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Objectives: We aimed to assess how the 2018 and 1999 classifications of periodontal diseases reflect (a) patients' characteristics, (b) disease severity/extent/progression and (c) tooth loss (TL) during observation period., Methods: A total of 251 patients were followed over 21.8 ± 6.2 years. For the 1999 classification, using clinical attachment level (CAL), patients were classified as localized/generalized, mild/moderate/severe and aggressive/chronic periodontitis. For the 2018 classification, patients were staged according to their CAL or bone loss (BL) and the number of lost teeth (stages I-IV). Further factors like probing pocket depths (PPD) or furcation involvement modified the stage. The extent was sub-classified as generalized/localized. Patients were graded according to the BL/age index, smoking and/or diabetes., Results: According to the 1999 classification, most patients suffered from generalized severe chronic periodontitis (203/251) or generalized aggressive periodontitis (45/251). Patients with aggressive periodontitis were younger and less often female or smokers. They showed similar TL (0.25 ± 0.22 teeth/patient*year) as generalized severe chronic periodontitis patients (0.23 ± 0.25 teeth/patient*year). According to the 2018 classification, most patients were classified as generalized III-C (140/251), III-B (31/251) or IV-C (64/251). Patients' age, smoking status, CAL, PPD and BL were well reflected. TL differed between IV-C (0.36 ± 0.47), generalized III-C (0.21 ± 0.24) and localized forms (0.10-0.15)., Conclusions: Patients' characteristics, disease severity/extent/progression and TL were well reflected by the 2018 classification., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: Outcome and comparator choice strongly determine the validity and implementation of clinical trial results. We aimed to assess outcome and comparator choice in intervention studies on molar incisor hypomineralisation (MIH) using systematic review and social network analysis (SNA)., Design and Data Sources: Medline, Embase, Cochrane Central, Google Scholar, opengrey.eu as well as DRKS.de and Clinicaltrials.gov were searched for MIH intervention studies. The search covered the period from 1980 to 2019., Eligibility Criteria: Clinical single-arm/multiarm, controlled/uncontrolled studies reporting on the management of MIH were included. Reported outcomes and comparators were extracted and categorised. SNA was used to evaluate comparator choice and the resulting trial networks., Data Extraction: Of the 7979 identified records, 100 were evaluated in full text and 35 studies (17 randomised controlled trials, 14 prospective and 4 retrospective cohort studies) were included., Results: In total, 2124 patients with a mean age of 11 years (min/max 6/70 years) were included. Outcomes fell in one of 11 different outcome categories: restoration success, aesthetic improvement, pain/hypersensitivity/discomfort, mineral gain, space management, anaesthesia effectiveness, preventive success, efficiency, quality of life, gingival and periodontal health and patient satisfaction. Comparators were mainly restorative interventions (17 studies), remineralisation (3), treatment of hypersensitivity (10), aesthetic interventions (5) and orthodontic interventions (3). Two highly clustered comparator networks emerged; many interventions were not robustly linked to these networks., Conclusions: MIH intervention studies recorded both clinically centred and patient-centred outcomes. Core outcome set development should consider these and supplement them with outcomes on, for example, applicability. The high number of compared interventions tested in only few studies and our SNA results implicate that the current evidence may not be robust., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: We applied deep convolutional neural networks (CNNs) to detect apical lesions (ALs) on panoramic dental radiographs., Methods: Based on a synthesized data set of 2001 tooth segments from panoramic radiographs, a custom-made 7-layer deep neural network, parameterized by a total number of 4,299,651 weights, was trained and validated via 10 times repeated group shuffling. Hyperparameters were tuned using a grid search. Our reference test was the majority vote of 6 independent examiners who detected ALs on an ordinal scale (0, no AL; 1, widened periodontal ligament, uncertain AL; 2, clearly detectable lesion, certain AL). Metrics were the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive/negative predictive values. Subgroup analysis for tooth types was performed, and different margins of agreement of the reference test were applied (base case: 2; sensitivity analysis: 6)., Results: The mean (standard deviation) tooth level prevalence of both uncertain and certain ALs was 0.16 (0.03) in the base case. The AUC of the CNN was 0.85 (0.04). Sensitivity and specificity were 0.65 (0.12) and 0.87 (0.04,) respectively. The resulting positive predictive value was 0.49 (0.10), and the negative predictive value was 0.93 (0.03). In molars, sensitivity was significantly higher than in other tooth types, whereas specificity was lower. When only certain ALs were assessed, the AUC was 0.89 (0.04). Increasing the margin of agreement to 6 significantly increased the AUC to 0.95 (0.02), mainly because the sensitivity increased to 0.74 (0.19)., Conclusions: A moderately deep CNN trained on a limited amount of image data showed satisfying discriminatory ability to detect ALs on panoramic radiographs., (Copyright © 2019 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Aim: A range of predictors for tooth loss in periodontitis patients have been reported. We performed a systematic review and meta-analysis to assess the consistency and magnitude of any association between a total of 12 predictors and tooth loss., Materials and Methods: Medline/Embase/Central were searched for longitudinal studies investigating the association between predictors and tooth loss in periodontitis patients. Random-effects meta-analysis was performed, and study quality assessed., Results: Twenty studies (15,422 patients, mean follow-up: 12 years) were included. The mean annual tooth loss/patient was 0.12 (min./max: 0.01/0.36). Older patients (n = 8 studies; OR: 1.05, 95% CI: 1.03-1.08/year), non-compliant ones (n = 11; 1.51, 1.06-2.16), diabetics (n = 7; 1.80, 1.26-2.57), those with IL-1-polymorphism (n = 3; 1.80; 1.29-2.52) and smokers (n = 15; 1.98, 1.58-2.48) had a significantly higher risk of tooth loss. Teeth with bone loss (n = 3; 1.04, 1.03-1.05/%), high probing pocket depth (n = 6; 3.19, 1.70-5.98), mobility (n = 4; 3.71, 1.65-8.38) and molars (n = 4; 4.22, 2.12-8.39), especially with furcation involvement (n = 5; 2.68, 1.75-4.08) also showed higher risks. Gender (n = 16; 0.95, 0.86-1.05) and endodontic affection (n = 3; 3.62, 0.99-13.2) were not significantly associated with tooth loss., Conclusions: Older, non-compliant, smoking or diabetic patients, and teeth with bone loss, high probing pocket depth, mobility, or molars, especially with furcation involvement showed higher risks of tooth loss., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

We applied deep convolutional neural networks (CNNs) to detect periodontal bone loss (PBL) on panoramic dental radiographs. We synthesized a set of 2001 image segments from panoramic radiographs. Our reference test was the measured % of PBL. A deep feed-forward CNN was trained and validated via 10-times repeated group shuffling. Model architectures and hyperparameters were tuned using grid search. The final model was a seven-layer deep neural network, parameterized by a total number of 4,299,651 weights. For comparison, six dentists assessed the image segments for PBL. Averaged over 10 validation folds the mean (SD) classification accuracy of the CNN was 0.81 (0.02). Mean (SD) sensitivity and specificity were 0.81 (0.04), 0.81 (0.05), respectively. The mean (SD) accuracy of the dentists was 0.76 (0.06), but the CNN was not statistically significant superior compared to the examiners (p = 0.067/t-test). Mean sensitivity and specificity of the dentists was 0.92 (0.02) and 0.63 (0.14), respectively. A CNN trained on a limited amount of radiographic image segments showed at least similar discrimination ability as dentists for assessing PBL on panoramic radiographs. Dentists' diagnostic efforts when using radiographs may be reduced by applying machine-learning based technologies.

Aims: Endodontic instruments are frequently compared against each other for their cyclic fatigue resistance (CFR). It is unclear what drives the comparator choice in CFR studies, and how comparators and comparisons have evolved over time. We aimed at evaluating CFR study networks, hypothesizing that indications and instrument properties (alloy, manufacturer) drive comparisons., Methods: A systematic review was performed via Medline and Embase (1986-2017). In vitro studies analyzing the CFR of ≥2 engine-driven instruments in an artificial curved root canal system were included. We classified instruments according to name, alloy, and manufacturer. Study networks were analyzed using social network analysis techniques., Results: Eighty-five studies on 56 different instruments (9 alloys, 17 manufacturers) were included. For instruments, a low-density (0.19), highly clustered (0.71) network with 3 separate subnetworks (for glide path, shaping, and retreatment instruments) emerged. Certain instruments (ProTaper Universal [Dentsply Maillefer, Ballaigues, Switzerland], Mtwo [VDW Dental, Munich, Germany]) served as hub nodes and possible gold standards. Conventional Nickel-Titanium was the most frequently used alloy. Few manufacturers dominated the network. The diversity of tested instruments, alloys, and manufacturers increased in recent years., Conclusions: Comparisons of CFR were usually made along indications. Some instruments and alloys (conventional Nickel-Titanium) dominated the networks. Overall risk of bias by comparator choice seems moderate; however, the evidence on certain, less often tested instruments may not be robust. Factors underlying the network geometry (eg, sponsorship) should be explored., (Copyright © 2019 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

The aims of this study were to assess the trends in dental caries experience in the permanent dentition (i.e., the number of decayed, missing, or filled teeth, DMFT) in Germany from 1997-2014 and to project caries experience to 2030. Components of caries experience (decayed teeth, DT, missing teeth, MT, filled teeth, FT) from repeated waves (1997, 2005, 2014) of the nationally representative German Oral Health Studies were analyzed in 12-, 35-44-, and 65-74-year-olds. Weighted means were interpolated cross-sectionally by fitting piecewise-cubic spline-curves and were then subjected to longitudinal regression and combined with population estimates. In 1997, children (12-year-olds) had a mean caries experience (decayed, missing, filled teeth, DMFT) of 1.7 teeth; this experience decreased to 0.5 teeth in 2014. For 2030, an experience of 0.2 teeth is projected. In adults (35-44-year-olds), a decrease was recorded (1997: 16.1 teeth; 2014: 11.2 teeth). This decrease is expected to continue until 2030 (to 7.7 teeth). Similarly, in seniors (65-74-year-olds), a decrease was recorded (1997: 23.6 teeth; 2014: 17.7 teeth); this decrease is expected to continue until 2030 (to 14.9 teeth). While the number of missing teeth has decreased consistently across age groups, the number of filled and decayed teeth has increased in seniors and is expected to continue to increase. The cumulative caries experience has decreased from 1.1 billion DMFT in 2000 to 867 million in 2015 and is expected to decrease to 740 million in 2030. Caries experience in the permanent dentition has been decreasing substantially, mainly due to a decrease in missing teeth. Younger age groups also show fewer decayed and filled teeth, while in older groups, restorative needs have not decreased, as more teeth are retained. Concepts for addressing the emanating morbidity shifts are required.

Objective: With more teeth retained for longer in an ageing population, population-wide periodontal treatment needs may increase. We assessed and projected periodontal treatment needs from 1997 to 2030 in Germany., Methods: Partial-mouth probing-pocket depths (PPDs) from repeated waves (1997, 2005, 2014) of the nationally representative German Oral Health Studies were transformed into full-mouth PPDs via decision-tree-based ensemble-modelling. In line with German healthcare-regulations, teeth with PPD ≥ 4 mm were regarded as needing periodontal treatment. Weighted means were interpolated cross-sectionally by fitting spline-curves and then regressed longitudinally 1997-2030., Results: In 1997, younger adults (35-44 years old) had a mean of 7.4 teeth needing treatment (overall 93.8 million teeth); this decreased to 4.8 teeth (47.3 million teeth) in 2014. For 2030, we project 3.2 teeth (33.7 million teeth). In seniors, an increase was recorded (1997: 4.5 teeth, 33.5 million teeth; 2014: 7.5 teeth, 63.4 million teeth); this is expected to continue until 2030 (to 12.2 teeth, 140.8 million teeth). The cumulative number of teeth needing treatment increased from 2000 (355 million) to 2015 (365 million), and will increase further to 2030 (464 million)., Conclusions: Population-wide periodontal treatment needs may increase until 2030, mainly in the elderly. Concepts for addressing, these growing needs are required., (© 2018 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd.)

Objectives: The Hall Technique (HT), Non-Restorative Cavity Control (NRCC) and conventional carious tissue removal and restoration (CR) are strategies for managing cavitated caries lesions in primary molars. A randomized controlled three-arm parallel group trial in a university clinic in Germany was used to measure the cost-effectiveness of these strategies., Methods: 142 children (HT: 40; NRCC: 44; CR: 58) were followed over a mean 2.5 years. A German healthcare perspective was chosen. The primary outcome was estimated molar survival; secondary outcomes were not needing extraction, not having pain or needing endodontic treatment/extraction, or not needing any re-intervention at all. Initial, maintenance and endodontic/restorative/extraction re-treatment costs were derived from fee items of the statutory insurance. Cumulative cost-effectiveness and cost-effectiveness acceptability were estimated from bootstrapped samples., Results: HT molars survived longer (estimated mean; 95% CI: 29.7; 26.6-30.5 months) than NRCC (25.3; 21.2-28.7 months) and CR molars (24.1; 22.0-26.2 months). HT was also less costly (66; 62-71 Euro) than NRCC (296; 274-318 Euro) and CR (83; 73-92 Euro). HT was more cost-effective than NRCC and CR in >96% of samples, and had acceptable cost-effectiveness regardless of a payer's willingness-to-pay. This superior cost-effectiveness was confirmed for secondary health outcomes. Cost-advantages were even more pronounced when costs were calculated per year of tooth retention (mean annual costs were HT: 29, NRCC: 154, CR: 61 Euro)., Conclusions: HT was more cost-effective than CR or NRCC for managing cavitated caries lesions in primary molars, yielding better dental health outcomes at lower costs., Clinical Significance: If choosing between these three strategies for managing cavitated caries lesions in primary molars, dentists should prefer HT over NRCC or CR. This would also save costs for the healthcare payer., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: We assessed time trends in root caries experience, i.e. the sum of filled and carious root surfaces (FRS, CRS), and evaluated risk indicators of FRS/CRS in Germany., Methods: FRS and CRS from repeated waves (1997, 2005, 2014) of the nationally-representative German Oral Health Studies were analyzed in 35-44- and 65-74-year-olds (adults/younger seniors; n = 4388). Weighted means were interpolated cross-sectionally across age groups by fitting piecewise-cubic spline-curves, and population-level FRS and CRS calculated. We also projected population-level FRS and CRS to 2030. To evaluate risk indicators of FRS and CRS, zero-inflated negative-binomial regression was applied., Results: In adults FRS increased from 1997 to 2005 at individual and population level (from a mean of 0.49 to 0.63 surfaces; from a total of 6.2 to 8.7 million surfaces) and then decreased to 2014 (to 0.16 surfaces/1.6 million surfaces). CRS constantly increased (1997: 0.37 surfaces/4.7 million surfaces; 2014: 0.94 surfaces/9.3 million). In younger seniors, FRS increased from 1997 to 2005 (from 0.67 to 1.92 surfaces; 5.0 to 17.5 million surfaces) and then decreased to 2014 (0.89 surfaces/7.5 million surfaces). CRS constantly increased (1997: 0.39 surfaces/2.9 million surfaces; 2014: 1.43 surfaces/12.1 million surfaces). Driven by demographic changes until 2030, population-level FRS and CRS is likely to increase in younger seniors, but not adults. Sex, toothbrushing behavior, age, coronal caries experience and the number of teeth with probing-pocket-depths≥4 mm were associated with FRS and CRS., Conclusions: While FRS does not show a clear trend, CRS has constantly increased since 1997. Concepts for preventing and managing CRS in Germany are needed., Clinical Significance: Evaluating time trends and assessing risk indicators of root caries experience is helpful to understand morbidity dynamics, plan resource allocation and identify individuals/groups at risk. While FRS shows no clear trend, CRS has increased since 1997 in Germany. Concepts for addressing the emanating treatment needs are needed., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Regular and/or preventive dental services utilization is an indicator of healthcare access and associated with improved health outcomes. We assessed the proportion of individuals regularly/preventively utilizing dental services, and how this was affected by demographic, health-related and social factors., Sources: Three electronic databases (Medline, Embase, Central) were searched (2005-2017)., Study Selection: We included observational studies investigating the association between preventive/regular dental service utilization and age, oral and general health, edentulism, family structure and health literacy., Data: The proportion of individuals with regular/preventive utilization overall and in different sub-groups were extracted. Random-effects meta-analyses, with subgroup analyses by region, were performed. Meta-regression was used to assess whether and how associations changed with time and countries' human developmental status (HDI). 103 studies on 7,395,697 participants from 28 countries were included. The global mean (95% CI) proportion of individuals regularly/preventively utilizing dental services was 54% (50-59%). In countries with higher HDI, more individuals regularly/preventively utilized services (p < 0.001). Age did not have a significant impact on utilization in adults (OR = 1.00; 0.89-1.12). Utilization was significantly lower in younger than older children (OR = 0.52; 0.46-0.59), individuals with poorer general health (OR = 0.73; 0.65-0.80) and poorer oral health (OR = 0.64; 0.52-0.75), edentulous individuals (OR = 0.32; 0.23-0.41), and individuals with less supportive family structures (OR = 0.81; 0.73-0.89) or poor health literacy (OR = 0.41; 0.01-0.81). The observed differences within populations did not significantly change with time and were universally present., Conclusions: Regular/preventive utilization varied widely between and within countries. Understanding and tackling the reasons underlying this may help to consistently improve utilization., Clinical Significance: Higher developmental status of countries is reflected in greater regular/preventive utilization of dental services. However, large demographic, health-related and social differences in utilization remain. These may contribute to dental health inequalities., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: Micro-invasive treatment (sealing, infiltration) seems more efficacious to arrest early (non-cavitated) proximal carious lesions than non-invasive treatment (NI). Uncertainty remains as to the efficacy of sealing versus infiltration and the robustness of the evidence. We aimed to review and synthesize this evidence using pairwise and network meta-analysis (NMA) and to perform trial sequential analysis (TSA)., Sources: Searching three electronic databases (Medline, Embase, Cochrane Central) was complemented by hand searches and cross-referencing., Study Selection: Randomized controlled trials comparing micro-invasive strategies against each other, NI or placebo for managing proximal carious lesions were included. The primary outcome was radiographically assessed lesion progression. Pairwise and Bayesian network meta-analyses as well as TSA were used for synthesis., Data: Thirteen split-mouth studies (486 participants, mean age 15 years) were included. Mean follow-up was 25 months (min/max 12/36 months). Firm evidence on the superior efficacy of sealing/infiltration over NI (OR; 95% CI: 0.25; 0.18-0.32) was reached. Firm evidence was also reached on the superior efficacy of sealing (OR; 95% CI: 0.29; 0.18-0.46, 7 studies) and infiltration (OR; 95% CI: 0.22; 0.15-0.33, 7 studies) over NI. One study compared infiltration versus sealing and found no significant difference (0.70; 0.34-1.47). Based on Bayesian NMA, infiltration was ranked first in 80% of the simulations (sealing 20%, NI 0%). The surface-under-the-cumulative-ranking (SUCRA) values were 0.90 for infiltration, 0.60 for sealing and 0.00 for NI. We did not detect significant inconsistency (p = 0.89, node-split)., Conclusions: Sealing or infiltration are likely to be more efficacious for arresting early (non-cavitated) proximal lesions than NI., Clinical Significance: Practitioners should strive to perform micro-invasive treatment instead of NI for early proximal lesions. The decision between sealing or infiltration should be guided by practical concerns beyond efficacy., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: We aimed to systematically review and meta-analyze the global, super-regional, regional and national prevalence of molar-incisor-hypomineralization (MIH) and to determine the numbers of prevalent and incident cases on different spatial scales. The review was registered (PROSPERO CRD42017063842)., Sources: Five electronic databases (Medline, EMBASE, LILACS, Web of Science, Google Scholar) were searched systematically., Study Selection: Observational studies on the prevalence of MIH were included and the prevalence on different spatial scales (global, super-regional, regional, national) synthesized using random-effects meta-analyses. The prevalence was then regressed on a large set of methodological, socioeconomic and environmental variables to estimate the global burden (incident and prevalent cases) of MIH., Data: Of 2239 identified studies, 99 studies on 113,144 participants from 43 countries were included. The meta-analysis yielded a mean (95% CI) prevalence of 13.1% (11.8-14.5%), with significant differences between super-regions, regions and countries. The number of prevalent cases in 2015 was estimated at 878 (791-971) million people, while the number of incident cases in 2016 was 17.5 (15.8-19.4) million. Of these, 27.4% (23.5-31.7%) (in mean, 240 million prevalent and 4.8 million incident cases, respectively) were or will be in need of therapy due to pain, hypersensitivity or posteruptive breakdown. Heavily populated countries contribute significantly to the burden of prevalent cases, while growing countries like India, but also Pakistan or Indonesia rank first with respect to the number of incident cases., Conclusions: MIH is highly prevalent across the globe. Certain (mainly low- and middle income) countries shoulder the majority of this burden. Clinical significance The consistently high prevalence and the large proportion of cases in need of care should be considered by both clinicians in their daily practice and healthcare planners and policy makers., (Copyright © 2017 Elsevier Ltd. All rights reserved.)