[Show abstract][Hide abstract] ABSTRACT: Background:
A questionable occlusal caries (QOC) lesion can be defined as an occlusal surface with no radiographic evidence of caries, but caries is suspected because of clinical appearance. In this study, the authors report the results of a 20-month follow-up of these lesions.
Fifty-three clinicians from The National Dental Practice-Based Research Network participated in this study, recording lesion characteristics at baseline and lesion status at 20 months.
At baseline, 1,341 QOC lesions were examined; the treatment that was planned for 1,033 of those at baseline was monitoring (oral hygiene instruction, applying or prescribing fluoride or varnish, or both), and the remaining 308 received a sealant (n = 192) or invasive therapy (n = 116). At the 20-month visit, clinicians continued to monitor 927 (90 percent) of the 1,033 monitored lesions. Clinicians decided to seal 61 (6 percent) of the 1,033 lesions (mean follow-up, 19 months) and invasively treat 45 (4 percent) of them (mean follow-up, 15 months). Young patient age (< 18 years) (odds ratio = 3.4; 95 percent confidence interval, 1.7-6.8) and the lesion's being on a molar (odds ratio = 1.8; 95 percent confidence interval, 1.3-2.6) were associated with the clinician's deciding at some point after follow-up to seal the lesion or treat it invasively.
Almost all (90 percent) QOC lesions for which the treatment planned at baseline was monitoring still were planned to undergo monitoring after 20 months. This finding suggests that noninvasive management is appropriate for these lesions.
Previous study results from baseline indicated a high prevalence of QOC lesions (34 percent). Clinicians should consider long-term monitoring when making treatment decisions about these lesions.
Full-text · Article · Nov 2014 · Journal of the American Dental Association (1939)
[Show abstract][Hide abstract] ABSTRACT: Documenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important step toward improving care. The authors conducted a study to quantify the concordance between clinical practice and published evidence across preventive, diagnostic and treatment procedures among a sample of dentists in The National Dental Practice-Based Research Network ("the network").
Network dentists completed one questionnaire about their demographic characteristics and another about how they treat patients across 12 scenarios/clinical practice behaviors. The authors coded responses to each scenario/clinical practice behavior as consistent ("1") or inconsistent ("0") with published evidence, summed the coded responses and divided the sum by the number of total responses to create an overall concordance score. The overall concordance score was calculated as the mean percentage of responses that were consistent with published evidence.
The authors limited analyses to participants in the United States (N = 591). The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent); procedure-specific concordance ranged from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent).
Dentists reported a medium-range concordance between practice and published evidence.
Efforts to bring research findings into routine practice are needed.
Full-text · Article · Jan 2014 · Journal of the American Dental Association (1939)
[Show abstract][Hide abstract] ABSTRACT: To better understand the effectiveness of xylitol in caries prevention in adults and to attempt improved clinical trial efficiency.
As part of the Xylitol for Adult Caries Trial (X-ACT), non cavitated and cavitated caries lesions were assessed in subjects who were experiencing the disease. The trial was a test of the effectiveness of 5 g/day of xylitol, consumed by dissolving in the mouth five 1 g lozenges spaced across each day, compared with a sucralose placebo. For this analysis, seeking trial efficiency, 538 subjects aged 21-80, with complete data for four dental examinations, were selected from the 691 randomized into the 3-year trial, conducted at three sites. Acceptable inter- and intra-examiner reliability before and during the trial was quantified using the kappa statistic.
The mean annualized noncavitated plus cavitated lesion transition scores in coronal and root surfaces, from sound to carious favoured xylitol over placebo, during the three cumulative periods of 12, 24, and 33 months, but these clinically and statistically nonsignificant differences declined in magnitude over time. Restricting the present assessment to those subjects with a higher baseline lifetime caries experience showed possible but inconsistent benefit.
There was no clear and clinically relevant preventive effect of xylitol on caries in adults with adequate fluoride exposure when non cavitated plus cavitated lesions were assessed. This conformed to the X-ACT trial result assessing cavitated lesions. Including non cavitated lesion assessment in this full-scale, placebo-controlled, multisite, randomized, double-blinded clinical trial in adults experiencing dental caries did not achieve added trial efficiency or demonstrate practical benefit of xylitol. Trial Registration: ClinicalTrials.Gov NCT00393055.
Full-text · Article · Nov 2013 · Community Dentistry And Oral Epidemiology
[Show abstract][Hide abstract] ABSTRACT: The American Dental Association has devoted substantial resources to the growth, development, and promotion of evidence-based dentistry for more than a decade. It has been active in three primary arenas, developing the evidence translating the evidence, and disseminating it, and helping practitioners incorporate the evidence into their practices. Members and non-members alike benefit from the improved access to the evidence that these activities have provided.
No preview · Article · Sep 2013 · Seminars in Orthodontics
[Show abstract][Hide abstract] ABSTRACT: This secondary analysis of data from the Prevention of Adult Caries Study (PACS) assesses risk factors for progression of coronal caries.
Participants (n = 983) were adults at increased caries risk with at least one cavitated and one noncavitated lesions who were enrolled in a randomized clinical trial to test the effect of a 10% w/v chlorhexidine varnish coating on caries progression. Calibrated examiners scored tooth surfaces using a modified International Caries Detection and Assessment System (ICDAS) classification at baseline and at 7 and 13 months postrandomization. Potential baseline predictors of caries risk were used in adjusted negative binomial regression models to predict net D2FS increment and in linear regression models to predict the rank-normalized net D12FS increment.
Mean (SD) D2FS and D12FS increments were and 2.4 (3.1) and 2.1 (6.9), respectively. In multivariate analyses, two or more baseline D2 lesions, consumption of acidic drinks, and increasing age were all significantly associated with increased D2FS and D12FS risk. Daily flossing also was associated with increased D2FS risk. More frequent dental care at baseline was associated with significantly decreased caries risk for both increments.
The general concordance of risk factors in the D12FS and D2FS models lends support to the hypothesis that the D1 increment is an intermediate stage in the progression to fully cavitated lesions.
Full-text · Article · Jul 2013 · Community Dentistry And Oral Epidemiology
[Show abstract][Hide abstract] ABSTRACT: Objectives:
The study aims to determine a) the extent of agreement between visual-tactile caries examination (VTE) and radiographic examination (RE) in detecting presumptive caries lesions on occlusal and proximal surfaces of posterior teeth of UNC Xylitol for Adult Caries Trial participants; and b) the additional caries diagnostic yield obtained by adding RE to VTE.
Data consisted of surface-level visual-tactile and radiographic classification of disease (cavitated and noncavitated caries lesions) or nondisease (sound surfaces). Participants (n = 114, adults with ≥12 erupted teeth and 1-10 caries lesions) received baseline VTE by a trained and calibrated examiner, and had interproximal radiographs obtained within 7 months before or after the VTE. Radiographs were assessed independently by two trained and calibrated examiners masked with respect to VTE results. The diagnostic threshold was surface-level disease/nondisease status. Kappa statistics provided an estimate of VTE-RE agreement on diseased surfaces. The additional diagnostic yield of the RE over VTE was calculated as the additional lesions detected radiographically as a percentage of the total number of lesions detected by VTE.
Four-hundred ninety-four (51 occlusal, 433 proximal) lesions were detected; of these, 81 (2 occlusal, 79 proximal) lesions were detected by both VTE and RE. Kappa statistics were 0.18 (all surfaces), 0.04 (occlusal), and 0.18 (proximal). The additional diagnostic yield was 69 percent (all surfaces), 55 percent (occlusal), and 71 percent (proximal).
There is poor agreement between VTE and RE to detect caries in posterior teeth of caries-active adults. However, an RE performed within 7 months of a VTE adds caries diagnostic yield in a clinical trial, especially on proximal surfaces.
Full-text · Article · Jun 2013 · Journal of Public Health Dentistry
[Show abstract][Hide abstract] ABSTRACT: The Xylitol for Adult Caries Trial was a three-year, double-blind, multi-center, randomized clinical trial that evaluated the effectiveness of xylitol vs. placebo lozenges in the prevention of dental caries in caries-active adults. The purpose of this secondary analysis was to investigate whether xylitol lozenges had a differential effect on cumulative caries increments on different tooth surfaces. Participants (ages 21-80 yrs) with at least one follow-up visit (n = 620) were examined at baseline, 12, 24, and 33 months. Negative binomial and zero-inflated negative binomial regression models were used to estimate incidence rate ratios (IRR) for xylitol's differential effect on cumulative caries increments on root and coronal surfaces and, among coronal surfaces, on smooth (buccal and lingual), occlusal, and proximal surfaces. Participants in the xylitol arm developed 40% fewer root caries lesions (0.23 D2FS/year) than those in the placebo arm (0.38 D2FS/year; IRR = 0.60; 95% CI [0.44, 0.81]; p < .001). There was no statistically significant difference between xylitol and control participants in the incidence of smooth-surface caries (p = .100), occlusal-surface caries (p = .408), or proximal-surface caries (p = .159). Among these caries-active adults, xylitol appears to have a caries-preventive effect on root surfaces (ClinicalTrials.gov NCT00393055).
Full-text · Article · Apr 2013 · Journal of dental research
[Show abstract][Hide abstract] ABSTRACT: Objectives: To investigate whether xylitol lozenges have a differential effect on cumulative caries increments on root vs. coronal tooth surfaces of Xylitol for Adult Caries Trial (X-ACT) participants.
Methods: X-ACT was a three-site placebo-controlled randomized trial that evaluated the effectiveness of xylitol in the prevention of dental caries in caries-active adults. Participants with at least one follow-up period (n=620, ages 21-80) consumed up to five 1.0 g xylitol or placebo lozenges daily for 33 months. Clinical caries examinations occurred at baseline, 12, 24 and 33 months using a modified ICDAS-II classification system. The primary outcome variable for the trial was the D23FS (cavitated caries lesions) caries increment for combined root and coronal surfaces. In the secondary analysis reported here, we estimated xylitol’s specific effects on caries increments for root and coronal surfaces. Explanatory variables included intervention, dental visit history, fluoride use, brushing/flossing habits, clinical site, age, and exposure time (or time at risk). Because of the different distributional properties for root and coronal caries, we used separate models for each surface type: zero-inflated negative binomial regression for root surfaces and negative binomial regression for coronal surfaces.
Results: Participants in the xylitol arm (0.23 D23FS/year) developed 40% less root caries than those in the placebo arm (0.38 D23FS/year; incidence rate ratio [IRR]=0.60; 95% CI=0.44, 0.81; p<0.001). There was no significant difference in coronal caries incidence rates between participants in the xylitol arm (2.51 D23FS/year) and those in the placebo arm (2.70 D23FS/year; IRR=0.93; 95% CI=0.83, 1.05; p=0.24).
Conclusions: Xylitol lozenges appeared to have a greater preventive effect on root caries than on coronal caries on participants in the X-ACT clinical trial. Supported by NIDCR U01DE018038, U01DE018047, U01DE018048, U01DE018049, and U01DE018050.
[Show abstract][Hide abstract] ABSTRACT: Objective: Categorize non-cavitated caries lesion transitions by individual tooth surface using longitudinal data.
Method: Data from the Xylitol Adult Caries Trial ( X-ACT *), on non-cavitated and cavitated caries lesions of crown and root surfaces combined, were available from all four clinical exams over 33 months for 543 caries active subjects aged 21-80 living in fluoridated communities . Over three successive periods of 12, 12 and 9 months teeth were visually assessed using modified ICDAS criteria. Using Boolean logic this analysis classified each tooth surface with at least one transition involving a non-cavitated lesion into a set of Patterns. Then it established a longitudinal Profile for these individual tooth surface patterns across three time transitions.
Result: Intraexaminer reliability weighted Kappa scores for distinguishing sound vs non-cavitated vs cavitated lesions were : Baseline 0.63 , 12 mths 0.84 , 24 mths 0.66 , 33 mths 0.67. Profile types ( n=10,335) expressed as a percentage of all profiles analysed and having a non-cavitated lesion were; Consistently Progressive (demin) 19.7%, Stable 14.0%, Consistently Reversing (remin) 28.7% , Complex (demin/stable/remin in any sequence ) 26.6%, Excluded Profiles 11.0% ( tooth number inconsistency when missing etc, excluded because they were not a part of the caries continuum).
Conclusion: Only one fifth of tooth surfaces included in this analysis exhibited a pattern of consistent progression to or beyond a non-cavitated lesion over 33 months in caries active adults from fluoridated communities. Only 8.0% progressed to cavitation or restoration.
* ClinicalTrials.gov NCT 0039005
NIDCR support U01DE018038, U01DE018047, U01DE018048, U01DE018049, and U01DE018050
[Show abstract][Hide abstract] ABSTRACT: Background. Although caries is prevalent in adults, investigators have tested few preventive therapies in adult populations. In a randomized controlled trial, the authors evaluated the effectiveness of xylitol lozenges in preventing caries in adults at elevated risk of developing caries. Methods. The Xylitol for Adult Caries Trial (X-ACT) was a three-site placebo-controlled randomized trial. Participants (n = 691) aged 21 through 80 years consumed five 1.0-gram xylitol or placebo lozenges daily for 33 months. They underwent clinical examinations at baseline and at 12,24 and 33 months. Results. Xylitol lozenges reduced the caries increment 10 percent. This reduction, which represented less than one-third of a surface per year, was not statistically significant. There was no indication of a dose-response effect. Conclusions. Daily use of xylitol lozenges did not result in a statistically or clinically significant reduction in 33-month caries increment among adults at an elevated risk of developing caries. Clinical Implications. These results suggest that xylitol used as a supplement in adults does not reduce their caries experience significantly.
Full-text · Article · Jan 2013 · Journal of the American Dental Association (1939)
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Questionable occlusal caries (QOC) can be defined as clinically suspected caries with no cavitation or radiographic evidence of occlusal caries. To the authors' knowledge, no one has quantified the prevalence of QOC, so this quantification was the authors' objective in conducting this study METHODS: A total of 82 dentist and hygienist practitioner-investigators (P-Is) from the United States and Denmark in The Dental Practice-Based Research Network (DPBRN) participated. When patients seeking treatment had at least one unrestored occlusal surface, P-Is quantified their number of unrestored occlusal surfaces and instances of QOC, if applicable. P-Is also recorded information about characteristics of patients who had QOC and had provided informed consent. The authors adjusted for patient clustering within practices. RESULTS: Overall, 6,910 patients had at least one unrestored occlusal surface, with a total of 50,445 unrestored surfaces. Thirty-four percent of all patients and 11 percent of unrestored occlusal tooth surfaces among all patients had QOC. Patient- and surface-level QOC prevalences varied significantly according to DPBRN region (P < .001 and P = .03, respectively). The highest percentages for patient- and surface-level prevalence occurred in Florida and Georgia (42 percent and 16 percent, respectively). CONCLUSIONS: To the authors' knowledge, this is the first study in which investigators have quantified the prevalence of QOC in routine clinical practice. These results document a high prevalence overall, with wide variation in prevalence among The DPBRN's five main regions. CLINICAL IMPLICATIONS: QOC is common in routine practice and warrants further investigation regarding how best to manage it.
Full-text · Article · Dec 2012 · Journal of the American Dental Association (1939)
[Show abstract][Hide abstract] ABSTRACT: Although caries is prevalent in adults, few preventive therapies have been adequately tested in adult populations . Xylitol efficacy has been controversial , with lack of Stage III trials and evidence based reviews reaching disparate conclusions. This three year , randomized , placebo controlled clinical trial ( CCT ) evaluated the effectiveness of xylitol mints in preventing dental caries in 691 caries-active adults at three fluoridated US sites ; UNC, UAB and UTHSCSA , with KPCHR as the data center. Participants aged 21-80 consumed five 1gm xylitol or placebo mints daily for 33 months. Clinical examinations occurred at baseline, 12, 24 and 33 months. Subjects usual preventive activities continued . Xylitol mints reduced the caries increment in the treatment group by 11% , a reduction that was not statistically significant. There was no indication of a dose-response effect. Essentially the same result was found when uncavitated plus cavitated caries lesions were used in the assessment of disease increment. Daily use of xylitol mints did not result in a statistically or clinically significant reduction in annual caries increment among caries active adults . Crude annualized D2FS increment , xylitol group 2.72 vs 3.05 placebo group (95% confidence interval (CI) for (RR) = 0.78, 1.03) The results of this trial temper overly optimistic expectations that xylitol used as a supplement in patients receiving dental care , for the public generally , or in organized preventive programs will substantially reduce their caries experience . ClinicalTrials.Gov NCT00393055
[Show abstract][Hide abstract] ABSTRACT: Objectives: The performance of a recently developed survey instrument that inquires about patients' experiences with the receipt of dental care was examined to evaluate its potential utility as a patient-reported outcome measure for dental care plans.
Methods: Individuals with dental insurance (n = 1,216) were surveyed using the Consumer Assessment of Health Care Providers and Systems (CAHPS) Dental Plan Survey. The instrument's pre-established composite and rating scores were compared across dental insurance carriers (6 most common and all others combined) using ANOVA. In addition, each score was analyzed separately using multivariate regression with respondent and plan characteristics as independent variables.
Results: There was significant differentiation among dental insurance carriers for three of the six scores (dental care composite, access to care composite, and dentist rating). Several respondent characteristics were associated with higher scores, including age, race, income level, and oral health self-rating. Having a choice of dental plans, and years with one's dental plan were associated with higher dental plan ratings, while having to find a new dentist to use the plan tended to lower all scores except the cost and services composite.
Conclusions: The results reported here reflect differences among dental insurance carriers, rather than among the many different dental plans offered by those carriers. Nevertheless, the CAHPS instrument scores reflected differences among patients' experiences (composite scores) and ratings (rating scores) across carriers, suggesting both that the instrument should be a useful tool for assessing patient-reported outcomes, and that comparisons of these outcomes should control for respondent characteristics as well as specific plan characteristics.
No preview · Article · Apr 2012 · Journal of Public Health Dentistry
[Show abstract][Hide abstract] ABSTRACT: Objectives: To determine 1:the extent of agreement between clinical (visual-tactile, CE) and radiographic (RE) examinations in detecting presumptive caries lesions on occlusal and proximal surfaces of posterior teeth of UNC Xylitol for Adult Caries Trial (X-ACT) participants; and 2:the additional caries diagnostic yield obtained by adding RE to CE.
Methods: Data consisted of surface-level clinical and radiographic scores of disease (cavitated and non-cavitated lesions, existing restorations) or non-disease (sound surfaces). Participants (18-80 years old with ≥12 erupted teeth and 1-10 coronal or root caries lesions) received baseline CE by a trained and calibrated examiner, and had interproximal radiographs obtained within 7 months before or after the date of the CE (N=114). Radiographs were assessed independently by two trained and calibrated examiners masked with respect to CE. Kappa statistics provided an estimate of agreement between CE and RE on diseased surfaces. The additional caries diagnostic yield of the RE over CE is the additional presumptive lesions detected radiographically as a percentage of the total number of presumptive lesions detected clinically.
Results: Surface-level CE-RE agreement (Kappa) and additional diagnostic yield from RE (n=2415 surfaces):
Caries Lesions Detected
Conclusions: There is poor agreement between CE and RE to detect caries in posterior teeth of caries-active adults. However, a RE performed within 7 months before or after a CE adds substantial caries diagnostic yield in a clinical trial, especially on proximal surfaces. Supported by NIDCR U01DE018038, U01DE018047, U01DE018048, U01DE018049, and U01DE018050. This was an X-ACT ancillary study and, as such, was designed, conducted, and analyzed by the co-authors only.
[Show abstract][Hide abstract] ABSTRACT: Objective
This paper uses baseline data from a randomized clinical trial to evaluate cross-sectional indicators of root caries in caries-active adults.
Materials and methods
Adults (21–80 years) having at least 12 erupted teeth and between one and ten caries lesions were enrolled. Participants (n = 437) received caries exams by trained, calibrated examiners and responded to baseline demographic and medical–dental questionnaires. We examined associations between baseline characteristics and (1) the presence of any root caries using Mantel–Haenszel hypothesis tests and odds ratio (OR) estimators and (2) the number of root surfaces with caries among study participants with exposed root surfaces (n = 349) using Mantel–Haenszel mean score tests and Mann–Whitney estimators.
Adjusting for study site and age, male gender [OR, 1.72; 95% confidence interval (CI), 1.08, 2.78], white race (OR, 2.39; 95% CI, 1.43, 3.98), recent dental visit (OR, 1.98; 95% CI, 1.07, 3.66), poor self-described oral health (OR, 2.65; 95% CI, 1.10, 6.39), and recent professional fluoride treatment (OR, 1.85; 95% CI, 1.06, 3.25) were significantly associated with increased odds to have any root caries, and study participants with exposed root surfaces characterized by male gender [Mann–Whitney probability estimate (MW) = 0.57; 95% CI, 0.51, 0.63), white race (MW, 0.61; 0.55, 0.68), recent dental visit (MW, 0.58; 0.50, 0.67), poor self-described oral health (MW, 0.61; 0.53, 0.69), and flossing at least once per day (MW, 0.57; 95% CI, 0.51, 0.62) were significantly more likely to have a greater number of root surfaces with caries than a randomly selected study participant from their respective complementary subgroups (female gender, non-white, etc.).
Our findings may help identify individuals at higher root caries risk.
Full-text · Article · Dec 2011 · Clinical Oral Investigations
[Show abstract][Hide abstract] ABSTRACT: The Prevention of Adult Caries Study, an NIDCR-funded multicenter, double-blind, randomized clinical trial, enrolled 983 adults (aged 18-80 yrs) at high risk for developing caries (20 or more intact teeth and 2 or more lesions at screening) to test the efficacy of a chlorhexidine diacetate 10% weight per volume (w/v) dental coating (CHX). We excluded participants for whom the study treatment was contraindicated or whose health might affect outcomes or ability to complete the study. Participants were randomly assigned to receive either the CHX coating (n = 490) or a placebo control (n = 493). Coatings were applied weekly for 4 weeks and a fifth time 6 months later. The primary outcome (total net D(1-2)FS increment) was the sum of weighted counts of changes in tooth surface status over 13 months. We observed no significant difference between the two treatment arms in either the intention-to-treat or per-protocol analyses. Analysis of 3 protocol-specified secondary outcomes produced similar findings. This trial failed to find that 10% (w/v) chlorhexidine diacetate coating was superior to placebo coating for the prevention of new caries (Clinicaltrials.gov registration number NCT00357877).
Full-text · Article · Dec 2011 · Journal of dental research