The use of bitewing radiographs in the management of dental caries: scientific and practical considerations

The objective of this paper is to synthesize published research on the use of radiographs in caries diagnosis in order to produce recommendations for guidelines that are clinically oriented but scientifically based. The options available include the use of various types of radiographic examination alone or in conjunction with other diagnostic aids. The outcomes should facilitate the optimal management of lesions as either preventive care advised (PCA) or operative care advised (OCA). Small initial lesions (PCA) require prompt detection, the application of appropriate preventive care and subsequent monitoring to maintain the most favourable tooth state achievable in the long term. Larger dentinal lesions (OCA) also require prompt detection so that appropriate high-quality operative care can be provided before further loss of tooth substance. Evidence was collected from the literature by updating several recent reviews by the author. The values employed were broadly analogous to those of the Canadian Task Force on the Periodic Health Examination. The use of ionizing radiation is always associated with a degree of risk: therefore all exposures must be kept as low as is reasonably achievable. Present evidence on the balance of risk and benefit indicates that the diagnostic yield for caries diagnosis is high enough to justify individualized examinations, particularly as changes in the morphology of caries have rendered clinical diagnosis of dentinal lesions less sensitive. This issue must be kept under review as alternative diagnostic technologies develop. There is good evidence that initial posterior bitewing radiographs are required for all new dentate patients over five years of age with posterior teeth. This procedure is required as an adjunct to clinical examination for the detection of caries on both the approximal and occlusal surfaces of the teeth. Although a 'blanket' regimen of routine radiographic examination at fixed intervals cannot be advocated, individualized bitewing examinations at varying frequencies determined on the basis of caries risk are supported. At the initial visit, an assessment of caries risk of the individual patient should be made. Varying intervals of first radiographic recall can then be suggested on the basis of differing degrees of risk. At present, risk assessment is imprecise, and risk status may change over time. Therefore, intervals between subsequent radiographic examinations must be re-assessed for each period. The purpose of detecting individual lesions should be to facilitate the planning of appropriate preventive treatment decisions based on lesion severity, caries risk and the patient. Different treatment should be employed for lesions in the PCA and OCA categories. Further rigorous studies are required to evaluate diagnostic methods appropriate for use in individual patient care, epidemiology and clinical research, and to increase the understanding of how findings from these applications inter-relate. Development and validation of reliable methods of caries risk assessment which are usable in general practice is a priority. Investigations of the processes involved in, and the outcomes of, dental decision-making are required to ensure that existing and new methods are used appropriately. Further work should develop and evaluate effective mechanisms of disseminating and implementing research findings by information transfer to dental educators and clinicians.     

What physicians should currently observe in the area of dental health

Several factors govern the development of human dental caries. The actual caries incidence in children depends greatly on fluoride consumption, reduction of fermentable sugar intake (in favour of the use of sugar substitutes), dental health habits and regular dental check-ups. A significant reduction of dental caries in children and young adults is achieved in many countries following these principles. However, there remains a group, about 25%, with a particularly high incidence of caries. Today, efforts are directed at detecting these risk subjects. Mutans streptococci and lactobacilli are the main causative bacteria of human dental caries. The initiation of dental caries is preceded by colonisation of the dentition by S. mutans, usually in early childhood. The early establishment of these bacteria in the mouth of human infants is dependent on intrafamilial--mainly maternal--transmission of saliva. The higher the level of S. mutans in the maternal saliva, the more likely is the colonisation of primary dentition by cariogenic bacteria. The earlier the colonisation, the higher the incidence of caries. Today we have new diagnostic aids: Simple microbiological tests to detect the individuals with high salivary levels of these cariogenic bacteria, so called SM-millionaires. The tests are also a good educational aid for motivating patients to individual prophylaxis. What could a paediatrician or gynaecologist do to help the dentist? He could inform the parents early enough to avoid saliva contacts. For example, the mother should not take the child's spoon or pacifier in her mouth. The dentist meets the children much later, at an age where they already have caries. The older methods, mentioned at the begin, are also still valuable.     

A mechanical comparison of subtrochanteric femur fracture fixation

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.     

The diabetic heart is more sensitive to ischemic injury

A review of the literature on the impact of dental care on the incidence of dental caries in children and adults suggests that the effect is small. Dental services were relatively unimportant in explaining the recent decline in caries in 5- and 12-year-olds. An important contribution of the dental services to the decline in caries was a change in the diagnostic and treatment criteria. The role of dentistry in reducing dental caries may lie mainly in the non-personal health services. Knowledge of the life history and patterns of caries attack rates within populations and individuals could be used as a benchmark against which interventions can be assessed. Different teeth and tooth sites are affected differentially at different levels of dental caries. This truism may appear obvious but it is not used to evaluate the effectiveness and quality of dental treatment. A working rule is that "As caries prevalence falls, the least susceptible sites (proximal and smooth surfaces) reduce by the greatest proportion, while the most susceptible sites (occlusal) reduce by the smallest proportion." There is a specific relationship between the mean DMFT and mean DMFS, and the percentage of caries-free subjects and the frequency distribution of subjects with different levels of caries. Further more, the best predictor of caries at older ages is DMFT at a younger age. Caries levels follow trend lines for each level of caries. As the mean DMFT declines so post-eruptive time increases for initiation of caries and the progression rates of caries through enamel decreases. This is true regardless of the presence of fluoride.     

Dental management and treatment of xerostomic patients

Saliva is extremely important for the health and comfort of the oral cavity. Diminution in salivary flow is accompanied by a plethora of problems. A salivary flow inadequate to protect the oral cavity may be an occult condition. Dentists should evaluate those patients presenting with a high incidence or increased incidence of dental caries for a decreased salivary flow. We have presented diagnostic aids, management techniques and treatment modalities for these patients.     

Fluoride, remineralization and root caries

This paper reviews the probable mechanism of dental caries and the role of fluoride in the inhibition or reversal of that process. The initial stages of root caries are comparable to enamel caries, being the acid dissolution of mineral resulting from acids generated by bacterial metabolism. The fermentation of carbohydrates by oral bacteria including mutans streptococci and lactobacilli initiate the root caries process, removing mineral from among the organic matrix which is primarily composed of collagen. Subsequent to this demineralization, the organic material can be further broken down by bacterial enzymes. Fluoride inhibits mineral loss during the acid dissolution process and enhances remineralization in a similar manner to that which occurs in dental enamel.     

Caries prophylaxis

The extent of dental caries incidence has reached such proportions that it may no longer be kept under control by restorative methods alone. Parodontopathy is besides tooth caried the most wide spread ailment. Bacterial plaque can be considered as main cause and key-factor for caries incidence and parodontopathy. All other causes are co-factors. It follows that decrease of dental plaque must be the most urgent goal in prophylactic dentistry. The combination of all caries and parodontal prophylactic remedies and methods determines as a complex the fate of hard and soft tissues exposed to bacterial plaque.     

Xylitol for messrooms--a method worth trying to prevent caries among seafarers

Oral diseases seem to be the most common health problem of seafarers world-wide. Seafaring as an occupation may create a risk for the dental health of crews of ships. Sitting in messrooms and eating snacks in between regular meals is a popular way of spending free time during the ships voyage. This means not only high caloric intake which contributes to overweight but also to high dental caries incidence among crews. During long sea voyages, the access of seamen to dental services is very limited and making regular check ups and treatment of caries is difficult. The best solution to the problem of poor teeth is a preventive one. Conventional methods for preventing caries are health education, restrictions the use of sugar-containing products, good oral hygiene and use of fluorides. A newer method to prevent caries is systematic use of xylitol. Scientific evidence shows that the addition of small quantities of xylitol, a natural carbohydrate sweetener, to the diet causes a significant reduction in the incidence of dental caries.     

Root caries in the older patient: significance, prevention, and treatment

Root caries is an emerging challenge to the dental professions because of the growing number of increasingly aging adults who have retained many or all of their teeth. Risk factors for developing root caries point to both intraoral and environmental factors, making the management of root caries complex and multidisciplinary. Prevention is the most desirable approach for management, but patients who have developed caries of the roots can be treated with remineralization strategies or a variety of restorative approaches. Dental professionals need to keep abreast of new approaches emerging for the management of root caries.     

Endometrial cancer treatment today

In industrialized countries, for the past few years, the decreasing prevalence of dental caries is due to the improvements of oral hygiene, alimentary prevention and water and salt fluoridation. The dental caries are promoted by the consumption of sucrose when it is too high and/or too frequent between meals. The well cooked sucrose-containing starch - are more cariogenic than sucrose alone. Prevention aims first at high consumers of cariogenic foods and at subjects who are genetically predisposed to dental caries.     

Apoptosis: a role in skin aging?

OBJECTIVE: This paper reports findings for dental caries and dental fluorosis in 8-10- and 13-16-year-old schoolchildren who were lifelong residents of communities having either naturally occurring low (Broken Bow and Holdrege, NE; < 0.3 ppm) or optimal (Kewanee, IL; 1 ppm) levels of fluoride in drinking water. METHODS: Findings are reported for participants who received both dental caries and dental fluorosis examinations (n = 495). The DMFS and TSIF indices, respectively, were used to assess dental caries and dental fluorosis. RESULTS: The mean DMFS score adjusted for age, sealant presence, and fluoride use was significantly lower in Kewanee (1.8) than was the adjusted mean caries score in either Holdrege (2.9) or Broken Bow (3.6). Adjusted mean DMFS scores in Broken Bow and Holdrege were not statistically different. The mean percent of fluorosed tooth surfaces per person, adjusted for age and use of dietary fluoride supplements, was similar in the three communities (approximately 15%); more than 80 percent of tooth surfaces in all participants were fluorosis-free. CONCLUSIONS: Findings from the present study suggest that water fluoridation still is beneficial and that dental sealants can play a significant role in preventing dental caries. In addition, findings from this survey appear to support the premise that the difference in dental fluorosis prevalence between fluoridated and nonfluoridated communities has narrowed considerably in recent years.     

Immunohistochemical localization of HLA-DR-positive cells in unerupted and erupted normal and carious human teeth

Class II major histocompatibility complex (MHC) antigen-expressing cells are generally associated with the early phase of the immune response. We have studied the distribution of class II-expressing cells in developing, normal, and carious human teeth to clarify when human pulp acquires an immunologic defense potential and how this reacts to dental caries. Antigen-expressing cells were identified immunohistochemically by means of HLA-DR monoclonal antibody. In the pulp of unerupted developing teeth, numerous HLA-DR-positive cells were distributed mainly in and around the odontoblast layer. In erupted teeth, HLA-DR-positive cells were located, for the most part, just beneath the odontoblast layer, with slender cytoplasmic processes extending into the layer. Superficial caries lesions caused an aggregation of HLA-DR-positive cells in dental pulp corresponding to the lesion. In teeth with deeper caries lesions, this aggregation of cells expanded to include the odontoblast layer. Also noted were HLA-DR-positive cells lying along the pulp-dentin border, with cytoplasmic processes projecting deep into the dentinal tubules, where they co-localized with odontoblast processes. These findings suggest that: (1) human dental pulp is equipped with immunologic defense potential prior to eruption; (2) in the initial stage of caries infection, an immunoresponse mediated by class-II-expressing cells is initiated in human dental pulp; and (3) HLA-DR-positive cells trespass deep into dentinal tubules as the caries lesion advances.     

Dental caries and sugar consumption into the 21st century

New trends towards the effect and role of sugar consumption in the etiology of dental caries into the 21st century are presented, analyzed and discussed. Many factors such as the amount of sugar consumed, the frequency of sugar intake and the kind of sugars ingested have to be taken into consideration. Over the years, the relative importance of these factors has changed. For a very long time, sugar has been "blamed" as a primary etiological factor in the development of dental caries. However, a number of recent reports have attributed a much less important role to carbohydrates. Sugar consumption only does not affect caries prevalence as much as it used to. It is obvious that the role of sugar in the etiology of caries must be reviewed. Additional factors like overall nutrition, the number of meals and snacks per day, education and motivation, fluoride (in tablets or drops, in mouthwashes, toothpastes, baby foods, formulas, beverages, milk, vitamin supplements and/or fluoridated water ingested), socioeconomic group, ethnicity, oral hygiene status, use of preventive methods and sweeteners other than sucrose are presented.     

Recent advances in the surgical treatment of faecal incontinence

STATEMENT OF PROBLEM: Even though assessments of borderline restorative items in terms of accuracy and interexaminer variation have been reported, no attempt has been made to simultaneously evaluate diagnostic and treatment planning decision using objective normative standards. PURPOSE: This study established the accuracy of caries presence assessment as compared with gold standards, interexaminer agreement in assessment of caries presence and restorative needs, and influences of perceived caries status and restoration quality on treatment planning in borderline restorative situations. MATERIALS AND METHODS: Fifteen senior dental students in Mexico City (66% women; mean age 23.2 years) evaluated predetermined areas in 109 restored and unrestored posterior teeth in an in vitro model. Teeth were subsequently assessed for restoration quality and the presence of enamel and dentinal caries by use of histologic and specific dye techniques. Student's t test, Cohen's kappa, and Pearson's correlation analyses were used to analyze the data. RESULTS: There were significant caries misdiagnoses and substantial overtreatment proposed. In a few instances, teeth were left untreated, but usually they were programmed for restoration. Interexaminer agreement varied markedly and was not high. However, performance while correctly detecting lesions was better than in treatment planning. CONCLUSION: There was a high correlation between a diagnosis of caries and restorative treatment in unrestored teeth; the correlation was lower for restored teeth, although they were allocated to restorative treatment more often. This difference hinged on perceived quality of the restoration, an important factor in the frequency of proposed re-restoration.     

Morquio's syndrome. A case report and review of clinical findings

Morquio's syndrome is a genetic disorder caused by the lack of the enzyme responsible for the breakdown of the mucopolysaccharide keratin sulfate. The resulting buildup of keratin sulfate causes a specific pattern of abnormalities, including short stature, spinal deformity, cardiac abnormalities, corneal opacities, deafness and dental abnormalities. The specific dental findings in the patient described here are as follows: the posterior teeth were tapered and had pointed. cusps; the maxillary anterior teeth were spaced and flared, and on radiographs, the enamel was less than 25 percent of normal thickness but of normal radiodensity. Despite these findings, the patient exhibited a low rate of caries. This paper is a review of medical and dental findings in the Morquio's patient and how this may affect dental management.     

Identification of caries risk children and prevention of caries in pre-school children

A special model for dental care in pre-school children was used in a small clinic in the county of Blekinge in southern Sweden. The model is based on screening of caries risk performed by a dental assistant before the caries attack. Any single risk factor or risk behavior in pre-school children was considered. The aim was to 1) evaluate the dental assistant's selection of caries risk children up to the age of three years, 2) compare dental health variables in 4 yr olds in the test clinic with those for the whole county in 1994 and 3) compare time spent by the dentist and the dental assistant in the test clinic and in the whole county per child up to the age of four. 102 children participated. One specially trained dental assistant screened all children using background factors combined with clinical examinations at ages 1, 2 and 3. Eighty-two children participated each year from one year. A systematized form for questioning the parents was used. Individual caries prevention was given including fluoride and antimicrobial treatments as well as fissure sealants in primary molars at caries risk. The proportion of children with caries lesions at four years and a caries risk assessment up to the age of two was 1.0 (sensitivity). The proportion of children with no caries lesions at four years and no caries risk assessment at year two was 0.7 (specificity). The most frequent risk factors found at 2 yrs were frequency order: lack of oral hygiene (visible plaque), deep fissures in molars and frequent intakes of sweet drinks. The proportion of children with no caries lesions at 4 yrs of age in the test clinic was 92.9% compared to a county mean of 76.4%. In the group of children where a risk assessment was made each year from one year the proportion of caries free children was 96.3%. The total time spent per child in the test clinic was 22 minutes more than the county mean. However, dentist's time, excluding assistance, was 28 minutes less in the test clinic. The results suggest that the model used for caries prevention in pre-school children is cost-effective, and that dental health can be remarkably improved.     

Iscom (Immuno Stimulating Complex)-vaccine of equine influenza virus--transmission electron microscopic investigation and literature review]

Dental caries is the major cause of tooth loss in elderly individuals with physical and mental disabilities. The diagnosis of caries in elderly individuals is difficult due to a complicated oral environment compounded by the prevalence of physical and mental barriers to care. The restoration of tooth structure and the replacement of teeth lost due to caries result in considerable economic and biological cost to both individuals and society. Decisions to remineralize, restore, or extract teeth depend largely upon the extent of the structural damage caused by the infection. Teeth with small lesions can be remineralized with fluorides, whereas teeth with large lesions may be restored or extracted. Caries risk assessment based on the history of previous infection, salivary parameters, and ingestion of sugar can be used as a basis for placing a patient on a caries-preventive regimen. This paper discusses the pathophysiology of caries to explain the appropriate diagnosis, prevention, and treatment of dental caries in elderly individuals with chronic disabilities.     

Validity and reproducibility of clinical examination, fibre-optic transillumination, and bite-wing radiology for the diagnosis of small approximal carious lesions: an in vitro study

This study measured validity and reproducibility of unaided clinical diagnosis, fibre-optic transillumination (FOTI), and bite-wing radiology in the diagnosis of approximal caries. Sixty models were made using extracted premolars and molars, each containing four teeth with six contacting approximal surfaces. The teeth were examined first using unaided clinical examination and then using FOTI. Bite-wing radiographs were then taken of the teeth set in the models and examined. The three examinations were repeated after 1 week. Histological sections of the undecalcified teeth were prepared following their removal from the models, and those showing signs of caries were examined to give the valid state of disease in each surface. The diagnostic threshold was caries penetrating into dentine. The reproducibility of all three methods was acceptable with kappa values exceeding 0.6. All specificity values exceeded 0.95. Statistically significant differences were seen between sensitivities for clinical (0.38) and bite-wing (0.59) diagnosis and between clinical and FOTI (0.67) examination, but not between bite-wing and FOTI. It is concluded that the validity of FOTI is at least as high as that of bite-wing radiology, and both are superior to unaided clinical diagnosis.     

Digital radiology in dentistry: experience with direct intraoral techniques (radiovideography)

The aim of this paper was to discuss the techniques for intraoral digital radiography (radiovisiography) and to compare their accuracy in dental radiographical diagnosis. Emphasis was given to their potential applications in oral radiology. Radiovisiography was compared with intraoral films and electronic magnifications from digital panoramic radiographs in 38 patients, for a total amount of 36 caries, 27 periapical conditions and 58 metal implants. Moreover, the accuracy of the measurements made with the three techniques was assessed on a specimen of mandibular and maxillary arches containing 28 extracted teeth with endodontic files of known length. Radiovisiography was as effective as intraoral films and more effective than digital panoramic radiographs in the diagnosis of caries and periapical lesions. Nevertheless, it produced a significant magnification and yielded unreliable measurements of root canals and metal implants. Radiovisiography is very easy to use and does not require dark room procedures nor chemicals of any kind. In addition, it reduces patient's X-ray exposure by over 50% with respect to film studies. For these reasons, this technique seems to be worthy of widespread use in dental radiography, with the exception of the conditions requiring an exact measurement of working length.     

Validity of two methods for assessing oral health status of populations

OBJECTIVE: This investigation assessed two methods for estimating epidemiologic indicators of oral health status among children: (1) a visual-only screening, performed independently by a dental hygienist and a registered nurse; and (2) a parent- or guardian-completed questionnaire. The indicators included dichotomous variables measuring dental caries and treatment needs, presence of sealants, injuries to the anterior teeth, and dental fluorosis. METHODS: Following training and calibration, data were collected over an eight-day period in April 1994 among 632 elementary schoolchildren (aged 5 to 12 years) in Monticello, Georgia. Both screening and questionnaire findings were compared pairwise with results from visual-tactile examinations done by a dentist. Validity, represented by sensitivity, specificity, and predictive values, was assessed for screening results from the dental hygienist, the nurse, and the parent-completed questionnaire. RESULTS: Validity was high for screening for caries and treatment needs (> 90% for sensitivity, specificity, and predictive values in a sample having 30% to 40% prevalence). Less valid data--mainly an effect of false negatives--were obtained for fluorosis, injuries, and presence of sealants. No significant difference in validity was observed between the nurse and the dental hygienist. One-third of respondents to the questionnaire did not know if their children needed fillings (a proxy for untreated decay) or had received sealants; only knowledge of restorations was comparable to results from screening. Intraexaminer reliability for the two screeners ranged from 85 to 100 for percent agreement and 0.70 to 0.93 for kappa scores. CONCLUSIONS: Screening by dental hygienists or nurses can provide valid data for surveillance of dental caries and treatment needs. Training for visual assessment of fluorosis and injuries must be improved to diminish the proportion of false negatives. A parent-completed questionnaire is less effective than visual screening for evaluating oral health status in children.