis of JIA according to the ILAR criteria. This particular substudy draws on a subset of data from the first study visit, including assessments of TMD as part of a broader oral health examination. Children and adolescents with JIA were matched with healthy controls according to gender, age, and centre site. Five calibrated examiners performed the clinical oral examinations according to a standardised protocol, including shortened versions of the diagnostic criteria for TMD (DC/TMD) and the TMJaw Recommendations for Clinical TMJ Assessment in Patients Diagnosed with JIA. Symptoms were recorded and followed by a clinical examination assessing the masticatory muscles and TMJs. Results In our cohort of 221 participants with JIA and 221 healthy controls, 88 (39.8%) participants with JIA and 25 (11.3%) healthy controls presented with TMD based on symptoms and clinical signs. Painful TMD during the last 30 days was reported in 59 (26.7%) participants with JIA vs. 10 (5.0%) of the healthy controls (p Conclusion Symptoms and clinical signs of TMD were seen in approximately half of the JIA patients compared to about one fourth of their healthy peers. Painful palpation to masticatory muscles and decreased vertical unassisted jaw movement were more frequent in participants with JIA than among healthy controls and should be part of both medical and dental routine examinations in patients with JIA.

Objectives To query the experience of oral surgeons concerning referral routines and preferences for radiographic imaging modality before surgical removal of mandibular third molars and investigate factors that influence imaging modality preferences. Materials and methods Members of the Swedish Association of Oral and Maxillofacial Surgeons (n = 280) were invited to participate in a web-based digital survey concerning their experiences and use of three imaging modalities in pre-surgical assessment of mandibular third molar removal. The survey comprised multiple-choice questions and four cases depicted in images; respondents reported whether they would supplement the cases with other images and, if so, from which modality. Results The response rate was 64%. Panoramic radiographs were most commonly used in pre-surgical planning (response options: always or often), significant difference between professions (p = 0.039), and considered to facilitate treatment planning (87%), as was CBCT (82%); for 51%, CBCT reduced post-operative complications. Preferred modality for localizing the mandibular canal was fairly evenly distributed and for non-complex case, significant difference between subgroups of OMFS surgeons was found (p = 0.003) as to preference for intraoral radiographs. Conclusions A majority of respondents received a report within 2 weeks of their referral for CBCT and would read the report and view the images before surgery. Image modality preference differed depending on case complexity, with a greater perceived need for CBCT. Profession and practical experience affected choice. Clinical relevance Choice of imaging modality in mandibular third molar assessment is also important from dose delivery and social economy standpoints.

Background Children and adolescents with juvenile idiopathic arthritis (JIA) may suffer from temporomandibular disorder (TMD). Due to this, imaging diagnosis is crucial in JIA with non-symptomatic TM joint (TMJ) involvement. The aim of the study was to examine the association between clinical TMD signs/symptoms and cone-beam computed tomography (CBCT) findings of TMJ structural deformities in children and adolescents with JIA. Methods This cross-sectional study is part of a longitudinal prospective multi-centre study performed from 2015–2020, including 228 children and adolescents aged 4–16 years diagnosed with JIA, according to the International League of Associations for Rheumatology (ILAR). For this sub-study, we included the Bergen cohort of 72 patients (32 female, median age 13.1 years, median duration of JIA 4.5 years). Clinical TMD signs/symptoms were registered as pain on palpation, pain on jaw movement, and combined pain of those two. The severity of TMJ deformity was classified as sound (no deformity), mild, or moderate/severe according to the radiographic findings of CBCT. Results Of 72 patients, 21 (29.2%) had pain on palpation at and around the lateral pole, while 41 (56.9%) had TMJ pain upon jaw movement and 26 (36.1%) had pain from both. Of 141 TMJs, 18.4% had mild and 14.2% had moderate/severe structural deformities visible on CBCT. CBCT findings were not significantly associated with either the pain on palpation or the pain on jaw movement. A significant difference was found between structural deformities in CBCT and the combined pain outcome (pain at both palpation and movement) for both TMJs for the persistent oligoarticular subtype (p = 0.031). Conclusions There was no association between painful TMD and CBCT imaging features of the TMJ in patients with JIA, but the oligoarticular subtype of JIA, there was a significant difference associated with TMJ pain and structural CBCT deformities.

Background Adenoid hypertrophy among orthodontic patients may be detected in lateral cephalograms. The study investigates the aerodynamic characteristics within the upper airway (UA) by means of computational fluid dynamics (CFD) simulation. Furthermore, airflow features are compared between subgroups according to the adenoidal nasopharyngeal (AN) ratios. Methods This retrospective study included thirty-five patients aged 9–15 years having both lateral cephalogram and cone beam computed tomography (CBCT) imaging that covered the UA region. The cases were divided into two subgroups according to the AN ratios measured on the lateral cephalograms: Group 1 with an AN ratio ms), maximum wall shear stress (Pws), and minimum wall static pressure (Pw). Results The maximum Vms exhibits nearly 30% increases in Group 2 at both inspiration (p = 0.013) and expiration (p = 0.045) compared to Group 1. For the other aerodynamic parameters such as ΔP, the maximum Pws, and minimum Pw, no significant difference is found between the two groups. Conclusions The maximum Vms seems to be the most sensitive aerodynamic parameter for the groups of cases. An AN ratio of more than 0.6 measured on a lateral cephalogram may associate with a noticeably increased maximum Vms, which could assist clinicians in estimating the airflow features in the UA.

Objectives: This retrospective observational study aimed to evaluate the diagnostic accuracy of two-dimensional radiographs on canine-induced root resorption (CIRR) in lateral incisors and identify predictors of CIRR in patients with impacted maxillary canines (IMC). Methods: Ninety-nine patients aged 9–17 years, with 156 IMCs, were included in the study. All had CBCT-volumes and two-dimensional radiographs consisting of at least one panoramic radiograph. Two radiologists jointly viewed all cases twice. First, radiographic features related to the IMC and possible CIRR were recorded from two-dimensional radiographs. Then, CIRR was determined from CBCT and according to position and extension classified as mild, moderate and severe. Results: CIRRs was detected in 80% of lateral incisors (mild: 45%; moderate: 44%; severe: 11%). The sensitivity was generally low at mild and moderate cut-offs (29 and 29%), and somewhat higher for severe (50%). Corresponding specificities were 48%, 63% and 68%. Canine cusp-tip superimposing the lateral incisor’s middle third and root/crown ratio >1 was positively associated with mild CIRR, with an odds ratio (OR) of 3.8 and 6.7, respectively. In addition, the root development stage was positively associated with moderate/severe CIRR when the canine root was nearly or fully developed (OR = 3.1). Conclusions: The diagnostic accuracy of two-dimensional radiographs was inadequate for detecting CIRR amongst patients referred for CBCT examinations. Based on our results, none of the suggested two-dimensional radiographic features could predict moderate/severe CIRR except for root development stage. IMC in a later stage of root development seems to be associated with a higher risk of moderate/severe CIRR.

Background Optimal utilization of dental caries data is crucial in epidemiological research of individuals with juvenile idiopathic arthritis (JIA). The aims were to: explore whether caries is more prevalent among children and adolescents with JIA compared to controls; examine presence of caries according to JIA group, socio-behavioral and intraoral characteristics, and the extent to which surface-specific caries varies between and within individuals; assess whether surface-specific caries varies according to JIA group and dentition; and investigate whether disease-specific clinical features of JIA are associated with presence of caries. Methods In this comparative cross-sectional study, calibrated dentists examined index teeth (primary 2. molars, 1. permanent molars) of 4–16-year-olds with JIA (n = 219) and matched controls (n = 224), using a detailed caries diagnosis system (including enamel caries). JIA-specific characteristics were assessed by pediatric rheumatologists and socio-behavioral information collected by questionnaires. Multilevel mixed-effect logistic regressions reporting odds ratios (OR) with 95% confidence interval (CI) were applied (caries at surface level as outcome variable). Potential confounders were adjusted for, and the effect of dependency of surface-specific caries data was estimated by calculating intra-class correlation coefficients (ICC). Results At individual level, no significant difference in caries prevalence was found between individuals with JIA and controls, regardless of inclusion of enamel caries. Proportion of enamel lesions exceeded dentine lesions. JIA was not associated with presence of caries, but in both groups, low maternal educational level was associated with presence of caries (OR: 2.07, 95% CI: 1.24–3.46). Occlusal and mesial surfaces, compared to buccal surfaces, had generally higher OR according to presence of caries than distal and lingual surfaces (ICC = 0.56). Surface-specific caries in the permanent dentition differed significantly according to group affiliation. Some JIA disease-specific variables were suggested to associate with presence of caries. Conclusions No overall difference in caries prevalence between individuals with JIA and controls was observed, but for both groups, low maternal educational level and tooth surface associated with presence of caries. Associations between JIA disease-specific variables and presence of caries cannot be excluded. Due to predominance of enamel lesions, the potential of preventative dental strategies is considerable.

Objectives The aim was to evaluate the characteristics of the mandibular third molars, especially in relation to the inferior alveolar nerve. Further aims were to investigate incidental findings in panoramic radiographs in an adult population, and to investigate image quality related to patient positioning. Materials and Methods From a previous study with 451 randomly selected adult participants who lived in Sweden, 442 panoramic radiographs from four dental public health clinics were used. The third molars’ characteristics and relation to inferior alveolar nerve were evaluated. Incidental findings and patient positioning were recorded. Statistical Analysis Frequency analysis was used to investigate the occurrence of all findings and their possible interconnections. Whether the patients’ age or gender had an impact or not was also analyzed. Results The third molars were erupted in vertical position among 73% regardless of age. When retained or semi-retained, they were most commonly in mesioangular positions. The inferior alveolar nerve was located inferior to the roots in 52%, whereas an overlapped position was most common if the third molar was retained (90%), semi-retained (83%) or the age was less than 30 years (66%). Common incidental findings were apical radiolucencies, idiopathic osteosclerosis, and tooth fragments. Suboptimal patient positioning was found in one-third of the radiographs. Conclusions Panoramic radiography is a useful method to evaluate third molar prior to surgical removal and may be the only image required. Most incidental findings on panoramic radiographs does not seem to require any further odontological management. publishedVersion

Objective: Evaluation of cone beam CT (CBCT) examination with a low-dose scanning protocol for assessment of the temporomandibular joint (TMJ). Methods: 34 adult patients referred for CBCT imaging of the TMJ underwent two examinations with two scanning protocols, a manufacturer-recommended protocol (default) and a low-dose protocol where the tube current was reduced to 20% of the default protocol. Three image stacks were reconstructed: default protocol, low-dose protocol, and processed (using a noise reduction algorithm) low-dose protocol. Four radiologists evaluated the images. The Sign test was used to evaluate visibility of TMJ anatomic structures and image quality. Receiver operating characteristic analyzes were performed to assess the diagnostic accuracy. κ values were used to evaluate intraobserver agreement. Results: With the low-dose and processed protocols, visibility of the TMJ anatomical structures and overall image quality were comparable to the default protocol. No significant differences in radiographic findings were found for the two low-dose protocols compared to the default protocol. The area under the curves (Az) averaged for the low-dose and processed protocols, according to all observers, were 0.931 and 0.941, respectively. Intraobserver agreement was good to very good. Conclusion: For the CBCT unit used in this study, the low-dose CBCT protocol for TMJ examination was diagnostically comparable to the manufacturer-recommended protocol, but delivered a five times lower radiation dose. There is an urgent need to evaluate protocols for CBCT examinations of TMJ in order to optimize them for a radiation dose as low as diagnostically acceptable (the as low as diagnostically acceptable principle recommended by NCRP). publishedVersion

Objectives The aim of this study was to evaluate the reliability of bitewing and panoramic radiographs in marginal bone level measurements in terms of inter- and intra-observer agreement. Methods Fifty paired bitewing and panoramic images were used. Eight observers measured marginal bone level at the mesial and distal surfaces of tooth 25 and tooth 35. Thus, in total 100 radiographs of 400 measurements were obtained for each observer. To evaluate intra-observer agreement, three observers re-evaluated the radiographs after a minimum of 1 month. Intra-class correlation coefficient (ICC) was applied to evaluate the inter- and intra-observer agreement. The t test was applied to assess possible difference in measurement between bitewing and panoramic radiographs. Results The mean ICC value of inter-observer agreement was 0.85 for bitewing and 0.66 for panoramic radiographs. The mean intra-observer agreement was 0.92 and 0.76 for bitewing and panoramic radiographs, respectively. There was no statistically significant difference between bitewing and panoramic radiographs in measurements of marginal bone level on maxillary tooth 25, whereas a statistically significant difference was found between the two image modalities on mandible tooth 35. Conclusion Bitewing examination should be the choice of image modality for assessment of marginal bone level at premolar region due to good to excellent reliability and low radiation dose. However if a panoramic radiograph already exists, a rough estimation of marginal bone level at premolar region is clinically acceptable bearing in mind that the bone height of the mandible premolar region might be overestimated as compared to bitewing radiograph. publishedVersion

Background Autologous grafting, despite some disadvantages, is still considered the gold standard for reconstruction of maxillofacial bone defects. The aim of this study was to evaluate bone regeneration using bone marrow-derived mesenchymal stromal cells (MSCs) in a clinical trial, a less invasive approach than autologous bone grafting. This comprehensive clinical trial included subjects with severe mandibular ridge resorption. Methods The study included 11 subjects aged 52–79 years with severe mandibular ridge resorption. Bone marrow cells were aspirated from the posterior iliac crest and plastic adherent cells were expanded in culture medium containing human platelet lysate. The MSCs and biphasic calcium phosphate granules as scaffolds were inserted subperiosteally onto the resorbed alveolar ridge. After 4–6 months of healing, new bone formation was assessed clinically and radiographically, as were safety and feasibility. Bone at the implant site was biopsied for micro-computed topography and histological analyses and dental implants were placed in the newly regenerated bone. Functional outcomes and patient satisfaction were assessed after 12 months. Results The bone marrow cells, expanded in vitro and inserted into the defect together with biphasic calcium phosphate granules, induced significant new bone formation. The regenerated bone volume was adequate for dental implant installation. Healing was uneventful, without adverse events. The patients were satisfied with the esthetic and functional outcomes. No side effects were observed. Conclusions The results of this comprehensive clinical trial in human subjects confirm that MSCs can successfully induce significant formation of new bone, with no untoward sequelae. Hence, this novel augmentation procedure warrants further investigation and may form the basis of a valid treatment protocol, challenging the current gold standard. Trial registration EudraCT, 2012-003139-50. Registered on 21 August 2013. ClinicalTrials.gov, NCT 02751125. Registered on 26 April 2016.

Introduction In this study, we aimed to evaluate the adenoidal nasopharyngeal ratio (ANR) on lateral cephalograms by assessing upper airway volumes using cone-beam computed tomography (CBCT) images as the validation method. Methods Fifty-five patients were included in the study, and it was essential that the lateral cephalograms and CBCT images taken at their examinations were not more than 1 week apart. There were 32 subjects in group A (age ≤15 years) and 23 subjects in group B (age >15 years). The ANR was measured on the lateral cephalograms. The area and volumetric measurements of the nasopharynx and the total upper airway were obtained from CBCT images. Repeated measurements of the ANR and airway volume were performed on 10 subjects by 2 observers. Results Group A had a higher correlation (r = −0.78) between the ANR and the nasopharynx volume than did group B (r = −0.57). The ANR had a weak correlation with the total upper airway volume (group A, r = −0.48; group B, r = −0.32). Both measurements made on lateral cephalograms and CBCT were highly reproducible in terms of intraobserver and interobserver agreement. Conclusions Based on our results, the measurement of the ANR on lateral cephalograms can be used as an initial screening method to estimate the nasopharynx volumes of younger patients (age ≤15 years).

The aim of this study was to evaluate the performance of the automatic exposure control (AEC) in an intraoral digital system.Three series of radiographs were captured with the activated AEC on seven dry mandibles adhered to different thicknesses of Plexiglas((R)), which represented soft tissue. Exposure times required for each radiograph of the specimens were analysed as functions of the added Plexiglas thickness. Differences in mean grey levels between pairs of the three images obtained from the same specimen were analysed by employing the subtraction technique. Additionally, four radiographs of all seven mandibles were manually exposed with one layer of Plexiglas, which employed one and two steps below and above the registered automatic exposure time. Six observers evaluated the series of radiographs exposed with one layer of Plexiglas in a random order. The observers were instructed to classify the quality of the diagnostic images as unacceptable, acceptable or excellent.The results demonstrated a good correlation between the exposure times determined by AEC and Plexiglas thickness (r = 0.85). Mean grey level values for subtraction images obtained from radiographs exposed with different thickness of Plexiglas with activated AEC indicated that almost identical radiographs were obtained, regardless of the Plexiglas thickness. The subjective observer evaluation of the most satisfactory radiographic image quality as a function of exposure time demonstrated that the highest scores were for radiographs exposed with the AEC function activated.The AEC function may accurately determine the appropriate exposure times related to object thickness, providing radiographs with satisfactory image quality, and may thus be advantageous in clinical radiographic work.

Objective The objective of this study was to compare detection of approximal caries in vitro by black-and-white and color-coded digital radiographs. Study design The material comprised 2 groups of tooth sample. One group consisted of 40 premolars mounted in groups of 3 or 4 and the other group included 90 premolars mounted in groups of 5. Radiographs, respectively exposed with the Dixi and the Digora Optime digital radiographic systems, were color-coded using specially designed software. Seven observers in each of 2 centers subjectively evaluated one series of black-and-white and color-coded radiographs. The teeth were subsequently sectioned for histological determination of the lesions. ROC analyses were performed. Differences between the area under the ROC curves for the digital black-and-white and the color-coded radiographs were analyzed by ANOVA. Results There were no significant differences between the black-and-white and the color-coded radiographs in detection of approximal caries. Conclusion Color-coded digital radiographs may be used as an alternative to digital black-and-white radiographs.

The aims of this in vitro study were 2-fold: 1) to evaluate two fluorescence methods (DIAGNOdent and QLF (quantitative light-induced fluorescence)) for quantification of white spot lesions adjacent to fixed orthodontic appliances; and 2) to determine the inter-observer agreement of the DIAGNOdent and QLF methods for quantification of incipient enamel lesions adjacent to fixed orthodontic appliances. Forty-one premolar teeth with visually sound smooth surfaces or visually white spot enamel lesions were included in the study. Orthodontic brackets were fixed adjacent to the lesions, thus simulating the position of fixed appliances during orthodontic treatment. All teeth were measured using both the DIAGNOdent and QLF methods. Of the 41 teeth, 20 smooth surfaces were randomly selected and analyzed by 4 operators using both DIAGNOdent and QLF. The teeth were sectioned into 300-microm-thick slices using a water-cooled diamond saw and the slices manually ground to 80-100 microm thickness. Histopathology and transverse microradiography were performed to provide the gold standards for verification of lesion depth and mineral loss, respectively. The Spearman rank correlation coefficients between lesion depth determined by histopathology and the DIAGNOdent and QLF were 0.76 and 0.82, respectively, whereas the Pearson correlation coefficients between mineral loss and the two methods were 0.64 and 0.84, respectively. Inter-observer agreement was found to be 0.80 and 0.93 for DIAGNOdent and QLF, respectively. In conclusion, QLF may be a suitable method for quantifying incipient carious lesions adjacent to fixed orthodontic appliances.

Objective: To evaluate if digital compensation for exponential attenuation and the characteristics of the human visual system improves the diagnosis of approximal caries from digital radiographs. Material and methods: Forty premolar teeth were mounted in plaster blocks. Radiographs of the teeth were exposed with the Dixi digital intraoral system employing a Prostyle Intra dental X-ray unit (Planmeca Oy, Helsinki, Finland). Thirteen radiographs were then processed to compensate for the exponential attenuation and for the characteristic of the human visual system using equations presented in the paper. Ten observers were asked to diagnose approximal caries in all radiographs. ROC analyses were performed. The teeth were subsequently sectioned for histological validation of the lesions. The areas under ROC curves of original and processed radiographs were compared and analysed using Wilcoxon’s signedranks test. Results: There were significant diagnostic diAerences between the two types of radiographs (all lesions P=0.005, enamel P=0.028, and dentine P=0.050). Conclusion: Digital radiographs processed to compensate for exponential attenuation and the characteristics of the human visual system significantly improves the diagnosis of approximal caries in vitro. Dentomaxillofacial Radiology (2002) 31, 113‐116. DOI: 10.1038/sj/dmfr/4600675

The aims of this study were to investigate the anti-inflammatory effect and the effect on bone regeneration of hyaluronan in surgical and non-surgical groups.In each of 15 individuals, 2 teeth with defects of similar character and magnitude in the upper or lower jaw were chosen. There were at least 2 teeth between the test and the control sites. In the surgical group, a bioabsorbable membrane was used for both test and control sites, and hyaluronan was placed in the intrabony pocket of the test site. In the non-surgical group, the periodontal pockets were scaled and hyaluronan was administered 3 times with an interval of 1 week in the test pockets. Alveolar bone height and bone healing patterns were analyzed using digital intraoral radiographs. Measurements of bone height were performed in the original digital black-and-white radiographs to obtain quantitative data on bone gain or loss. Bone healing patterns were studied with color-coded radiographs, using specially designed software in a personal computer with subsequent combinations of radiographs. Gingival crevicular fluid immunoglobulin (Ig)G, C3, and prostaglandin E2 (PGE2) responses; periodontal probing depth; bleeding on probing; and the presence of plaque were studied to evaluate the anti-inflammatory effect. Data were obtained at baseline before treatment, and at 2 weeks, and 1, 3, 6, and 12 months after treatment.For the surgical treatments, bone height was increased in the test group treated with hyaluronan (mean value 2.2%, corresponding to an average increase of approximately 0.5 mm) and reduced in the control group (mean value -1.8%, corresponding to an average decrease of approximately - 0.4 mm) (P0.05) after 12 months. For the non-surgical treatments, bone height was reduced by a mean value of -1.1% (corresponding to an average decrease of approximately -0.25 mm) in the test group treated with hyaluronan and -3.3% (corresponding to an average decrease of approximately -0.75 mm) in the control group after 12 months (N.S.). According to the digital color-coded radiographs, the test sites in the surgical and non-surgical groups showed apposition of bone minerals. Immune responses showed no differences during the 12 months studied for the surgical and non-surgical sites. Mean periodontal probing depths were reduced between 2.5 mm and 4.1 mm in the surgical and non-surgical groups.The observed difference in bone height between test and control sites in the surgical group after 12 months was less than 1 mm, which was only detectable on radiographs. No statistical difference was found on radiographs in the non-surgical group, where a decrease in bone height was found for both groups after scaling. Probing depth reduction after the surgical treatment, as well as after scaling and root planing, was as expected. Hyaluronan in contact with bone and soft tissues had no influence on the immune system in this study. Further studies are needed to determine the extent to which hyaluronan can lead to clinically significant healing of periodontal lesions.

A new generation of the laser fluorescence device, DIAGNOdent, for caries detection and quantification has been introduced recently. It is the DIAGNOdent pen. The aim of this study was to compare the validity and reliability of both laser-based devices, DIAGNOdent and the DIAGNOdent pen, in quantifying smooth surface caries.The material comprised a sample of 52 premolar teeth extracted on orthodontic indication. The teeth were visually sound or had various stages of non-cavitated carious lesions on smooth surfaces. All teeth were photographed and measured with both DIAGNOdent and the DIAGNOdent pen by two examiners independently. The teeth were then sectioned into 300-microm slices and analysed under a microscope for verification of lesion depth. Histopathological analyses were performed by two observers to assess lesion depth, which was classified into five categories ranging from sound to dentinal caries. Reliability and validity of the two devices were evaluated in terms of intra-class coefficients and Spearman rank correlation coefficient, respectively. The relation between measurements performed by DIAGNOdent and the DIAGNOdent pen was analyzed using Pearson's correlation coefficient.Both DIAGNOdent and the DIAGNOdent pen had excellent intra-observer agreement and acceptable inter-observer agreement. The correlation with histology for DIAGNOdent and the DIAGNOdent pen ranged between 0.47 and 0.57, although the correlation between DIAGNOdent and the DIAGNOdent pen was high.In this in vitro study, the new laser fluorescence device, the DIAGNOdent pen, showed similar reliability and validity at quantification of smooth surface caries compared to the conventional DIAGNOdent device. Agreement between DIAGNOdent and the DIAGNOdent pen was excellent.

The aims of this study were to evaluate the effect of two caries-preventive programs, and to apply the laser fluorescence method, DIAGNOdent, for longitudinal quantification of changes in incipient carious lesions. Twelve subjects with 127 test teeth exhibiting white spot lesions on the buccal surfaces after completed orthodontic therapy were enrolled in the study. Visual examination was performed at baseline and after 12 months. The subjects were divided into two groups: one group received repeated professional tooth cleaning combined with oral hygiene instruction; and the control group received repeated oral hygiene instruction only. The white spot lesions were measured by DIAGNOdent at baseline, and at 3, 6, 9, and 12 months thereafter. There was a significant difference in the DIAGNOdent readings between the first and the final evaluations. However, there was no statistically significant difference between the two treatment groups regarding changes of DIAGNOdent values over time. In conclusion, it may be possible to use DIAGNOdent for longitudinal quantification of carious lesions on smooth surfaces over a period of 1 yr under in vivo conditions. The combination of professional tooth cleaning and oral hygiene instruction had a similar efficacy to professional tooth cleaning only for promoting the remineralization of white spot lesions.

The diagnostic value of DIAGNOdent in detecting primary occlusal caries has been investigated in many studies, although its use in in vivo detection of secondary caries remains unclear. The aim of this study was to investigate the ability of DIAGNOdent in in vivo detection of secondary caries on teeth with amalgam restorations. The material comprised 51 posterior teeth restored with amalgam material. Bitewing radiographs were taken of all teeth, in accordance with the standard clinical protocol, and analysed by five observers with respect to secondary caries. The restoration margins of each tooth were carefully scanned with DIAGNOdent and the site of the highest reading and its value were registered in a digital picture. The color (stained/unstained) of the restoration margins was also documented. The restoration material was removed and all cavities were examined carefully by two observers together, both visually and by probe. The results showed that the sensitivity and specificity of DIAGNOdent and conventional radiography in detecting secondary caries were 0.60/0.81 and 0.56/0.92, respectively. For DIAGNOdent, 100% of the teeth in the false-positive fraction had stains. Regarding receiver operating characteristic analyses, the Az values were 0.78 and 0.69 for DIAGNOdent and radiography, respectively. We conclude that DIAGNOdent may be used only as an adjunct to conventional methods in detecting secondary caries on teeth with amalgam restorations.

It is hypothesized that occlusal lesions are initiated on the fissure walls and can therefore be obscured by sound superficial tissue. Additionally, there is evidence that one effect of regular use of fluorides is greater opacity of enamel, which may obscure underlying lesions in dentin, the so-called 'hidden lesions'. Dental radiographs are inadequate for detecting decay in the occlusal surfaces until the lesion is well advanced through the enamel and into the dentin. The clinician relies on visual observation of texture and discoloration, clinical judgment based upon experience, and on tactile sense by probing with an explorer. An objective detection method to complement the traditional visual assessment is used by the clinician for arriving at clinical decisions on the management of the carious lesion: whether invasive therapy or a more conservative, noninvasive approach. Objective and reliable longitudinal monitoring of the lesion's response to preventive measures allow the selection of an appropriate therapy before the lesion progresses to the stage where invasive treatment is required. This paper discusses the problem of the lack of appropriate clinical methods for the detection and quantification of carious lesions. A few commercially available methods are described (the quantitative light-induced fluorescence method, the DIAGNOdent device, and electrical caries monitor) and some new techniques mentioned.

A colour scale has been developed as a complement to the grey scale in radiographs. The aim of the present study was to compare colour-coded with conventional black-and-white radiographs in terms of the perceptibility curve test.Twelve digital radiographs were exposed on a test object from low to high exposures and recorded using the DIXI system (Planmeca Oy, Helsinki, Finland). An aluminium test object was used containing ten object details in the form of holes with depths ranging from 0.03 mm to 0.30 mm in steps of 0.03+/-0.01 mm. The new colour scale was used to transform the conventional black-and-white radiographs into colour radiographs by specially designed software. Ten observers were asked to analyse four sets of radiographs, i.e. colour-coded and black-and-white radiographs, and reversed colour-coded and reversed black-and-white radiographs. The object detail having the lowest perceptible contrast in each radiograph was registered for each observer. Perceptibility curves were plotted based on the mean value of observer data.Results from the perceptibility curve test showed that the information in colour-coded radiographs was at least as good as that in black-and-white radiographs. In fact, in the lower exposure range, colour-coded radiographs exhibited better perception than conventional black-and-white radiographs.Radiographs that are colour-coded with the applied colour scale may be used as an alternative to conventional black-and-white radiographs.

DIAGNOdent is now well documented for detection of primary occlusal caries, but not as yet for secondary caries. The aim of this study was to investigate the application of DIAGNOdent for in vitro detection of secondary caries. The material comprised 66 extracted teeth: 48 with amalgam restorations and 18 with tooth-colored restorations. Digital images of occlusal surfaces were captured for each specimen. The teeth were mounted in groups of 3 or 4 in plaster blocks simulating their anatomical positions. Bitewing radiographs of each block were assessed for secondary caries by 5 observers. The margins of each restoration were carefully scanned with DIAGNOdent; the site of the highest reading was localized in digital images; and the corresponding values were registered. Marginal integrity and staining were also documented. The restorations were then removed and the teeth were hemi-sectioned. For verification, two observers working together examined all the cavities under a stereomicroscope at 16 x magnification followed by probing. Sensitivity and specificity for DIAGNOdent and conventional radiography were 0.77/0.81 and 0.65/0.81, respectively. Regarding ROC analyses, the Az values were 0.89 and 0.72 for DIAGNOdent and radiography. For DIAGNOdent, the false-positive fraction included only stained teeth. Cohen's kappa statistics disclosed moderate agreement between the 2 methods, with an agreement of 56%. DIAGNOdent tended to give more positive diagnoses than bitewing radiography. The results indicate that DIAGNOdent may be a helpful tool for detecting secondary caries.

The Electronic Caries Monitor (ECM) and the recently introduced laser-based KaVo DIAGNOdent have been developed as clinical diagnostic aids in the detection and quantification of occlusal carious lesions. The aim of this in vitro study was to compare their reproducibility and validity. The ability of DIAGNOdent to retrieve sites of occlusal carious lesions without reference to photographs or drawings from previous assessments was also tested. The material comprised 87 premolar teeth: the occlusal surfaces were sound or exhibited non-cavity carious lesions of varying severity. All were photographed and measured by DIAGNOdent and ECM on 2 occasions, 2 weeks apart. The teeth were then sectioned into 300 microm thick slices. Two observers independently classified the sections according to the histopathology, into 5 categories, ranging from sound to dentinal caries in the inner part of the dentin. Statistical analysis comprised intra-class correlation coefficients (ICC) to test reproducibility and regression analysis of validity. Sensitivity and specificity were also calculated for detection of D3 lesions for both devices. DIAGNOdent recorded maximum readings at identical sites on both occasions in 89% of the teeth. The ICC for readings on 2 separate occasions was 0.97 for DIAGNOdent and 0.71 for ECM. The correlations with histology were r = 0.93 and 0.83, for DIAGNOdent and ECM, respectively. For detection of D3 lesions, the sensitivity and specificity were 0.8 and 1 for DIAGNOdent and 0.75 and 0.88 for ECM. In this in vitro study, DIAGNOdent was superior to ECM for occlusal caries detection.

The aims were 1) to validate a laser-based device, KaVo DIAGNOdent, for quantification of caries lesions on smooth surfaces, using histopathologic and microradiographic analyses as the gold standard, and 2) to test inter- and intra-observer agreements. We also investigated the influence on DIAGNOdent readings of the storage medium used for extracted teeth. Two observers measured independently the tooth surfaces of 40 extracted premolars that had been stored in thymol-saturated saline. After subsequent storage in neutral-buffered formalin for 14 days they were re-measured. The teeth were then sectioned for histopathologic and microradiographic analysis. The Spearman rank correlation coefficients between lesion depth and DIAGNOdent readings were 0.78-0.83 and 0.85 for teeth stored in thymol-saturated saline and formalin, respectively. Inter- and intra-observer agreements were 0.94 and 0.95 when the teeth were stored in thymol-saturated saline. The DIAGNOdent reading was almost 1.5 times higher for teeth stored in formalin than for those stored in thymol saline. The Spearman rank correlation coefficient between mineral loss in enamel (deltaZ) and DIAGNOdent readings ranged from 0.64 to 0.68. It was concluded that DIAGNOdent may be helpful for assessing smooth-surface caries, but the cut-off points need to be assessed under clinical conditions. The increase in fluorescence associated with storage of teeth in formalin warrants further investigation.

The aim was to compare the detection and quantification of smooth surface caries by KaVo DIAGNOdent and quantitative laser/light–induced fluorescence (QLF) using a laser and a lamp as two different light sources. On 40 premolar teeth extracted from adolescents, 71 non–cavitated approximal surfaces were assessed. For QLF, both mean and maximum fluorescence losses were registered. To provide a gold standard for verification, the teeth were then sectioned and lesion depth, stratified on a five–point scale, was determined by histopathology and microradiography. The correlation between the gold standard and the two methods was assessed by Spearman’s rank correlation coefficient. The sensitivity and specificity of the methods for detection of smooth surface caries at D3 level were also assessed. For lesion depth, correlation with the gold standard was similar for QLF and DIAGNOdent: about 0.85. With respect to dentinal caries detection, sensitivity for DIAGNOdent was 0.75 and specificity 0.96, with a cut–off point of 9. The corresponding values for QLF were 0.94 and 1, with a cut–off value of 20% of fluorescence loss. Spearman’s rank correlation coefficients for enamel mineral loss and QLF and DIAGNOdent, respectively, were 0.76 and 0.67. It was concluded that for quantification of smooth surface caries, the methods are of equal merit, but for scientific purposes, QLF offers the advantage of closer correlation with changes in mineral content.

OBJECTIVES To assess intra- and interobserver agreement on marginal changes in periodontal bone from color-coded compared with subtraction radiographs. METHODS Sequential radiographs from patients undergoing periodontal treatment were acquired using direct digital intra-oral radiography. Fifty-one pairs of color-coded and subtraction radiographs were produced and evaluated twice by six dentists for changes in marginal bone. Intra- and interobserver agreement were calculated. RESULTS Intra-observer agreement was significantly higher for the color-coded radiographs (P < 0.05). Interobserver agreement was significantly higher for color-coded radiographs at the second (P < 0.001) but not the first (P = 0.34) evaluation. CONCLUSIONS Color coding of radiographic differences by means of image addition may be a feasible alternative to the subtraction technique for evaluating periodontal bone changes.

A new technique was developed making it possible to visualize changes that take place after premolar transplantation. Three sequential radiographs from a series of standardized control examinations were digitized and registered to the first radiograph in the series using subtraction technique. The digitized radiographs were then transformed into monochromatic images: red, blue, and green. After correction of gray level and contrast, the three radiographs were superimposed. All details that were common in the radiographs were then displayed in black-and-white. Details that were different appeared in color. Red and blue combines into magenta, blue and green into cyan, and green and red into yellow. A procedure was developed to create color-coded radiographs according to the above. The procedure was applied to cases that had been treated by premolar transplantation. The color coding offers the possibility to identify any radiographic changes that take place over time, eg, growth, apposition or resorption of bone, and progression or regression of pathological processes.

A new laser fluorescence method, KaVo DIAGNOdent, was tested with respect to reproducibility and validity and compared with radiography regarding accuracy in the detection of occlusal caries. Seventy–six extracted premolar and molar teeth were measured twice with DIAGNOdent under both wet and dry conditions, at an interval of 2 weeks. Conventional film radiographs were exposed. Microradiographic analysis of sections of the teeth served as the gold standard. Intra–class correlation coefficient and Pearson’s correlation coefficient were used to assess the reproducibility and the validity of the method, respectively. The influence of time and varying humidities on DIAGNOdent readings were analysed by two–way repeated measure ANOVA. ROC curves were plotted for DIAGNOdent readings and radiographic registration of caries by 6 observers, and the areas under the curves were compared using Student’s t test. Under both wet and dry conditions, the reproducibility of the DIAGNOdent method was excellent: R = 0.97 and 0.96, respectively. The diagnostic accuracy of DIAGNOdent was significantly better than that of radiography (p≤0.001). In this in vitro study of detection of occlusal caries, the diagnostic performance of the DIAGNOdent method was superior to that of radiography.